TRACHEOTOMY

Tracheotomy – Between 43-80% of the patients with tracheotomy tubes will manifest signs of aspiration or aspiration pneumonia. Dysphagia is produced by physiological changes associated with opening the trachea to atmospheric pressure, not merely the presence of the tube in the neck ( Murray, T, Carrau, R, 2006)

Physiciologic changes following a Tracheotomy

• Loss or change in airway pressure
• Inability to generate subglottic air pressure during the swallow
• Reduced ability to produce an effective cough
• Loss of sense of smell
• Loss of phonation
• Reduced mucosal sensitivity
• Reduced true vocal cord closure and coordination
• Disruption of the respiration and swallowing pattern/cycle
• Foreign body effect
• Reduced laryngeal elevation during deglutition

(Murray, T, Carrau, R, 2006)

Expiratory Valve – Most use a Passy-Muir Valve (PMV) –This is a removable one-way valve that opens to permit inhalation, but closes during expiration to divert the airflow through the larynx.

Advantages: (Gross RD, Eibling DE, Carrau R, Murray T, 2006)

· Patient can communicate verbally

· Airflow provides proprioceptive cues during swallowing exercises and learning maneuvers

· True VC adduction exercises will be maximized because of the subglottic air pressure build up

· Improved pressure to aid in bolus propulsion

Contraindication for Valve:

• Unconscious patient
• Behavioral problems
• Medical instability, esp. pulmonary
• Tracheal stenosis
• Airway obstruction above the tube
• Thick and copious secretions that persist after valve placement
• Foam filled tube cuff
• Total laryngectomy
• Inability to tolerate cuff deflation
• Sever cognitive disorders

Signs and Symptoms of difficulty tolerating the Valve

• Increasing respiratory rate over time with or without nasal flaring
• Increased irritability, increased fear, anxiety
• Decreased chest movement
• Skin color changes

Dysphagia Evaluation – For clinicians unfamiliar with inflating and deflating cuffed tracheotomies, with suctioning, and with medical emergency techniques, the eval should be complete with nursing or approp medical personnel.

1. Be sure patient is seated upright, optimal position for feeding
2. Have patient suctioned both orally and via trach to ensure clear airway prior to evaluation
3. Present with ice chip or liquid. Momentarily occlude tracheostomy (cuff deflated) with a finger to establish near normal tracheal pressure while swallowing. Observe the presence or absence of laryngeal elevation and look for overt signs of dysphagia. Suction immediately if any difficulty is noted.
4. If patient is successful with first trial, select appropriate consistency to assess further and repeat above instructions with ½ tsp size boluses. May use a blue dye with food consistencies. Prior to proceeding to a new consistency, suction again. This helps differentiate the specific consistencies.

Dysphagia Treatment – PMV’s can improve swallowing and can be used during assessment and treatment phase of dysphagia management.

A patients ability to perform compensatory strategies and facilitative techniques that promote increased airway protection during PO (i.e. Supraglottic swallow, Super supraglottic swallow, Mendelsohn maneuver) and swallowing exercises that focus on muscle retraining to improve laryngeal elevation and vocal cord function (i.e. falsetto/pitch exercises, vocal cord adduction exercises, Mendelsohn maneuver, E-Stim) should be enhanced when the PMV is in place.

ENG biofeedback techniques used in dysphagia intervention (Buchholz, 1994) can be applied effectively with trachs while wearing the PMV.