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Management of Communication and
Swallowing for Adults with
Tracheostomy Tubes
Sally L. Gorski, M.A. CCC
Purpose of Artificial Airways
Provide adequate ventilation and
oxygenation
 Maintain a patent airway
 Eliminate airway obstruction
 Reduce potential for aspiration
 Provide access to the airway for
pulmonary toilet

Endotracheal Intubation
Creating an alteration in the airway:
Translaryngeal
-orally
-nasally
 Transtracheal

Endotracheal Intubation
Creates an artificial airway
 Insertion of a tube into the mouth or
nose
 Passes through the pharynx and vocal
cords
 Need for airway protection
 Need for mechanical ventilation
 Temporary

Intubation Issues
Depends on the route of intubation
 Size of the tube
 Trauma during intubation or selfextubation
 Length of intubation

Complications of Oral Intubation
Trauma to teeth and gums
 Abrasion of the lips, tongue, pharynx
and larynx
 Damage to the vocal folds
 Overinflated cuff
 Hypoxemia
 Rare – damage to the recurrent
laryngeal nerve

Complications of Nasal Intubation
Trauma to nasal passages
 Necrosis may result
 Removal of the tube may cause
epistaxis
 Otitis media and conductive hearing loss
due to mechanical blockage of the
Eustachian tube

Long Term Complications
Stenosis
 Pressure necrosis
 Granuloma – may develop into a polyp
 Persistent hoarseness
 Laryngeal web
 Compromised laryngeal closure and
airway protection

Cricothyroidotomy
Procedure usually performed in an
emergency situation
 Surgical creation of an opening into the
cricothyroid membrane
 May be necessary due to upper airway
obstruction

Tracheostomy
Tracheotomy

The surgical creation of an opening into
the trachea through the neck.

The surgical placement of a plastic or
metal tube into the trachea to create an
airway.
Indications for Tracheostomy
Facilitate weaning from the ventilator
 Bypass an obstruction of the upper
airway
 Facilitate removal of secretions
 Facilitate long-term airway management
 Prevent gross aspiration from the
pharynx or GI tract
 Decreased risk of accidental removal

Procedure – tube choice
Depends on the patient’s ventilation
needs, age, size
 Medical status
 Physician preference
 Institution preference/practice

Procedure - tracheostomy

Placement of the tube above or below
the 2nd and 3rd tracheal ring

Incision type and placement
 Vertical skin incision is most common
 Horizontal skin incision, rarely used today
Risks with Trach placement
Stenosis at the stoma site: 1-8%
 Massive hemorrhage: 1%
 Aspiration of oral secretions
 Pneumothorax
 Incorrect placement of the tube can lead
to cardiorespiratory arrest

Long Term Complications
Tracheal granuloma
 Tracheomalacia
 Tracheal stenosis – assoc with longer
term tracheotomy
 Tracheoesophageal fistula

Percutaneous Trach
Minimally invasive, “simple” technique
 Eliminates a trip to the OR
 Reduced blood loss
 Reduced infection rates (0 to 3.3%) (As
high as 36% in open trach procedure.)
 Stenosis rates range from 0 – 9%
 Performed in the ICU

Complications of Perc Trach
Risk of bleeding
 False passage of the tube
 Infection and tracheal wall injury


Long Term –
 Tracheal granuloma
 Stenosis
 Tracheomalacia
Clinical Conditions – Trach
Obstructive disease; COPD, asthma
 Restrictive disease; ARDS, pneumonia,
scleroderma
 Chest wall disorders; kyphoscoliosis,
chest trauma
 Neuromuscular; ALS, Guillain-Barre’,
muscular dystrophy, post polio
syndrome, multiple sclerosis, SCI

Clinical Conditions - Trach
Upper airway; trauma, tumors, infection
 Respiratory center dysfunction;
sedation, narcotics, anesthesia, CVA,
drug overdose
 Cardiac/circulation; cardiopulmonary
arrest, pulmonary edema, congestive
heart failure

Types of Tubes
Design: Cuffed, uncuffed, TTS cuff,
fenestrated
 Composition: Silicone plastic, metal,
polyvinyl chloride (PVC), etc.
 Manufacturers: Shiley, Portex-Bivona,
Pilling-Weck

Components of a Trach Tube
Neck flange
 Inner & Outer cannula
 Obturator
 Cuff
 Pilot balloon, cuff inflation line
 Plug, cap or button
 Standard length; extra long

The Referral to Speech Path

When to intervene?
-Upon consult from the physician
-While pt is intubated, if awake and alert
-After trach is placed, if awake and alert
-As soon as the patient is
communicative; yes/no head nods,
mouthing, writing, gestures, etc.
The Initial Consult
Review the chart
 Discuss pt’s status with the RN,
physician and the respiratory care
practitioner
 Can pt tolerate cuff deflation?
 Level of ventilatory support
 Secretion status

