Evidence-Based Swallowing Related
Issues in Patients with
Tracheotomy Tubes
Steven B. Leder, Ph.D.
Yale University School of Medicine
Debra M. Suiter, Ph.D.
University of Memphis
Impetus
Swallowing Rx with Head and Neck
Cancer Patients with Postoperative
Tracheotomy
Diagnostic Therapy
„
Intra-oral examination
„
Appropriate bolus consistency and placement
„
Cover tracheotomy tube (or open site) with a finger
„
Swallow with tracheotomy tube (or open site) occluded
„
Other compensatory strategies: Head position, posture
Findings
No pattern of success or failure noted re:
incidence of aspiration and tracheotomy
tube or tracheostoma occlusion status
Literature
„
Kremen AJ. Cancer of the tongue. Surgery 30:227-240,
1951
Case Study - Dysphagia resolved with
decannulation.
„
Betts RH. Post-tracheotomy aspiration. N Eng J Med
273:155, 1965
Ltr. To Ed. – Anecdotal experience & attribute
dysphagia due to inflated tracheotomy tube cuff
impinging on esophagus.
Literature (Con’t)
„
Feldman SA et al. Disturbance of swallowing
after tracheotomy. Lancet 1:954-955, 1966
Case Reports (3) – Attribute dysphagia to
either desensitization of larynx due to
diversion of the normal air flow through
the tracheotomy or fixation of the larynx by
the tracheotomy.
Literature (Con’t)
„
Bonanno PC. Swallowing dysfunction after
tracheotomy. Ann Surg 174:29-33, 1971
N = 43 and only 3/43 (7%) exhibited
dysphagia due to diminution of the
elevation and anterior rotation of the larynx,
not from compression of the esophagus.
No statistical treatment of the data.
Laryngeal Tethering & Cuff Status
„
No definitive research to demonstrate that a
tracheotomy and placement of a tracheotomy
tube impairs hyolaryngeal movement.
„
No definitive research to demonstrate that a
tracheotomy tube cuff impinges on the
esophagus to cause “spillover” aspiration.
Tracheotomy Tube Cuff
„
„
Bone DK et al. Aspiration pneumonia. Ann Thoracic
Surg 18:3-37, 1974
High volume, low pressure cuff prevented
aspiration.
Pinkus NB. Dangers of feeding with cuffed
tracheostomy tubes. Med J Aust 1:1238-1240, 1973
High volume, low pressure cuffs do not
prevent aspiration.
Trach. Tube Cuff (Con’t)
„
Pavlin EG et al. Failure of high-compliance lowpressure cuff to prevent aspiration. Anesthesiology
42:216-219, 1975
Does not prevent aspiration (dog model).
„
Ding R. & Logemann JA. Swallow physiology in
patients with trach cuff inflated or deflated: a
retrospective study. Head & Neck 27:809-813, 2005
Trach. Tube Cuff (Con’t)
„
„
Results: Reduced laryngeal elevation and silent
aspiration were significantly higher in the cuffinflated v. cuff-deflated condition.
Significant swallow physiology changes also
found among various medical diagnostic
categories
Trach. Tube Cuff (Con’t)
„
„
„
BUT
It was not possible to assess swallow physiology
in the same subject in both cuff-inflated and
cuff-deflated conditions.
Only by doing this can the effect of cuff
inflation status on swallow physiology be
determined.
Trach. Tube Cuff (Con’t)
„
„
It may well be that the more seriously ill patients
required cuff inflation for ventilatory purposes.
Therefore it may not be cuff status but the more
debilitating medical condition (Leder et al., 2005;
Donzelli et al., 2005) that resulted in the
reported reduced elevation during swallowing.
Trach. Tube Cuff (Con’t)
„
What is of interest, and not reported, is whether
reduced laryngeal elevation resulted in increased
incidence of aspiration (!).
Trach. Tube Cuff (Con’t)
„
Cameron et al. Aspiration in patients with
tracheotomies. Surg Gynecol Obstet 136:68-70,
1973
Inflated cuff had no effect on incidence of
aspiration.
