Breathe, Speak, Eat: What the SLP Needs to Know About Trach and Vents

Editor's Note: This text is a transcript of the course Breathe, Speak, Eat: What the SLP needs to know about trach and vents, presented by George Barnes, MA, CCC-SLP, BCS-S. 

Learning Outcomes

After this course, participants will be able to: 

• Describe the effects of trach/vent on speech, airflow, and swallowing.
• Identify the salient features of mechanical ventilator management.
• Describe how to evaluate and troubleshoot use of a speaking valve.

Introduction

This is a topic that I am extremely excited about and have been passionate about in my career for a number of years. I've been working in a critical illness recovery hospital, basically only seeing trachs and vents for the better part of my career. In this course, I want to discuss trachs and vents, describe the connection between trachs, vents, and dysphagia, and discuss speaking valve use and troubleshooting.

I mostly see patients with medical complexity with trachs and vents, typically after respiratory failure from pulmonary disease and cardiopulmonary disease. I have also spent a number of years in a small community acute care hospital and acute rehab. With a passion for cooking and eating, I've gravitated towards a career helping other people enjoy these same simple but very meaningful pleasures in life. And it's true that we certainly don't know what we have until it's gone, and many of our patients suffer through that. I believe that we can play a very meaningful part in their lives by helping them get back to eating and drinking again.

Trachs and Vents

One main takeaway from this course is that small changes can make a big difference for patients. For example, the use of a speaking valve, which seems like just a small piece of plastic, is a brilliant product. It's a small piece of plastic with a membrane put over the trach site, and suddenly, the patient who couldn't communicate before or couldn't communicate effectively, now has the ability to say words and communicate basic needs. There are many other examples of how we can help so profoundly with this population.

Reasons to Trach

There are three basic reasons why patients may require mechanical ventilation or tracheostomy tubes. A patient who is at very high risk for secretion management, aspiration of those secretions, or aspiration of food and liquid may need a trach for pulmonary toileting, which is when we suction out any excess secretions or contents that can make their way down into the airway. We want to suction those out before they cause obstructions or infection.

Obstruction is another reason why somebody may need a tracheostomy tube. If a patient has an obstruction to airflow in the upper airway, they're going to need a tracheostomy tube to allow air to flow in and out of their lungs below the level of that obstruction.

The final reason is mechanical ventilation. Patients who have had respiratory failure and are now unable to take in adequate pulmonary volume and or oxygen levels independently will require some level of respiratory support, in this case mechanical ventilation, to allow them to live and breathe.

Decision to Trach

The decision to put a trach in a patient is typically made between seven and ten days of intubation. During the COVID-19 pandemic, that rule did not apply, and we had many patients who were orally intubated for weeks. There were a lot of risk factors to be considered at the time, and so that rule was disregarded.

We're starting to see patients returning to more appropriate lengths of intubation, but the seven to 10-day mark is not always the window that we see. We can see two weeks or three weeks, and there is a direct connection between the length of intubation and the number of times a patient is intubated and trauma to the larynx, trauma to the airway, and trauma to the patient's ability to swallow. Research suggests that 23% of patients who have been intubated less than three days fail a swallow screen. If it's more than three days, up to 78% of patients fail a swallow screen, and additionally, the risk of dysphagia doubles from one to two days intubated. Therefore, we have to think about patients who are intubated for weeks at a time. It's certainly not the only factor to consider, but it is one of the most important factors when determining what level of trauma and what level of difficulty a patient may have after they're extubated or after they have a tracheostomy placed.

Trach Tubes

If a patient has been on a ventilator for seven to 10 days or a couple of weeks and they are unable to be weaned from it, they will have a tracheostomy tube placed to improve access to the lungs and decrease the damage caused to the upper airway from putting the tube in through the vocal folds and through the mouth.  The trach tube also allows patients to wean from sedatives and get started on a recovery process.  This is where we come in; they can participate in speech and swallowing (but it depends on a few factors I will discuss later). 

Overview

A tracheostomy tube is an artificial airway put into the trachea that bypasses the nose and mouth to create easier access to the lungs, as well as other factors previously mentioned.

