DYSPHAGIA RELATED TO TRACHEOSTOMY &
VENTILATOR DEPENDENCE
Ventilation
Presented By:
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Ventilation Indications
Ventilation Associated Complications
 Disruption of normal air exchange into and out of lungs
 Lung barotrauma
 Causes of respiratory failure:
 Oxygen toxicity
 Decreased urine
 Respiratory illness
 Atelectasis
 Cardiac events
 Nosocomial pneumonia
 Neurological injury
 Neuromuscular disease
 Trauma
 Environmental contamination
 Airway obstruction
 Decreased venous return
 Decreased cardiac output
 Hypotension
 Gastrointestinal bleeding
 Malnutrition
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014





output/altered renal
function
Altered fluid balance
Increased intracranial
pressure
Respiratory alkalosis
Accidental disconnect of
ventilator/power loss
Loss of airway pressure
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Artificial Airway Purposes
 Maintain patent airway
Artificial Airways
 Connect to mechanical ventilation
 Provide access to lungs for pulmonary toilet
 Control ventilation
 Control oxygenation
 Circumvent airway obstruction
 Reduce aspiration potential
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
1
Endotracheal Intubation
 Insertion of endotracheal tube into airway
 Somewhat flexible but retains shape in airway
Orotracheal Intubation
 Orotracheal: Inserted into mouth, passing through pharynx and vocal
folds into trachea
 Used for short-term:
 To provide artificial airway
 To connect to mechanical ventilation for airway protection and
ventilation
 May stabilize severe facial fractures
 May not be possible with tracheal stenosis and tumors
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Nasootracheal Intubation
Short-Term Endotracheal Intubation
Complications
 Nasotracheal: Inserted into nose, passing into pharynx and vocal
 Trauma
folds into trachea
 Otitis media
 Damage to vocal folds or recurrent laryngeal nerve
 Hypoxemia
 Improper positioning
 Esophageal intubation or rupture
 Cardiac complications
 Traumatic extubation with cuff inflated
 Increased intracranial pressure
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Long-Term Endotracheal Intubation
Complications
Cricothyroidotomy
 Pressure necrosis
 Emergency surgical opening into
cricothyroid membrane
 Granuloma
 Potential complications:
 Stenosis
 Chronic vocal changes
 Laryngeal web
 Glottic incompetence
 Injury to:
 Trachea
 Larynx
 Vocal cords
 Esophageal perforation
 Subglottal stenosis
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
2
Tracheotomy
Tracheotomy
 Surgical opening directly into trachea
 Surgical or endoscopic
 May be maintained as long as needed
procedure
 Between 2nd and 3rd
tracheal rings
 Horizontal vs. vertical
incision
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Cricoid Cartilage
Tracheal Rings
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Tracheostomy Materials
Tracheostomy Materials: PVC
 Disposable:
 Disposable
 Can retain bacteria
 Inexpensive
 Should be discarded and
 Widely used
replaced every 28-30 days
 Non-disposable: Must be
sterilized routinely
Thyroid Cartilage
 More rigid than silicone
 Soften in heat
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Tracheostomy Materials: Silicone
Tracheostomy Materials: PVC/Silicone Mix
 Disposable or non-disposable
 Commonly used
 Flexible
 Strength of PVC with bacteria resistance of silicone
 Softer than PVC or metal
 May weaken and collapse over
time
 Contains fewer chemical additives
 Properties reduce encrustation of secretions and tendency of
bacteria to adhere to tube
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
3
Tracheostomy Materials: Metal
Tracheostomy Size
 Silver or stainless steel
 Often denoted on flange
 More sanitary
 Typically measured in French sizes
 Not typically used for individuals
 Determined based on age, weight, and height
requiring ventilation
 Less comfortable
 Often used at home
 Goal:
 Tube with sufficient airflow but not too large
 Fill no more than ⅔-¾ of tracheal lumen
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Tracheostomy Components: Flange
Tracheostomy Components
Outer Cannula
Cuff
Pilot Line
1.
2.
3.
6
1
4.
5.
6.
Pilot Balloon
15 mm hub
Flange
Obturator
8. Button
9. Inner cannula
10. Syringe
7.
