Weaning from tracheostomy / Bedside Evaluation of Swallowing / Eating and Drinking

It has been documented over the years that the presence of a tracheostomy tube can sometimes adversely effect swallowing in patients who previously had no dysphagia, and may further impair the swallowing function in those who already have neurological or mechanical disorders of swallowing.

“If the complex inter-relation between deglutition (prolonged artificial feeding) and respiration is disrupted, significant impairment can result. Additionally, due to the shared functions of the hypopharynx and larynx, the impact of the dysphagia is often heightened for the individual with respiratory compromise.” (Dikeman and Kazandjian 1995).
The following may occur in the presence of a tracheostomy tube:
  1. Reduction of antero-superior movement of the larynx (Logemann 1993, Dikeman and Kazandjian 1995).
  2. Tracheal irritation at rest and during swallowing.
  3. Reduced laryngeal closure
  4. Compression of the oesophagus by the tracheostomy tube cuff (Becker, Weitez, Dettenmeier 1994)
  5. Disruption of airway pressure of swallowing (Gross et al 1992)
  6. Reduction of airflow through the glottis
  7. Elimination of inspiratory airflow when cuff is inflated
  8. Blunting of the reflex cough (Tippetts and Siebens, 1991)
  9. Non co-ordination of the glottic closure response
  10. Reduced laryngeal sensitivity (Cameron et al 1973, Bone et al 1974, Bonnano 1971, Sasaki et al 1977)Speech and Language Therapists are only involved in the assessment and management of patients with tracheostomies who present with swallowing difficulties. These patients require swallowing screening prior to the commencement of oral feeding, this is to reduce the risk of aspiration which may lead to aspiration pneumonia (Myers 1995).  A multidisciplinary approach is recommended to ensure appropriate and effective care for the individual patient.

Not all patients with tracheostomies will have swallowing problems. 

Speech and Language Therapists are only involved in the assessment and management of patients with tracheostomies who present with swallowing difficulties. These patients require swallowing screening prior to the commencement of oral feeding, this is to reduce the risk of aspiration which may lead to aspiration pneumonia (Myers 1995).  A multidisciplinary approach is recommended to ensure appropriate and effective care for the individual patient.

Oral intake for patient with a tracheostomy

Proceed with caution

It is advisable that oral intake should only be considered and offered when the cuff is deflated and a speaking valve or decannulation cap is in place.   Patients will require a cuff deflation tolerance test to ensure that they can endure cuff deflation with no adverse signs.  This must be assessed by a competent healthcare practitioner.    It is recommended that all patients undergo a water swallow test (see appendix 4) to establish their ability to  swallow safely before they proceed to other fluids and  solids.
 

When to consider a referral to a Speech and Language Therapist for swallow assessment

Referral would be appropriate for patients with tracheostomies  who have:
  • Neurological involvement e.g. bulbar involvement
  • Following head and neck surgery
  • Evidence of aspiration of food, fluid or oral secretions
  • Persistent weak and wet voice when cuff deflated and speaking valve or decannulation cap is in place.
  • Patients who have failed a water swallow test or where diagnosis of dysphagia has been made

Pre water swallow test assessment

There is evidence that the presence of a tracheostomy tube can cause swallowing difficulties in some patients with no previous problems and can exacerbate difficulties in some patients with existing neurological or mechanical swallowing problems (Murray 1998). 

Criteria for cuff deflation must be achieved (see Cuff Deflation Criteria). This decreases the risk of aspiration and facilitates the use of a weaning device. There is evidence that occluding the tracheostomy tube during swallowing may further reduce the risk of aspiration (Leder, Logemann et al 1997).

Before carrying out the water swallow test patients MUST  be able to
  • Remain alert for a minimum of 15 minutes in order to maintain sufficient oral intake safely (SIGN Guidelines78, 2004)
  • Stay awake and alert for 15 minutes while seated upright
  • Attempt swallowing without undue associated pain
  • Maintain oxygenation on 40% oxygen therapy.
  • Have maintained stable vital signs for 24 hours
  • Cope with oral secretions e.g. no drooling/excessive salivation

Click here for instruction on water swallow test part I

Ideally, oral intake is deferred until cuff deflation is achieved. However, in special circumstances eg quality of life issues a ulti-disciplinary team decision for small amounts of oral  intake with partial cuff deflation may be indicated.

The competent healthcare practitioner must ensure that the potential risk for secondary complications are made clear to all personnel.

Click here for instruction on water swallow test part II (follows from part I)

Immediate return of dye from the tracheostomy is a clear ndicator that the patient has aspirated. However, there is evidence that, in some cases, the return of blue dye after assessment can be delayed by >24 hours (Dikeman & Kazandjian 1995).  In this instance make the patient NIL BY MOUTH and repeat full WST once per day over a 2 day period. If the patient fails the WST over 2 days contact the Speech and Language Therapy Department.

Click here for instruction on water swallow test part III (follows from part II)

Immediate return of dye from the tracheostomy is a clear  indicator that the patient has aspirated and the WST should be discontinued immediately and Speech and Language Therapy Department contacted.

Written documentation of the WST must be available for all patients utilising the “Checklist for Swallowing Difficulties inTracheostomised Patients” (see Water Swallow Chart/Appendix 3).

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