Parts of the Trach. Parts of the trach include a cuff, which is essentially a small balloon that goes around the trach on the inside and seals off the airway. When air goes in through the tracheostomy tube, the balloon inflates around it so that the air cannot leak up through to the upper airway. There are certain trach tubes that allow air to flow up, but a patient would not have that in unless the team anticipates the patient would come off of the vent or be a good candidate for an inline speaking valve.

A tracheostomy tube and mechanical ventilation, in general, are meant to help the patient survive. Breathing is always going to come before speaking and swallowing.  When the patient is intubated, and a tracheostomy tube is placed, the medical team generally opts for a larger tube to create the most space possible to ventilate the lungs. That's important to mention because when we begin to work with the patients, whether they're still on the vent or have recently come off, a bigger tube makes it more difficult for us because it becomes an obstruction in the airway. The bigger the tube, the more space it takes up in the trachea.

Other parts of the trach include the pilot balloon, which is a small balloon on the outside of the trach that assesses how much air is in the cuff; the shaft is the tube itself; the hub is the visible part of the tube that sticks out from the neck, and the inner cannula. Not every tube has one, but the inner cannula can be removed and cleaned of any excess secretions, especially dried secretions that can cause mucus plugging. The inner cannula can then be placed back in without causing a possible obstruction for the patient.

Finally, there are fenestrated trach tubes, which are simply holes in the shaft to allow more airflow to flow up to the upper airway. This is used for a patient typically when they're off the vent or coming off the vent in order to create more airflow for a speaking valve or capping trials where we put a cap over the tracheostomy tube and get a patient ready for breathing on their own.

The downside to fenestrated tubes is that they do increase the risk of granuloma, and most research states that the risk significantly increases after two weeks of use. Therefore, if a patient is not expected to be decannulated within a couple of weeks, we don't want to use that fenestrated tube because it could worsen the situation.

Trach Types. There are different trach types that can be used depending on the hospital, the doctors, and their preferences; and there are advantages and disadvantages to the different types.

• Jackson tubes are metal, more rigid, and less porous, which could mean a lower risk of infection for the patient.
• Portex tubes are made of polyvinyl chloride; they're more flexible and typically blue. These are used at my facility.
• Shiley tubes are also made of polyvinyl chloride. They're a bit more rigid and tend to come in white.
• Bivona trach tubes are silicone, flexible, and white.

Trach types can also be differentiated by the number of cannulas (i.e., single versus double), the length (i.e., XLT, distal versus proximal), the diameter (the inner diameter for airflow), and the cuff (i.e., cuffed vs cuffless, type - air, water or foam, inflated vs deflated), and Tight to shaft (TTS) which goes around the shaft in order to remove excess space being taken up by the cuff.

The most important takeaway from this course is that we cannot place a speaking valve on a patient who has an inflated cuff. We also cannot place a speaking valve on a patient who has a foam cuff because they do not deflate. Those are typically used for patients who have wounds on the inside for less trauma to the surrounding area from that cuff. 

Mechanical Ventilation

There are multiple modes that are possible. Always seek the advice and guidance from the respiratory team. While I'm going to discuss the basics, it's best to befriend your respiratory therapist and your pulmonologist to fully understand what is being used in your facility, why those certain types of modes are used, what that tells us about how stable the patient is and how ready they are for our services.  However, every facility is different. It depends on the team, the culture, the facility protocols, and several other factors. 

Normal Breathing and Boyle's Law

When talking about mechanical ventilation, it's important to understand normal breathing. Boyle's Law states that when volume is increased, pressure is decreased.  In terms of the lungs, we increase the volume in our thoracic cavity when we take a breath. As we take a deep breath, there's more space in our lungs, which decreases the pressure, and high pressure likes to go to areas that have low pressure. So, it reduces the pressure relative to the atmosphere (i.e., the space outside of our bodies), and as the pressure decreases in our lungs, the pressure from the outside wants to be pulled in, like a vacuum. 

The reverse would be decreasing the volume, increasing the pressure in the chest, and pushing the air back out. This occurs when we are breathing passively. It's a relaxation of those muscles. Mechanical ventilation, though, does away with that law. It forces air in. It's positive pressure being forced in by a machine to increase the volume in the lungs. Exhalation is just the natural recoil of the diaphragm and the intercostals within the ribcage that pushes air back out through the tracheostomy tube and back into the ventilator.

