Feeding Tracheostomy Patients with the Cuff Inflated
What does the evidence say?
What are Speech Pathologists doing on the ground?
Klint Goers and Kat Symeou on behalf of:
Critical care and Tracheostomy EBP group
NSW SP EBP Showcase 2nd Dec 2014
Overview
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Anatomy refresher
Tracheostomy – does it cause dysphagia?
Cuff status and potential impact on swallow
Why did we want to look at this area?
What did we already know?
2014 clinical question
2014 clinical bottom line
Survey of speech pathologists across Australia and their clinical
practice
Summary and where to from here
Acknowledgements
Tracheostomy
Tracheostomy and
dysphagia
• CAT 2011: Does a tracheostomy tube cause dysphagia?
• Limited and low level evidence indicates that the presence of
a tracheostomy tube alone (cuff deflated, with no occlusion
via cap or speaking valve) has no causal effect on the
parameters of swallow function investigated. It is suggested
that the patients underlying diagnosis and co morbidities are
the cause of any apparent dysphagia. It is important to note
that the literature critiqued indicates mixed results as to
whether the manipulation of the tube (e.g. cuff up or down)
and the presence of a speaking valve elevates the risk of
aspiration. However, exploration of this issue was not within the
scope of this CAT.
What about feeding patients
with the cuff inflated?
The oral pharyngeal swallow may be impacted when
a patient is fed with an inflated cuff
•Anchoring of the larynx on tracheal wall affecting hyoid movement
•Changes to airflow through the upper airway therefore may impact
sensation and/or swallow
•Reduced effectiveness of cough
Why therapists may be reluctant to feed with the cuff up:
Previous case reports of perforation of the oesophagus when patient’s
fed with high pressure inflated cuffs
What about feeding patients
with the cuff inflated?
Why did we want to look at this?
•Differences in practice across members/sites in relation to
feeding patients with the cuff up
•Speech Pathologists recognising the importance of early
intervention (i.e. when the patients are still ventilated) in order to
improve QOL, potentially prevent disuse and atrophy
•Acknowledgement that this is a contentious issue
•2013 Trache ACI CPG reported the results for cuff up feeding
and aspiration were mixed.
All these factors combined meant that we needed to review the
evidence as a group
What about feeding patients
with the cuff inflated?
What did we already know?
This topic was last looked at in this group in 2002 via 2 x CAP’s. The
clinical question was: Does an inflated cuff exacerbate/increase
aspiration at the level of the vocal folds?
Study 1. Davis 2002: Non ventilated respiratory patients. Level IV
Old clinical bottom line: Cuff inflation may exacerbate/increase
aspiration at the level of the vocal folds and an MBS should be
pursued for further detail.
2014 clinical question
In patients with a tracheostomy (+/- mechanical ventilation),
does an inflated cuff exacerbate / increase aspiration of food or
fluids at the level of the vocal folds compared to a deflated cuff?
• Search last 15 years via Google scholar and Medline
• 6 articles identified
• Inclusion criteria: Used instrumental assessment to compare
the same patient with cuff up/cuff down feeding and
evaluate aspiration as an outcome
• 2 met criteria for inclusion
ARTICLE SUMMARIES
ARTICLE
LEVEL
PARTICIPANTS
METHOD
DIAGNOSTIC
TOOL
OUTCOME
MEASURE
RESULTS
SUPPORT
FOR
CLINICAL
QUESTION?
Davis et al
(2002)
IV
12 participants
Prospective
blinded analysis
in regards to
cuff status.
VFSS studies –
target 8 swallow
studies per patient
5 point aspiration
scale, Assessed by
radiologist –
blinded to cuff
status
Cuff deflation = fewer
episodes of aspiration and
reduced severity of
aspiration.
Cuff inflation resulted in
2.7 time higher rate of
aspiration (17.8% vs 6.5%)
= nearly statistically
significant
Lowest rate of aspiration
with solids across both
conditions
Statistically significant
predictors of aspiration:
• Cuff status (p=0.032)
• Type of substance
(p=0.025)
Yes
Cuff status (inflated
/deflated) had no effect on
penetration or aspiration.
The majority of penetration /
aspiration episodes were
silent highlighting
importance of objective
assessment.
Duration of hyoid maximum
anterior excursion was
significantly longer for
deflated cuff vs inflated cuff.
Maximum laryngeal elevation
was sig greater for deflated
cuff vs inflated cuff (only
significant with puree)
One way valve did not
significantly affect any
swallow duration measures
or extent of hyolaryngeal
excursion
Yes
Acted as own controls
as assessed under two
variable conditions (cuff
up / down)
Swallowing
with a
tracheosto
my tube in
place: Does
cuff
inflation
matter?
Suiter et al
(2003)
Effects of
cuff
deflation
and one
way
tracheosto
my
speaking
valve
placement
on swallow
physiology.
Off ventilator, medically
stable, ready to begin
oral feeding,
Excluded if
haemodynamic
instability, poor
positioning, incapable of
following commands
IV
18 participants met the
inclusion criteria (14
cuffed and 4 cuffless
tracheostomies)
13 males / 5 females
Non ventilator
dependant
Ability to tolerate cuff
deflation during VFSS
At least 1 aspiration
occurrence on thin
fluids or puree without
valve in situ during
VFSS Tracheostomy in
situ for respiratory
difficulties not
obstruction
8 VFSS studies
conducted per
patient
0 = No Aspiration
1 = Aspiration <
10% with coughing,
choking, distress
2 = Aspiration <
10% without cough
3 = Aspiration >
10% with cough
4 = Aspiration >
10% without cough
Cuff inflated /
deflated
Trialled with:
Thin / Thick
fluids
Puree / solids
Replicable
design
MBS completed
for 3 conditions
(1. Cuff inflated,
2. Cuff deflated
/cuffless tube, 3.
