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Raynor EM, Wohl D. Tracheostomy-Related Swallowing Issues in Children. Otolaryngol Clin North Am 2024:S0030-6665(24)00030-6. [PMID: 38508881 DOI: 10.1016/j.otc.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024]
Abstract
Children with tracheostomies have multiple challenges with respect to achieving normal deglutition. These children may have underlying neurologic or genetic conditions that can predispose to dysphagia, but even in children without underlying comorbidities, the presence of a tracheostomy tube impacts the mechanics of swallowing, leading to difficulty with different consistencies as well as management of normal oral secretions. Intubation prior to tracheostomy also impacts sensation in the upper aerodigestive tract increasing the risk of aspiration. Occlusion of the tracheostomy with a speaking valve or cap improves outcomes in swallow and prognosis for oral feeding.
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Affiliation(s)
- Eileen M Raynor
- Department of Head and Neck Surgery & Communication Sciences, Duke Health System, DUMC Box 3805, Durham, NC 27710, USA.
| | - Daniel Wohl
- Pediatric Otolaryngology Associates, 4114 Sunbeam Road, Jacksonville, FL 32257, USA
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2
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Baijens LWJ, Walshe M, Aaltonen LM, Arens C, Cordier R, Cras P, Crevier-Buchman L, Curtis C, Golusinski W, Govender R, Eriksen JG, Hansen K, Heathcote K, Hess MM, Hosal S, Klussmann JP, Leemans CR, MacCarthy D, Manduchi B, Marie JP, Nouraei R, Parkes C, Pflug C, Pilz W, Regan J, Rommel N, Schindler A, Schols AMWJ, Speyer R, Succo G, Wessel I, Willemsen ACH, Yilmaz T, Clavé P. European white paper: oropharyngeal dysphagia in head and neck cancer. Eur Arch Otorhinolaryngol 2020; 278:577-616. [PMID: 33341909 PMCID: PMC7826315 DOI: 10.1007/s00405-020-06507-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022]
Abstract
Purpose To develop a European White Paper document on oropharyngeal dysphagia (OD) in head and neck cancer (HNC). There are wide variations in the management of OD associated with HNC across Europe. Methods Experts in the management of specific aspects of OD in HNC across Europe were delegated by their professional medical and multidisciplinary societies to contribute to this document. Evidence is based on systematic reviews, consensus-based position statements, and expert opinion. Results Twenty-four sections on HNC-specific OD topics. Conclusion This European White Paper summarizes current best practice on management of OD in HNC, providing recommendations to support patients and health professionals. The body of literature and its level of evidence on diagnostics and treatment for OD in HNC remain poor. This is in the context of an expected increase in the prevalence of OD due to HNC in the near future. Contributing factors to increased prevalence include aging of our European population (including HNC patients) and an increase in human papillomavirus (HPV) related cancer, despite the introduction of HPV vaccination in various countries. We recommend timely implementation of OD screening in HNC patients while emphasizing the need for robust scientific research on the treatment of OD in HNC. Meanwhile, its management remains a challenge for European professional associations and policymakers.
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Affiliation(s)
- Laura W J Baijens
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, Maastricht, The Netherlands. .,GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Margaret Walshe
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
| | - Leena-Maija Aaltonen
- Department of Otorhinolaryngology, Head and Neck Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Christoph Arens
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Magdeburg, Otto-von-Guericke University, Magdeburg, Germany
| | - Reinie Cordier
- Department of Special Needs Education, University of Oslo, Oslo, Norway.,School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Perth, Australia
| | - Patrick Cras
- Department of Neurology, Born Bunge Institute, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Lise Crevier-Buchman
- Voice, Speech, Swallowing Lab, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital UVSQ and Research lab CNRS-UMR7018, Hôpital Foch, Suresnes, France
| | - Chris Curtis
- Swallows Head and Neck Cancer Charity, Blackpool, UK
| | - Wojciech Golusinski
- Department of Head and Neck Surgery, The Greater Poland Cancer Centre, Poznan University of Medical Sciences, Poznan, Poland
| | - Roganie Govender
- Head and Neck Cancer Centre, University College London Hospital, London, UK
| | - Jesper Grau Eriksen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Kevin Hansen
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | - Kate Heathcote
- Robert White Centre for Airway, Voice and Swallow, Poole Hospital NHS Foundation Trust, Dorset, UK
| | - Markus M Hess
- Deutsche Stimmklinik, Hamburg, Germany.,Departement of Voice, Speech and Hearing Disorders, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sefik Hosal