Types of Mechanical Ventilation

There are several types of mechanical ventilation, three of which are used at my facility.  Assist control, otherwise known as volume control, is full support. The ventilator does everything for you. Pressure support is a spontaneous mode of mechanical ventilation where the vent gives you a little push. And SIMV, which is infrequently used, especially now, can be useful for certain patients. SIMV stands for synchronized intermittent mechanical ventilation, where the ventilator does most of the work but not all of the work.

With assist control, the patient receives a preset volume. The pulmonologist writes an order, the respiratory therapist sets the volume for the ventilator and the ventilator pushes in the set volume, no more and no less, in order to give the patient adequate air and oxygen.

Patients who are on assist control may be too unstable for a speaking valve and PO trials. However, it depends on why they require assist control. Is it a patient with severe lung disease who is too medically unstable, or is it a patient with phrenic nerve damage and paralysis of the diaphragm who is always going to require assist control? These two patients will present very differently, and the implications for how they're going to do with a speaking valve and food and liquid will be very different from one another. Therefore, we need to know why they require mechanical ventilation and what the mode means for their overall medical trajectory. Meaning, how are they trending? Are they getting better or worse? Is there potential to get better, or are they stable and staying the same? I always ask if the patient is being actively weaned. If the goal is to get the patient off of the vent, what's holding them back from a lower level of support, like pressure support?

Remember, pressure support, known as spontaneous breathing, is when the ventilator delivers a preset pressure. The volume is going to be variable depending on how well the patient is taking in that air. Is the patient stable? There are multiple factors to consider. First, what level of pressure support are they on? A pressure support of 20 is very similar to assist control. They're getting basically all of the support through the vent. They are basically just triggering the breath. How stable are they? What's happening with the disease process? What does the chest x-ray look like? What does the arterial blood gas look like? What is the respiratory team saying? How alert are they? There are many factors to consider, but the mode is one among many that we should take note of and determine what it means for the overall medical trajectory of the patient.

With SIMV, there are a number of predetermined breaths set per minute based on pressure or volume. For example, the respiratory therapist decides that they want the patient to get eight breaths per minute. For those eight breaths, they are basically on assist control. The machine gives it to them, and they get all the support they need from the vent, but they're also allowed to practice spontaneous breathing. It's kind of combining assist control and pressure support because when the patient takes a breath, they're only given a certain amount of pressure support to assist in that breath. You might hear the patient is on SIMV of eight with a pressure support of 16, meaning they're getting eight breaths per minute and have 16 centimeters of water pressure to assist them in breathing. You might want to ask the same question that you're asking for assist control: Why is the patient not yet on pressure support? Why are they not on a weaning mode? If the patient is actively being weaned, what's holding them back from a lower level of support?

Earlier, I mentioned the example of a pressure support of 20 being a really high level of support, similar to what you might get from assist control every time you elicit a breath. But if you also see a patient on a pressure support of eight or even 10, that is basically just overcoming the resistance of the ventilator tubing, and they might be ready to come off the vent. They may be extremely stable at that time. Again, it all depends. So, it is best to know your facility, discuss with your team, and ask questions. Talk with the team to determine what's going on with the patient, what can be done, and when.

Reading the Vent

All of the information we need is on the vent screen.  Respiratory rate/heart rate, the fraction of inspired oxygen, and the percentage of oxygen in the air that is being delivered to the patient (21% is room air) are all listed on the screen. It also has title volume, which is the amount of air delivered to the lungs.  The alarms on the vent are safety mechanisms that indicate whether or not the patient is receiving enough pressure or volume, or if there is a disruption in the tubing.

The PEEP is an important piece. PEEP is positive end-expiratory pressure, which is how much air is left in the lungs after the patient completely exhales. We all have natural PEEP due to resistance of the upper airway, the vocal folds, the nose, and the mouth. That allows air or forces air to stay in the lungs without completely deflating. A natural PEEP is approximately five to 10, but for patients with tracheostomy tubes, once there's a hole there, they no longer have that upper airway resistance. If a patient exhaled completely out of a tracheostomy tube, the PEEP would go way down. Patients on vents are provided with artificial PEEP so that air is constantly flowing through the ventilator to provide some resistance against the exhale to ensure that all of the air is not completely let out of their lungs.  That could result in a collapse of the airways or a collapse of the alveoli.

