20Q: Beyond the Swallow - Tracheostomy Tube and Ventilator Management

From the Desk of Ann Kummer

After completing my master’s degree at Indiana University, I took a job in the public schools in North Carolina. Although I realized as a new grad that I still had a lot to learn, I felt fairly comfortable with my caseload. At least I knew that I was unlikely to hurt anyone!

After 3 years in the public schools, my husband and I moved back home, and I began a new job at Cincinnati Children’s Hospital. I had not had a practicum in a hospital during grad school, so I didn’t really know what to expect. What I found out the first week was that I was totally unprepared to work with medically compromised kids. What scared me the most was working with kids with tracheostomies and those on ventilators!

I believe that still today, most SLPs who accept a position in a hospital or other medical facility come with a lack of education and training to effectively manage patients with tracheostomies and ventilators. Because of this issue, I am really excited about this 20Q article by George Barnes.

For years, George Barnes MS CCC-SLP has had a focus on diagnostics in the medically complex population through his dedication to a variety of medical settings. In addition, he has developed an expertise in dysphagia. His coaching program with FEESible Swallow Solutions supports SLPs with the guidance they need to reach their clinical and career goals. George yearns to make education useful, research clinical-focused, and quality care accessible. He co-founded a mobile FEES service to bring the highest quality assessment to the patient's bedside. His webinars bridge research and patient care. George strives to go beyond the swallow in dysphagia management by looking at the whole patient which is evident in his work on a pneumonia risk calculator. With a passion for food and a deep appreciation for the joy and connection it gives to our lives, he has dedicated his life to helping others enjoy this simple, but deep-rooted pleasure.

In this course, George addresses the various questions that may arise for the medical SLP involved in the care of patients with tracheostomy and/or mechanical ventilation. This course is meant to lead the reader down a path of further education, training, and understanding for this often complex patient population.

Now…read on, learn, and enjoy!

Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors
Contributing Editor 

Browse the complete collection of 20Q with Ann Kummer CEU articles at www.speechpathology.com/20Q

20Q: Beyond the Swallow -Tracheostomy Tube and Ventilator Management

Learning Outcomes

After this course, readers will be able to: 

• list the possible causes of respiratory failure.
• list at least 2 risks to consider when providing intervention for a patient with tracheostomy and ventilation.
• list at least 2 indicators that a patient is a candidate for a speaking valve.
• identify factors to consider before starting PO trials or advancing the diet of a patient with a trach/vent.

George Barnes

1. Why is it so important that the speech-language pathologist (SLP) develop an adequate understanding of tracheostomy tubes and mechanical ventilation?

The need for highly trained medical practitioners in critical care is growing. 800,000 people require ventilation each year (Mehta et al., 2015; Wunsch et al., 2010) and this number only continues to grow with the aging population in the United States (Zilberberg et al., 2008; Zilberberg et al., 2012). Unfortunately, most SLPs do not receive adequate education and training to effectively manage patients with tracheostomies and ventilators. However, this won’t stop the extraordinarily dedicated professionals that make up the SLP field from engaging in personal growth via continuing education and training to bridge that gap. The role of the SLP has gone through a whirlwind of changes over the last few decades. Today, the SLP has become an integral member of the interdisciplinary team (IDT) within critical care. With expertise on the aerodigestive tract, the SLP can provide a tremendous amount of value to the IDT in terms of determining if, when, and how patients are ready for basic communication, use of the speaking valve, PO trials, feeding tube weaning, and even tracheostomy tube decannulation.

2. Why does somebody require a tracheostomy and ventilation, to begin with?

Patients who require a tracheostomy and ventilation are typically critically ill, but the cause for that illness varies. Respiratory failure may occur when the patient is unable to adequately exchange gas at the alveolar level (respiration) or effectively mobilize air in and out of the lungs (ventilation). There are two types of respiratory failure. Both type one and type two result from insufficient oxygen, but type one occurs when the patient has low levels of carbon dioxide and type two occurs when the patient’s carbon dioxide begins to build up (Shebl, et. al. 2020). Underneath the two types of respiratory failure are six possible causes, which include neurological, lung disease, traumatic chest injury, spinal deformities, chemical effects, and acute lung injuries (NIH: National Heart, Lung, and Blood Institute, 2018). Understanding the cause of respiratory failure is the first step towards understanding the patient’s status, stability, and prognosis.