2
 Allows tube to be held in place with
string ties
 Prevent:
 Tube from advancing into trachea
 Accidental decannulation
 Often denotes some features
5
8
3
9
4
10
7
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Tracheostomy Components: Outer
Cannula
Tracheostomy Components: Inner
Cannula
 Provides basic structure
 Can be removed:
 Remains in place to maintain airway
 Single lumen tubes:
 Have only outer cannula
 Least airway resistance
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
 For cleaning
 Quickly if obstructed
 Smaller lumen increases work of breathing
 May be disposable or non-disposable
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
4
Tracheostomy Components:
Fenestration
Tracheostomy Components:
Fenestration
 Windows/holes in body of outer or
inner cannula
 Allows air to pass from trachea to vocal
folds
 Not used in individuals at high risk for
aspiration
 Often used as part of weaning process
 Improperly aligned fenestration may
result in:
 Granulation
 Occlusion
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Fenstrated Inner
Cannula
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Non-Fenstrated
Inner Cannula
Tracheostomy Components: Cuff
Tracheostomy Components: Cuff
 Cuff:
 High volume, low pressure
 Internal balloon surrounding body of
tracheostomy tube
 Low volume, high pressure
 Pressure-controlled
 Compensates for area in tracheal
lumen not filled by tube
 Soft plastic molds to tracheal walls
 Prevents air from escaping around
tube, especially during ventilation
 Reduces risk of aspirated material
immediately entering trachea
 Foam
 Cuffless: Allows air to escape around
body of outer cannula to upper airway
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Tracheostomy Components: Cuff
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Tracheostomy Components: Pilot
If tracheostomy is cuffed:
 Pilot line: pathway for air
to inflate and deflate cuff
 Pilot balloon:
Inflated Cuff & Pilot
Deflated Cuff & Pilot
 Indicates amount of air in
cuff
 Prevents air escape from
cuff
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
5
Tracheostomy Components
Tracheostomy Benefits (Compared to
ET tube)
 Obturator
 Decreased risk of accidental decannulation
 Improved secretion management
 Larynx is not involved in procedure
 Decreased airflow resistance
 Button:
 Increased comfort
 Closes tracheostomy
 Decreased physical restriction
 Used during
 Increased options for oral feeding and communication
weaning/decannulation
process
 Options for transfer out of intensive care unit
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Tracheostomy Complications
 Pneumothorax
 Bleeding
 Inadvertent
or in trachea
Tracheal web
Pneumonia
Aspiration
Ineffective cough
Dysphagia
Tracheal
granuloma
 Tracheomalacia
 Tracheal stenosis
 Fistulae


decannulation

 Cardiorespiratory 
arrest

 Thyroid injury

 Recurrent
laryngeal nerve
damage
 Cuff rupture
 Discomfort
 Infection at stoma
Swallowing Physiology
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Impact
Impact: Laryngeal Excursion
 Swallow may or may not be affected by presence of
 Reduced due to:
tracheostomy
 Potential for dysphagia is increased due to:
 Tracheostomy tube presence
 Surgical procedures
 Neurological/respiratory impairments
 Fixation of muscles
 Weight of equipment and tubing
 Cuff inflation anchors tracheostomy tube
 Results in:
 Decreased tongue base movement and propulsion force
 Risk of aspiration is increased by presence of tracheostomy
 Dragging along walls during attempts at elevation
 Consequences of aspiration are more serious
 Inflated cuff partially obstructing esophagus
 Impaired smell and taste
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
6
Impact: Laryngeal Excursion
Esophageal
Bulge
Cuff in Place
Impact: Secretions
 Disturbance in saliva and secretion management due to:
 Airflow disruption
 Medication side effects
 Thick secretions
 Infections
 Interruption of filtration and hydration
 Results in:
 Insufficient saliva
 Excess saliva
