Home > GP and Clinician Area > Clinical Resources > Tracheostomy guidelines > Swallowing

Swallowing

Bedside evaluation of swallowing, eating and drinking

Not all patients with tracheostomies will have swallowing problems.1-3 Speech and Language Therapists (SLT) are only involved in the assessment and management of tracheostomised patients who present with swallowing or specific communication difficulties.

An assessment of swallowing function by an SLT is required prior to the commencement of oral feeding in patients, identified as being at risk of dysphagia. This is to reduce the risk of aspiration, which may lead to aspiration pneumonia.4 A multi-disciplinary approach is recommended to ensure appropriate and effective care for the individual patient.

“If the complex interrelation between deglutition (prolonged artificial feeding) and respiration is disrupted, significant impairment can result. Additionally, due to the shared functions of the hypopharynx and the larynx, the impact of dysphagia is often heightened for the individual with respiratory compromise”.5

The evidence around the effects of a tracheostomy tube is controversial, but suggests that the following may occur in the presence of a tracheostomy tube:

  • Reduction of antero-superior movement of the larynx4,5,6
  • Tracheal irritation at rest and during swallowing1
  • Reduced laryngeal closure5
  • Compression of the oesophagus by the tracheostomy tube cuff 7
  • Reduced subglottal air pressure8
  • Reduction or elimination of airflow through the glottis
  • Blunting of the reflexive cough9
  • Non co-ordination of the glottic closure response10
  • Reduced laryngeal sensitivity6,11,12
  • Disuse atrophy of the laryngeal muscles

Oral Intake for tracheostomised patients who do not present with dysphagia

While it has been suggested that oral intake should be considered and offered only when the tracheostomy cuff is deflated, new evidence has shown that cuff deflation does not result in swallowing success or increased swallowing safety.13,14 It is, therefore recommended that patients be assessed on an individual basis. Cuff deflation must be assessed by a proficient practitioner in order to minimise the effects of over- inflation of the cuff which can result in laryngeal trauma.

When to consider a referral to the speech & language therapy department for swallowing assessment

  • Referral would be appropriate for tracheostomised patients with:
  • Neurological involvement e.g. bulbar involvement
  • Head & Neck surgery
  • Evidence of aspiration of food/fluid/oral secretions on tracheal suctioning
  • Persistent wet or weak voice when cuff is deflated and speaking valve or decannulation cap in place
  • Coughing in relation to oral intake
  • Oxygen desaturation in conjunction with oral intake
  • Patient anxiety or distress during oral intake

Oral Intake for Tracheostomised Patients following Head & Neck Surgery

It is recommended that the SLT perform a detailed assessment of this patient group; ideally at the pre-operative stage.

Box 9.1 Procedure for oral intake in tracheostomised patients who do not present with dysphagia
Action
Rationale
Sit the person upright in the bed or in a chair, with the chin flexed slightly towards the chest

Aspiration risk is increased if the patient is semi upright with the neck extended

Suction the tracheostomy tube simultaneously with cuff deflation
Secretions may pool above the inflated cuff. When the cuff is deflated these secretions may enter the lungs.
Check the voice quality and cough by occluding the tracheostomy tube (with a gloved finger or gauze pad) or by using a speaking valve and ask the patient to say “ah” or count out loud, “one” to “five”.
If the patient’s voice is wet or “gurgly”, this could indicate difficulty managing their own secretions and an aspiration risk.
The patient who can successfully tolerate cuff deflation should be trialled with a speaking valve. If tolerated the patient should be encouraged to wear the speaking valve during oral intake. If the patient is using a speaking valve attach it to the connection on the tracheostomy tube.
Although use of a speaking valve during oral intake is not considered essential15,16 it will maximise supraglottic airflow and enable voice quality to be monitored. A “wet” voice quality is considered a predominant indicator of aspiration17
Check:
a. The weaning plan to ascertain length of time speaking valve can be tolerated.
b. That the inner cannula is removed if not fenestrated when a fenestrated tracheostomy tube is in situ.
If the voice is clear, proceed with trials of small sips of water. If voice quality deteriorates and sounds wet, encourage the patient to clear any secretions by coughing and re-swallowing
It is recommended that all patients commence oral intake with sips of water to establish their ability to swallow safely before they proceed to other fluids and solids1
Trials of other fluids and solids can be conducted following success at this level