- Department of Otolaryngology, Head and Neck Surgery, Faculty of Medicine, Atılım University, Medicana International Ankara, Ankara, Turkey
| | - Jens Peter Klussmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | - C René Leemans
- Department of Otolaryngology, Head and Neck Surgery, Amsterdam University Medical Centres, Vrije Universiteit, Amsterdam, The Netherlands.,Cancer Center Amsterdam, Amsterdam University Medical Centres, Vrije Universiteit, Amsterdam, The Netherlands
| | - Denise MacCarthy
- Division of Restorative Dentistry and Periodontology, Faculty of Health Sciences, Trinity College Dublin, Dublin Dental University Hospital, Dublin, Ireland
| | - Beatrice Manduchi
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
| | - Jean-Paul Marie
- Department of Otorhinolaryngology, Head and Neck Surgery, Rouen University Hospital, Rouen, France
| | - Reza Nouraei
- Department of Ear Nose and Throat Surgery, The Robert White Centre for Airway Voice and Swallowing, Poole Hospital NHS Foundation Trust, University of Southampton, Southampton, UK
| | - Claire Parkes
- Department of Speech and Language Therapy, St. James's Hospital, Dublin, Ireland
| | - Christina Pflug
- Departement of Voice, Speech and Hearing Disorders, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Walmari Pilz
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,MHeNs School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Julie Regan
- Department of Clinical Speech and Language Studies, Trinity College Dublin, Dublin, Ireland
| | - Nathalie Rommel
- Department Neurosciences, Experimental Otorhinolaryngology, Deglutology, University of Leuven, Leuven, Belgium
| | - Antonio Schindler
- Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy
| | - Annemie M W J Schols
- Department of Respiratory Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Renee Speyer
- Department of Special Needs Education, University of Oslo, Oslo, Norway.,School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Perth, Australia.,Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Centre, Leiden, The Netherlands.,Faculty of Health, School of Health and Social Development, Victoria, Australia
| | - Giovanni Succo
- Head and Neck Oncology Service, Candiolo Cancer Institute, FPO - IRCCS, Candiolo, TO, Italy.,Department of Oncology, University of Turin, Orbassano, TO, Italy
| | - Irene Wessel
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anna C H Willemsen
- GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Respiratory Medicine, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands.,Division of Medical Oncology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Taner Yilmaz
- Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Pere Clavé
- Gastrointestinal Physiology Laboratory, Hospital de Mataró, Universitat Autònoma de Barcelona, Mataró, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
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3
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Dawson C, Riopelle SJ, Skoretz SA. Translating Dysphagia Evidence into Practice While Avoiding Pitfalls: Assessing Bias Risk in Tracheostomy Literature. Dysphagia 2020; 36:409-418. [PMID: 32623527 DOI: 10.1007/s00455-020-10151-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 06/20/2020] [Indexed: 11/29/2022]
Abstract
Critically ill patients who require a tracheostomy often have dysphagia. Widespread practice guidelines have yet to be developed regarding the acute assessment and management of dysphagia in patients with tracheostomy. In order for clinicians to base their practice on the best available evidence, they must first assess the applicable literature and determine its quality. To inform guideline development, our objective was to assess literature quality concerning swallowing following tracheostomy in acute stages of critical illness in adults. Our systematic literature search (published previously) included eight databases, nine gray literature repositories and citation chasing. Using inclusion criteria determined a priori, two reviewers, blinded to each other, conducted an eligibility review of identified citations. Patients with chronic tracheostomy and etiologies including head and/or neck cancer diagnoses were excluded. Four teams of two reviewers each, blinded to each other, assessed quality of included studies using a modified Cochrane Risk of Bias tool (RoB). Disagreements were resolved by consensus. Data were summarized descriptively according to study design and RoB domain. Of 6,396 identified citations, 74 studies met our inclusion criteria. Of those, 71 were observational and three were randomized controlled trials. Across all studies, the majority (> 75%) had low bias risk with: participant blinding, outcome reporting, and operationally defined outcomes. Areas requiring improvement included assessor and study personnel blinding. Prior to translating the literature into practice guidelines, we recommend attention to study quality limitations and its potential impact on study outcomes. For future work, we suggest an iterative approach to knowledge translation.