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Impact: Airway Pressure
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Impact: Glottic Competence
 Decreased subglottic pressure:
 When normal, prevents oropharyngeal contents from entering
airway
 Valsalva maneuver
 Results in: accumulation of residue in pharynx
 Mechanical ventilation may result in less aspiration than
spontaneous breathing with tracheostomy
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Impact: Glottic Competence
Normalizing Airway Pressure
 Decreased glottic closure response:
 During swallow, nearer normal pressure can be attained by:
 Gradual loss of laryngeal sensation
 Eliminates reflexive cough and throat clear
 Reduced cough effectiveness
 May use expiratory airflow of ventilator for airway
clearance if cuff is deflated
 Incoordination of glottic closure with swallow
 Disruption of apneic interval when ventilator is required
 Protective function does not immediately return once cuff
is deflated
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
 Digital occlusion
 One-way valve
 Capping
 Individuals who are ventilator-dependent:
 Often swallow worsens when on ventilator
 Tidal volume may be increased to compensate for lost volume
and to provide increased subglottic pressure
 Must learn to time swallow with ventilator cycle of expiration
 With ventilator, instruct in glottic control to compensate for
air leak during cuff deflation
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
7
Cuff Deflation
 At least partial cuff deflation should be attained prior to
Cuff Deflation for Swallow
swallow assessment and feeding:
 Cuff deflated sufficiently for air to move through larynx
 Allows brief occlusion of tracheostomy
 Cuff must be at least partially deflated to identify
potential aspiration
 Full cuff deflation is goal
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Cuff Deflation
Partial Deflation
With Cuff Inflation
Full Deflation
 Fully inflated cuff should not completely seal against tracheal
walls
 Aspirated material can pool on top of cuff and may:
 Fall into airway when cuff is deflated even with proper
suctioning after cuff deflation
 Fall between trachea and cuff, especially as cuff slides with
movement of larynx
 Become bacterially colonized
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
With Cuff Inflation
 With fully inflated cuff, individual cannot cough through
larynx to clear laryngeal vestibule
 With repetitive swallow movements, inflated cuff rubbing
on tracheal walls can cause tracheoesophageal fistula
 Without cuff deflation, only oral stage and ability to trigger
swallow can be assessed
 Individuals who are so medically fragile as to preclude cuff
deflation are usually not candidates for significant oral intake
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
With Cuff Inflation
Material Above and
Around Cuff
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
8
With Cuff Inflation
 Oral intake should be deferred until at least partial cuff
deflation is achieved
 If medical clearance cannot be attained:
Suctioning and Cuff Deflation
 Fully explain and document limitations and dangers of
swallowing in presence of inflated cuff
 If physician has been educated and still desires individual eat
with fully inflated cuff, recommendations made during
dysphagia assessment are useless
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Suctioning and Cuff Deflation
Suctioning and Cuff Deflation
 “…Clinicians must be competent to perform any activity by
 Mississippi Department of Health is silent, stating “it is a
virtue of education, training, and experience”
 Appropriate training and support is necessary to undertake
any activity in which SLP is not already competent
 SLP may perform suctioning and cuff deflation if accepted
under State Licensure and fully trained
 “Suctioning is complicated and can be a life threatening
procedure. The procedure should always be done by those
who are properly trained and know the complications and the
individual.”
