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Home | CCC | Assessment of Swallow in a Tracheostomy Patient

Assessment of Swallow in a Tracheostomy Patient

by Dr Chris Nickson, last update February 10, 2019

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

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About Dr Chris Nickson

An oslerphile emergency physician and intensivist suffering from a bad case of knowledge dipsosis. Key areas of interest include: the ED-ICU interface, toxicology, simulation and the free open-access meducation (FOAM) revolution. @Twitter | INTENSIVE| SMACC

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