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

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

Endotracheal Intubation

Creating an alteration in the airway:  Translaryngeal -orally -nasally  Transtracheal

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

Intubation Issues

 Depends on the route of intubation  Size of the tube  Trauma during intubation or self extubation  Length of intubation

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

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

Long Term Complications

 Stenosis  Pressure necrosis  Granuloma – may develop into a polyp  Persistent hoarseness  Laryngeal web  Compromised laryngeal closure and airway protection

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

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.

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

Procedure – tube choice

 Depends on the patient’s ventilation needs, age, size  Medical status  Physician preference  Institution preference/practice

Procedure - tracheostomy

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

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

Long Term Complications

 Tracheal granuloma  Tracheomalacia  Tracheal stenosis – assoc with longer term tracheotomy  Tracheoesophageal fistula

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

Complications of Perc Trach

 Risk of bleeding  False passage of the tube  Infection and tracheal wall injury  Long Term –  Tracheal granuloma  Stenosis  Tracheomalacia

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

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

Types of Tubes

 Design: Cuffed, uncuffed, TTS cuff, fenestrated  Composition: Silicone plastic, metal, polyvinyl chloride (PVC), etc.

 Manufacturers: Shiley, Portex-Bivona, Pilling-Weck

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

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.

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

Passy-Muir Speaking Valve

 If the patient can tolerate cuff deflation, on or off the ventilator, proceed with the initial trial of the PMV.

Open Tracheostomy Tube

 Inflated Cuff  Breathing in and out through the tube only  No airflow through the upper airway  Lack of vocal production

Open Tracheostomy Tube

 Inflated Cuff  Decreased sense of smell/taste  Risk of tissue necrosis  Cuff impingement on esophagus may cause reflux

Lack of Airway Pressure

 Decreases effectiveness  Patient is unable to mobilize secretions effectively  Patient requires more frequent suctioning

Lack of Airway Pressure

 Decreased physiologic PEEP  Decreased gas exchange due to reduced surface area of alveoli  Decreased oxygenation  Possible atelectasis

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

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

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”

Animations courtesy of Passy-Muir Inc. Irvine, CA.

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

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

Physiologic Benefits of the PMV  Improved secretion management  Improved cough  Decreased suctioning needs  Decreased risk of tracheal damage

Patient Selection

 Where is the patient?

 What type of trach tube?

 What type of vent?

 Who are your allies?

 Where do you begin?

Team Members

 Varies depending on the setting  Speech-Language Pathologist  Respiratory Care Practitioner  Nurse  Physician

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’

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

Patient Assessment

 Medically stable  Adequate level of alertness  Ability to handle secretions  Swallowing status/risk for aspiration  Viscosity and abundance of secretions

Patient Assessment

 Monitor baseline parameters  Oxygen saturation  Heart rate  Respiratory rate  Blood pressure  Breath sounds

Normal Values

 Oxygen Saturation: 90-100%  Respiratory Rate: <28 bpm  Heart Rate: <120 bpm  Acid-Base Balance (pH): 7.35-7.45

 Albumin: 3.5-5.5

Ventilator Adjustments

 Alarms -Volume -Pressure  Compensate for loss of airflow through vocal cords if necessary

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

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.

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

In-Line Suction Catheter

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

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

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

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

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

Educate Staff

 When using the Passy-Muir Valve the cuff must be

completely

deflated  Use the warning label provided with the patient care kit

Trach/Vent Patients

Tracheostomy Cuffs

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.

Cuff Presence and Aspiration

 Does not prevent aspiration  Even when the cuff is deflated, can still be bulky in the trachea

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

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

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

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

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

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”

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

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

Dysphagia Treatment

 MBSS completed 4/11, absent swallow response  FEES completed 4/24, profound pharyngeal dysphagia  Trach placed, PEG placed following the MBSS

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

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

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

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

J.B., MBSS – Aug 23

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

D.K., MBSS – Aug 22

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

D.K., MBSS – Sep 22

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

A.B., MBSS – Mar 23

QUESTIONS?