Finally, blood oxygen saturation levels, or SPO2, are very important to monitor as we are providing intervention. The normal range is 88 - 100%.

Weaning Candidates

Who can be weaned from the vent? We may not want to wean a patient if they are unstable or have phrenic nerve involvement, which means that the diaphragm may be paralyzed and they are unable to take a breath. We may not want to wean a person if they have a progressive neurological disorder such as ALS.

If a patient cannot be weaned, we meet with the interdisciplinary team to determine the best course of action. Can we start earlier? Even though the patient is on assist control and high levels of support, can we deflate the cuff and start working on an inline speaking valve? 

Ultimately, we want to focus on the big picture. What's most important? It's easy to get bogged down by the numbers. Having policies and procedures is extremely important. But we also want to take a step back, look at the patient, and try to see the full picture. What's the patient's medical trajectory? How are they trending? Are they getting worse? Are they getting better? Are they staying the same for weeks, and how long have they been like that? Look at the big picture and look at the patient to see how they're doing physically. Take your gaze off the ventilator and see how a patient's doing. Are they struggling? Are they gasping for air? Are they engaging in clavicular breathing and trying to get as much air as possible? These signs tell us a lot about how the patient's doing.  The numbers, protocols, and policies are extremely important. They help give us a map. But you can't drive by just looking at the map. You have to look at the road too.

Tracheostomy Management

When a patient is on the vent, they are engaging in an unnatural form of breathing. Mechanical ventilation saves a person's life. It's a wonderful thing to have, but it's important to realize that it does disrupt some natural processes.  We no longer use the dead space of our nose and mouth, which filters out certain contents and provides heat and moisture to the air delivered to the lungs. Also, the patient on the vent cannot engage in effective breathing and swallowing coordination, which means they may be more likely to take food and liquid into the lungs as they are breathing.

Heat and moisture are extremely important. One of the biggest reasons patients have so many secretions when they're on the ventilator is that this artificial air being provided doesn't have the same natural heat and moisture that we have when taking air in from the atmosphere. We are able to heat and moisten that air to the point that it is exactly what the environment of the lungs wants. Dry air and cold air are abrasive to the lungs and cause the lungs and cilia to protect themselves by creating their own moisture in the form of secretions.

Depending on the mode of mechanical ventilation, it can be difficult to regulate when and how much air we are taking in a breath. This can disrupt the entire natural swallowing process because we need a certain level of subglottic pressure for propulsion and airway protection.

Are they stable? There's a reason why I keep bringing this up. Ensuring medical stability is going to lower the risk of further decline and helps us determine when we should start seeing them. Oftentimes, patients who are still on full support and the endotracheal tube has been taken out may not be ready. There's a reason why they need this kind of support, and if they're not medically stable, we shouldn't be starting our services yet.

Swallowing with Tracheostomy

Can a patient swallow with the tracheostomy tube? In short, yes, but there are, of course, some risk factors. Tracheostomy tubes reduce upper airflow naturally, and upper airflow is important for subglottic pressure, voice, valsalva sensation, cough, taste, and smell. There is an increase in secretions and reduced PEEP.  

A tracheostomy tube may also have some other side effects for swallowing. Some research suggests that there is laryngeal desensitization due to the decreased airflow through the upper airway. There is also tethering of the laryngeal rise, holding it down and not getting full laryngeal elevation and excursion.  Finally, there is impaired glottal closure. The person isn't getting adequate subglottic pressure to close and protect the airway.

Does a tracheostomy tube increase the risk of aspiration? Some research says yes, and some research says no. Marvin and Thibeault (2021) found 81% of patients with tracheostomy tubes aspirated silently, 81%. Of patients who had trach and vents, 33% aspirated, and 82% of that (basically 1/3 of the population) aspirated silently. So 81% and 82% in two completely different studies, almost 20 years apart.  According to Suiter et al., 2003, cuff inflation and deflation had no effect on penetration or aspiration. In the acute care setting, Lader and Ross (2000) found no causal relationship between the tracheostomy tube and aspiration status.

These findings suggest that it's not just the trach at play that is skewing some of the results; it is the population being studied and the person with the trach tube. There are underlying risk factors. What happened to the patient, and why do they need a ventilator and/or a tracheostomy tube? Having a tracheostomy tube certainly does not help. If an otherwise healthy person had a trach put in, there probably wouldn't be too much difference in the way that they swallow. It's the associated risk factors of the disease process itself that cause so many issues.