3. What is critical illness myopathy and what does it have to do with tracheostomy and ventilation?

Critical illness myopathy may occur in a medically complex patient who remains absent from functional activity for an extended period. This patient no longer has the resistance throughout the day needed to build their muscles. 62% of people who become ventilator dependent begin to have some level of neuromuscular weakness (Shepherd et al., 2016). The reason the SLP needs to be aware of the high incidence of critical illness myopathy in the tracheostomy and ventilator dependent population is that the weakness is often widespread, substantial, and not limited to areas of the body that are below the neck. Lingual, labial, laryngeal, and pharyngeal function is often impacted by critical illness myopathy, causing significant issues with speaking and swallowing. This may lead to increased dependence and higher risks involved with introducing food and liquid; not only because of the high risk of aspiration but also because that aspiration may be more likely to result in a subsequent infection (Langmore et al., 1998 and 2002). 

4. What types of risks do we need to consider when providing intervention for a patient with tracheostomy and ventilation?

The complex nature of individuals who require tracheostomy and ventilator support creates a context where additional caution must be employed throughout the decision-making process. There are many risks involved with any kind of intervention in this population. The major ones include respiratory distress and further cardiopulmonary decline, infection, and functional regression. This does not mean that we cannot intervene with these patients. In fact, it’s all the more important that we are involved to help them progress. The patient’s lack of movement may lead to a process called muscle atrophy. Patients with tracheostomy tubes and mechanical ventilation are at a particularly high risk of diffuse muscle atrophy because of the nature of their critical illness (Burkhead, 2011). Balancing the possibility of a functional decline due to disuse atrophy and the risks of a decline due to cardiopulmonary complications can be a very thin tightrope to walk on. This is why every step we take must be carefully chosen. 

5. With such high risk, how do we know when the right time is to start our intervention?

This question has no easy answer. My motto is to, “Move slowly, but move.” Intervening with a highly medically complex patient is going to have risks, but at the same time, the research tells us that a patient standing still has risks that we have to confront as well (Burkhead, 2011).  The best approach involves a careful review of the chart, continuously assessing status changes with the IDT, and engaging in an ongoing collaborative discussion with the patient and family. This should give us the information we need to make an informed decision. There may never be an easy answer, but there is always a right one for that patient at that moment. That’s the answer we are trying to find.

6. Is there ever a time when we should not intervene?

Definitely. Many of our patients have had extended and multiple intubations up to three weeks at a time (Chalkidou, et. al., 2019). Given the location of the placement of the endotracheal tube, these patients often present with disorders of the oropharyngeal and laryngeal structures ultimately leading to a high incidence of dysphagia and a high risk for aspiration (Benjamin, 2018; Burkhead, 2011; Duncan et al., 2020; Puyo et al., 2018). Sometimes, time itself can be the best form of intervention. The hard part is that we have to wait for it to take effect. SLPs are often guilty of something called commission bias which weighs the benefit of action over inaction. We want to do something, anything, to help the patient. However, this bias blinds us from the potential downfalls of beginning our intervention too soon which may result in cardiopulmonary decline if the patient is not yet stable. Sometimes the best action is inaction.

7. How do we balance the risk of disuse atrophy and cardiopulmonary decline?

This is probably the most challenging aspect of working with the medically complex tracheostomy and ventilator population. The key is to get all the relevant information we can about the patient through our own evaluation process and discussing with the IDT in order to make an informed decision based on our findings. Moving slowly when advancing patients will also give us time to examine any changes and make any adjustments as needed.

