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
- 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
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.
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)
- 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
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of LITFL.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of two amazing children.
On Twitter, he is @precordialthump.