Tracheostomy Tubes:
Managing Communication and
Swallowing Issues
Carmin Bartow, MS, CCC-SLP
Speech Pathologist
Vanderbilt University Medical Center
Nashville, TN
1
Objectives




Describe changes in physiology after tracheotomy
regarding speech, swallowing and respiration
Differentiate between various communication
options for trach and vent dependent patients
Determine the most appropriate swallowing
evaluation and treatment techniques for trach and
vent dependent patients
Describe how the Passy-Muir Speaking Valve works
and explain the physiologic benefits of the valve
2
Topics
Trach overview
 Communication Options
 Passy-Muir Speaking Valves
 Pediatrics (brief )
 Mechanical Ventilation
 Dysphagia Management
 Conclusion / Hands-on time

3
Tracheostomy Overview
 Tracheostomy
Tubes
 Physiologic
Changes after
Tracheotomy
4
Tracheotomy
Indications for tracheotomy
 Prolonged intubation
 Need for long term mechanical ventilation
 Need for permanent tracheostomy tube
 Upper airway obstruction / edema
5
Trach Tube Components
6
Tracheostomy Tube
Inflated Cuff
7
Tracheostomy Tube
Deflated Cuff
8
Tracheostomy Tube
Over-inflated cuff
9
Trach Tubes - Shiley
10
Trach Tubes - Bivona
11
Trach Tubes – Portex
12
Trach Tubes – Jackson Metal
13
Physiologic Changes after
Tracheotomy
14
Physiologic Changes after
Tracheotomy


Respiration – breathing
in and out through trach
tube
Speech – inability to
produce phonation due
to lack of airflow
through vocal folds
15
Physiologic Changes after
Tracheotomy


Smell/taste – decreased
sense of smell and taste due
to lack of airflow into upper
airway
Secretion management –
inability to mobilize
secretions effectively due to
decreased cough effort
16
Physiologic Changes after
Tracheotomy
Swallowing – many research studies regarding
trach tubes and swallowing report a negative
impact on swallowing efficiency
Aspiration
Pressure
Differences
Airflow Differences
Cuff issues
Laryngeal Sensitivity
17
Aspiration

An association b/t aspiration and trachs has been
well documented
 Trach associated with increased risk of
aspiration and pneumonia (Muz et al, 1987)
 Delayed laryngeal vestibule closure which was
associated with tracheal aspiration (Abraham
and Wolf, 2000)
 Disruption of vocal fold function (Nash 1988,
Shaker, 2000)
18
Pressure Differences



Aerodigestive tract is a set of tubes and valves
(Logemann, 1988); swallowing is a pressure
driven event
There is an inability to build up adequate pressure
to propel the bolus through the pharynx with an
open trach (Eibling and Gross, 1996)
When subglottic pressure is altered with a trach,
neuroregulation of pharyngeal swallow physiology
is likewise altered (Gross, et al, 2003)
19
Airflow differences

The loss of expiratory airflow through the
upper airway for normal respiration has
been linked to increased pooling of
secretions within the larynx and pharynx
(Siebens, et al, 1993)
20
Cuff issues
Reduced laryngeal elevation and silent
aspiration were significantly higher in
cuff inflated vs. cuff deflated condition
(Logemann, 2005)
 The cuff DOES NOT prevent aspiration
(Ross & White, 2003); it is not
“watertight”

21
Laryngeal sensitivity

Normal laryngeal sensitivity = Cough

Trach tubes result in reduced pharyngeal /
laryngeal sensation (Tippet et al, 1991)
22
VFSS - aspiration
23
Communication Options

Non-Verbal




Writing
AAC
Communication board
Mouthing

Verbal
 Leak speech
 Finger occlusion
 Talking Trach
 Blom Trach System
 Speaking valves
 Plugging / capping
24
Leak Speech
Ability to produce voice with airflow
“leaking” around a trach tube into upper
airway
 Occurs most often with cuffless tubes,
deflated cuffs or fenestrated trachs
 Airflow takes path of least resistance
through trach tube typically making speech
breathy and weak

25
Finger Occlusion

Placing finger over the hub of the trach tube
to allow for increased airflow into the upper
airway for phonation
26
Talking Tracheostomy Tube