Blue Dye: Cameron et al.
„
„
„
Most widely cited tracheotomy and aspiration
study, but significant design flaws.
METHODS: 4 drops blue dye on tongue q4h
Routine suctioning
+ blue dye = aspiration
RESULTS: 69% tracheotomized patients
aspirated v. 0% endotracheal tube patients
Blue Dye (Con’t)
Design Flaws:
„
„
1. TIME: Tracheotomy: 1-28 DAYS
Endotracheal Tube: 8-30 HOURS
2. METHODS: 1 drop blue dye every 4
hours up to 48 hours (when possible).
Blue Dye (Con’t)
„
3. Subjects: About 50% with tracheotomy had
neurological or trauma etiology v. 0% with ETT.
a. Neurological or trauma increase aspiration
risk (Gilbert et al. Ann Otol Rhinol Laryngol
96:561-564, 1987; Leder et al. Dysphagia 13:208212, 1998; Leder J Head Trauma Rehab 14:448453, 1999).
Blue Dye (Con’t)
„
4. Therefore, time, methods, and subject
differences confound the findings.
Laryngeal Sensation
„
Sasaki CT et al. Laryngeal abductor activity in
response to varying ventilator resistance. Trans
Am Acad Ophthalmol Otolaryngol 77:403-410, 1973.
PCA activity decreases (1 wk)/stops (4 wks)
with decrease in airway resistance, i.e.,
bypassing upper airway with a tracheotomy.
Need to “wean” patient off trach. to prevent
inspiratory stridor.
Laryngeal Sensation (Con’t)
„
Sasaki CT et al. Effect of tracheostomy on the
laryngeal closure reflex. Laryngoscope 87:14281432, 1977.
Chronic (6-8 months) upper airway bypass
alters reflex glottic closure, i.e., decreases in
strength and sensitivity (erratic & delayed)
but not abolished.
(dog model)
Tracheotomy and Aspiration
„
Dysphagia persists after decannulation.
DeVita MA et al. Swallowing…prolonged
trach. tubes. Crit Care Med 18:1328-1330, 1990
„
Dysphagia resolves with continued tracheotomy use.
Tolep et al. Swallowing…prolonged mechanical
ventilation. Chest 109:167-172, 1996;
Leder SB. Serial FEES evaluations… Arch Phys Med
Rehabil 79:1264-1269, 1998
Causes Oropharyngeal Dysphagia
„
„
„
„
„
Shaker et al. Coordination of deglutitive glottic
closure with…swallowing. Gastroenterology
98:1478-1484, 1990
Premature spillage (weak/delayed swallow)
Abnormal coordination of oropharyngeal
motility (tongue, pharynx, larynx movement)
Abnormal glottic closure
Residue due to ineffective bolus transport
Causes (Con’t)
Logemann JA. Aspiration in head & neck
surgical patients. Ann Otol Rhinol Laryngol 94:373376, 1985.
(No mention of tracheotomy status - assume
decannulated)
„ Multiple causes for aspiration
„ Before, During, After the swallow : Alone or in
combination
„
Variability and Compensation
„
Patients are variable
Dx, medical condition, mental status, age
„
Swallowing mechanism is complex allowing for
redundancy in the system which permits some
behaviors to compensate for impaired
behaviors.
H.L. Mencken
“For every complex question
there is a solution that is simple,
neat, and wrong.”
Coincidence
„
„
Def.: A surprising concurrence of events,
perceived as meaningfully related, with no
apparent causal connection, i.e. pure
happenstance.
However, just by merely noticing a coincidence,
we elevate it to something that transcends its
definition of pure chance.
(Belkin L. Coincidence in an age of conspiracy.
NYTimes Mag. 08/11/02)
Coincidence (Con’t)
„
„
„
Literature reports high percentages of aspiration
associated with tracheotomy (>50%).
But so many tracheotomies would not be
performed if this was true. Actually, the vast
majority of patients swallow well post-trach.,
you just remember the ones that do not.