scope of practice issue”
 It is advisable for each facility to develop written policy that
addresses:
 Level of involvement of SLP
 Training required
 Mechanism for verifying competency
ASHA's Code of Ethics
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Suctioning Indications
Suctioning Material Above Cuff
 Inability to effectively clear secretions
 Foreign materials collect in airway above
 Need to remove material from airway to prevent obstruction
 Respiratory conditions
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
level of cuff
 Suctioning through tracheostomy tube
with inflated cuff does not remove
material above cuff
 Materials above cuff are cleared by
suctioning via mouth and through vocal
folds or after cuff deflation
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
9
Suctioning Complications
 Mucosal trauma
Cuff Deflation
Partial Deflation
Full Deflation
 Cardiac arrhythmia
 Hypoxemia due to oxygen being removed from lungs
 Laryngospasm
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Cuff Deflation
Ventilation With Cuff Deflation Benefits
 Medical clearance by physician is necessary before any
 Improves access to upper airway during suctioning
attempt at deflation
 Some individuals are not candidates for deflation
 Normalizes airflow through upper airway for airway
protection reflexes
 Air escapes on inspiration and travels through upper airway
instead of remaining in closed loop between ventilator and
individual
 Reduces trauma to mucosal tissue
 Decreases interference with laryngeal elevation during
swallowing
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
History
Clinical Assessment
 Additional information which is useful:
 Intubation:
 Date
 Planned vs. emergent
 Associated trauma
 Extubation:
 Date
 Associated trauma
 Tracheostomy information
 Secretions
 Ventilator history
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
10
Contraindications to Assessment
Clinical Assessment
 Decreased alertness
 Valuable but limited information is gathered
 Extreme agitation
 Rarely is final step in tracheostomy dysphagia assessment:
 Severe cognitive impairment
 Medical instability
 Extreme fragility
 Inflated cuff
 Typically leads to instrumental assessment
 Only if completely confident of individual’s ability to manage
oral intake should recommendation for oral feeding be made
based solely on clinical assessment
 More often, stand0alone when already eating and there are
questions regarding management of particular diet or when
aspiration is overt
 May require multiple sessions
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Clinical Assessment Procedure
Clinical Assessment Procedure
 Oro-motor assessment
 Dry test swallow:
 Suction
 Prior to advancing to trial swallows, consider if individual
 Deflate cuff
can:
 Digital occlusion or one-way valve placement:
 Swallow
 Phonate
 Phonate
 Clear throat
 Cough
 Expectorate secretions
 Clear throat
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Clinical Assessment Procedure
 Trial swallows:
 Assess with tracheostomy unoccluded and with tracheostomy
occluded during swallow
 Provide controlled bolus sizes and types
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Clinical Assessment Procedure
 Observe:
 Oral transit/control
 Initiation speed
 Pharyngeal swallow
 Vocal quality changes
 Cough: cough may occur unrelated to swallow due to changes in
sensations and pulmonary status
 Increased secretions or need for suctioning
 Typical signs of dysphagia and aspiration
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
11
Clinical Assessment Procedure
Clinical Assessment Reliability
Limitations
 Encourage cough or throat clear if needed
 Possible loss of cough reflex
 Suction, rest, re-suction
 Changes in vocal quality or inability to phonate
 Re-inflate cuff and return to baseline ventilator settings, if
 Secretion management differences
needed
 General decreased reliability of clinical assessment in
identifying aspiration
 Cannot assess:
 Cause of aspiration
 Compensatory strategies
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Cervical Auscultation
Blue Dye Test
 Tracheal sounds observed with tracheostomy differ
 Used to enhance ability to discern bolus from surrounding
from those without tracheostomy
mucosa or secretions
 May identify aspiration of more than trace amounts
 May not effectively identify trace aspiration
 Optimally performed over several sessions during 48-72
hour period
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Blue Dye Test Protocol
Blue Dye Test Protocol
 Place 2-3 drops of sterile water mixed with blue food
 If no evidence of aspiration of saliva, can mix blue dye with
coloring on tongue
 Suction trachea immediately and at 15-minute intervals over
1 hour period, recording presence of any blue material in
tracheal secretions
 Can repeat secretion testing every 4 hours over 48-hour
period
 Does not compromise individual, as individual only aspirates
own secretions
food consistencies
 Proceed one consistency at time, waiting at least 4-6 hours
between consistencies
 Positive result:
 Presence of blue material in any tracheal suctioning
 Alerts to presence of aspiration
 Dictates conservative approach to further assessment
 Negative result:
 Absence of dye
 Allows further test swallows
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
12
Blue Dye Test Protocol
Blue Dye Test Tracking Sheet
 Alert nursing and respiratory care staff that blue dye test is in
progress
 Cuff status should be noted during presentations and
Name:___________________
SLP: _____________________
Date:______________
Phone #: ____________
suctioning
 Bedside tracking sheet assists with documentation of
DATE
TIME
CONSISTENCY
PRESENTED
CUFF
STATUS
None
DYE PRESENCE
Min.
Mod .
Sev.
