Feeding Tracheostomy Patients with the Feeding Tracheostomy Patients with the Cuff InflatedCuff Inflated

What does the evidence say? What does the evidence say? What are Speech Pathologists doing on the ground?What are Speech Pathologists doing on the ground?

Klint Goers and Kat Symeou on behalf of:Critical care and Tracheostomy EBP group

NSW SP EBP Showcase 2nd Dec 2014

OverviewOverview• Anatomy refresher • Tracheostomy – does it cause dysphagia?• Cuff status and potential impact on swallow• Why did we want to look at this area?• What did we already know?• 2014 clinical question• 2014 clinical bottom line• Survey of speech pathologists across Australia and their clinical

practice• Summary and where to from here • Acknowledgements

TracheostomyTracheostomy

Tracheostomy and Tracheostomy and dysphagiadysphagia

• CAT 2011: Does a tracheostomy tube cause dysphagia?

• Limited and low level evidence indicates that the presence of a tracheostomy tube alone (cuff deflated, with no occlusion via cap or speaking valve) has no causal effect on the parameters of swallow function investigated. It is suggested that the patients underlying diagnosis and co morbidities are the cause of any apparent dysphagia. It is important to note that the literature critiqued indicates mixed results as to whether the manipulation of the tube (e.g. cuff up or down) and the presence of a speaking valve elevates the risk of aspiration. However, exploration of this issue was not within the scope of this CAT.

What about feeding What about feeding patients with the cuff patients with the cuff

inflated?inflated?The oral pharyngeal swallow may be impacted when a patient is fed with an inflated cuff

•Anchoring of the larynx on tracheal wall affecting hyoid movement•Changes to airflow through the upper airway therefore may impact sensation and/or swallow•Reduced effectiveness of cough

Why therapists may be reluctant to feed with the cuff up:Previous case reports of perforation of the oesophagus when patient’s fed with high pressure inflated cuffs

What about feeding What about feeding patients with the cuff patients with the cuff

inflated?inflated?Why did we want to look at this?

•Differences in practice across members/sites in relation to feeding patients with the cuff up•Speech Pathologists recognising the importance of early intervention (i.e. when the patients are still ventilated) in order to improve QOL, potentially prevent disuse and atrophy•Acknowledgement that this is a contentious issue •2013 Trache ACI CPG reported the results for cuff up feeding and aspiration were mixed.

All these factors combined meant that we needed to review the evidence as a group

What about feeding What about feeding patients with the cuff patients with the cuff

inflated?inflated?What did we already know?

This topic was last looked at in this group in 2002 via 2 x CAP’s. The clinical question was: Does an inflated cuff exacerbate/increase aspiration at the level of the vocal folds?

Study 1. Davis 2002: Non ventilated respiratory patients. Level IV

Old clinical bottom line: Cuff inflation may exacerbate/increase aspiration at the level of the vocal folds and an MBS should be pursued for further detail.

2014 clinical question2014 clinical questionIn patients with a tracheostomy (+/- mechanical ventilation), does an inflated cuff exacerbate / increase aspiration of food or fluids at the level of the vocal folds compared to a deflated cuff?

•Search last 15 years via Google scholar and Medline•6 articles identified•Inclusion criteria: Used instrumental assessment to compare the same patient with cuff up/cuff down feeding and evaluate aspiration as an outcome •2 met criteria for inclusion

ARTICLE SUMMARIESARTICLE SUMMARIESARTICLE

LEVEL

PARTICIPANTS

METHOD DIAGNOSTIC TOOL

OUTCOME MEASURE

RESULTS SUPPORT FOR CLINICAL QUESTION?

Davis et al (2002)

Swallowing with a tracheostomy tube in place: Does cuff inflation matter?

IV 12 participants

Acted as own controls as assessed under two variable conditions (cuff up / down)

Off ventilator, medically stable, ready to begin oral feeding,

Excluded if haemodynamic instability, poor positioning, incapable of following commands

Prospective blinded analysis in regards to cuff status.

8 VFSS studies conducted per patient

Cuff inflated / deflatedTrialled with:Thin / Thick fluidsPuree / solids

VFSS studies – target 8 swallow studies per patient

5 point aspiration scale, Assessed by radiologist – blinded to cuff status

0 = No Aspiration1 = Aspiration < 10% with coughing, choking, distress2 = Aspiration < 10% without cough3 = Aspiration > 10% with cough4 = Aspiration > 10% without cough

Cuff deflation = fewer episodes of aspiration and reduced severity of aspiration.Cuff inflation resulted in 2.7 time higher rate of aspiration (17.8% vs 6.5%) = nearly statistically significantLowest rate of aspiration with solids across both conditionsStatistically significant predictors of aspiration:•Cuff status (p=0.032)•Type of substance (p=0.025)

Yes

The results indicate there may be an increased risk of aspiration in patients ready to start oral trials with tracheostomy with an inflated cuff

Suiter et al (2003)

Effects of cuff deflation and one way tracheostomy speaking valve placement on swallow physiology.