Passy-Muir Speaking Valve

If the patient can tolerate cuff deflation,
on or off the ventilator, proceed with the
initial trial of the PMV.
Open Tracheostomy Tube

Inflated Cuff
 Breathing in and out through the
tube only
 No airflow through the upper airway
 Lack of vocal production
Open Tracheostomy Tube

Inflated Cuff
 Decreased sense of smell/taste
 Risk of tissue necrosis
 Cuff impingement on esophagus
may cause reflux
Lack of Airway Pressure

Decreases effectiveness
 Patient is unable to mobilize
secretions effectively
 Patient requires more frequent
suctioning
Lack of Airway Pressure

Decreased physiologic PEEP
 Decreased gas exchange due to
reduced surface area of alveoli
 Decreased oxygenation
 Possible atelectasis
Open Position Valves
All other valves are open position valves
 Patient must exhale to close the
diaphragm of the valve
 Secretions travel up the tube and may
occlude the valve
 For communication only

Passy-Muir Valve Design
Closed position, “no leak” design
 Open only during inspiration with
minimal effort
 Closes automatically before the end of
the inspiratory cycle/beginning of the
expiratory cycle

Passy-Muir Valve Design
No air leakage occurs through the PMV
during exhalation
 A column of air is trapped in the PMV
and in the trach tube that inhibits
secretions from entering the tube
 Restores more normal “closed
respiratory system”

Animations courtesy of Passy-Muir Inc. Irvine, CA.
Physiologic Benefits of the PMV
Improved voice production
 Improved sense of smell/taste
 Restoration of normal physiology may
prevent aspiration

 Deflated cuff allows for increased laryngeal
elevation
Physiologic Benefits of the PMV

Restoration of subglottic pressure
facilitates a better swallow and
decreases the risk or aspiration
 Swallow is not only mechanical, but
a pneumatic system as well
 The patient has a more efficient and
effective cough
Physiologic Benefits of the PMV

Improved secretion management
 Improved cough
 Decreased suctioning needs
 Decreased risk of tracheal damage
Patient Selection
Where is the patient?
 What type of trach tube?
 What type of vent?
 Who are your allies?
 Where do you begin?

Team Members

Varies depending on the setting
 Speech-Language Pathologist
 Respiratory Care Practitioner
 Nurse
 Physician
Indications for Use of the
PMV - review
Traumatic Brain Injury
 Spinal Cord Injury
 Chronic Obstructive Pulmonary Disease
 Chest or laryngeal trauma
 Acute Respiratory Distress Syndrome
 Neuromuscular diseases; ALS, MS,
Guillain-Barre’

Contraindications for Use of the
PMV
Unconscious and/or comatose patients
 Inflated cuff on the trach tube
 Foam-filled cuffed trach tube
 Severe airway obstruction
 Severe risk for aspiration
 Severely reduced lung elasticity

Patient Assessment
Medically stable
 Adequate level of alertness
 Ability to handle secretions

 Swallowing status/risk for aspiration
 Viscosity and abundance of
secretions
Patient Assessment

Monitor baseline parameters
 Oxygen saturation
 Heart rate
 Respiratory rate
 Blood pressure
 Breath sounds
Normal Values
Oxygen Saturation: 90-100%
 Respiratory Rate: <28 bpm
 Heart Rate: <120 bpm
 Acid-Base Balance (pH): 7.35-7.45
 Albumin: 3.5-5.5

Ventilator Adjustments

Alarms
-Volume
-Pressure

Compensate for loss of airflow through
vocal cords if necessary
Placement of the PMV Inline
Assess whether the pt can exhale
around the trach tube and through the
upper airway
 Trach tube should be sized for sufficient
airflow around trach tube
 Trach tube cuff may create bulk even in
the deflated condition

Assess for Upper Airway Patency

With the vent dependent patient, deflate
the cuff, let patient adjust his
respirations, encourage the patient to
open mouth slightly and say “ahhh”
when exhaling and encourage a cough
or throat clear.
Placement Guidelines
Suction patient tracheally and orally
 Deflate cuff slowly, allowing patient time
to adjust
 Suction again as necessary
 Encourage pt to clear throat and
expectorate secretions from the oral
cavity
 Place PMV inline with the vent circuit

In-Line Suction Catheter
The Initial Trial – How Long?
Continue to monitor the vital signs;
SaO2 level, RR, HR, etc.
 Is the patient talking?
 Are they breathing comfortably?
 Continue as tolerated

Troubleshooting Issues

Changes in breathing – pt may require
short trials and/or gradual transition

Increased coughing – due to airflow
through upper airways. Remove valve
and reassess
Troubleshooting Issues
Anxiety and fear – educate patient,
reassure patient that feelings or fears
are valid
 Depression or lack of motivation – enlist
family involvement; allow pt to
communicate, perhaps with a chaplain
or psychologist

If Patient is Unable to Exhale:
Remove PMV immediately
 Check trach cuff for complete deflation
 Make sure patient and trach tube are
positioned appropriately
 Repeat suctioning tracheally and orally
 Nasal suctioning may be indicated

If Patient is Unable to Exhale
Assess trach tube size for possible
downsizing
 Consider edema as a factor, try again in
24 hours
 Potential for change to a cuffless trach
 Potential for change to a Bivona trach
with a tight-to-shaft cuff

Educate Staff
When using the Passy-Muir Valve the
cuff must be completely deflated
 Use the warning label provided with the
patient care kit

Trach/Vent Patients
Tracheostomy Cuffs
Bonnano, P.C. (1971)

Difficulty in swallowing results by direct
inhibition of the hyomandibular complex.