INITIALS
suctioning results
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Blue Dye Test Limitations
 Up to 50% false-negative error rate
 Subjective grading of degree of dye present
 Unable to determine:




One-Way Valve Use
Cause of aspiration
Timing of aspiration
Quantity of aspiration
Effectiveness of compensatory strategies
 Should be interpreted conservatively and not used
exclusively to determine candidacy for oral feeding
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
One-Way Speaking Valves
“It is the role of the speech-language pathologist, following
referral from and in collaboration with medical specialists,
to determine the need for and appropriate type of voice
prostheses.The speech-language pathologist also assesses the
effectiveness of these communication devices and provides
rehabilitation to help the individual obtain an optimum level
of communication function.”
One-Way Speaking Valves
 Function:
 Allows air to enter tracheostomy tube on
inspiration
 During expiration, valve is closed, and air is
directed into trachea and upward to vocal
folds
 Can be used with individuals using
oxygen, humidified air, or ventilator
 Entire team should be aware of purpose
and use of valve
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
One-Way
Valve
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
13
One-Way Speaking Valve Benefits
One-Way Speaking Valve Requirements
 Normalizes airflow
 Awake and alert
 Restores more normalized
 Tolerance of full cuff deflation:
physiology
 Design inhibits secretions from
entering tracheostomy
 Proper size of tube relative to tracheal
lumen
 48-72 hours after tracheostomy initially
performed or tracheostomy change to
allow for decrease in edema
Airflow with One-Way Valve
and Cuff Inflated
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
One-Way Speaking Valve
Contraindications
 Inflated cuff
 Tracheostomy tube with sponge or foam-filled cuff
 Airway obstruction that affects airflow through upper airway even when








tracheostomy size is adjusted and cuff deflated
Bilateral adductor vocal cord paralysis
Severe tracheal/laryngeal stenosis
Unstable medical/pulmonary status
Reduced lung elasticity which may create air trapping
Unmanageable, thick, copious pulmonary secretions
Endotracheal tube
Unconscious; comatose; sleeping
Laryngectomy
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
One-Way Speaking Valve Cautions
 Respiratory treatments or medications should not be
administered during valve use
 Caution should be taken with:
 End-stage pulmonary disease
 Heat moisture exchange device
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
One-Way Speaking Valve Procedure
One-Way Speaking Valve Procedure
 Position individual optimally
 Attempt digital occlusion
 Instruct with procedure for deflation and speaking valve
 If digital occlusion tolerated place valve
placement
 Suction appropriately (tracheal and oral)
 Deflate cuff:
 If inner cannula of tracheostomy has grasp ring:
 Ensure ring does not extend beyond hub of tracheostomy tube
 If ring does impede valve movement, remove inner cannula
 Allow acclimation prior to initial placement of valve
 Make necessary changes to ventilator settings
 Cuffless tracheostomy is ideal and should be considered
 Monitor continually
 Remove T-Piece if needed
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
14
One-Way Speaking Valve Procedure
 Observe for:
Swallow Treatment
 Adequate airflow around tube
 Signs of respiratory distress
 Prolonged, excessive coughing
 If any distress (or at completion of trial):
 Remove valve
 Replace T-piece
 Re-inflate cuff
 Return to original ventilator settings
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Treatment
Compensatory Techniques
 After assessment, treatment can proceed similarly to
 Changes in posture:
individuals without tracheostomy
 If swallow is not elicited, treatment focus is on indirect
treatment to elicit swallow until individual consistently
swallows independently
 Therapeutic feeding trials: considerations same as with
clinical assessment with tracheostomy
 When full cuff deflation is not possible:
 Some exercises can be used to strengthen and prepare for swallow
 Repeated laryngeal elevation required by some exercises increases
 Chin tuck
 Head turn
 Chin tuck & turn
 Head tilt
 Head back
 Reclined
 All may be physically difficult due to equipment in place
potential for tracheo-esophageal fistulae
 Consider each exercise individually
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Compensatory Techniques
Compensatory Techniques
 Diet modifications:
 Changes in bolus presentation:
 Non-oral options
 Bolus size
 Changes in consistency of liquids
 Rate
 Changes in consistency of solids
 Placement
 Teach digital occlusion during swallow and for several
seconds after swallow
 Clearance




No straw
Liquid by spoon
