Communication And Swallowing Management Of Tracheostomized And Ventilator Dependent Adults
Elida Obrian
The scope of this page includes communication and swallowing disorders in patients with tracheostomy tubes or endotracheal tubes (ETTs), both with and without mechanical ventilator dependence, across the life span.
Communication and Swallowing Management of Tracheostomized and Ventilator Dependent Adults
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Speech-language pathologists (SLPs) with appropriate training contribute to the communication and swallow assessment and management of patients with tracheostomy tubes or ETTs, both with and without mechanical ventilator dependence, in cooperation with an interprofessional team.
Patients have diverse experiences in the type and severity of communication and swallowing difficulties due to the wide variety of medical conditions that may necessitate a tracheostomy (with or without mechanical ventilation). Individualized assessment and management require interprofessional collaborative practice. A tracheostomy team may include (but is not limited to) an otolaryngologist, a pulmonologist, a respiratory therapist, nurses, and an SLP.
Tracheostomy tube placement and mechanical ventilator dependence can impact social development in pediatric populations. SLPs may need to make modifications to the environment, patient positioning, and patient handling to improve social interactions. Physical therapy and occupational therapy may be consulted as necessary. SLPs provide counseling and education to family members regarding the developmental status of communication, swallowing, voice, articulation, and related functions as appropriate.
In summary, prolonged weaning from mechanical ventilation constitutes a significant burden in terms of morbidity and mortality in the ICU. Successful liberation of such patients from mechanical ventilation lies in availing a multidisciplinary approach to care in any setting, developing specialist weaning units, and following standard weaning protocols. When working with patients who are being weaned from mechanical ventilation, clinicians must appreciate the interaction between respiration, swallowing, and communication systems. Impairment in these systems is closely linked; and in conjunction with other comorbidities of chronic illness, such as recurrent infections and decreased nutrition, the ventilator weaning process is often challenging. Multidisciplinary teams must work together to facilitate patient recovery and liberation from mechanical ventilation.
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.
We conducted a retrospective case series on patients with COVID-19 who had a tracheostomy. We included patients who had undergone mechanical ventilation for 14 days or longer, had a surgical tracheostomy, been discharged from intensive care to a medical unit, and received PT and SLP referrals. We compiled retrospective data from electronic medical records, analyzing days from tracheostomy to achievement of PT and SLP functional milestones, including mobility, communication, and swallowing. Of six critically ill patients with COVID-19 who had tracheostomy placement at our facility, three met inclusion criteria: patient 1, a 33-year-old woman; patient 2, an 84-year-old man; and patient 3, an 81-year-old man. For all patients, PT interventions focused on breathing mechanics, secretion clearance, posture, sitting balance, and upper and lower extremity strengthening. SLP interventions focused on cognitive reorganization, verbal and nonverbal communication, secretion management, and swallowing function. Intensity and duration of the sessions were adapted according to patient response and level of fatigue.
We found that time to tracheostomy from intubation for the three patients was 23 days, 20 days, and 24 days, respectively. Time from tracheostomy insertion to weaning from ventilator was 9 days for patient 1, and 5 days for patient 2 and patient 3. Regarding time to achieve functional PT and SLP milestones, all patients achieved upright sitting with PT prior to achieving initial SLP milestone of voicing with finger occlusion. Variations in progression to swallowing trials were patient specific and due to respiratory instability, cognitive deficits, and limitations in production of an effortful swallow. Patient participation in therapy sessions improved following establishment of oral verbal communication.
In the intensive care unit (ICU), pulmonary protection mechanisms are usually abnormal,(11 Simonian MA, Goldberg NA. Swallowing disorders in the critical care patient. In: Carrau RL, Murry T. Comprehensive management of swallowing disorders. San Diego: Singular; 1999. p. 363-8) and dysphagia is a common finding.(22 Zielske J, Bohne S, Brunkhorst FM, Axer H, Guntinas-Lichius O. Acute and long-term dysphagia in critically ill patients with severe sepsis: results of a prospective controlled observational study. Eur Arch Otorhinolaryngol. 2014;271(11):3085-93.) Some researchers have investigated an association between oropharyngeal dysphagia and the presence of an endotracheal tube and cuffed tracheostomy(33 Elpern EH, Jacobs ER, Bone RC. Incidence of aspiration in tracheally intubated adults. Heart Lung. 1987;16(5):527-31.
4 DeVita MA, Spierer-Rundback L. Swallowing disorders in patients with prolonged orotracheal intubation or tracheostomy tubes. Crit Care Med. 1990;18(12):1328-30.
5 Elpern EH, Scott MG, Petro L, Ries MH. Pulmonary aspiration in mechanically ventilated patients with tracheostomies. Chest. 1994;105(2):563-6.-66 Tolep K, Getch CL, Criner GJ. Swallowing dysfunction in patients receiving prolonged mechanical ventilation. Chest. 1996;109(1):167-72.) because these patients may present silent tracheal aspiration.(55 Elpern EH, Scott MG, Petro L, Ries MH. Pulmonary aspiration in mechanically ventilated patients with tracheostomies. Chest. 1994;105(2):563-6.
6 Tolep K, Getch CL, Criner GJ. Swallowing dysfunction in patients receiving prolonged mechanical ventilation. Chest. 1996;109(1):167-72.-77 Pannunzio TG. Aspiration of oral feedings in patients with tracheostomies. AACN Clin Issues. 1996;7(4):560-9.) Additionally, during the tracheostomy weaning process, patients may experience difficulty in swallowing saliva, and the likelihood of developing aspiration pneumonia is considerably high.(66 Tolep K, Getch CL, Criner GJ. Swallowing dysfunction in patients receiving prolonged mechanical ventilation. Chest. 1996;109(1):167-72.