This occurs as a result of the
tracheostomy tube anchoring the
trachea to the strap muscles and skin of
the neck.
Cuff Presence and Aspiration

Does not prevent aspiration

Even when the cuff is deflated, can still
be bulky in the trachea
Clinical Dysphagia Exam
Completed in conjunction with nurse or
RT
 Complete an oral mechanism exam
 Preferable to perform the exam with the
cuff deflated to maximize laryngeal
function

Clinical Dysphagia Exam
Preferable to conduct the exam with the
PMV in place
 Prepare consistencies with blue if
available
 Present in small amounts, suction after
each consistency type

Blue Food Coloring

At HCMC:
 Dispensed by the Pharmacy in 1 ml syringes
 Single use amounts
 Used for bedside exams with trach pts and
for FEES exams
 Approved by MDs and PharmDs
Modified Barium Swallow
Study

Considerations:
 Patient has to transport to
Radiology
 Will need RN and RT present if on
the vent
 Additional preparation completed by
the Speech Pathologist
 If pt is tolerating the PMV, place the
PMV during the MBSS
Fiberoptic Endoscopic Evaluation
of Swallowing
Exam can be conducted at the bedside
eliminating the need for transport
 Additional coordination provided by the
Speech Pathologist

Treatment Strategies
Traditional treatment approaches
 May only tolerate frequent, smaller
meals
 May receive primary nutrition/hydration
via an alternative source and have
limited oral intake “for pleasure” or “for
comfort”

Treatment Strategies
Post instructions regarding PMV use
during oral intake
 May need to add blue to food or liquid
items at each meal for several meals

Dysphagia Treatment

Case Study
 J. A., 28 y.o. admitted 3/29 with nausea and
vomiting x4 days
 Intubated for two surgical procedures
 PMHx: pituitary macroadenoma, s/p
resection in 2003
 Extubated 4/5 and referred to Speech
Pathology
Dysphagia Treatment
MBSS completed 4/11, absent swallow
response
 FEES completed 4/24, profound
pharyngeal dysphagia
 Trach placed, PEG placed following the
MBSS

Dysphagia Treatment
Repeated the MBSS 5/31, continued
severe dysphagia, continue NPO
 Pt’s trach is a Jackson, tolerates
plugging
 Dysphagia tx during the month of July

 Base of tongue exercises
 Pharyngeal strengthening exercises
Dysphagia Treatment

Repeat MBSS, 7/26
 Mild dysphagia, start oral intake
 Per ENT, subglottic granulation tissue, so
trach was not immediately removed
 Laser excision of granulation tissue in early
Sept, then decannulated
 PEG removed
 Persistent mild dysphonia secondary to right
TVC paralysis
Case Study
J.B., 42 y.o. admitted 8/16 w/ selfinflicted GSW right below chin
 Perc trach placed on DOA
 Clinical dysphagia exams 8/19 and 8/20
– no evidence of blue in secretions
 Holding on PMV – pt writing/gesturing to
communicate
 8/23 - MBSS

J.B., cont.
Nectar thick and water thin liquid selfpresented via syringe
 Encouraged him to administer 2-4 ml
per swallow
 Good oral control
 Timely pharyngeal response
 No aspiration
 OK for a Fractured Jaw Diet w/ syringe

J.B., MBSS – Aug 23
Case Study
D.K., 51 y.o. male, C5-C6 dislocation w/
resulting quadriplegia after a fall, onset
date 5/18
 ACDF 5/20
 Trach/PEG 5/27
 Discharged to acute rehab
 Outpatient MBSS 8/22. Bivona TTS
trach - capped

D.K., MBSS – Aug 22
D.K., cont.
Results: moderate dysphagia
 Pharyngeal residue
 Penetration with nectar and water
 Trace aspiration with water, delayed
cough
 Advance to Soft Diet, cont nectar thick
liquids

D.K., MBSS – Sep 22
D.K., cont.
Repeat MBSS 9/21/11
 Persistent dysphagia – silent aspiration
of trace amts of water thin liquid
 Advance to Mechanical Soft Diet, cont
nectar thick liquids
 Continue effortful swallow
 Strategy: Swallow, cough hard, swallow
again with all liquids

A.B., MBSS – Mar 23
QUESTIONS?