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A high risk of aspiration for patients with tracheostomies has been shown in research (Marvin & Thibeault, 2021). This aspiration risk has been implicated by the negative effects on swallowing that occur secondary to both changes in physiology due to the tracheostomy and by components of the tracheostomy tube itself. Some of the swallowing complications related to the presence of a tracheostomy tube, especially with an inflated cuff include reduced subglottic pressure, impaired laryngeal elevation, desensitization of the larynx, disuse atrophy of the larynx, decreased breathing and swallowing, and decreased effectiveness of the cough to clear secretions (Gross et al., 2003; Ding & Logemann, 2005; Prigent et al., 2011; Amethieu et al., 2012; Skoretz et al., 2020). These impairments can lead to an increased risk of aspiration in the patient with a tracheostomy.
Impact of a Tracheostomy Tube
Skoretz et al. (2020) reported a wide range of 11 – 93% dysphagia occurrence in patients with tracheostomies. This range is broad due to multiple factors: diagnosis, severity, co-existing factors, tracheostomy tube type and management, ventilator support or not, and more. A tracheostomy tube is placed due to medical complexities that warrant an artificial airway to support the respiratory system; it often has dysphagia as a complicating co-occurrence. However, having the complication of dysphagia for patients with tracheostomies is not unexpected due to the shared pathway of the respiratory and alimentary systems.
Marvin and Thibeault (2021) researched the frequency of aspiration and silent aspiration in patients with new tracheostomies. One variable the authors evaluated was open tracheostomy tube vs. closed tracheostomy tube with a cap, plug, or one-way speaking valve. The authors reported the odds of aspiration were twice as high in patients with uncapped tracheostomy compared to closed tracheostomy tubes (i.e., cap or speaking valve in place). The odds of silent aspiration were 4.5 greater with an uncapped tracheostomy.
Breathing and Swallowing Coordination
As the respiratory and alimentary systems share common pathways, breathing and swallowing coordination may be impaired for patients with a tracheostomy with and without mechanical ventilation. The typical breathing-swallowing pattern is to swallow mid-expiration which serves as a protective mechanism. The expiratory flow assists with expelling food and liquid that may be misdirected toward the airway; however, in patients with tracheostomies, expiration through the mouth and nose may not occur (cuff inflated) or may be inconsistent (open tracheostomy). Prigent et al. (2011) studied the breathing-swallowing interaction in patients with tracheostomies. They found that the expiratory flow towards the upper airway after swallowing was negligible when the tracheostomy tube was not occluded. However, expiratory flow through the upper airway after swallowing was restored with an occluded tracheostomy tube. The authors concluded that in patients with tracheostomy tubes, protective expiration towards the upper airway after swallowing is restored with occlusion.
Pressures During Swallowing
When considering pressures during the swallow, Gross et al. (2003) theorized that when the system is closed, a consequential segmental reflex arc may be stimulated that assists with the programming of pharyngeal musculature, in turn increasing the recruitment of the lower motor neurons. The occurrence of this stimulation may increase bolus speed, decrease pharyngeal contraction time, and strengthen the pharyngeal muscle action. With an open tracheostomy tube, Gross et al. (2003) discussed that a loss of stimulation of the reflex may increase bolus transit time and pharyngeal activity duration due to a loss of subglottic pressure and failure to stimulate the subglottic receptors. Consideration also was given to the possibility that a specific segmental swallowing reflex in the brainstem may be stimulated by tracheal air pressure, thus influencing the recruitment of pharyngeal swallowing musculature or signaling the oral cavity and the pharynx that the larynx has sufficiently protected the airway. When subglottal pressure is diminished significantly or eliminated, this reflex may not be elicited.
Gross et al. (2006) confirmed that subglottic pressure is generated during swallowing in healthy, non-tracheostomized adults. The subglottic pressure theory asserts that lung volume and respiratory recoil combine to generate positive subglottic pressure. This pressure peaks during swallowing when the vocal folds are closed and stimulates mechanoreceptors in the larynx. The mechanoreceptors provide afferent input to the brainstem which modifies the efferent signal for swallowing. Gross et al. (2006) also found that subglottic pressure was related to lung volumes which would be impacted by an open tracheostomy. Patients with open tracheostomies lack positive airway pressure which may negatively impact swallow function. When a tracheostomy tube is placed in the airway, this changes the system from a closed system with the ability to engage the glottis and increase pressure to an open system and poor to no involvement of the vocal cords. The ability to generate pressures is key to swallowing function.