IV 18 participants met the inclusion criteria (14 cuffed and 4 cuffless tracheostomies)

13 males / 5 femalesNon ventilator dependantAbility to tolerate cuff deflation during VFSSAt least 1 aspiration occurrence on thin fluids or puree without valve in situ during VFSS Tracheostomy in situ for respiratory difficulties not obstruction

Replicable design

MBS completed for 3 conditions (1. Cuff inflated, 2. Cuff deflated /cuffless tube, 3. One way valve)

Each MBS included 2 puree & 2 fluid boluses (thin).7 times of bolus transfer during the oral pharyngeal swallow were examined in each of the 3 conditions

VFSS studies - All participants completed a total of 12 swallow studies in 3 conditions

Residue scale 1 2 3

8 point aspiration scale

Hyoid movement distance

Bolus movement at 7 times during the oral pharyngeal swallow

Cuff status (inflated /deflated) had no effect on penetration or aspiration.The majority of penetration / aspiration episodes were silent highlighting importance of objective assessment.Duration of hyoid maximum anterior excursion was significantly longer for deflated cuff vs inflated cuff. Maximum laryngeal elevation was sig greater for deflated cuff vs inflated cuff (only significant with puree)One way valve did not significantly affect any swallow duration measures or extent of hyolaryngeal excursion

Yes

Even though cuff status had no significant impact on aspiration it should be noted that there was significantly greater maximum hyoid movement duration in the cuff deflated.

The study highlights the importance of objective swallow assessment in this population

New CAT 2014: New CAT 2014: clinical bottom lineclinical bottom line

• In non-ventilated respiratory patients with tracheostomy, there are mixed results on whether aspiration of food or fluid is exacerbated or increased by the presence of an inflated cuff. There were no studies in mechanically ventilated patients that answered the clinical question. In the non-ventilated cohort two small studies were identified, one suggested an increased risk, the other reported no increased risk in aspiration with cuff up when evaluated on MBS. We are not able to conclusively report either way on whether cuff status increases the risk of aspiration.

• Davis 2002, Suiter 2003

So the results are mixed

Wonder what's happening out there?

How can we investigate this ? A survey

Aim of SurveyAim of Survey• How much of this evidence do therapists know ?• How widespread is feeding with the cuff up

practiced in Australia?• How are speech pathologists interpreting the

evidence?• What are the factors that make a therapist more

likely to feed or not feed a patient with the cuff up.

Survey DesignSurvey Design• 75 respondents• Available for 3 weeks on Survey Monkey• Distributed via Critical Care and Tracheostomy

EBP google group/list serve (200 members) and the H&N google list serve ~ 200 members

• Also sent out via SPAN (NSW SP managers across NSW)

• Lengthy survey, unable to capture all of it today but please email Klint if you want a copy

• A note about bias. Potentially therapists who feed with the cuff up more likely to have responded

Survey Results Survey Results Feeding•54% don’t assess for cuff up feeding (46% do)

Survey Results cont’dSurvey Results cont’dKnowledge of Evidence•25% don’t know the evidence behind cuff up feeding •16% think there is an increased risk in the literature of aspiration•4% think no increased risk•52% think mixed

Survey Results cont’dSurvey Results cont’dAssessment •62% will do clinical, then consider instrumental if needed•9% will do instrumental only •18.75% will do instrumental as first choice but consider clinical if unable to arrange

Other: 1 site: 50 per year

Survey Results cont’dSurvey Results cont’dDifferences in Clinical Assessment •21% won’t assess without cuff down •32% will assess without cuff deflation•25% will contrast up and down swallow status

•Most sites do fewer than 2 cuff up assessments per year •One site does > 50 p/year •Sites that receive greater than 30 SP referrals per year for tracheostomy are more likely to practice cuff up feeding •70% of sites with > than 30 per year referrals are doing this practice

Survey Results cont’dSurvey Results cont’dDemographic data comparison: Location

•Therapists who responded from tertiary hospitals seemed to have more awareness that the evidence is mixed •Cuff up feeding assessment was practiced more by therapists at tertiary hospitals (% of respondents who feed at each site: tertiary = 67, metro = 33, rural =13)

Demographic data: Years of Experience

•Increased years of experience = increased knowledge of evidence•Increased years of experience = increased cuff up feeding practice•Years of experience did not determine a preference for clinical vs instrumental assessment

Other:

•People that said they don’t feed patients with the cuff up worked at sites with less than 30 trache referrals per year

One last thing One last thing

• Article did not meet criteria for inclusion but worth mentioning

• Instrumental assessment was used but it did not look for presence or absence of aspiration as outcome

• Small study (6 patients) using eMG on muscles of pharynx when cuff up at various pressures 5 - 60 mmhg

• Greater than 25mg of cuff pressure the swallow became affected on measures of latency.

• Infers that when doing an assessment for cuff up or when the patient is cleared to eat, cuff up pressures need to be below 25mg.

• ACI guideline rec: 20-30mmHg

Summary Summary • The evidence is inconclusive as to whether an

inflated cuff exacerbates / increases aspiration of food or fluids at the level of the vocal folds

• Based on the survey findings different clinical assessment of swallowing is occurring i.e., bedside, instrumental

• The survey shows cuff inflated swallow assessment / feeding differs from site to site. This appears to be due to a number of factors e.g. No of referrals / hospital size / late or early referral / policies and procedures / experience of speech pathologists in this area etc…

Where to ?Where to ?Should clinicians be considering cuff up feeding where we didn’t before with careful assessment, medical support given the potential benefits?

Other factors to consider may also include Quality of life approach for patients who are unable to have the cuff deflated.

Currently there is no evidence which indicates best practice for swallow assessment in tracheostomy with an inflated cuff. However, instrumental assessment is considered the gold standard for dysphagia management therefore it should be considered in this patient population.

Acknowledgements Acknowledgements Cuff up working group: Klint Goers, Rachelle Robinson, Katherine Symeou, Elise Hamilton-Foster, Karen McBarron, Christian Wiley

Trache and critical care group members: Rebecca Black; Lindsay Wagner; Katherine Watson; Katherine Symeou; Laura O'Carrigan; Kelly Richardson; Pip Taylor; Shaun Deery,

Thanks to Rebecca Black and Shaun Deery (retiring after 2 years) as leaders. New leaders in 2014: Kate Watson and Kelly Richardson