8. What is the first thing the SLP should do to determine if a patient is a candidate for our services?

Is the patient awake, alert, and responsive? It’s very difficult to communicate, tolerate and benefit from a speaking valve, or try anything by mouth if the patient is unconscious. There are patients whose status varies from day to day or even hour to hour depending on pain medication, anxiolytics, hemodialysis, and overall medical stability. This is why it is crucial to perform an ongoing evaluation over time with regular visits to examine the trajectory of the patient. How were they yesterday? Today? How do we expect them to be tomorrow? The answers to these questions will help us determine the right timing to start our intervention and what type to begin with. A discussion with the IDT, and specifically, the respiratory therapist and pulmonologist is crucial to understanding the overall status of the patient and improving the opportunity for a successful intervention (Nancarrow et al., 2013; Neumann et al., 2010; Temkin-Greener et al., 2004). Once a patient is consistently awake, alert, responsive, and stable, we can start to think about progressing the patient forward.

9. What should the SLP do in their initial assessment to make an informed decision about the patient’s care?

The initial assessment is all about figuring out what’s going on with the patient. What is the problem and what question are we trying to answer? Are we assessing for basic communication? Candidacy for cuff deflation? How about a speaking valve? Is it time to consider PO trials and if so, what consistency? No two patients are alike. This means we have some digging to do to fully understand the patient. A thorough chart review, in-depth discussions with the IDT, interview with the patient and family, and a comprehensive bedside assessment are all major components of an effective initial assessment. Further, these components should be incorporated into each subsequent assessment as well to get a continuous birds-eye view of how the patient is progressing (or regressing) so we can make accurate, clinical judgments at the moment and any adjustments as needed.

10. What do we have to know about the patient’s tracheostomy tube?

The width, length, type, and shape of a tracheostomy tube may mean the difference between a tube that easily allows airflow through and around it and one that is impenetrable from any attempts at upper airflow (Epstein, 2005). When we deflate the cuff while a patient is on the ventilator, the most important thing we are evaluating is whether or not the patient can breathe over the tube and out through the nose and mouth. We don’t want the tube to be too small or the patient may have difficulty obtaining access to adequate volumes from the ventilator, but when off the ventilator, smaller is typically better. Ideally, when the patient is “liberated” from the ventilator and they no longer need it to breathe, the patient should be considered for a tracheostomy tube “downsize” and/or to a “cuffless” tracheostomy tube. A downsize simply means a smaller tube (e.g., a #8 to a #6) and a cuffless tube no longer has the cuff used to block air to the upper airway to increase the efficiency of ventilation to the lungs. A cuffless tracheostomy tube is sometimes all you need to achieve adequate upper airflow because the cuff, even when deflated, takes up a substantial amount of space in the trachea. Other times you may need a downsize. Other times you may need a fenestrated tube (with windows) to allow even more airflow through the tracheal space. All of these options have costs and benefits that will need to be considered with IDT.

11. Does the tracheostomy tube cuff protect the patient from aspiration?

The short answer is no. The cuff is located below the level of the vocal folds and anything that falls below this level is already considered aspiration. The cuff does play a role in protecting the lungs because of its location well above the carina, but an inflated cuff does not seal off the trachea completely. It allows air, and even secretions, to leak around it all while a patient is unable to cough. This may be why research shows that cuff deflation appears to reduce the risk of pneumonia (Hernandez, 2013), not increase it. The decision of whether or not to deflate the patient’s cuff should be made with the IDT and based on a deep look at the patient’s respiratory status and risk for aspiration.

12. How do we know when a patient will begin to wean from the ventilator?

It is important to identify the patient’s potential for weaning so we can determine the appropriate timing and type of SLP intervention. Prolonged ventilation has a tremendous number of negative effects on the patient, including diaphragm dysfunction, lung injuries, and ventilator-associated pneumonia (Zein et.al., 2016). Therefore, the goal is to wean as quickly as is appropriate. One of the best indicators of ventilator weaning potential is the patient’s performance on something called a spontaneous breathing trial (SBT). This is an opportunity for the patient to try to breathe on their own without the ventilator. How the patient performs on this test will tell us how quickly we expect them to wean. The SBT gives the respiratory team the information it needs to make a plan for getting the patient off of the ventilator, which is typically done by following a facility weaning protocol (Zein et. Al, 2016).