Used for vent dependent patients who cannot tolerate
cuff deflation (will discuss further during mechanical
ventilation section)
Portex Trach-Talk
Bivona Trach with talk
attachment
27
Blom Trach System
-
-
-
-
Fenestrated Cuffed Tube Kit
Non-Fenestrated Uncuffed
Tube Kit
Subglottic Suctioning Cannula
Speech Cannula
LPV
SoftTouch™ Tube Holder
Exhaled Volume Reservoir™
(EVR™)
Training Disk
28
Capping / Plugging

Capping – placing a
“cap” or “plug” on the
trach to seal off
airflow
29
Passy-Muir Valves
30
Passy-Muir Valve
•Valve opens during
inhalation with less than
normal inspiratory
pressure
•Closes at the end of
inhalation
•Allows airflow to pass
through vocal folds for
phonation
31
Passy-Muir Valve
Remains in closed position except when
patient inhales
 No leakage of air through valve
 Restoration of a closed system
 Restoration of subglottic pressure

32
Passy-Muir Valve

Use on and off ventilator

FDA indicated for use in communication and
swallowing treatment

Medicare/Medicaid reimbursable

Supported by research as providing the best
speech quality as compared with other
speaking valves (Leder, 1994)
33
Passy-Muir Valves
34
Passy-Muir
Patient Care Kit
35
Patient Criteria

Awake and alert

Medically stable

Able to tolerate cuff
deflation
36
Patient Assessment
Can the patient exhale around the trach into
their upper airway?
 How to establish upper airway patency:
 Deflate the cuff
 Finger occlude the trach
 Listen for exhalation and/or phonation

37
Upper Airway Patency Issues
Sizing of trach tube -the #1 Issue
- Often requires downsizing trach

Other possibilities
 Upper airway edema / obstruction
 Granulation tissue
 Foam filled cuff
 Partially inflated cuff
 Secretions
38
Valve Placement
Team involvement is key to successful use of valve!
39
Valve Placement


Educate patient and family
Obtain baseline measurements
 Oxygen saturation (O2 sats)
 RR
 HR
 Color
 WOB
 Responsiveness
40
Valve Placement
Suction (if needed)
 Deflate cuff
 Suction again
(if needed)
 Place valve

41
Placement of Speaking Valve
42
Placement





Allow patient to adjust to
airflow change
Continue education and
reassurance
Establish phonation
Continue to monitor for
any changes from baseline
measurements
Remove valve if any
significant changes occur
43
Troubleshooting


Decreased O2 with cuff deflation – may need to
increase FI02 (must check with RT)
Inadequate exhalation/phonation
Check for:






Complete cuff deflation
Trach tube size
Suctioning needs
Need for MD assessment
Patient position
Trach position
44
Session Wrap-up
Wear times vary
 Confer with medical staff as needed
 Post warning labels
 Storage
 Care and Cleaning

45
Physiologic Benefits of the
Passy-Muir Valve
Improved voice
 Improved cough
 Improved secretion management
 Improved swallowing
 Quicker decannulation

* Can result in improved quality of life!
46
Pediatric Trachs
47
Pediatric Trach Differences
Typically no cuff
 Typically no inner cannula
 Sizes vary depending on brand (neonatal 00
– pediatric 4, but now some greater
variances)
 More difficulty with tolerance of speaking
valves especially at early age due to tiny
airways

48
Pediatric Vital Signs
Pre-term Newborn Infant
Weight
Child
6 –9
8 - 25
25 – 80
16 - 20
RR
50 –80
40 – 60
25 - 30
HR
125 –
170
100 130
50 – 90
80 - 120 80 -100
BP Systolic
80 – 90
120
49
Effects of Tracheostomy on
Communication Development



Caregiver interaction – lack of crying, cooing,
babbling, vocalizing can impact bonding /
caregiver interaction
Language – lack of prelinguistic development
often results in language delays
Voice – Studies report VF atrophy with prolonged
tracheostomy tubes
Pediatric Speaking Valve
Assessment

Many similarities to adult assessment
 Must have patent airway
 Address secretions / cuff status
 Monitor vital signs / patient responsiveness
 Same valves (no pediatric sizes)
Pediatric Speaking Valve
Assessment

Differences



Babies can “crash” more quickly
Babies / children often can’t tell you their comfort level
Watch closely for distress:






