1. Management of Communication and Swallowing for Adults with Tracheostomy Tubes Sally L. Gorski, M.A. CCC

5. Purpose of Artificial Airways
Provide adequate ventilation and oxygenation
Maintain a patent airway
Eliminate airway obstruction
Reduce potential for aspiration
Provide access to the airway for pulmonary toilet

6. Endotracheal Intubation
Creating an alteration in the airway:
Translaryngeal
-orally
-nasally
Transtracheal

7. Endotracheal Intubation
Creates an artificial airway
Insertion of a tube into the mouth or nose
Passes through the pharynx and vocal cords
Need for airway protection
Need for mechanical ventilation
Temporary

9. Intubation Issues Depends on the route of intubation Size of the tube
Trauma during intubation or self-extubation
Length of intubation

10. Complications of Oral Intubation
Trauma to teeth and gums
Abrasion of the lips, tongue, pharynx and larynx
Damage to the vocal folds
Overinflated cuff
Hypoxemia
Rare – damage to the recurrent laryngeal nerve

11. Complications of Nasal Intubation
Trauma to nasal passages
Necrosis may result
Removal of the tube may cause epistaxis
Otitis media and conductive hearing loss due to mechanical blockage of the Eustachian tube

12. Long Term Complications
Stenosis
Pressure necrosis
Granuloma – may develop into a polyp
Persistent hoarseness
Laryngeal web
Compromised laryngeal closure and airway protection

13. Cricothyroidotomy
Procedure usually performed in an emergency situation
Surgical creation of an opening into the cricothyroid membrane
May be necessary due to upper airway obstruction

14. Tracheostomy Tracheotomy
The surgical creation of an opening into the trachea through the neck.
The surgical placement of a plastic or metal tube into the trachea to create an airway.

15. Indications for Tracheostomy
Facilitate weaning from the ventilator
Bypass an obstruction of the upper airway
Facilitate removal of secretions
Facilitate long-term airway management
Prevent gross aspiration from the pharynx or GI tract
Decreased risk of accidental removal

16. Procedure – tube choice
Depends on the patient’s ventilation needs, age, size
Medical status
Physician preference
Institution preference/practice

17. Procedure - tracheostomy
Placement of the tube above or below the 2nd and 3rd tracheal ring
Incision type and placement
Vertical skin incision is most common
Horizontal skin incision, rarely used today

18. Risks with Trach placement
Stenosis at the stoma site: 1-8%
Massive hemorrhage: 1%
Aspiration of oral secretions
Pneumothorax
Incorrect placement of the tube can lead to cardiorespiratory arrest

19. Long Term Complications
Tracheal granuloma
Tracheomalacia
Tracheal stenosis – assoc with longer term tracheotomy
Tracheoesophageal fistula

20. Percutaneous Trach Minimally invasive, “simple” technique
Eliminates a trip to the OR
Reduced blood loss
Reduced infection rates (0 to 3.3%) (As high as 36% in open trach procedure.)
Stenosis rates range from 0 – 9%
Performed in the ICU

21. Complications of Perc Trach
Risk of bleeding
False passage of the tube
Infection and tracheal wall injury
Long Term –
Tracheal granuloma
Stenosis
Tracheomalacia

22. Clinical Conditions – Trach
Obstructive disease; COPD, asthma
Restrictive disease; ARDS, pneumonia, scleroderma
Chest wall disorders; kyphoscoliosis, chest trauma
Neuromuscular; ALS, Guillain-Barre’, muscular dystrophy, post polio syndrome, multiple sclerosis, SCI

23. Clinical Conditions - Trach
Upper airway; trauma, tumors, infection
Respiratory center dysfunction; sedation, narcotics, anesthesia, CVA, drug overdose
Cardiac/circulation; cardiopulmonary arrest, pulmonary edema, congestive heart failure

24. Types of Tubes Design: Cuffed, uncuffed, TTS cuff, fenestrated
Composition: Silicone plastic, metal, polyvinyl chloride (PVC), etc.
Manufacturers: Shiley, Portex-Bivona, Pilling-Weck

25. Components of a Trach Tube
Neck flange
Inner & Outer cannula
Obturator
Cuff
Pilot balloon, cuff inflation line
Plug, cap or button
Standard length; extra long
Review of all the trach tubes.

26. The Referral to Speech Path
When to intervene?
-Upon consult from the physician
-While pt is intubated, if awake and alert
-After trach is placed, if awake and alert
-As soon as the patient is communicative; yes/no head nods, mouthing, writing, gestures, etc.

27. The Initial Consult Review the chart
Discuss pt’s status with the RN, physician and the respiratory care practitioner
Can pt tolerate cuff deflation?
Level of ventilatory support
Secretion status

28. Passy-Muir Speaking Valve
If the patient can tolerate cuff deflation, on or off the ventilator, proceed with the initial trial of the PMV.