Swallowing with a Cuffed Trach

The cuff is the small balloon inside the tracheostomy tube. This can cause necrosis or even a tracheoesophageal fistula if overinflated, and swallowing with it could make that worse because it is constantly moving up and down. Some patients can swallow with an inflated cuff, but there are risks. We want to avoid overinflation by inflating the cuff with a barometer in order to measure the pressure so it's not too inflated and doesn't make extreme contact with the soft tissue and the trachea around the tracheostomy tube. If there is too much contact, it can create a hole in the posterior tracheal wall where the esophagus is.  

A cuff reduces airway closure. No air, or very little air, is getting into the upper airway with an inflated cuff, causing the vocal folds to stay open, and during swallowing, that can be a problem.

Additionally, reflux can occur because of the positioning of the tracheostomy tube. The tube is anterior to the esophagus, which can cause an impingement on the esophagus if the cuff is over-inflated. During eating and drinking, there can be an obstruction down into the esophagus, causing food and liquid to come back up.

Speaking Valve

A speaking valve is a tiny device that makes a huge difference. Remember, some patients have not verbally communicated for months. Communication may improve quality of life, participation in decision-making, and better pain management. But timing is everything. We don't want to start too soon, and we certainly don't want to wait too long.

There are many benefits of a speaking valve:

• Closing the system and allowing upper airflow 
• Subglottic pressure
• Coughing/throat-clearing
• Airway protection
• Secretion management 
• Voicing/communication
• Sensation
• Laryngopharyngeal reflex
• Taste/smell
• Restored PEEP (5)
• Reduced risk of atelectasis
• Improved oxygenation
• Quality of life
• Expedited weaning/decannulation, shorter LOS, and cost-saving

The patient had an open system with a tracheostomy tube. With a speaking valve, they now have a closed system allowing for upper airflow through the vocal folds, creating that subglottic pressure used to cough through our throat, protect the airway during swallowing, possibly manage secretions, and communicate with speech. Airflow through the upper airway may also increase sensation, which is why secretion management improves, as well as the ability to swallow and protect our airway. It also may improve the laryngeal reflex, taste/smell, restore PEEP, reduce the risk of atelectasis, improve oxygenation, and quality of life. It expedites weaning to cannulation, shortens the length of stay, and there is a cost saving. Again, there are a lot of benefits in a tiny valve.

Is a speaking valve necessary for swallowing? No, it's not. We already discussed the impact a tracheostomy tube has on certain patients and if it is going to impact a patient's swallow. Again, it depends on other risk factors occurring with the patient. There are inconsistencies with the research, again, because of the populations that the research is looking at. So, while a speaking valve may benefit certain patients, it's not necessary or even appropriate for everyone. Some patients will not tolerate it; it may increase respiratory rate and increase the work of breathing.

Candidacy

Who may be a candidate for a speaking valve? If a patient is on a vent, there are certain settings that are used to determine if a patient is a candidate for a speaking valve.  The parameters that are used in the critically ill recovery hospital that I work in are below.

The setting:

• Peak Inspiratory Pressure (PIP) less than or equal to 30
• Positive End Expiratory Pressure (PEEP) less than or equal to 6
• Fraction of inspired oxygen (FiO2) less than or equal to 50%

If a patient on the vent has numbers that fall within these parameters, they may be ready for a speaking valve.

To determine stability, look at: 

• Blood oxygen saturation levels (SPO2)
• Heart Rate (HR)
• Respiratory Rate (RR)

To determine alertness, are they:

• Awake
• Alert
• Responsive
• Attempting to communicate

There's some very new research stating that a patient might benefit from a speaking valve even if they are not 100% awake, alert, responsive and attempting to communicate. But typically, the standard protocol is that the patient should have these things.

Patent Airway: 

• Tolerate cuff deflation
• No signs of back pressure

Can the patient tolerate cuff deflation?  Is adequate airflow going up to the upper airway? Is the airway clear with no obstructions, or are there signs of back pressure? Back pressure can be assessed by putting on the speaking valve and slowly removing it. If any pressure is felt as we're removing it, that's back pressure. That means the air is not fully able to get around that tracheostomy tube.