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Affiliation(s)
- Camilla Dawson
- School of Audiology and Speech Sciences, University of British Columbia, 2177 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, Great Britain, UK
| | - Stephanie J Riopelle
- School of Audiology and Speech Sciences, University of British Columbia, 2177 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Stacey A Skoretz
- School of Audiology and Speech Sciences, University of British Columbia, 2177 Wesbrook Mall, Vancouver, BC, V6T 1Z3, Canada. .,Department of Critical Care Medicine, University of Alberta, 2-124 Clinical Sciences Building 8440-112 ST NW, Edmonton, AB, T6G 2B7, Canada. .,Centre for Heart Lung Innovation, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada. .,University of Alberta Hospitals, 8440 112 St NW, Edmonton, AB, T6G 2B7, Canada.
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A Systematic Review of Tracheostomy Modifications and Swallowing in Adults. Dysphagia 2020; 35:935-947. [PMID: 32377977 PMCID: PMC7202464 DOI: 10.1007/s00455-020-10115-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 04/15/2020] [Indexed: 01/21/2023]
Abstract
Dysphagia occurs in 11% to 93% of patients following tracheostomy. Despite its benefits, the tracheostomy often co-exists with dysphagia given its anatomical location, the shared pathway of the respiratory and alimentary systems, and the medical complexities necessitating the need for the artificial airway. When tracheostomy weaning commences, it is often debated whether the methods used facilitate swallowing recovery. We conducted a systematic review to determine whether tracheostomy modifications alter swallowing physiology in adults. We searched eight electronic databases, nine grey literature repositories and conducted handsearching. We included studies that reported on oropharyngeal dysphagia as identified by instrumentation in adults with a tracheostomy. We accepted case series (n > 10), prospective or retrospective observational studies, and randomized control trials. We excluded patients with head and neck cancer and/or neurodegenerative disease. Two independent and blinded reviewers rated abstracts and articles for study inclusion. Data abstraction and risk of bias assessment was conducted on included studies. Discrepancies were resolved by consensus. A total of 7079 citations were identified, of which, 639 articles were reviewed, with ten articles meeting our inclusion criteria. The studies were heterogeneous in study design, patient population, and outcome measures. For these reasons, we presented our findings descriptively. All studies were limited by bias risk. This study highlights the limitations of the evidence and therefore the inability to conclude whether tracheostomy modifications alter swallowing physiology.
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Skoretz SA, Riopelle SJ, Wellman L, Dawson C. Investigating Swallowing and Tracheostomy Following Critical Illness: A Scoping Review. Crit Care Med 2020; 48:e141-e151. [PMID: 31939813 DOI: 10.1097/ccm.0000000000004098] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Tracheostomy and dysphagia often coexist during critical illness; however, given the patient's medical complexity, understanding the evidence to optimize swallowing assessment and intervention is challenging. The objective of this scoping review is to describe and explore the literature surrounding swallowing and tracheostomy in the acute care setting. DATA SOURCES Eight electronic databases were searched from inception to May 2017 inclusive, using a search strategy designed by an information scientist. We conducted manual searching of 10 journals, nine gray literature repositories, and forward and backward citation chasing. STUDY SELECTION Two blinded reviewers determined eligibility according to inclusion criteria: English-language studies reporting on swallowing or dysphagia in adults (≥ 17 yr old) who had undergone tracheostomy placement while in acute care. Patients with head and/or neck cancer diagnoses were excluded. DATA EXTRACTION We extracted data using a form designed a priori and conducted descriptive analyses. DATA SYNTHESIS We identified 6,396 citations, of which 725 articles were reviewed and 85 (N) met inclusion criteria. We stratified studies according to content domains with some featuring in multiple categories: dysphagia frequency (n = 38), swallowing physiology (n = 27), risk factors (n = 31), interventions (n = 21), and assessment comparisons (n = 12) and by patient etiology. Sample sizes (with tracheostomy) ranged from 10 to 3,320, and dysphagia frequency ranged from 11% to 93% in studies with consecutive sampling. Study design, sampling method, assessment methods, and interpretation approach varied significantly across studies. CONCLUSIONS The evidence base surrounding this subject is diverse, complicated by heterogeneous patient selection methods, design, and reporting. We suggest ways the evidence base may be developed.