Must consider the study population and
remember phenomenon of coincidence.
Causality
„
„
„
Causality is involved when the occurrence of 1 event is
reason enough to expect the production of another.
Specific to the current issue, a causal relationship exists
when a tracheotomy is a sufficient condition for the
occurrence of aspiration.
Therefore, if the effect (aspiration) occurs before its
cause (tracheotomy) a causal relationship does not exist
(Heise DR, Causal Analysis, John Wiley, NY, 1975).
Causality (Con’t)
„
„
„
„
„
Do tracheotomy tubes cause aspiration?
Do patients prone to aspirate get trach. tubes?
Do patients who already aspirate get trach.
tubes?
Fundamental flaw in the literature was that no
pre-tracheotomy aspiration data were reported.
Why?: Too sick for a swallow evaluation;
Already orally intubated.
Causality (Con’t)
„
Leder SB & Ross DA. Causal relationship
between tracheotomy and aspiration. Laryngoscope
110:641-644, 2000.
„
Results: 19/20 (95%) patients exhibited the
same aspiration status before and after
tracheotomy, i.e., 12/12 aspirated pre/post. and
7/8 no aspiration pre/post-tracheotomy.
Causality (Con’t)
„
Conclusion: No causal relationship between
tracheotomy and aspiration status was exhibited.
„
Aspiration due to other causes (Shaker et al.
1990; Logemann, 1985; Leder, In Press).
Tracheotomy Occlusion
Literature reveals that a fundamental problem
is subject selection criteria.
„ Subject selection may account for reported
differences in aspiration results based on
tracheotomy tube occlusion status.
„
Trach. & Occlusion (Con’t)
„
Specifically, subjects aspirated both liquid
and puree consistencies 100% of the time and no
change in aspiration based on occlusion status of
tracheotomy tube.
(Leder et al., Dysphagia 11:254-258,1996; Dysphagia
13:167-171,1998; Dysphagia 14:73-33, 1999;
Dysphagia 16:79-82, 2001)
Versus…
Trach. & Occlusion (Con’t)
„
Variable pattern of aspiration for liquid and
puree consistencies.
(Dettelbach et al., Head Neck 17:297302,1995; Eibling et al., Ann Otol Rhinol
Laryngol 105:253-258, 1996; Elpern et
al., Passy-Muir valve and aspiration… J
Acute Crit Care 29:287-293, 2000)
Trach. & Occlusion (Con’t)
Cuff deflation and 1-way speaking valve
„ Pen-Asp Scale scores not affected by cuff status
„ Pen-Asp scores reduced with valve for liquid
boluses only
„ But valve use increased laryngeal penetration (?)
„ Valve no affect on duration measures or extent
of hyolaryngeal movement
(Suiter et al. Dysphagia 18:284-292, 2003)
„
Trach. & Occlusion (Con’t)
Variable pattern of aspiration:
„
„
Requires greater number of swallows with
tracheotomy tube occluded/unoccluded to find
significant differences.
Requires an explanation as to why the variability
occurs.
Questions
„
„
„
„
„
What is the clinical significance of “less
aspiration”? (Dettelbach et al.)
Does volume matter?
Does consistency matter?
Is one swallow clinically important?
Above refer to scintigraphy (Muz et al., Am J
Otolaryngol 10:282-286, 1989; Head Neck 16:1720, 1994; Stachler et al., Laryngoscope 106:231234,1996)
Questions (Con’t)
„
„
„
Increased subglottic air pressure key to
swallowing success (Eiblilng & Gross, 1996)
BUT
True vocal folds adducted during swallowing
(Shaker et al., 1990).
Unilateral vocal fold paralysis does not result in
aspiration in majority of patients. (Heitmiller et
al. Dysphagia 15:184-187, 2000; Leder & Ross,
Dysphagia 20:163-167,2005).
Questions (Con’t)
„
„
Glottic Closure facilitated by:
Negative intrathoracic pressure;
Glottic Closure inhibited by:
Positive intrathoracic pressure (i.e., increased
subglottic pressure).