Never place a speaking valve: When the cuff is inflated; with a foam-filled cuff (it reinflates); or on a laryngectomy patient, these patients will not tolerate and will suffocate.

Steps before placing the speaking valve:

• Talk to the patient. Make sure they understand what we are doing and why. Show them a diagram; show them what this means for their anatomy and physiology.
• Position the patient. We don't want them slouching to the side or lying back. They need to be in a good position to breathe and talk.
• Suction the patient beforehand if they need it.
• Deflate the cuff if you forget everything else.

When deflating the cuff while the patient is on the ventilator, be sure to do it slowly.  Deflating too quickly or all at once increases secretions. There is poor secretion management for patients with tracheostomy tubes, especially inflated cuffs, because they're not getting that airflow and that sensation and that ability to protect their airways. All of those secretions end up sitting on top of the cuff. If we deflate the cuff all at once, the secretions are going to go into the lungs. The patient could get a bronchospasm, they start coughing, they're uncomfortable, they don't want any part of the procedure anymore, or the numbers on their ventilators are out of control. Then, the respiratory therapist stops the procedure, puts them back on the vent, and reinflates the cuff.

All of that can be avoided by slowly deflating the cuff over one minute or even a few minutes to allow the patient to get used to those secretions coming down. That way, you or the respiratory therapist can suction and manage those secretions effectively and get the patient back on track.

When deflating the cuff while the patient's on the vent, the main thing to look for is upper airflow.  If there is a lower exhalation volume (about 50% less) and a drop in peak airway pressure (also about 50% less), that suggests a loss of air. That air is no longer going back into the vent.  Most of it is going up the upper airway because there is no obstruction. 

Policy

Have a policy in place for speaking valves that addresses inclusion/exclusion criteria, settings, and supervision. Who's watching the patient? How long are we monitoring them? Having any kind of policy, no matter what it is, as long as it's mutually agreed upon by your respiratory team and your weaning team, is essential because it tells us what we should be looking at.  Who are the right candidates, and who is responsible for what?

Cleaning 

How do we clean the valve? Clean daily by gently swishing soapy water and then air drying.  We don't want to push down on the sensitive membrane on the valve window.  Disrupting it can cause the valve not to work properly.  If there are any strange sounds coming from the valve (e.g., a honking sound), discard it and get a new one. These valves don't last forever. The average duration is about two months for a Passy-Muir Valve (PMV) and one month for most other brands.

Poor Tolerance

How do we know if a patient isn't tolerating a speaking valve? We can listen to subjective complaints by the patient, such as saying they're having difficulty breathing, they're anxious, or they just don't feel right. There may be changes in airflow. Is there back pressure? Is there increased peak inspiratory pressure building over time, which means that the patient is "air stacking" below the level of the tracheostomy tube, indicating that there is an obstruction in the upper airway.  If the patient is unable to phonate or blow, that is another sign of decreased airflow.

Respiratory changes include changes in vitals and abnormal breathing patterns that tell us the patient's not tolerating the speaking valve.

Troubleshooting

A patient who is aphonic, dysphonic, or has strangled vocal quality could indicate an upper airway obstruction. If a patient can blow out of their nose and mouth but can't talk, then they have upper airway airflow, but aren't talking because they don't have adequate respiratory support or they have a paralyzed vocal fold, or maybe vocal fold dysfunction from an extended intubation.

There are a few factors to consider.  First, look at the size of the trach. Earlier, I mentioned that a bigger trach is better to ventilate the lungs. That's what the medical team cares about. But if a patient is four feet tall and has a number eight Shiley DCT trach, that trach is going to take up a ton of space in the airway. The trachea is only about the width of the knuckle on your pinky finger; it's tiny. So, think about a small person with a huge trach. Yes, it's going to be great for blowing air into the lungs, but not so great for creating an obstruction for air to flow up to the nose and mouth.

In my experience, the patient does much better downsizing and preferably a cuffless trach. If they're not tolerating it, suction, reposition and repeat. When downsizing, know the type of trachs that the doctors usually use. There are some downsides to downsizing, such as an increase in mucus plugging, before capping, there might be a tighter space for breathing and ventilation and the patient may blow out the cuff.  So you want to make sure the patient is off the vent and not going back on, at least not anytime soon.