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Affiliation(s)
- Stacey A Skoretz
- School of Audiology and Speech Sciences, University of British Columbia, Vancouver, BC, Canada
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
- Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, BC, Canada
- University of Alberta Hospitals, Alberta Health Services, Edmonton, AB, Canada
| | - Stephanie J Riopelle
- School of Audiology and Speech Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Leslie Wellman
- University of Alberta Hospitals, Alberta Health Services, Edmonton, AB, Canada
- Royal Alexandra Hospital, Alberta Health Services, Edmonton, AB, Canada
| | - Camilla Dawson
- School of Audiology and Speech Sciences, University of British Columbia, Vancouver, BC, Canada
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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6
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Occlusion of Tracheostomy Tubes Does Not Alter Pharyngeal Phase Kinematics But Reduces Penetration by Enhancing Pharyngeal Clearance: A Prospective Study in Patients With Neurogenic Dysphagia. Am J Phys Med Rehabil 2017; 96:268-272. [PMID: 27552353 DOI: 10.1097/phm.0000000000000602] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Tracheostomy tubes (TT) are often needed in patients with severe neurologic injuries to protect the respiratory system from aspiration. However, TTs alter physiological oral-nasal airflow and are suspected to influence the pattern of pharyngeal swallowing. The aim of this work was to evaluate the effect of TT occlusion on pharyngeal swallowing physiology and to determine penetration-aspiration (PA) values of open versus closed TTs in neurogenic dysphagia. DESIGN Prospective controlled clinical study with 20 tracheotomized patients after unilateral hemispheric stroke. Pharyngeal manometry and flexible endoscopic evaluation of swallowing were performed simultaneously to determine pharyngoesophageal pressure and timing, as well as PA scores with open and occluded TTs. In each condition, patients had to swallow 5 mL of puree 5 times. RESULTS Pharyngoesophageal pressure amplitudes, duration, and timing of the swallows did not change as a result of the tracheostomy tube status. Penetration-aspiration values were significantly lower in the occluded tube condition (P = 0.024). CONCLUSIONS Airflow and tracheostomy tube status did not influence the physiology of pharyngoesophageal swallowing in patients with neurogenic dysphagia. However, occluded TTs permitted the voluntary clearance of laryngeal residue and resulted in improved PA scores. We recommend performing dysphagia therapy in tracheotomized patients as soon as possible with uncuffed and occluded tubes.
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7
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Kim YK, Lee SH, Lee JW. Effects of Capping of the Tracheostomy Tube in Stroke Patients With Dysphagia. Ann Rehabil Med 2017; 41:426-433. [PMID: 28758080 PMCID: PMC5532348 DOI: 10.5535/arm.2017.41.3.426] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 09/09/2016] [Indexed: 11/25/2022] Open
Abstract
Objective To investigate the impact of tracheostomy tube capping on swallowing physiology in stroke patients with dysphagia via videofluoroscopic swallowing study (VFSS). Methods This study was conducted as a prospective study that involved 30 stroke patients. Then, 4 mL semisolid swallowing was conducted with capping of the tracheostomy tube or without capping of the tracheostomy tube. The following five parameters were measured: laryngeal elevation, pharyngeal transit time, post-swallow pharyngeal remnant, upper esophageal sphincter width (UES), and penetration-aspiration scale (PAS) score. Results On assessment of the differences in swallowing parameters during swallowing between ‘with capping’ and ‘without capping’ statuses, statistically significant differences were found in the post-swallow pharyngeal remnant (without capping, 48.19%±28.70%; with capping, 25.09%±19.23%; p<0.001), normalized residue ratio scale for the valleculae (without capping, 0.17±0.12; with capping, 0.09±0.12; p=0.013), normalized residue ratio scale for the piriform sinus (without capping, 0.16±0.12; with capping, 0.10±0.07; p=0.015), and UES width (without capping, 3.32±1.61 mm; with capping, 4.61±1.95 mm; p=0.003). However, there were no statistically significant differences in laryngeal elevation (x-axis without capping, 2.48±1.45 mm; with capping, 3.26±2.37 mm; y-axis without capping, 11.11±5.24 mm; with capping, 12.64±6.16 mm), pharyngeal transit time (without capping, 9.19± 10.14 s; with capping, 9.09±10.21 s), and PAS score (without capping, 4.94±2.83; with capping, 4.18±2.24). Conclusion Tracheostomy tube capping is a useful way to reduce post-swallow remnants and it can be considered an alternative method for alleviating dysphagia in stroke patients who can tolerate tracheostomy tube capping when post-swallow remnants are observed.