30. Open Tracheostomy Tube
Inflated Cuff
Breathing in and out through the tube only
No airflow through the upper airway
Lack of vocal production

31. Open Tracheostomy Tube
Inflated Cuff
Decreased sense of smell/taste
Risk of tissue necrosis
Cuff impingement on esophagus may cause reflux

32. Lack of Airway Pressure
Decreases effectiveness
Patient is unable to mobilize secretions effectively
Patient requires more frequent suctioning

33. Lack of Airway Pressure
Decreased physiologic PEEP
Decreased gas exchange due to reduced surface area of alveoli
Decreased oxygenation
Possible atelectasis

34. Open Position Valves All other valves are open position valves
Patient must exhale to close the diaphragm of the valve
Secretions travel up the tube and may occlude the valve
For communication only

36. Passy-Muir Valve Design
Closed position, “no leak” design
Open only during inspiration with minimal effort
Closes automatically before the end of the inspiratory cycle/beginning of the expiratory cycle

37. Passy-Muir Valve Design
No air leakage occurs through the PMV during exhalation
A column of air is trapped in the PMV and in the trach tube that inhibits secretions from entering the tube
Restores more normal “closed respiratory system”

39. Closed Position Design
Animations courtesy of Passy-Muir Inc. Irvine, CA.

40. Physiologic Benefits of the PMV
Improved voice production
Improved sense of smell/taste
Restoration of normal physiology may prevent aspiration
Deflated cuff allows for increased laryngeal elevation

41. Physiologic Benefits of the PMV
Restoration of subglottic pressure facilitates a better swallow and decreases the risk or aspiration
Swallow is not only mechanical, but a pneumatic system as well
The patient has a more efficient and effective cough

42. Physiologic Benefits of the PMV
Improved secretion management
Improved cough
Decreased suctioning needs
Decreased risk of tracheal damage

43. Patient Selection Where is the patient? What type of trach tube?
What type of vent?
Who are your allies?
Where do you begin?

44. Team Members Speech-Language Pathologist Respiratory Care Practitioner
Varies depending on the setting
Speech-Language Pathologist
Respiratory Care Practitioner
Nurse
Physician

45. Indications for Use of the PMV - review
Traumatic Brain Injury
Spinal Cord Injury
Chronic Obstructive Pulmonary Disease
Chest or laryngeal trauma
Acute Respiratory Distress Syndrome
Neuromuscular diseases; ALS, MS, Guillain-Barre’

46. Contraindications for Use of the PMV
Unconscious and/or comatose patients
Inflated cuff on the trach tube
Foam-filled cuffed trach tube
Severe airway obstruction
Severe risk for aspiration
Severely reduced lung elasticity

47. Patient Assessment Swallowing status/risk for aspiration
Medically stable
Adequate level of alertness
Ability to handle secretions
Swallowing status/risk for aspiration
Viscosity and abundance of secretions

48. Patient Assessment Oxygen saturation Heart rate Respiratory rate
Monitor baseline parameters
Oxygen saturation
Heart rate
Respiratory rate
Blood pressure
Breath sounds

49. Normal Values Oxygen Saturation: 90-100% Respiratory Rate: <28 bpm
Heart Rate: <120 bpm
Acid-Base Balance (pH):
Albumin:

50. Ventilator Adjustments
Alarms
-Volume
-Pressure
Compensate for loss of airflow through vocal cords if necessary

51. Placement of the PMV Inline
Assess whether the pt can exhale around the trach tube and through the upper airway
Trach tube should be sized for sufficient airflow around trach tube
Trach tube cuff may create bulk even in the deflated condition

52. Assess for Upper Airway Patency
With the vent dependent patient, deflate the cuff, let patient adjust his respirations, encourage the patient to open mouth slightly and say “ahhh” when exhaling and encourage a cough or throat clear.

53. Placement Guidelines Suction patient tracheally and orally
Deflate cuff slowly, allowing patient time to adjust
Suction again as necessary
Encourage pt to clear throat and expectorate secretions from the oral cavity
Place PMV inline with the vent circuit

54. In-Line Suction Catheter

55. The Initial Trial – How Long?
Continue to monitor the vital signs; SaO2 level, RR, HR, etc.
Is the patient talking?
Are they breathing comfortably?
Continue as tolerated

56. Troubleshooting Issues
Changes in breathing – pt may require short trials and/or gradual transition
Increased coughing – due to airflow through upper airways. Remove valve and reassess

57. Troubleshooting Issues
Anxiety and fear – educate patient, reassure patient that feelings or fears are valid
Depression or lack of motivation – enlist family involvement; allow pt to communicate, perhaps with a chaplain or psychologist

58. If Patient is Unable to Exhale:
Remove PMV immediately
Check trach cuff for complete deflation
Make sure patient and trach tube are positioned appropriately
Repeat suctioning tracheally and orally
Nasal suctioning may be indicated

