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
Critical Care
Compendium
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