Cease the oral trial if:

  • The patient’s condition deteriorates
  • The patient becomes fatigued
  • Voice is consistently sounding wet
  • Persistent coughing is evident (in association with eating and drinking)
  • There are signs of aspiration on tracheal suction
  • If indicated by the patient’s respiratory status (e.g. signs of distress, increased respiratory rate, decreased SpO2)
Referral to SLT should be implemented if any of the above signs are noted

 

BOX 9.2 Procedure for bedside evaluation of swallowing by a speech & language therapist

In cases where dysphagia is suspected, a referral is accepted from any member of the multidisciplinary team and confirmed with the medical team, if required, prior to the SLT assessing the patient.

Action
Rationale

The SLT will initially carry out a clinical assessment of the patient’s swallowing ability. This will include:-

  • Obtaining information pertaining to medical history and current admission
  • Reason for the tracheostomy
  • Type and size of tracheostomy tube
  • Current method of ventilation
  • Frequency of suctioning
  • Ability to tolerate cuff deflation
  • Full oro-motor assessment
  • Establishment of basic communication status and cognitive function

To ensure that all background information and current cognitive, neurological and structural information has been established.

Eye protection should be worn by staff throughout the assessment and universal precautions adhered to.
To reduce the risk of cross infection from the patient’s secretions via the unprotected mucous membrane of the eye.
Medical agreement will be obtained prior to cuff deflation.
The patient should not be at risk of aspiration. Cuff deflation during ventilation will affect the delivery of respiratory support
Following agreement from the medical team (this must be recorded in the medical notes), cuff deflation trials can commence.
Liaison with the MDT is essential to ensure all information regarding the patient is accurate.
If the medical team will not permit cuff deflation the SLT should explain the limitation of a swallowing assessment in the presence of an inflated cuff and a team discussion on the management of the individual case should follow.
The medical team may be considering quality of life issues.
Regular suctioning should be available throughout by nursing or physiotherapy staff. They therefore must remain in attendance at all times.
To ensure a clear airway.
If the patient is ventilated, a trained member of the MDT, will be required to make the necessary modifications to the ventilator settings.
To silence ventilator alarms.

The patient’s response to cuff deflation will be monitored:

  • Respiratory rate
  • Fatigue
  • SpO2 levels
  • Signs of distress
To ascertain tolerance for cuff deflation
In the patient who has a fenestrated tracheostomy tube, ensure that the inner cannula is replaced by fenestrated inner cannula if available, or removed if not.
To maximise airflow through to the glottis.
Finger occlusion of the tube or speaking valves can be used at this stage if tolerated.
Increased airflow is directed through the larynx that stimulates subglottic receptors before the swallow and may improve vocal cord closure1 . Expiratory airflow can assist in clearing the larynx following the swallow and determine upper airway patency.
Assessment of the patient’s ability to produce voice, and cough into the mouth should occur.
It is important to establish a baseline of vocal quality and strength of cough prior to the introduction of oral intake.

Assessment of the patient’s swallowing function should occur, and will include:

  • Saliva swallow
  • Water swallow
  • Progression onto other liquids and solids if appropriate

Judgement of the oro-pharyngeal swallow and safety for commencement of oral intake will be based on the patient’s performance in a number of clinical parameters. These will include:

  • Level of alertness and cognitive awareness
  • Laryngeal competency and voicing ability
  • Strength of reflexive and spontaneous cough
  • Risk of aspiration
Impairment in laryngeal function may pose an increased risk of aspiration during oral intake. Consideration of a referral to the ENT department should occur. A reduction in strength of cough may not enable the patient to expectorate aspirated materials from the airway. Liaison with the physiotherapist to ascertain the true level of function should occur. Obtaining an accurate assessment of aspiration risk is difficult from a clinical assessment of swallowing function conducted at the bedside.1,18 Further objective methods of evaluation may be required, prior to implementation of any oral intake regime.