Secretions

Remember, the trach bypasses natural filtration, humidification, and the ability to moisten the air being provided to the lungs. We want the speaking valve to decrease the secretions by allowing that upper airflow to improve access to the upper airway so the patient is inhaling through the upper airway and getting back all of those natural filtration processes that were lost.

But if a patient still has an open trach, they may be suctioned and are unable to swallow or cough out those secretions at least effectively. If suctioning is the primary source of managing secretions, that is going to irritate the airways even more and cause more secretions. Suctioning causes more suctioning, and it's a vicious cycle.

There are various ways to manage those secretions. Coughing, clearing out, or capping trials to cough and clear out naturally is the best process. But there are nebulizers such as Albuterol to open up the airways and decrease inflammation, Pulmicort to decrease inflammation, and Mucomyst to thin out those secretions. Providing humidity, postural drainage, and chest physiotherapy can also help thin secretions. A Tobramycin inhaler is good to use if there's an infection. A Scopolamine patch should only be used with a doctor's order.  Be sure to document change over time with any of these management options.

Take a Look

We can't treat what we can't see.  Imaging is the best way to assess what's going on with swallowing and the airway. Specifically, FEES is very useful for seeing what the airway looks like after extubation.

Ice Chips

Ice chips are a great way to get a patient to eat and drink again. They're small and compact. They are easy to manipulate, stimulate neuroreceptors, and can facilitate oropharyngeal mobility. If your patient can't tolerate anything else, try small amounts of ice chips to get things moving. Even just a few ice chips a day can help improve secretion management and help remove some thick secretions in the mouth and throat. It's amazing for comfort, pleasure, and quality of life.

Decannulation

What are we considering before decannuation? Before the doctor decides to decannulate a patient, they will make sure the patient has a patent airway. Something we can help with is seeing how the patient is tolerating the speaking valve and capping trials. We can also assist with mentation, with our cognitive assessment, speaking valve tolerance, secretion tolerance, and airway protection. All of these areas can be assessed with our swallow evaluation and monitoring the patient after they've been doing speaking valve and capping trials. We play an important part when it comes to treating, managing, and eventually decannulating a patient with a tracheostomy tube.

Summary

Ultimately, working with patients with trachs is a team effort.  The better our team works together, the more likely our patients can get where they are going. Understanding the risks is vital.  Sometimes, time is the best thing we can offer. Lay low, be conservative, and see how the patient does. Wait until they are fully stable before working with them.

Check their status. Remember that medical trajectory: How is the patient trending? That will help determine if we should start working with them now or if we are interfering with a patient who is already teetering and may decline soon. Perhaps the patient is progressing well and will continue to progress with the use of a speaking valve, ice chips, swallow evaluation, and everything that we can do for the patient.

Finally, know the basics and ask lots of questions. Timing matters. For example, a patient who was just admitted to the facility, just came off of an endotracheal tube, was extubated, and now has a tracheostomy tube and mechanical ventilator a couple of days later, may still be very sick from what they had before. Compare that to a patient who is two or three weeks down the line, much more alert, much stronger after doing rehab, and much more ready for our services.  Not to say that we shouldn't start early, but we need to start when patients are stable and ready for those services because we don't want to be one of the reasons why the patient declined and is having trouble weaning.

Understand the risks and benefits of every clinical decision we make. Even waiting can be a risk or benefit.  We don't want to wait too long and cause the patient to atrophy, get frustrated, and not be able to work towards their goals. There are so many things that we can do. Even the small changes that were discussed earlier like a speaking valve for a few minutes a day and small amounts of ice chips after we've assessed the patient with an instrumental study, are ways that we can get the patient moving in the right direction. And, of course, use a team approach to understand all perspectives and all factors with each patient. 

Questions and Answers

Does the pressure support change depending on how big the patient is or how big the lungs are?

Typically, no, the pressure support is not going to change too much based on the patient's size. The volume is going to change, but the pressure being delivered will be about the same. We may see different levels of volume depending on the patient. A small patient might only have a title volume of 350, whereas a larger patient may have a tidal volume of 500. So it's the volume, not quite the pressure, that's most important there.