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Affiliation(s)
- Yong Kyun Kim
- Department of Physical Medicine and Rehabilitation, Myongji Hospital, Seonam University College of Medicine, Goyang, Korea
| | - Sang-Heon Lee
- Department of Physical Medicine and Rehabilitation, Myongji Hospital, Seonam University College of Medicine, Goyang, Korea
| | - Jang-Won Lee
- Department of Physical Medicine and Rehabilitation, Myongji Hospital, Seonam University College of Medicine, Goyang, Korea
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Abstract
The placement of a tracheostomy has become a routine procedure for intensive care unit patients who are mechanical ventilator dependent for a period of time, usually exceeding 1 or 2 weeks. It is vital for the intensivist to be familiar with all aspects of tracheostomies care including the timing of converting a patient to a tracheostomy, types of procedure, risks and benefits, and issues of daily care including oral feedings, speech, and decannulation. In this article we provide a comprehensive review for the intensivist regarding tracheostomies in the intensive care setting. We specifically review indications, timing, surgical options including percutaneous dilation tracheostomy, complications, decannulation, oral feeding, speaking devises, stomal stents, and routine tracheostomy care.
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Affiliation(s)
- A. Alan Conlan
- From the Division of Cardiothoracic Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Scott E. Kopec
- From the Division of Pulmonary, Allergy, and Critical Care, University of Massachusetts Medical School, Worcester, MA
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9
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Seidl RO, Nusser-Müller-Busch R, Ernst A. The influence of tracheotomy tubes on the swallowing frequency in neurogenic dysphagia. Otolaryngol Head Neck Surg 2016; 132:484-6. [PMID: 15746866 DOI: 10.1016/j.otohns.2004.09.047] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES: To compare the swallowing frequency in patients with neurogenic dysphagia with or without tracheotomy tubes (TT) to assess the underlying mechanisms of dysphagia to improve rehabilitation strategies. STUDY DESIGN AND SETTING: Prospective study, 10 patients (64 ± 7 years) with neurogenic dysphagia. Glasgow Coma Scale (GCS) less than 8 points, tracheotomy due to the dysphagia 2 weeks before the examination. The swallowing frequency (1 or less over 5 min) was assessed over 5 consecutive days with or without TT. RESULTS: The swallowing frequency increased after removal of the TT. These findings did not influence the GCS or the Coma Remission Scale. Over a 5-day period, the frequency of swallowing was increased. CONCLUSION: TTs decisively influence the swallowing behavior of vegetative patients. This phenomenon could be based on an improved sensitivity under re-established physiological expiration. We strongly favor removing the TT or deflating the cuff of the TT under therapeutic conditions in a rehabilitation therapy setting.
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Affiliation(s)
- Rainer O Seidl
- Department of Otolaryngology at UKB, Free University of Berlin, Berlin, Germany.
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10
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Srinet P, Van Daele DJ, Adam SI, Burrell MI, Aronberg R, Leder SB. A Biomechanical Study of Hyoid Bone and Laryngeal Movements During Swallowing Comparing the Blom Low Profile Voice Inner Cannula and Passy-Muir One Way Tracheotomy Tube Speaking Valves. Dysphagia 2015; 30:723-9. [DOI: 10.1007/s00455-015-9649-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 08/25/2015] [Indexed: 11/24/2022]
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11
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Sutt AL, Cornwell P, Mullany D, Kinneally T, Fraser JF. The use of tracheostomy speaking valves in mechanically ventilated patients results in improved communication and does not prolong ventilation time in cardiothoracic intensive care unit patients. J Crit Care 2015; 30:491-4. [PMID: 25599947 DOI: 10.1016/j.jcrc.2014.12.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 11/24/2014] [Accepted: 12/27/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The aim of this study was to assess the effect of the introduction of in-line tracheostomy speaking valves (SVs) on duration of mechanical ventilation and time to verbal communication in patients requiring tracheostomy for prolonged mechanical ventilation in a predominantly cardiothoracic intensive care unit (ICU). MATERIALS AND METHODS We performed a retrospective preobservational-postobservational study using data from the ICU clinical information system and medical record. Extracted data included demographics, diagnoses and disease severity, mechanical ventilation requirements, and details on verbal communication and oral intake. RESULTS Data were collected on 129 patients. Mean age was 59 ± 16 years, with 75% male. Demographics, case mix, and median time from intubation to tracheostomy (6 days preimplementation-postimplementation) were unchanged between timepoints. A significant decrease in time from tracheostomy to establishing verbal communication was observed (18 days preimplementation and 9 days postimplementation, P <.05). There was no difference in length of mechanical ventilation (20 days preimplementation-post) or time to decannulation (14 days preimplementation-postimplementation). No adverse events were documented in relation to the introduction of in-line SVs. CONCLUSIONS In-line SVs were successfully implemented in mechanically ventilated tracheostomized patient population. This resulted in earlier verbal communication, no detrimental effect on ventilator weaning times, and no change in decannulation times. PURPOSE The purpose of the study was to compare tracheostomy outcomes in mechanically ventilated patients in a cardiothoracic ICU preintroduction and postintroduction of in-line SVs. It was hypothesized that in-line SVs would improve communication and swallowing specific outcomes with no increase in average time to decannulation or the number of adverse events.