Clinical signs to consider following oral intake in determining aspiration risk include:-

  • Delay in elicitation of the pharyngeal swallow
  • Alteration in voice quality or a “wet” sounding voice
  • Consistent coughing
  • Increased respiratory rate/SOB
  • Reduced oxygen saturation level
  • Patient distress
  • Need for suctioning
  • Presence of liquid or food in tracheal secretions or around the tracheostomy tube site

Further assessment information may be obtained through use of:

Fiberoptic Endoscopic Evaluation of Swallowing (FEES) 19,20

Allows direct visualisation of pharyngeal and laryngeal anatomy and physiology before, partially during, and after the swallow21 at the bedside with critically ill or immobile patients, or in a clinic environment. Appropriate training in the FEES procedure is essential for all SLT’s prior to use of this tool clinically.

Videofluoroscopy

Videofluoroscopy enables radiographic visualisation of the swallow, the triggering of the pharyngeal swallow in relation to the bolus and the motor aspects of the pharyngeal swallow1. The SLT should be aware of the appropriateness of all these assessment measures for the individual patient. A competent practitioner must conduct all assessment procedures.

Other Assessment Techniques

Cervical Auscultation may be an adjunct to assessment, although its use is controversial 22,23,24,25 Cervical auscultation is a technique used to detect sounds of a swallow via a stethoscope placed on the larynx.

It may :

  • Determine upper airway sounds prior to the swallow trial
  • Determine the point in the respiratory cycle in which the swallow occurs
  • Determine a change in upper airway sounds post swallow
  • Be used to detect a swallow when laryngeal palpation is difficult

Management of dysphagia

After the Speech and Language Therapist has assessed the patient’s swallowing function, recommendations regarding swallowing management will be made. This should take the swallow assessment results and the MDT assessment of the patient into consideration.

Speech and Language Therapy intervention may recommend a range of interventions depending on the patient and the type of dysphagia. Russell and Matta26, list the following types of intervention:

Indirect therapy

This does not involve the introduction of a food/ fluids, but focus on the aspects of the swallow that have been identified as “abnormal.” These generally include a range of motion exercises and swallowing manoeuvres e.g. Falsetto – to increase laryngeal range of motion, Maseko –to increase tongue base retraction 1,27

Tracheostomy tube manipulation

Tube manipulation may be used to attempt to “normalise” a patient’s swallow, in order to improve swallow safety. e.g. The SLT might recommend down sizing a tracheostomy tube.

Diet Changes

The SLT may recommend modified food/fluid consistencies to optimise swallow safety. This may require liaison with the dietician

Positioning

The optimum safe position for swallowing is sitting upright with the chin slightly flexed. This may not be possible for some patients, so the SLT may make recommendations as to the safest position for swallowing.

Postural techniques and manoeuvres that can be used to increase swallow safety may also be recommended e.g. Head tilt or Mendelsohn’s manoeuvre.

Non-oral feeding

If the SLT recommends that a patient should be nil-by-mouth or that they can only begin oral trials, the patient may require alternative forms of feeding to maintain nutrition and hydration. The SLT will refer to the dietitian, in this instance. The SLT will also be involved in the multidisciplinary decision making process for long term non-oral feeding options.