59. If Patient is Unable to Exhale
Assess trach tube size for possible downsizing
Consider edema as a factor, try again in 24 hours
Potential for change to a cuffless trach
Potential for change to a Bivona trach with a tight-to-shaft cuff

62. Educate Staff
When using the Passy-Muir Valve the cuff must be completely deflated
Use the warning label provided with the patient care kit

63. Dysphagia Evaluation and Management
Trach/Vent Patients
Dysphagia Evaluation and Management

64. Tracheostomy Cuffs

65. Bonnano, P.C. (1971)
Difficulty in swallowing results by direct inhibition of the hyomandibular complex.
This occurs as a result of the tracheostomy tube anchoring the trachea to the strap muscles and skin of the neck.

66. Cuff Presence and Aspiration
Does not prevent aspiration
Even when the cuff is deflated, can still be bulky in the trachea

67. Clinical Dysphagia Exam
Completed in conjunction with nurse or RT
Complete an oral mechanism exam
Preferable to perform the exam with the cuff deflated to maximize laryngeal function

68. Clinical Dysphagia Exam
Preferable to conduct the exam with the PMV in place
Prepare consistencies with blue if available
Present in small amounts, suction after each consistency type

69. Blue Food Coloring At HCMC: Dispensed by the Pharmacy in 1 ml syringes
Single use amounts
Used for bedside exams with trach pts and for FEES exams
Approved by MDs and PharmDs

70. Modified Barium Swallow Study
Considerations:
Patient has to transport to Radiology
Will need RN and RT present if on the vent
Additional preparation completed by the Speech Pathologist
If pt is tolerating the PMV, place the PMV during the MBSS

71. Fiberoptic Endoscopic Evaluation of Swallowing
Exam can be conducted at the bedside eliminating the need for transport
Additional coordination provided by the Speech Pathologist

72. Treatment Strategies Traditional treatment approaches
May only tolerate frequent, smaller meals
May receive primary nutrition/hydration via an alternative source and have limited oral intake “for pleasure” or “for comfort”

73. Treatment Strategies
Post instructions regarding PMV use during oral intake
May need to add blue to food or liquid items at each meal for several meals

74. Dysphagia Treatment Case Study
J. A., 28 y.o. admitted 3/29 with nausea and vomiting x4 days
Intubated for two surgical procedures
PMHx: pituitary macroadenoma, s/p resection in 2003
Extubated 4/5 and referred to Speech Pathology

75. Dysphagia Treatment MBSS completed 4/11, absent swallow response
FEES completed 4/24, profound pharyngeal dysphagia
Trach placed, PEG placed following the MBSS

78. Dysphagia Treatment
Repeated the MBSS 5/31, continued severe dysphagia, continue NPO
Pt’s trach is a Jackson, tolerates plugging
Dysphagia tx during the month of July
Base of tongue exercises
Pharyngeal strengthening exercises

80. Dysphagia Treatment Repeat MBSS, 7/26
Mild dysphagia, start oral intake
Per ENT, subglottic granulation tissue, so trach was not immediately removed
Laser excision of granulation tissue in early Sept, then decannulated
PEG removed
Persistent mild dysphonia secondary to right TVC paralysis

81. Case Study
J.B., 42 y.o. admitted 8/16 w/ self-inflicted GSW right below chin
Perc trach placed on DOA
Clinical dysphagia exams 8/19 and 8/20 – no evidence of blue in secretions
Holding on PMV – pt writing/gesturing to communicate
8/23 - MBSS

82. J.B., cont.
Nectar thick and water thin liquid self-presented via syringe
Encouraged him to administer 2-4 ml per swallow
Good oral control
Timely pharyngeal response
No aspiration
OK for a Fractured Jaw Diet w/ syringe

83. J.B., MBSS – Aug 23

84. Case Study
D.K., 51 y.o. male, C5-C6 dislocation w/ resulting quadriplegia after a fall, onset date 5/18
ACDF 5/20
Trach/PEG 5/27
Discharged to acute rehab
Outpatient MBSS 8/22. Bivona TTS trach - capped

85. D.K., MBSS – Aug 22

86. D.K., cont. Results: moderate dysphagia Pharyngeal residue
Penetration with nectar and water
Trace aspiration with water, delayed cough
Advance to Soft Diet, cont nectar thick liquids

87. D.K., MBSS – Sep 22

88. D.K., cont.
Repeat MBSS 9/21/11
Persistent dysphagia – silent aspiration of trace amts of water thin liquid
Advance to Mechanical Soft Diet, cont nectar thick liquids
Continue effortful swallow
Strategy: Swallow, cough hard, swallow again with all liquids

89. A.B., MBSS – Mar 23

90. QUESTIONS?