No talking
Moisten mouth prior to meal
 Can proceed as without tracheostomy
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
15
Compensatory Techniques
Facilitation Strategies (Caution with
Full Cuff Inflation)
 Increased sensory input:
 Effortful Swallow
 Mendelsohn Maneuver: Often used in individuals with
 Temperature
tracheostomy
 Pressure
 Supraglottic Swallow Maneuver: Difficult to maintain breath
 Flavor
hold unless digital occlusion or one-way valve is in place
 Texture
 Can proceed as without tracheostomy
 Super-Supraglottic Swallow Maneuver: Difficult to maintain
breath hold unless digital occlusion or one-way valve is in
place
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Therapeutic Techniques
 Oral motor exercises
 Tongue base exercises
Other Issues
 Pharyngeal exercises: Masako: Caution with full cuff inflation
 Laryngeal elevation exercises: Contraindicated with full cuff
inflation
 Laryngeal closure exercises: Breath hold difficult to maintain
unless digital occlusion or one-way valve is in place
 Thermal-tactile stimulation
 Sour bolus swallows
 VitalStim: Adjustments are made to electrode positioning
 DPNS: Contraindicated
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Endotracheal Intubation
Consider
 First meal after extubation, individual
 Goal is to reduce risk for clinical decompensation
is at high risk for aspiration
 Greatest risk of aspiration is within 24
hours following extubation
 Greatest risk of respiratory distress and
re-intubation is within 4-6 hours after
extubation
 Immediately after extubation,
individual often exhibits hoarseness,
spontaneous coughs, and congestion,
making clinical observations unreliable
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
 Must consider when treating individuals with tracheostomy:
 Aspiration characteristics
 Condition of individual
 Underlying lung condition
 Systemic factors can interfere with compensation
 Continued monitoring is crucial, since individuals with
tracheostomy often demonstrate more rapid and frequent
changes in tolerance of feedings than other populations
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
16
 American Speech-Language-Hearing Association. (1993). Position statement
References


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

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American Speech-Language-Hearing Association. (2010). Code of ethics
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Conway, N. (1994). Speech evaluation of the individual with a tracheostomy
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Crary, M. A., Groher, M. E. (2003). Introduction to adult swallowing
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Publishing, San Diego.
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
 Dougherty, D. (2009). Bedside evaluation of the dysphagia individual. Cross
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after tracheotomy. Lancet, 1: 954-955.
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Fornataro-Clerici, L., Roop, T. A. (1997). Clinical management of adults
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Groher, M. E. (1984). Dysphagia: Diagnosis and management. Butterworth
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Logemann, J. (1992). Management strategies during videofluoroscopy.
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Logemann, J. A. (1993). Manual for the videofluorographic study of
swallowing, Second Edition; Pro-Ed.
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
Pro-Ed. Austin, Tx.
for fragile individuals. ASHA Health Care 2006.
 Nash, M. (1988). Swallowing problems in the tracheostomized individual.
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Procedure. (2011). Bedside swallow assessment.
 Passy-Muir Inc. (2008). Passy-Muir tracheostomy & ventilator swallowing
and speaking valves instruction booklet.
 Siddharth, P., Mazzarella, L. (1985). Granuloma associated with fenestrated
trachestomy tubes. American Journal of Surgery, Vol. 150: 279-280.
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
 Sottille, F. D., Marrie, T. J., Prough, D. S., Hobgood, C. D., Gower, D. J.,
Webb, L. X., Coserton, J. W., Gristina, A. G. (1986). Nosocomial pulmonary
infection: Possible etiologic significance of bacteria adhesion to endotracheal
tubes. Critical Care Medicine, 14(4): 265-270.
 Sullivan, P. A. (2006). Aspiration syndromes and polypharmacy in critically
ill individuals. ASHA Health Care 2006.
 Tippett, D., Siebens, A. (1991). Using ventilators for speaking and
swallowing. Dysphagia, 6: 94-99.
 Weymuller, E. A. (1992). Prevention and management of intubation injury of
the larynx and trachea. American Journal of Otolaryngology 13(3): 139-144.
Dysphagia Related to Tracheostomy & Ventilator
Dependence
Lisa H. Renfroe, M.C.D., CCC-SLP
February 21, 2014
17