13. How do secretions interfere with the patient’s goals and SLP intervention?

The amount and viscosity of secretions will tell us a great deal about how a patient may tolerate SLP intervention (Griggs, 1998; Lichtman et al., 1995). If a copious or large amount of thick secretions are blocking the trachea and upper airway, it will be difficult for the patient to achieve upper airflow for exhalation; which will ultimately result in difficulty speaking, swallowing, and breathing. If the secretions are found to be a major barrier towards progressing the patient, the respiratory team may agree on a treatment regimen of any combination of mucolytics, postural drainage, humidity, and/or fluid intake for hydration to loosen the secretions and make them easier to mobilize and clear out (Marcin, 2017). The SLP can help in these discussions by relaying the appearance of the secretions from day to day and to support the patient in their ability and efforts to cough up their secretions. Assessing and developing a patient’s cough throughout the treatment session may also help in determining and reducing a patient’s risk of aspiration pneumonia (Sakai et al., 2019).

14. What are some indicators that the patient might be ready for a speaking valve trial?

A speaking valve is a one-way valve that allows patients to take air in through the tracheostomy but diverts air up and out through the upper airway upon exhalation. This small device can make a huge difference for a patient who has not been able to speak or communicate since their initial intubation. When the patient is consistently awake, alert, stable, and able to manage their secretions independently, they may be ready for a speaking valve trial (Prigent et al., 2011).  Changing the airflow for a patient who has a known history of cardiopulmonary complications can have unintended consequences and must be considered carefully with the IDT. The benefits of a speaking valve go beyond direct communication and may include improved ventilator weaning, secretion management, and PO tolerance (Dettelbach et al., 1995; Elpern et al., 2000, Fisher et al., 2012; Kinneally, 2018; Suiter et al., 2003). Before, during, and after speaking valve placement, the patient should be closely monitored for any changes in heart rate, respiratory rate, oxygen saturation, and work of breathing to make sure the patient remains stable.

15. Can a speaking valve be used while the patient is still on the ventilator?

While more complicated and possibly at a higher risk to the patient, a speaking valve can be successfully placed on a patient while they are still ventilator dependent. A patient who is on the ventilator cannot be considered for a cuffless tracheostomy tube and may not be appropriate for a tracheostomy tube downsize either. This means the patient’s tracheostomy tube may take up a large area of tracheal space needed for adequate upper airflow with the speaking valve. The most dangerous scenario that can occur is if the patient’s cuff is left inflated after the speaking valve is placed. With an inflated cuff, the patient will not be able to exhale any air around the tracheostomy tube to the upper airway, keeping all air below the level of the cuff and suffocating the patient. If pursued, a speaking valve trial in-line with the patient's ventilator tubing should be done under a clearly defined, facility mandated protocol and only after appropriate IDT discussions occur for medical clearance. Lastly, respiratory therapy should be present for this evaluation and should be trained and skilled in the various settings and alarms that will need to be adjusted. 

16. What are some signs that the patient is not tolerating the speaking valve?

Signs of poor speaking valve tolerance include reports of difficulty breathing, anxiety, or inability to speak. Further, the SLP may see changes in the patient’s cardiopulmonary status (e.g. a drop in oxygen saturation or an increase in respiratory or heart rate). Visible fatigue may also be observed in the form of the patient inadvertently using accessory muscles to support adequate lung ventilation. The SLP may also notice that the patient is unable to phonate. This may be due to an issue in airway patency, breath support, or vocal fold function. Backpressure when removing the speaking valve may indicate that the upper airway is not patent (obstructed) (Lichtman, 1995). Any signs that the patient is unable to tolerate the speaking valve should be an alarm to remove the speaking valve as restricted upper airway airflow may result in respiratory insufficiency or failure (Prigent et al., 2011). The SLP may suction, reposition, and re-educate the patient before reattempting the speaking valve. If these strategies are unsuccessful and a tracheostomy tube downsize has already been completed, further consideration of respiratory insufficiency and/or upper airway obstruction should be pursued with the assistance of the pulmonologist and ENT.