References

  1. Logemann JA. (1998) Evaluation and Treatment of Swallowing Disorders Texas Pro-Ed Publishers
  2. Leder SB, Ross DA. (2000) Investigation of the Causal Relationship between Tracheostomy and Aspiration in the Acute Care Setting The Laryngoscope 110: 641-644
  3. Sharma OP, Oswanski MF, Singer D, Buckley B, Courtright B, Raj SS, Waite PJ, Tatchell T, and Gandaio A The American Surgeon 2007; 73(11):1117-21
  4. Meyers AD (1995) The Modified Evans blue dye procedure in the tracheotomised patient, Dysphagia 10: 175-176.
  5. Dikeman KJ, Kazandjian MS (1995) Communication and Swallowing Management of Tracheostomy and Ventilator-Dependent Adults San Diego Singular Publishing Group, Inc
  6. Bonnano P (1971) Swallowing Dysfunction after Tracheostomy Annals Surgery 174: 29-33
  7. Becker Weilitz P, Dettenmeier PA. (1994) Back to Basics: Test your Knowledge of Tracheostomy Tubes American Journal of Nursing 94:(2) 46-50
  8. Gross RG, Dettlebach MA, Zajac DJ, Eibling DE. (1992) Measure of Subglottic Air Pressure during Swallowing in a Patient with Tracheostomy Paper presented at the annual convention of the American Academy of Otolaryngology- Head & Neck Surgery. Sept. San Diego
  9. Tippett DC, Siebens AA. (1991) Speaking and Swallowing on a Ventilator; Dysphagia 6:(2) 94-99
  10. Nash M (1988) Swallowing Problems in the Tracheostomised Patient Otolaryngologic Clinics of North America 21: (4) 701-709
  11. Cameron JL, Reynolds J, Zuidema GD. (1973) Aspiration in Patients with Tracheostomies Surg Gynae Obstet 136: 68-70
  12. Sasaki C, Susaki M, Horiuchi M, Kirshner J. (1977) The Effects of Tracheostomy on the Laryngeal Closure Reflex. Laryngoscope 87: 1428-1433
  13. Suiter DM, McCullough GH, Powell PW. Effects of cuff deflation and one-way tracheostomy speaking valve placement on swallow physiology. Dysphagia 2003;18:284-92.
  14. Terk AR, Leder SB, Burrell MI. Hyoid bone and laryngeal movement dependent upon presence of a tracheotomy tube. Dysphagia. 2000;22:89–93.
  15. Leder SB, Tarro JM, Burrell MI. Effect of occlusion of a tracheotomy tube on aspiration. Dysphagia. 1996;11:254–258.
  16. Leder SB. Effect of a one-way tracheotomy speaking valve on the incidence of aspiration in previously aspirating patients with tracheotomy. Dysphagia. 1999;14:73–77
  17. Murray, K., & Brzozowski, L. (1998). Swallowing in Patients with Tracheotomies. American Association of Critical-Care Nurses, 9, 416-426.
  18. D.G. Smithard, MRCP; P.A. O’Neill, MD; C. Park, BSc; J. Morris, BSc; R. Wyatt, BSc; R. England, FRCR D.F. Martin, FRCR Complications and Outcome After Acute Stroke Does Dysphagia Matter? Stroke. 1996;27:1200-1204.
  19. Langmore SE, Schatz K, Olsen N. Fiberoptic endoscopic examination of swallowing safety: a new procedure. Dysphagia 1988;2:216-9.
  20. Kelly, A, Drinnan, M, Leslie, P. Assessing Penetration and Aspiration: How Do Videofluoroscopy and Fiberoptic Endoscopic Evaluation of Swallowing Compare? Laryngoscope 2007: 1723-1727
  21. Langmore SE Endoscopic Evaluation of Swallow, 2001 Thieme Publishing, New York
  22. Hamlet S, Penney DG, Formolo J: Stethoscope acoustics and cervical auscultation of swallowing. Dysphagia 1994;9:63-6823.
  23. Takahashi, Groher & Michi, Methodology for Detecting Swallowing Sounds Dysphagia 1994; 9; 54-62
  24. Zenner P, Losinski D, Mills R: Using cervical auscultation in the clinical dysphagia examination in long-term care. Dysphagia 1995; 10:27–31
  25. P. Leslie, MJ Drinnan, I. Zammit-Maempel, JL Coyle, GA Ford, JA Wilson. Dysphagia 2007 Vol. 22,:90-298.
  26. Russell C, Matta B, eds. Tracheostomy:Multiprofessional Handbook. Cambridge University Press, Cambridge: 187-210
  27. Mepani, R., Antonik, S., Massey, B., Kern, M., Logemann, J., Pauloski, B., Rademaker,A., Easterling, C., Shaker, R. Augmentation of Deglutitive ThyrohyoidMuscle Shortening by the Shaker Exercise. Dysphagia 200924:26-3