7 Pannunzio TG. Aspiration of oral feedings in patients with tracheostomies. AACN Clin Issues. 1996;7(4):560-9.
8 Lima CA, Siqueira TB, Travassos EF, Macedo CM, Bezerra AL, Paiva Júnior MD, et al. Influence of peripheral muscle strength on the decannulation success rate. Rev Bras Ter Intensiva. 2011;23(1):56-61.-99 Hernandez G, Pedrosa A, Ortiz R, Cruz Accuaroni Mdel M, Cuena R, Vaquero Collado C, et al. The effects of increasing effective airway diameter on weaning from mechanical ventilation in tracheostomized patients: a randomized controlled trial. Intensive Care Med. 2013;39(6):1063-70.)
Early speech therapy in the ICU has received growing attention by researchers and clinicians.(1616 Padovani AR, Andrade CR. Perfil funcional da deglutição em unidade de terapia intensiva clínica. einstein (São Paulo). 2007;5(4):358-62.,1717 Padovani AR, Moraes DP, Sassi FC, Andrade CR. Avaliação clínica da deglutição em Unidade de Terapia Intensiva. CoDAS. 2013;25(1):1-7.) A recent study showed that among the 222 patients submitted to a rehabilitation program in an Italian acute care hospital, 14% were referred from the intensive care unit.(1818 Schindler A, Vincon E, Grosso E, Miletto AM, Di Rosa R, Schindler O. Rehabilitative management of oropharyngeal dysphagia in acute care settings: data from a large Italian teaching hospital. Dysphagia. 2008;23(3):230-6.) However, rehabilitation interventions remain uncommon in the management of tracheostomized patients under mechanical ventilation, and studies in this subject are scarce. An Australian retrospective observational study analyzed 140 critically ill patients and reported a 78% incidence of speech-language pathology. The first assessment was performed on average only 14 days after tracheostomy insertion, and the median time to oral intake was 15 days.(1919 Freeman-Sanderson A, Togher L, Phipps P, Elkins M. A clinical audit of the management of patients with a tracheostomy in an Australian tertiary hospital intensive care unit: Focus on speech-language pathology. Int J Speech Lang Pathol. 2011;13(6):518-25.) Some commentaries regarding the relevance of this intervention(2020 Weber B. Eating with a trach. Am J Nurs. 1974;74(8):1439.
21 Weisinger W, Goldsmith T. Artificial ventilation: its impact on communication and swallowing. Probl Respir Care. 1988;1:204-16.
22 Godwin JE, Heffner JE. Special critical care considerations in tracheostomy management. Clin Chest Med. 1991;12(3):573-83. Review.
23 Cowley RS, Swanson B, Chapman P, Kitik BA, Mackay LE. The role of rehabilitation in the intensive care unit. J Head Trauma Rehabil. 1994;9:32-42.
24 Dikeman KJ, Kazandjian MS. Oral communication options. In: Dikeman KJ, Kazandjian MS. Communication and swallowing management of tracheostomized and ventilator-dependent adults. San Diego: Singular; 1995. p. 141-95.
25 Langmore SE. Dysphagia in neurologic patients in the intensive care unit. Semin Neurol. 1996;16(4):329-40.
26 Logemann JA. Evaluation and treatment of swallowing disorders. Texas: Pro-ed; 1998.
27 Murray KA, Brzozowski LA. Swallowing in patients with tracheotomies. AACN Clin Issues. 1998;9(3):416-26; quiz 456-8.
28 Hauck KA. Communication and swallowing issues in tracheostomized/ventilator-dependent geriatric patients. Top Geriatr Rehabil. 1999;15:56-70.
29 Goldsmith T. Evaluation and treatment of swallowing disorders following endotracheal intubation and tracheostomy. Int Anesthesiol Clin. 2000;38(3):219-42.
30 Britton D, Jones-Redmond J, Kasper C. The use of speaking valves with ventilator-dependent and tracheostomy patients. Curr Opin Otolaryngol Head Neck Surg. 2001;9:147-52.
31 Conway D, Parker C. Should we allow ventilated patients with a tracheostomy to eat and drink? Hosp Med. 2004;65(12):764.-3232 Ward E, Jones C, Solley M, Cornwell P. Clinical consistency in tracheostomy management. J Med Speech Lang Pathol. 2007;15(1):7-26.) and some case reports have been published.(3333 Tippett DC, Siebens AA. Using ventilators for speaking and swallowing. Dysphagia. 1991;6(2):94-9.
34 Siebens AA, Tippett DC, Kirby N, French J. Dysphagia and expiratory air flow. Dysphagia. 1993;8(3):266-9.
35 Phelan BA, Cooper DA, Sangkachand P. Prolonged mechanical ventilation and tracheostomy in the elderly. AACN Clin Issues. 2002;13(1):84-93.-3636 Antunes MF, Santos AM, Santos JS, Vecina AL, Coronatto AG, Ferreira OB, et al. Uso da válvula de fonação em paciente traqueostomizado dependente de ventilação mecânica na UTI de um hospital privado: relato de caso. Rev Bras Ter Intensiva. 2006;18 Supl:76.) However, there is a lack of information on swallowing rehabilitation outcomes in prospective studies that address the effectiveness of swallowing function or the feasibility of reintroducing an oral diet during mechanical ventilation.