One way valve)
Each MBS
included 2
puree & 2 fluid
boluses (thin).
7 times of bolus
transfer during
the oral
pharyngeal
swallow were
examined in
each of the 3
conditions
VFSS studies - All
participants
completed a total
of 12 swallow
studies in 3
conditions
Residue scale 1 2 3
8 point aspiration
scale
Hyoid movement
distance
Bolus movement at
7 times during the
oral pharyngeal
swallow
The results
indicate there may
be an increased
risk of aspiration
in patients ready
to start oral trials
with tracheostomy
with an inflated
cuff
Even though cuff
status had no
significant impact
on aspiration it
should be noted
that there was
significantly
greater maximum
hyoid movement
duration in the
cuff deflated.
The study
highlights the
importance of
objective swallow
assessment in this
population
New CAT 2014: clinical
bottom line
• In non-ventilated respiratory patients with
tracheostomy, there are mixed results on whether
aspiration of food or fluid is exacerbated or
increased by the presence of an inflated cuff.
There were no studies in mechanically ventilated
patients that answered the clinical question. In the
non-ventilated cohort two small studies were
identified, one suggested an increased risk, the
other reported no increased risk in aspiration with
cuff up when evaluated on MBS. We are not able to
conclusively report either way on whether cuff
status increases the risk of aspiration.
• Davis 2002, Suiter 2003
So the results are mixed
Wonder what's happening out there?
How can we investigate this ? A survey
Aim of Survey
• How much of this evidence do therapists know ?
• How widespread is feeding with the cuff up
practiced in Australia?
• How are speech pathologists interpreting the
evidence?
• What are the factors that make a therapist more
likely to feed or not feed a patient with the cuff up.
Survey Design
• 75 respondents
• Available for 3 weeks on Survey Monkey
• Distributed via Critical Care and Tracheostomy EBP
google group/list serve (200 members) and the H&N
google list serve ~ 200 members
• Also sent out via SPAN (NSW SP managers across
NSW)
• Lengthy survey, unable to capture all of it today but
please email Klint if you want a copy
• A note about bias. Potentially therapists who feed
with the cuff up more likely to have responded
Survey Results
Feeding
• 54% don’t assess for cuff up feeding (46% do)
Survey Results cont’d
Knowledge of Evidence
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25% don’t know the evidence behind cuff up feeding
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16% think there is an increased risk in the literature of aspiration
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4% think no increased risk
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52% think mixed
Survey Results cont’d
Assessment
• 62% will do clinical, then consider instrumental if needed
• 9% will do instrumental only
• 18.75% will do instrumental as first choice but consider clinical if unable to
arrange
Other: 1 site: 50 per year
Survey Results cont’d
Differences in Clinical Assessment
• 21% won’t assess without cuff down
• 32% will assess without cuff deflation
• 25% will contrast up and down swallow status
• Most sites do fewer than 2 cuff up assessments per year
• One site does > 50 p/year
• Sites that receive greater than 30 SP referrals per year for
tracheostomy are more likely to practice cuff up feeding
• 70% of sites with > than 30 per year referrals are doing
this practice
Survey Results cont’d
Demographic data comparison: Location
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Therapists who responded from tertiary hospitals seemed to have more awareness
that the evidence is mixed
Cuff up feeding assessment was practiced more by therapists at tertiary hospitals
(% of respondents who feed at each site: tertiary = 67, metro = 33, rural =13)
Demographic data: Years of Experience
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Increased years of experience = increased knowledge of evidence
Increased years of experience = increased cuff up feeding practice
Years of experience did not determine a preference for clinical vs instrumental
assessment
Other:
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People that said they don’t feed patients with the cuff up worked at sites with less
than 30 trache referrals per year
One last thing
• Article did not meet criteria for inclusion but worth mentioning
• Instrumental assessment was used but it did not look for
presence or absence of aspiration as outcome
• Small study (6 patients) using eMG on muscles of pharynx
when cuff up at various pressures 5 - 60 mmhg
• Greater than 25mg of cuff pressure the swallow became
affected on measures of latency.
• Infers that when doing an assessment for cuff up or when the
patient is cleared to eat, cuff up pressures need to be below
25mg.
• ACI guideline rec: 20-30mmHg
Summary
• The evidence is inconclusive as to whether an
inflated cuff exacerbates / increases aspiration of
food or fluids at the level of the vocal folds
• Based on the survey findings different clinical
assessment of swallowing is occurring i.e., bedside,
instrumental
• The survey shows cuff inflated swallow assessment /
feeding differs from site to site. This appears to be
due to a number of factors e.g. No of referrals /
hospital size / late or early referral / policies and
procedures / experience of speech pathologists in
this area etc…
Where to ?
Should clinicians be considering cuff up feeding where we didn’t
before with careful assessment, medical support given the
potential benefits?
Other factors to consider may also include Quality of life
approach for patients who are unable to have the cuff deflated.
Currently there is no evidence which indicates best practice for
swallow assessment in tracheostomy with an inflated cuff.
However, instrumental assessment is considered the gold
standard for dysphagia management therefore it should be
considered in this patient population.
Acknowledgements
Cuff up working group: Klint Goers, Rachelle Robinson, Katherine
Symeou, Elise Hamilton-Foster, Karen McBarron, Christian Wiley
Trache and critical care group members: Rebecca Black;
Lindsay Wagner; Katherine Watson; Katherine Symeou; Laura
O'Carrigan; Kelly Richardson; Pip Taylor; Shaun Deery,
Thanks to Rebecca Black and Shaun Deery (retiring after 2 years)
as leaders. New leaders in 2014: Kate Watson and Kelly
Richardson