Fear
Stridor
Grunting
Decreased chest movement
Decreased LOA
Change in vital signs, color or WOB
Speaking Valve Tolerance



SLP must discern whether “tolerance” is
behavioral or physiologic.
Recommendations and therapy based on this
If poor tolerance physiologically – must either
wait for growth or request smaller trach.
Pediatric Placement Ideas






Behavior modification techniques (older children)
Place just before waking
Keep child’s hands busy
Blowing games (to increase oral exhalation)
Distraction (PLAY!)
Toby Tracheasaurus
54
“Baby Trach” guru
Suzanne Abraham

Provides national
seminars through NSS
on “Baby Trachs:
Airway Safety,
Secretions,
Swallowing in Infants
and Young Children
with Tracheostomies”
Mechanical Ventilation

Mechanical ventilation

Communication options for ventilator
dependent patients
56
Mechanical Ventilation

Settings
Rate
 Tidal Volume
 FIO2
 PIP
 PEEP

57
Mechanical Ventilation

Modes
Control Mode
 Assist Control
 SIMV
 Pressure Support

58
Communication Options for
Ventilator Patients
Non-verbal
 Verbal
 Leak speech
 Talking trach
 Blom Trach System
 Passy-Muir Speaking Valve

59
Leak Speech for
Ventilator Dependent Patients







Need MD order for cuff deflation trials
Suction if needed
Slowly deflate cuff (may only need partial cuff
deflation)
Ventilator adjustments by respiratory therapist
(FI02, tidal volume, alarms)
Encourage vocalization
Monitor vital signs throughout trial
Establish plan of care for continued leak speech
trials
60
Talking Trach Tube
Portex Trach Talk
Bivona trach with talk attachment
61
Talking Trach
Used primarily for ventilator dependent
patients with adequate oral motor function
who cannot tolerate cuff deflation.
 Description - Cuffed trach tube with an
additional tube that connects to an air
source. Air travels through this tube and
flows out of an opening above level of cuff

62
Talking Trach Tube
63
Talking Trach Use







Educate patient re: airflow
Suction if needed
Connect external tube to air source
Connect humidification
Turn on air source (begin with 6 liters; max 15
liters)
Occlude port
Encourage vocalization
64
Talking Trach – Pros / Cons


Pros
Can be used with cuff
inflation
Allows for verbal
communication while
on the vent




Cons
Airflow issues
Quality of voice
Patient comfort
Secretion issues
65
Blom Trach System

“How does the Blom Speech Cannula work?
 The Blom Speech Cannula has two unique valves that re-direct air
allowing speech for ventilator dependent patients with a fully
inflated cuff.
 During Inhalation the Flap Valve opens and the Bubble Valve
expands into the fenestration sealing it, preventing air escaping to
the upper airway.
 During Exhalation the Flap Valve closes, the Bubble Valve
collapses to unblock the fenestration and air is directed up through
the fenestration to the vocal cords allowing speech”.
From www.Pulmodyne.com
66
Passy-Muir Mechanical
Ventilation Video
67
Passy-Muir Valve
Placement In-Line With Ventilator




Respiratory therapist should be present
Deflate cuff gradually
Suction if needed
Place valve with appropriate adapter
68
Passy-Muir
Adapters for in-line use
69
Ventilator Adjustments
Respiratory therapist must be present to
make vent adjustments
Volume compensation during cuff deflation
 Alarms
 PEEP
 Humidification

70
Transitioning/Troubleshooting

Typically will have shorter sessions

Increased airflow through upper airway

Anxiety

Airway patency
71
Removal of Speaking Valve
After In-line Placement

Replace original circuit set-up

Return ventilator settings and alarms to prespeaking valve parameters

Re-inflate cuff
72
Specifics on Cuff Inflation
and Deflation

Deflation - To make sure the cuff is fully deflated,
continue to remove air until resistance is met

Inflation - An over-inflated cuff can result in damage to
the tracheal walls. Recommended cuff pressure is
approximately 20 – 25 mmHg. Techniques to measure cuff
inflation include:
 Minimal leak technique
 Cuff manometry
73
Dysphagia Management
Assessment
 Treatment

74
Dysphagia Assessment
 Clinical
bedside assessment (with or
without blue dye)
 FEES
 VFSS
75
Blue Dye Test
No set standards; varies from facility to
facility
 Involves use of blue food coloring to dye
secretions, liquids or foods
 Tracheal secretions that are either coughed
or suctioned from trach are monitored for
signs of aspiration