Improving Function With the Use of a Passy-Muir Valve on the Tracheostomy Tube
Since a primary issue is an open system with a tracheostomy tube in place, initiating a way to close the system for the patient has implications for improving swallow function. One way to close the system is to consider implementing the use of the Passy-Muir® Tracheostomy & Ventilator Swallowing and Speaking Valve (PMV®). It has been reported that the use of the PMV improves swallow efficiency and reduces penetration and aspiration for patients with tracheostomies and mechanical ventilation. In the studies reviewed, there are reports of improved swallow safety with the use of the Passy-Muir Valve and rationales to support the use of the PMV to aid early swallowing intervention. Some studies also provide evidence that subglottic pressure and upper airway airflow is a necessary component of normal swallowing, and, therefore, significant for patients with tracheostomies.
The Passy-Muir Valve is a bias-closed position, no-leak valve that redirects 100% of exhalatory airflow up through the vocal folds, mouth, and nose. Use of the Valve allows the patient to create positive airway pressure and restores a more normal closed respiratory system. By redirecting airflow up through the vocal folds, the patient can engage the glottis. This restoration of airflow through the upper airway and positive airway pressure has numerous clinical benefits including improved voice, secretion management, cough effectiveness, and swallowing ability.
Researchers have found that when the PMV is on the tracheostomy tube, patients demonstrate lower penetration-aspiration scores, faster bolus transit time, and shorter pharyngeal muscle duration time (Gross et al., 2003; Rodrigues et al., 2015; Han et al., 2018; O’Connor et al., 2019). Blumenfeld et al. (2011) prospectively evaluated 21 patients with tracheostomies and dysphagia. Patients were randomized into a speaking valve experimental group or a tracheostomy tube-only control group. All patients underwent four days of identical swallowing therapy. The experimental group wore the Passy-Muir Valve for 45 minutes a day and during dysphagia therapy. All patients were evaluated with FEES on day 1 and day 4 with the experimental group having a Passy-Muir Valve during testing. The results of this study showed no differences in Penetration-Aspiration Scores (PAS) or secretion ratings between days 1 and 4 for the control group (p > 0.05). However, the PAS for the Passy-Muir Valve group improved from 3.67 to 1.75 (p < 0.001) and the secretion rating improved from 2.91 to 1.55 (p < 0.001). The authors concluded that the PMV may positively impact swallowing function and rehabilitation.
O’Connor et al. (2019) conducted a systematic review of research occurring between 1985 – 2017, with a supplementary search through May 2018, to investigate the physiological and clinical outcomes associated with use of the PMV. The review found that reduced aspiration occurred with the use of the Passy-Muir Valve. Additionally, statistically significant results were found for olfaction, secretion management, and ventilation.
With the use of the Passy-Muir Valve to close the system, restoration of post-expiration swallowing in patients with tracheostomies can occur which is thought to be a protective mechanism to assist with expelling laryngeal vestibule penetration that may have occurred during swallowing. Prigent et al. (2011) investigated the effect of a speaking valve on breathing-swallowing interactions and on the volume expelled through the upper airway after swallowing. They found that expiratory flow towards the upper airway after swallowing was negligible without the speaking valve and was restored by adding the speaking valve. Additional research that addressed breathing and swallowing coordination and airflow patterns with and without the Passy-Muir Valve was conducted by Han et al. (2018). The authors investigated the impact of PMV use on patients with acquired brain injuries and tracheostomies. They concluded that the use of the PMV resulted in improved hyoid superior movement, UES opening diameter, upper airway airflow, and pressure in patients with tracheostomies following acquired brain damage.
Early swallowing intervention also was studied by Rodrigues et al. (2015). The authors studied the feasibility of early implementation of a swallowing rehabilitation program in patients with tracheostomies and mechanical ventilation with dysphagia who used the Passy-Muir Valve. The authors concluded that swallowing rehabilitation with the PMV is feasible for patients on mechanical ventilation and may help to improve the swallowing function and oropharyngeal dysphagia severity. Even though early swallowing intervention is beneficial for patients with tracheostomies, special considerations for the open tracheostomy and changes to physiology may impact how therapy is done (see Figure 1).
Conclusion
Having a tracheostomy and the changes that occur by having an open system may negatively impact swallowing due to a loss of pressure, loss of upper airflow, and changes in overall respiratory and swallowing coordination which increase the risk of dysphagia. Addressing the potential dysphagia in this patient population warrants clinical assessment and potentially instrumental assessment to determine swallowing efficiency and function both with and without the use of a speaking valve. While the Passy-Muir Valve will not ameliorate dysphagia in every patient, it can benefit many patients by restoring subglottic pressure and more normal breathing and swallowing coordination. Research also has shown that the PMV may improve the safety of swallowing by reducing penetration and aspiration. Use of the Passy-Muir Valve should be considered an important part of dysphagia rehabilitation programs for patients with tracheostomies and for those requiring mechanical ventilation as it may help with swallow safety and efficiency, and it also may allow for faster return to oral diets.
References
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