Assessment of Swallow in a Tracheostomy Patient

OVERVIEW

The presence of a tracheostomy tube can adversely effect swallowing

• in patients who previously had no dysphagia
• and further impair swallowing function in those who already have neurological or mechanical disorders of swallowing.

Assessing the swallow of a tracheostomy involves the following steps to assess:

• Stability and Severity of illness
• Aspiration Risk
• Tracheostomy
• Assess Swallow
• Assess Nutritional Needs
• Involve an SLT

Patients who have undergone prolonged mechanical ventilation or have a tracheostomy insitu may have a greater incidence of swallowing dysfunction.

PHYSIOLOGY OF SWALLOW

See Swallowing

CAUSE OF SWALLOWING DYSFUNCTION

The cause is more likely to be due to:

• critical illness
• the presence or exacerbation of an underlying condition

rather than the tracheostomy tube itself.

ASSESSMENT STEPS

1. Stability and Severity of illness

• improving function
• weaning from ventilation

2. Aspiration Risk

• clinical assessment of bulbar function
• assessment of oral secretions (severity = increased risk of aspiration)
• assessment of above cuff secretions (e.g. Mallinckrodt EVAC tracheostomy to facilitate above cuff subglottic secretion assessment)

3. Tracheostomy

• consider exchange to a tracheostomy with above cuff, subglottic suction capabilities
• consider conversion to a cuffless tube if ventilated
• consider a fenestrated tube if weaned from mechanical ventilation and no aspiration risk
• consider down-sizing tracheostomy

4. Assess Swallow

• assess motor movement of the lips, face, tongue, jaw and palate for strength, symmetry, speed, accuracy and range of motion for specific nerve deficits
• observe elevation of larynx with attempted swallowing
• strength of cough
• assess phonation (if able to cough against a closed glottis -> unlikely to have vocal cord dysfunction post intubation)
• videofluoroscopic swallowing study (VFSS) (gold standard)
• fibreoptic endoscopic evaluation of swallow (FEES) -> more sensitive assessment than a clinical examination alone and is useful in the ICU setting or where a VFSS is unable to be performed.
• methylene blue test is not recommended (added to enteral feeds and sought in tracheal secretions -> unreliable due to false negative rate)
• glucose oxidase testing (elevated glucose in tracheal secretions -> suggests aspiration)

-> passing a swallow test does not eliminate risk of aspiration

5. Assess Nutritional Needs

• will patient need supplementation
• involve a dietician

6. Involve Speech and Language Therapy

• will need ongoing rehabilitation of speech once out of ICU
• graded swallowing assessments

Refer the following in particular to SLT:

• 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

References and Links

• Garuti et al. Swallowing disorders in tracheostomised patients: a multidisciplinary/multiprofessional approach in decannulation protocols. Multidisciplinary Respiratory Medicine20149:36