FREE WATER PROTOCOL INFORMATION

The placement of a tracheostomy tube creates an artificial airway, which while essential for pt’s medical management, can lead to several physiological changes, which can affect the safety of the swallow. Studies have found the incidence of aspiration associated with trachs to be 67%-87%. Lack of airflow through the upper airway results in a reduction in taste and smell, reduced sensation in the oropharynx, decreased awareness of secretions and poor secretion management. Increase in secretions is noted as the body reacts to the trach as a foreign object. Donzelli et al. (2006) revealed a significant positive correlation between high secretion levels and a greater incidence of penetration and aspiration. Furthermore, they found the secretion level predicts aspiration. The presence of the trach below the vocal folds results in a lack of sub-glottic air pressure. Reduced laryngeal excursion is also documented, possibly due to tethering by the trach.

Addressing the trach status prior to initiation of PO trials

An inflated cuff is required when a pt is on mechanical ventilation. Research has found dysphagia to be more severe with inflated cuffs. Weaning from cuff inflation with mechanical ventilation to a deflated cuff with or without a one way speaking valve is suggested prior to PO trials. Davis et al. (2002) researched the relationship between the cuff status and aspiration of feedings. The study revealed, “when the cuff was inflated, the aspiration rate was 2.7 times higher.” Also, Ding and Logemann (2005) found reduced laryngeal elevation and silent aspiration to be significantly more prevalent with patients with an inflated cuff vs a deflated cuff. Further more, they speculated, “that an inflated cuff blocks the expiratory air flow through the larynx which results in decreased sensitivity for detecting aspiration.”

Cuff Deflation

Cuff deflation will allow airflow through the pharynx as this creates a pathway for air to escape past the trach and into the pharyngeal, oral, and nasal cavities. Increased hyo-laryngeal elevation and excursion, improved sensation, presence of subglottic pressure, and reduction of secretions are a few positive affects of cuff deflation. Full cuff deflation should not be performed by SLP alone as Physician clearance and the presence of a Respiratory Therapist are required.

Weaning Protocol:

(Windhorst, 2009)

Initial Cuff Deflation: The pt may require tracheal and oral suction for management of secretions. Cuff deflation must be achieved prior to initiation of PO trials (Dikeman, 1995)

Placement of the One-Way Speaking Valve: SLP can evaluate speech, voice, and swallow at this level

Valve Toleration: Pt wears one way speaking valve for increasing amounts of time

Tracheostomy Cap Trials: Pt is able to tolerate one-way speaking valve and has the goal of decannulation

One Way Speaking Valve

One way speaking valves are trialed and placed when the pt is able to tolerate a deflated cuff. The pt is able to inhale through the trach/valve and exhale through their mouth/nose. Dettelbach et al. (1995) hypothesized that the use of a Passy-Muir Valve (PMV) may restore more normal subglottic and glottic air flow and reduce aspiration. The study found a reduction or elimination in aspiration in all participants (11 patients with tracheostomy and known aspiration) when PMV was placed in comparison with an unvalved tube. In addition to the positive effects one-way speaking valves have on dysphagia they also reduce secretions as pressures begin to normalize.

The Blue Dye Test

A blue dye test involves staining saliva, liquids, and foods and the use of suction by a nurse or a trained respiratory therapist to detect aspiration. Donzelli et al. (2001) investigated the reliability of detection of aspiration with Modified Evans Blue Dye Tests (MEBD) when compared with video nasal endoscopic examination of the swallow (VEES). The study revealed a 50% false-negative error rate with the MEBD when compared with the VEES. Furthermore, the MEBD failed to detect trace aspiration. Peruzzi et al. (2001) investigated the reliability of a bedside colored dye assessment by comparing the results with a videofluoroscopic study. The results of the study revealed that “the videofluoroscopic study detected a significantly greater frequency of aspiration than the colored dye test” and therefore indicated a more sophisticated method of determining aspiration should be considered when making decisions regarding aspiration and PO intake.

References:

Davis, D.G., Bears, S., Barone, J.E., Corvo, P.R., & Tucker, J.B. (2002). Swallowing with a tracheostomy tube in place: Does cuff inflation matter? Journal of Intensive Care Medicine, 17(3), 132-135.

Dettelbach, M.A., Gross, R.D., Mahlmann, J., & Eibling, D.E. (1995). Effects of the passy-muir valve on aspiration in patients with tracheostomy. Head and Neck, 17(4), 297-302.

Dikeman, K.J., & Kazandjian, M.S. (1995). Communication and swallowing management. Albany, NY: Delmar.

Ding, R. & Logemann, J. (2005). Swallow physiology in patients with trach cuff inflated or deflated: a retrospective study. Head and Neck, 27(9), 809-813.

Donzelli, J., Brady, S., Wesling, M., & Craney, M. (2001). Simultaneous modified Evans blue dye test procedure and video nasal endoscopic evaluation of the swallow. Laryngoscope, 111(10), 1746-50.

Donzelli, J., Brady, S., Wesling, M., & Theisen, M. (2006). Secretions, occlusion status, and swallowing in patients with a tracheostomy tube: a descriptive study. Ear, Nose, and Throat Journal, 85(12), 831-834.

Peruzzi, W.T., Logemann, J.A., Currie, D., & Moen, S.G. (2001). Assessment of aspiration in patients with tracheostomies: comparison of the bedside colored dye assessment with videofluoroscopic examination. Respiratory Care, 46(3), 243-7.

Swigert, N. B. (2003, March 18). Blue Dye in the Evaluation of Dysphagia: Is It Safe?. The ASHA Leader.

Windhorst, C., Harth, R. & Wagoner, C. (2009, January 20). Patients Requiring Tracheostomy and Mechanical Ventilation : A Model for Interdisciplinary Decision-Making. The ASHA Leader.