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Affiliation(s)
- Anna-Liisa Sutt
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia.
| | - Petrea Cornwell
- Behavioural Basis of Health, Griffith Health Institute, Griffith University, Mt Gravatt, Australia; Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Australia
| | - Daniel Mullany
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia
| | - Toni Kinneally
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia
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Clarett M, Andreu MF, Salvati IG, Donnianni MC, Montes GS, Rodríguez MG. [Effect of subglottic air insufflation on subglottic pressure during swallowing]. Med Intensiva 2013; 38:133-9. [PMID: 23473519 DOI: 10.1016/j.medin.2013.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 01/09/2013] [Accepted: 01/09/2013] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine whether there are differences between subglottic pressure during swallowing with and without air insufflation via a subglottic catheter in tracheostomized patients. DESIGN A prospective, randomized cross-over study was made. SETTING Adult Intensive Care Units. PARTICIPANTS Patients requiring mechanical ventilation and tracheostomy with a subglottic catheter, and with tolerance to deflation of the balloon and a speaking valve placed over the opening of the tracheostomy tube. INTERVENTIONS Subglottic pressure was measured during swallowing of a thickened solution with and without the delivery of airflow through the subglottic catheter. MAIN VARIABLE Subglottic pressure during swallowing. RESULTS Twelve out of 14 patients showed higher subglottic pressure values during swallowing with air insufflation. Two patients showed no differences between both conditions. Median (Med) values of subglottic pressure for the first, second and third swallow were 5, 4 and 4.5 cmH2O (Med 4.5 cmH2O) without air insufflation, and 8, 5.5 and 7.5 cmH2O (Med 5.5 cmH2O) with air insufflation, respectively (Wilcoxon, Z=-3.078; p=.002). CONCLUSION In a group of tracheostomized patients, air insufflation via a subglottic catheter increased subglottic pressure levels measured during swallowing.
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Affiliation(s)
- M Clarett
- Unidad de Kinesiología, Departamento de Diagnóstico y Tratamiento, Hospital de Agudos Donación Francisco Santojanni, Buenos Aires, Argentina.
| | - M F Andreu
- Unidad de Kinesiología, Departamento de Diagnóstico y Tratamiento, Hospital de Agudos Donación Francisco Santojanni, Buenos Aires, Argentina
| | - I G Salvati
- Unidad de Kinesiología, Departamento de Diagnóstico y Tratamiento, Hospital de Agudos Donación Francisco Santojanni, Buenos Aires, Argentina
| | - M C Donnianni
- Unidad de Kinesiología, Departamento de Diagnóstico y Tratamiento, Hospital de Agudos Donación Francisco Santojanni, Buenos Aires, Argentina
| | - G S Montes
- Unidad de Kinesiología, Departamento de Diagnóstico y Tratamiento, Hospital de Agudos Donación Francisco Santojanni, Buenos Aires, Argentina
| | - M G Rodríguez
- Unidad de Kinesiología, Departamento de Diagnóstico y Tratamiento, Hospital de Agudos Donación Francisco Santojanni, Buenos Aires, Argentina
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Pilot date on swallow function in nondysphagic patients requiring a tracheotomy tube. Int J Otolaryngol 2009; 2009:610849. [PMID: 20107572 PMCID: PMC2809432 DOI: 10.1155/2009/610849] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2009] [Revised: 08/13/2009] [Accepted: 08/24/2009] [Indexed: 11/18/2022] Open
Abstract
Objective. To evaluate the effects of occlusion status (i.e., open, finger, capped) of the tracheotomy tube and removal of the tracheotomy tube that may have upon bolus flow and durational measurements in nondysphagic persons requiring a tracheotomy tube.
Study Design. Prospective, single subject, repeated measure design.