(Ikari & Sasaki. Glottic closure reflex: control
mechanisms. Ann Otol 89:220-224, 1980)
Ventilator Dependency &
Swallowing
„ Leder SB. Incidence and type of aspiration
in acute care patients requiring mechanical
ventilation via a new tracheotomy.
Chest 122:1721-1726, 2002
Vent. Dep. & Swallowing (Con’t)
„
„
N = 52 adults
28 men (mean 58 yrs.; range 19-83 yrs.)
24 women (mean 70 yrs.; range 53-87 yrs.)
FEES used to determine incidence and type of
aspiration
Overt v. Silent aspiration
Vent. Dep. & Swallowing (Con’t)
Results:
„
„
„
„
„
35/52 (67%) did not aspirate
17/52 (33%) aspirated
14/17 (82%) who aspirated = silent aspiration
Aspirators were significantly older (73 v. 59 yrs.)
Aspirators were post-tracheotomy for sig. less
time than non-aspirators (14 v. 23 days)
Vent. Dep. & Swallowing
Conclusions:
„
„
„
Two thirds swallowed successfully
Aspiration mostly silent
Need to consider age, number days posttracheotomy, functional reserve, and clinical
judgment of recovery rate prior to swallow
evaluation
Vent. Dep. & Swallowing (Con’t)
„
Swallowing success will occur most frequently:
In patients < 70 years of age;
At approximately 3 weeks posttracheotomy in
patients > 70 yeas of age;
At approximately 1 week posttracheotomy in
patients < 70 years of age; and
In conjunction with improving medical and
respiratory status.
Tracheotomy In/Out
Presence of a Tracheotomy Tube and Aspiration
Status in Early, Post-Surgical Head and Neck
Cancer Patients
Leder et al., Head & Neck, 27:757-761, 2005
Tracheotomy In/Out
„
„
N = 22 (17M/5F)
Conditions:
1. Trach. tube present;
2. Trach. tube removed and tracheostoma
covered by gauze sponge;
3. Trach. tube removed and tracheostoma left
open and uncovered.
Tracheotomy In/Out
„
„
„
For all 3 conditions:
FEES
Endoscope inserted into tracheostoma to view
distal trachea to carina
Tracheotomy In/Out
„ Results
„
Aspiration Status: 100% agreement between
FEES and tracheostoma examination
13/22 (59%) swallowed successfully
9/22 (41%) aspirated
Tracheotomy In/Out
„ Results (con’t)
„
Aspiration Status: 100% agreement for 3
conditions:
1. Trach. tube present;
2. Trach. tube removed and tracheostoma
covered by gauze sponge;
3. Trach. tube removed and tracheostoma
left open and uncovered.
Tracheotomy In/Out
„ Conclusions
„
„
„
„
Aspiration status not affected by tracheotomy
tube or decannulation.
Clinical impressions of increased aspiration/risk
with tracheotomy tube not supported.
Pre-trach. co-morbidities predispose aspiration
Aspiration/risk due to critical illness that
necessitated the tracheotomy in the first place.
Tracheotomy In/Out
Effects of the Removal of the Tracheotomy Tube
on Swallowing During the Fiberoptic
Endoscopic Exam of the Swallow (FEES)
Donzelli et al., Dysphagia 20:283-289, 2005
Tracheotomy In/Out
„
„
„
N = 37 (23M/14F)
Location: Rehabilitation hospital
Conditions:
1. Trach. tube present;
2. Trach. tube removed and tracheostoma
covered by gauze sponge;
3. Trach. tube removed and tracheostoma left
open and uncovered.
Tracheotomy In/Out
„
„
„
For all 3 conditions:
FEES
Endoscope inserted into tracheostoma to view
distal trachea to carina
Tracheotomy In/Out
„
„
„
Results
Removal of tracheotomy tube did not alter
swallowing function, i.e., incidence of laryngeal
penetration or aspiration
Clinical notion that swallowing will improve
following decannulation is not supported