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:

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:

rather than the tracheostomy tube itself.

ASSESSMENT STEPS

1. Stability and Severity of illness

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

6. Involve Speech and Language Therapy

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

Critical Care

Compendium