TRACHEOSTOMY & VENTILATION IN DYSPHAGIA

Bedoor Nagshabandi, MS, CCC-SLP

Why is Tracheostomy Placed

■ Airway obstruction ! ex: tumor

■ Edema ! ex: trauma to the neck

■ Ventilation ! prolonged use of ventilation

Tracheotomy Vs Tracheostomy■ tracheotomy is a surgical procedure which involves creating a direct

airway incision made on the trachea

■ whereas tracheostomy refers to the stoma (opening) where a tracheotomy tube is inserted to provide the artificial airway

■ https://youtu.be/d_5eKkwnIRs

Other Important Terminology

Weaning: the gradual process of removing a patient from the mechanical ventilation

Decannulation: the removal of a tracheotomy tube

Types of Tracheostomy Tubes ■ Single vs double ! double means that there are 2

cannula tubes, an outer cannula and an inner cannula that can be removed and cleaned and reinserted

■ Cuff vs non cuff ! a cuff means that there is a balloon at the end of the cannula that can be inflated and deflated using a pilot balloon

■ Fenestrated vs unfenestrated ! fenestrated will not be used with patients who are on ventilation, because there will not be a good seal. When the trach is fenestrated is allows the air to move up the upper airway and vocal cords allowing for speech production when the cuff is deflated

Cuff Inflation ■ When the cuff is inflated the air

can come in and out from the tracheostomy tube only but not pass the vocal fold to the mouth or nose.

■ Its main function is to maintain the air delivered from the ventilator to a patient's lungs.

■ https://youtu.be/FsL8LgYlFxY

The Flange

■ It main function is to secure the position of the tracheotomy tube

Mechanical Ventilators

■ Patients are placed on mechanical ventilation when they are unable to breath on their own or when they need assistance with their breathing

■ It is a form of support and does not treat the underlying problem

Basic Settings ■ Respiratory rate is the minimum amount of breaths that the patient will be allowed to

take. This rate is programmed into the ventilator, often set between 12 and 18.

■ TV (Tidal Volume) is the amount of air that will go into the patient's lungs with each breath. This is based on the ideal body weight of the patient, most often calculated at 10 mL/kg. Some patients may require a smaller TV due to poor lung compliance (the amount of stretch the lungs can handle without damage). TV is usually set between 400 mL for a small person and up to 800 mL for a larger person.

■ FiO2 (the fraction of inspired oxygen) is the amount of oxygen the patient requires to maintain appropriate blood oxygen levels, and it is measured in percentage

■ PEEP (positive end-expiratory pressure)  is the pressure that's applied at the end of the expiratory phase that helps keep the alveoli from snapping shut when the patient exhales. This can minimize the risk of developing atelectasis and prevent shearing force trauma to the alveoli. Shearing is caused when the alveoli are opening and shutting too quickly. PEEP can also be used to help open areas of collapsed alveoli, also known as atelectasis. PEEP is measured in centimeters of water and is often seen at levels between 5 and 10 cm H2O.

■ Peak Inspiratory Pressure (PIP) Highest proximal airway pressure reached during inspiration. Target PIP is < 35 cm H2O. Low PIP may result in hypoventilation; high PIP may cause lung damage.

Ventilator Modes ■ Assist control (AC) ! it is use when patients are unable to breath on

their own at all, commonly seen in patient in ICU. Swallowing and speaking valves assessment are not completed usually when patients are in this mode especially in acute setting Sometime a swallow assessment and speaking valve can be completed in cases when patients are in long term acute care and if there settings permit. ■ Synchronized intermittent mandatory ventilation (SIMV) ! is also a

common mode of ventilation used in the ICU. It works on the same basic principles of AC mode—a set number of breaths will be delivered each minute, but the patient can breathe as many times a minute as he or she feels the need to.

■ Continuous Positive Airway Pressure (CPAP) ! the ventilators provides help to the patient when needed. used to help the patient wean from the ventilator.

ENDOTRACHEAL INTUBATION is a medical procedure in which a tube is placed into the windpipe (trachea) through the mouth. Used for short periods (21 days max)

Noninvasive Ventilation Methods ■ Bilevel positive airway pressure

(BIPAP): provides positive airway pressure during both inspiration and exhalation. This helps assist patients with impending respiratory failure who are spontaneously breathing with ventilation and gas exchange. It can also provide supplemental oxygen along with inspiratory pressure

■ It uses a mask that's placed over the nose or face delivering positive airway pressure and oxygen to help assist breathing. 

The Effects of a Tracheostomy on Swallowing ■ The placement of a tracheotomy tube may or may not

affect swallowing

■ However the risk of aspiration increases and the effect of aspiration can increase due to the patient’s respiratory issues

Prevalence ■ The incidence of aspiration in patients with tracheostomy is between 50 to

87%. Pannunzia (1996)

■ The incidence of aspiration in patents with new tracheostomy on ventilation is 33% with 82% of the aspiration occurring to be silent.