Methods. Participants had their swallow evaluated with 5 mL pureed boluses using nasal endoscopy with the tracheotomy tube in place, removed, and under the following occlusion conditions: open, finger, and capped. The order of occlusion condition was randomized.
Results. Aspiration was never observed but laryngeal penetration was a common finding. Durational measurements for swallow initiation and duration of white out were not significantly different by occlusion status or after removal of the tracheotomy tube.
Conclusion. This study provides corroborating evidence demonstrating the lack of a relationship between a tracheotomy tube and swallowing dysfunction.
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Tracheotomy: Airway Management, Communication and Swallowing, 2nd ed. Edited by Eugene N. Myers and Jonas T. Johnson. Dysphagia 2008. [DOI: 10.1007/s00455-008-9186-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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15
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Gross RD, Atwood CW, Ross SB, Eichhorn KA, Olszewski JW, Doyle PJ. The Coordination of Breathing and Swallowing in Parkinson’s Disease. Dysphagia 2007; 23:136-45. [PMID: 18027027 DOI: 10.1007/s00455-007-9113-4] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2006] [Accepted: 07/03/2007] [Indexed: 11/25/2022]
Affiliation(s)
- Roxann Diez Gross
- Division of Otolaryngology, University of Pittsburgh, Eye & Ear Institute, Suite 500, 200 Lothrop Street, Pittsburgh, Pennsylvania 15213, USA.
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Contribution of Tracheotomy Tubes and One-way Speaking Valves to Swallowing Success. TOPICS IN GERIATRIC REHABILITATION 2007. [DOI: 10.1097/01.tgr.0000299162.52493.6f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Terk AR, Leder SB, Burrell MI. Hyoid Bone and Laryngeal Movement Dependent Upon Presence of a Tracheotomy Tube. Dysphagia 2007; 22:89-93. [PMID: 17287926 DOI: 10.1007/s00455-006-9057-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2006] [Accepted: 07/31/2006] [Indexed: 10/23/2022]
Abstract
The aim of this prospective, consecutive study was to investigate the biomechanical effects, if any, of the presence of a tracheotomy tube and tube cuff status, tube capping status, and aspiration status on movement of the hyoid bone and larynx during normal swallowing. Seven adult patients (5 male, 2 female) with an age range of 46-82 years (mean = 63 years) participated. Criteria for inclusion were no history of cancer of or surgery to the head and neck (except tracheotomy), normal cognition, normal swallowing, and ability to tolerate decannulation. Digital videofluoroscopic swallowing studies were performed at 30 frames/s and with each patient seated upright in the lateral plane. Variables evaluated included maximum hyoid bone displacement and larynx-to-hyoid bone approximation under three randomized conditions: tracheotomy tube in and open with a 5-cc air-inflated cuff; tracheotomy tube in and capped with deflated cuff; and tracheotomy tube out (decannulated). Differences between maximum hyoid bone displacement and larynx-to-hyoid approximation (cm) based on presence/absence of a tracheotomy tube, tube cuff status, and tube capping status were analyzed with the Student's t test. Reliability testing with a Pearson product moment correlation was performed on 21% of the data. No significant differences (p > 0.05) were found for both maximum hyoid bone displacement and larynx-to-hyoid bone approximation during normal swallowing based on tracheotomy tube presence, tube cuff status, or tube capping status. Intraobserver reliability for combined measurements of maximum hyoid displacement and larynx-to-hyoid approximation was r = 0.97 and interobserver reliability for the absence of aspiration was 100%. For the first time with objective data it was shown that the presence of a tracheotomy tube did not significantly alter two important components of normal pharyngeal swallow biomechanics, i.e., hyoid bone movement and laryngeal excursion. The hypothesis that a tracheotomy tube tethers the larynx thereby preventing hyoid bone and laryngeal movement during normal swallowing is not supported.
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Affiliation(s)
- Alyssa R Terk
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut 06520-8041, USA
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18
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Donzelli J, Brady S, Wesling M, Theisen M. Secretions, Occlusion Status, and Swallowing in Patients with a Tracheotomy Tube: A Descriptive Study. EAR, NOSE & THROAT JOURNAL 2006. [DOI: 10.1177/014556130608501216] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We conducted a prospective, descriptive study of 40 tracheotomized patients to investigate the relationships between (1) levels of accumulated oropharyngeal secretions and laryngeal penetration/aspiration status, (2) secretion levels and tube-occlusion status, and (3) tube-occlusion status and aspiration status. Assessments of secretion status were quantified with the use of a 5-point rating scale. All evaluations were made by fiberoptic endoscopic evaluation of swallowing. We found that patients with higher secretion levels were more likely to aspirate than were patients with lower secretion levels. Also, patients who tolerated placement of a tube cap had the lowest mean secretion level, and those who tolerated only light finger occlusion had the highest; likewise, most patients with normal secretion levels tolerated a capped tube, and a plurality of patients with profound secretion levels tolerated only light finger occlusion. Finally, no significant differences were observed with respect to occlusion status and aspiration rates.