I had an inline speaking valve trial where we obtained adequate title volume loss with cuff deflation, but the peak inspiratory pressure did not drop. It actually increased.  Troubleshooting this situation, the patient was suctioned and repositioned, but no change. Would you still place the valve?

So, the tidal volume being provided to the patient and being put back into the ventilator went below 50%. Most of that air now is going through the nose and mouth after the cuff was deflated, but the peak inspiratory pressure did not drop; it actually began to increase. So, there is a problem with back pressure. The patient was probably breath stacking and didn't have adequate space around the tracheostomy tube to get adequate airflow up, even though you saw an adequate drop in the volume; because that pressure is still building, it means that they're not tolerating. So, you might have to wait until the patient's off of the vent or see if they could be placed on a smaller trach with a cuff.

A patient is not tolerating the speaking valve. They have severe dysphagia and very poor secretion tolerance. Would we still change to a cuffless tube or would we deflate the cuff and then see when they are taken off the vent?

First, you can't be changed to a cuffless tube while you're still on the vent. You need that cuff in order to get adequate volume, and you should never deflate the cuff and leave that patient like that for 24 hours. The cuff should only be deflated if we are anticipating the use of a speaking valve. So we deflate the cuff, we monitor the numbers, see if there's adequate upper airway airflow through loss of PIP and loss of PEEP, try the speaking valve. If they're not tolerating, for example, secretion management, we suction, reposition, repeat, whatever it is. But this patient would not be appropriate for a cuffless tube, and it would not be appropriate just to deflate the cuff and leave them like that. You may consider getting a smaller trach. Sometimes, smaller trachs can result in fewer secretions because there's less of an obstruction there, and the use of a speaking valve can help with those secretions as well.

Would trialing a speaking valve be indicated if a patient has vocal cord paralysis?

It depends on where the vocal folds are in that paralysis. Are they open, closed, or midline? If the vocal folds are paralyzed when they're closed, a speaking valve would not be indicated, and the only way to see that would be through a FEES or laryngoscopy from an ENT.

What is breath stacking?

Breath stacking is another word for back pressure. When a patient is placed on a speaking valve or is capped, we have pressure that may build up in the lungs because they're not getting airflow to the upper airway. Think of it as an obstruction to the upper airway, whether it be from a tracheostomy tube that's too big, a cuff that's slightly inflated or inflated by accident, or another obstruction maybe from secretions, a growth, stenosis, or tracheomalacia. There are many reasons why we could have an obstruction. But that air can't get all the way through, and so it stacks, it builds, and that's why we were talking about increased peak inspiratory pressure. The vent is still providing breaths, and it's stacking and getting heavier and heavier to the point that the patient will no longer be able to breathe because they can't exhale. So, back pressure and air stacking are basically the same thing.

Can you walk through the approach you take with a trach patient in a radiologic swallow evaluation that's video fluoroscopy with both cuffed and uncuffed trach? Or do you only use FEES (which we don't have available)?

In my facility, we only use FEES, but you can certainly use videofluoroscopy. Sometimes, SLPs like to do an instrumental with the cuff inflated and deflated. So, you would have the respiratory therapist deflate the cuff and maybe place the speaking valve to see how the patient performs with different types of clinical scenarios.

How often do you use FEES with this patient population to help guide trach weaning?

Any patient that might be able to start eating and drinking, I do a FEES with them. It helps us determine what's going on with the airway if the patient can eat and drink. It also helps the team when determining if they are ready to start capping and providing speaking valve trials. So basically everyone, if I think that they're a candidate.

Are any strengthening exercises relevant for patients on vents?

We can certainly try exercises. We just have to be mindful that the increased use of swallowing on the vent, if the cuff is overinflated, could cause some trauma to the surrounding tissue around the cuff.

I'm a home health SLP with limited trach experience. What questions should I be asking of the caregiver during eval? What goals should be addressed first?

You are going to want to work with your respiratory team and your interdisciplinary team. I haven't worked in home health before, but I'm sure that there's a respiratory therapist who will be working with the patient. You'll want to talk to the pulmonologist and see what the goals are for this patient. Can we try a speaking valve? What kind of trach does the patient have? Would a speaking valve even be appropriate? It's best to determine the goals with the whole interdisciplinary team to see if 1) you can try a speaking valve and 2) you can try PO trials. Could this person be a candidate for an instrumental study to see if we can try any kind of PO?