Leder (2002)

The Effect of the Tracheostomy on Laryngeal Elevation

■ The placement of the tracheostomy can have an effect on the laryngeal elevation due to the following; – Fixation of the muscles – Weight of the tube

■ But you also have to know that other medical conditions can cause reduced laryngeal elevation

The Effect of Tracheostomy on Airway Pressure

■ Decreased subglottic pressure

Cuff Deflation During Swallowing Assessment ■ Prior to swallow and food presentation, the cuff should be at least partially

deflated allowing for air to go through the larynx to allow for the ability to detect aspiration

■ When food is presented during a swallow evaluation with the cuff inflated, aspirated materials can pool on top of the cuff and can then either;– Fall into the trachea when cuff is deflated – Fall between the cuff and trachea with movement – Collection of bacteria which will have significant consequences if

aspirated – Multiple swallows can cause friction between the cuff and trachea

resulting in a fistula – If a patient is unable to handle cuff deflation! it should be an indication

that the patient might not be stable enough for oral intake

Suctioning ■ Check the rules and regulation of the setting you

are working in, in terms of:– Level of SLP involvement – Training and competency level – Presence of RT

■ Inappropriate suction can lead to trauma, cardiac arrhythmia, and hypoxemia (oxygen removed from the lungs)

■ Why do we suction? – Because the patient is unable to effectively

clear his secretions – Removal of aspirated materials – Cleaning

■ https://youtu.be/R6hMV4kYd48

Blue Dye Test ■ So what is a Blue Dye Test?■ Why the color blue?■ Current research indicate that the blue dye test should only be

used as a screener because it can only identify gross aspiration but not small trace aspiration amount.

■ The availability of the blue dye test has been limited due to an FDA advisory in 2003. The advisory was issued due to issues related to its safety and storage.

Blue Dye Protocol■ Place 2-3 drops of sterile water mixed with blue food coloring on tongue ■ Suction trachea immediately and at 15-minute intervals over 1 hour period,

recording presence of any blue material in tracheal secretions ■ If no evidence of aspiration of saliva, can mix blue dye with food consistencies ■ Proceed one consistency at time, waiting at least 4-6 hours between

consistencies ■  Positive result:

– Presence of blue material in any tracheal suctioning – Alerts to presence of aspiration – Dictates conservative approach to further assessment

■ Always inform the nurse and the respiratory therapist that you have completed the blue dye test as they are your eyes when you are not with the patient

Bedside Swallow Evaluation ■ History -->

– Intubation ! the date it was inserted, planned vs emergent, associated trauma, previous intubation

– Extubation ! date; you should not perform a swallow assessment before completing 24 hours after extubation (there is disagreement on this statement); ■ Greatest risk of aspiration is within 24 hours following extubation. Greatest

risk of respiratory distress and re-intubation is within 4-6 hours after extubation

■ Immediately after extubation, individual often exhibits hoarseness, spontaneous coughs, and congestion, making clinical observations unreliable

– Tracheostomy type – Secretions – Ventilator history – What is the reason for tracheostomy placement

■ Check heart rate and oxygen level in the monitors■ Oral motor examination ■ Assess oral hygiene ■ Suction ■ Deflate cuff and assess tolerance ■ Capping, one way valve placement to assess tolerance,

phonation, and coughing . The valve when placed with cuff deflated, allows patient to inhale and exhale using their upper airway

■ Dry swallows ■ When the patient is able to pass all the previous steps then

proceed to trials ■ It’s a good idea to start with ice chips

Contraindication for Completing the Swallow Assessment ■ Decrease alertness ■ High ventilator settings ■ Medical instability ■ Inability to tolerate cuff deflation

■ Is it in the Scope of Practice for Speech-Language Pathologists to Change Tracheotomy tubes or Suction Patients?

■ ASHA's Code of Ethics stipulates that clinicians must be competent in any area in which they practice. ASHA's Scope of Practice in Speech-Language Pathology is quite broad and does not address specific procedures; however, procedures should be related to the assessment and treatment of patients with communication or swallowing disorders. Individual facilities usually have specific processes for "credentialing" staff and will provide training and support for teaching speech-language pathologists to suction. Speech-language pathologists should also consider potential liability issues of related activities, such as changing or capping tracheotomy tubes, as these may be considered procedures that should be done by medical professionals. 

■ State licensure laws vary; for example, Maryland has determined that tracheal suctioning is within the scope of practice for speech-language pathologists. Other states may or may not have such specific guidance.

References ■ Belafsky, P., Blumenfeld, L., Lepage, A., & Nahrstedt, K. (2010). The accuracy of the modified evan's

blue dye test in predicting aspiration. 113(11), 1969 – 1972.■ FDA Issues Public Health Advisory on Blue Dye. The ASHA Leader, 8(20), 2-22. doi:10.1044/

leader.NIB.08202003.2 ■ Fornataro-Clerici, L., Roop, T. A. (1997). Clinical management of adults requiring tracheostomy tubes

and ventilators: A reference guide for healthcare practitioners. ■ Leder, S. (2002). Incidence and type of aspiration in acute care patients requiring mechanical

ventilation via a new tracheotomy. Chest, 5(122), 1721 -1726.■ Mayer, J. & Huber, K. (2018). Tracheostomy and dysphagia [Online Course]. Retrieved from https://

cme.surgery.wisc.edu/watch/379■ Nash,M.(1988).Swallowing problems in the tracheostomized individual. Otolaryngologic Clinics of

North America, 21(4): 701-709. ■ Pannunzio, T. (1996). Aspiration of oral feeding in patients with tracheostomies. AACN Clin ,7 ,560-

569.■ Swigert, N. (2003). Blue dye in the evaluation of dysphagia: Is it safe?. The ASHA Leader, 8(5), 16-17.