17. How do we know when a patient is ready to begin PO trials?

Once we determine that a patient is awake, alert, stable, and tolerating the speaking valve, the patient can be considered for PO trials. The speaking valve is not an absolute prerequisite for PO trials, but it is preferable given that it closes the open circuit of the airway and allows for subglottic pressure which has been shown to improve taste/smell, sensation, and the ability to cough and clear the throat (Elpern et al., 2000; Dettelbach et al., 1995; Kinneally, 2018). It should be noted that there are patients who cannot tolerate the speaking valve, but tolerate PO without significant difficulty (Suiter et al., 2003).

There is no such thing as 0% risk while eating. We are all at risk of aspirating and choking. However, the risk is much higher for some people vs others. Having a tracheostomy tube and/or a mechanical ventilator may increase the risk significantly (Elpern et al., 1994), as does the comorbidities often associated with this population (i.e., COPD, CHF, bed-bound, tube feeding, dependent for feeding, polypharmacy, etc.) (Langmore et al., 1998). Therefore, erring on the side of caution with our patients is prudent. With the complex array of risks and benefits involved with the decision to begin initial PO trials, it is best to consult with the IDT, including the patient and family to determine what the goals are and what the level of accepted risk is to pave a path forward.

18. How do we know when to advance a patient’s diet?

Depending on the level of risk, either an initial bedside swallow evaluation or an initial instrumental swallow study should be conducted to determine the patient’s anatomy and physiology, the risk for aspiration and choking, and the patient’s candidacy for PO advancement. When managing a patient with a tracheostomy and/or ventilator it is best to get an instrumental study at some point (if not as an initial evaluation) before diet advancement is recommended because of the high risk of silent aspiration (Elpern et al., 1994).  The patient’s risk of aspirating harmful contents as well as their ability to clear potential aspiration and fight off a possible infection should all be assessed before diet advancement (Langmore et al., 1998; Ferguson & Gailey, 2018, Yu et al., 2018). Some risk factors to consider include the severity of dysphagia, neurological deficits, cardiopulmonary issues, length of intubation, current infection, GI disease, medical complexity, age, head and neck CA, immunocompromise, reduced mobility, tube feeding dependence, signs of delirium, and recent weight loss. (Altman et al., 2010; Gomes et al., 2003; Langmore et al., 1998; Langmore, et al., 2002; Leder et al, 2007; Mokhlesi et al., 2002; Stein et al., 1990).

19. What is the SLP’s role in feeding tube weaning?

The SLP will have a valuable role to play in determining if, when, and how the patient is tolerating full meals. By monitoring the patient closely during mealtime, discussing meal performance with the IDT, and reviewing the chart for possible signs of infection (i.e., abnormal CXR or lab work), we can get a good sense of how the patient is doing after meals have been introduced. If there are no red flags and the patient is tolerating an adequate volume of PO (as determined by the dietitian), this patient may be a good candidate to consider feeding tube removal. Removing the feeding tube will simultaneously reduce the risk of aspiration pneumonia (Langmore et al., 1998), improve independence, and increase their opportunity for a facility discharge. Ongoing collaboration with the registered dietitian is necessary to determine if and when the patient is ready to have the feeding tube removed.

20. What is the role of the SLP in improving the independence of patients with tracheostomy and ventilation?

The SLP has an important role to play in improving the patient’s independence. The SLP will be responsible for assessing speaking valve candidacy and tolerance which will allow the patient to communicate and advocate for themselves. Successful speaking valve use may also bridge the gap from an open tracheostomy tube to capping trials. The SLP is also responsible for determining PO candidacy and tolerance which will provide the IDT with knowledge about how the patient can protect their airway and consume adequate nutrition which will help determine if they are ready for decannulation and feeding tube weaning. The SLP has a lot to offer the patient and the IDT within this patient population and with the right training and skill development, can facilitate a successful transition home for the patient.

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