76
Clinical Bedside Swallowing
Assessment








Diagnosis
Physical, medical and nutritional status
Underlying pulmonary disease
Ability to manage secretions
H/o dysphagia
Type of trach tube
Mechanical ventilation
H/o endotracheal intubation
 How long?
 How many times?
77
Clinical Bedside Swallowing
Assessment
Deflate cuff (if cannot deflate cuff, must
proceed with instrumental assessment)
 Suction as needed
 Place speaking valve if present
 Oral mech exam

78
Clinical Bedside Swallowing
Assessment
Begin po trials with or without blue dye
 Observe for s/s of aspiration
 Vocal quality
 Cough
 Evidence of aspiration in tracheal
secretions (immediate and delayed
assessment)

79
The Blue Dye Dilemma
False negatives
 Availability
 Potential systemic effects
 Limitations
 Use results cautiously

80
VFSS/FEES





Objective results
Can be performed on vent and non-vent patients
Identifies etiology of aspiration (not just presence
of aspiration)
Can implement therapeutic maneuvers and
strategies
Anecdotal evidence re: FEES vs VFSS in vent
patients
81
Eating while on the vent
66% of patients swallowed successfully; no
aspiration. Of the patients that did aspirate
(33%), 80% was silent aspiration (Leder, 2002)
This indicates:
1) MANY patients can eat even when on the vent
2) Need for instrumental assessment for our vent
dependent patients
82
Treatment
Oral hygiene program
 Traditional swallow therapy
 Compensatory strategies
 Diet modifications
 Restoration of a closed system

83
Oral hygiene


Considerable evidence exists to support a relationship between
poor oral health, the oral microflora and bacterial pneumonia,
especially ventilator-associated pneumonia in institutionalized
patients
A number of studies have shown that the mouth can be
colonized by respiratory pathogens and serve as a reservoir for
these organisms. Other studies have demonstrated that oral
interventions aimed at controlling or reducing oral biofilms can
reduce the risk of pneumonia in high-risk populations. Taken
together, the evidence is substantial that improved oral hygiene
may prevent pneumonia in vulnerable patients.
84
Traditional Swallow Therapy
General tips:
- Most traditional swallow exercises are fine
- Don’t do Shaker with this population
- Mendelsohn - don’t do it if it causes pain (if
in doubt, don’t do it)
- Breath holding techniques like the
supraglottic won’t work with open trach
85
Compensatory Strategies and
Diet Modifications

Same as non-trach / non vent dependent
patients
 Head turns, chin tucks, reduce bolus size,
multiple swallows, etc
 Diet changes
86
Restoration of a closed system
Decannulation
 Plug
 Passy-Muir Valve

87
Restoration of a closed system

Open trach vs closed trach








Muz et al (1989)
Muz et al (1994)
Logemann et al (1998)
Dettelbach et al (1995)
Stachler et al (1996)
Elpern et al (2000)
Gross et al (2003)
Suiter et al (2003)
All report improved swallow
function with a closed trach
88
Use of Passy-Muir to aid
swallowing function
Restored airflow through vfs to prevent further
vf atrophy
 Improved sensation in the oropharynx allows
the patient to sense pooled secretions
 Restored subglottic pressure
 Cuff issues negated due to always having cuff
down with PMSV
 Restored cough function

89
Treatment
“The predisposition to aspirate with an open
tracheostomy tube is now well recognized.
Decannulation is known to benefit many of
these patients by reducing or eliminating
aspiration. Moreover, we have now shown
that the use of a one-way speaking valve
will also result in improvement.” (Gross,
1996)
90
Speech Pathologists play a key role
in intervention with the
tracheostomized and ventilator
dependent population
91
Quality of Life
Ventilator dependent patients’ feelings of
anxiety, fear, panic and insecurity caused
by inability to talk and communicate
“Assessment of Patients’ Experience of Discomforts
During Respirator Therapy”
(Bergbom-Engberg, Haljamai, 1989)
92
SLP Intervention
Improved communication
 Improved swallowing
 Improved cough and secretion management
 Improved ability to participate in decision
making
 Improved quality of life

93
Thank You!
94