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Affiliation(s)
| | - Susan Brady
- Department of Speech-Language Pathology, Marianjoy Rehabilitation Hospital, Wheaton, Ill
| | - Michele Wesling
- Department of Speech-Language Pathology, Marianjoy Rehabilitation Hospital, Wheaton, Ill
| | - Melissa Theisen
- Department of Speech-Language Pathology, Marianjoy Rehabilitation Hospital, Wheaton, Ill
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Frank U, Mäder M, Sticher H. Dysphagic patients with tracheotomies: a multidisciplinary approach to treatment and decannulation management. Dysphagia 2006; 22:20-9. [PMID: 17024547 DOI: 10.1007/s00455-006-9036-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2005] [Accepted: 05/09/2006] [Indexed: 11/28/2022]
Abstract
In 2000 a multidisciplinary protocol for weaning dysphagic patients from the tracheotomy tube and a decannulation decision chart created according to principles of the F.O.T.T.((R)) Concept (Face and Oral Tract Therapy) were introduced in the Swiss Neurological Rehabilitation Centre REHAB in Basel. In the present study we introduce these guidelines and present an evaluation of the treatment and decannulation procedure. We retrospectively compared data from patients before and after introduction of the multidisciplinary procedure with regard to mean cannulation times and success of decannulation. Furthermore, we analyzed the rehabilitation progress of the group who underwent multidisciplinary treatment as well as the participation of the speech language therapist. The results show that the treatment introduced to improve swallowing functions and wean patients from the tracheotomy tube led to a fast and safe decannulation of our patients. The mean length of cannulation time was reduced significantly. After decannulation the patients showed clear functional improvements. Interdisciplinary treatment using the approach discussed in this study can be considered efficient and an important basis for further functional progress in the rehabilitation process.
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Affiliation(s)
- Ulrike Frank
- Department of Linguistics, University of Potsdam, Potsdam, Germany.
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20
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Donzelli J, Brady S, Wesling M, Theisen M. Effects of the Removal of the Tracheotomy Tube on Swallowing During the Fiberoptic Endoscopic Exam of the Swallow (FEES). Dysphagia 2006; 20:283-9. [PMID: 16633873 DOI: 10.1007/s00455-005-0027-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This study investigated the effects, if any, that the presence of a tracheotomy tube has on the incidence of laryngeal penetration and aspiration in patients with a known or suspected dysphagia. This was a prospective, repeated-measure design study. A total of 37 consecutive patients with a tracheotomy tube underwent a fiberoptic endoscopic evaluation of swallowing (FEES). Patients were first provided with pureed food boluses with the tracheotomy tube in place. The tracheotomy tube was then removed and the tracheostoma site was covered with gauze and gentle hand pressure was applied. The patients were then evaluated without the tracheotomy tube in place with additional puree. Aspiration status was in agreement with and without the tracheotomy tube in place in 95% (35/37) of the patients. The two patients who demonstrated a different swallowing pattern with regard to aspiration demonstrated aspiration only when the tracheotomy tube was removed. Laryngeal penetration status was in agreement with and without the tracheotomy tube in place in 78% (29/37) of the patients. For the majority of the patients, the removal of the tracheotomy tube made no difference in the incidence of aspiration and/or laryngeal penetration. Results of this study do not support the clinical notion that the patient's swallowing function will improve once the tracheotomy tube has been removed.
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Affiliation(s)
- Joseph Donzelli
- Otolaryngology, Head & Neck Surgery, Ltd., Naperville, Illinois, USA
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21
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Leder SB, Joe JK, Ross DA, Coelho DH, Mendes J. Presence of a tracheotomy tube and aspiration status in early, postsurgical head and neck cancer patients. Head Neck 2005; 27:757-61. [PMID: 16086412 DOI: 10.1002/hed.20239] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND We sought to investigate the effects, if any, that the presence of a tracheotomy tube has on aspiration status in early, postsurgical head and neck cancer patients. METHODS Twenty-two consecutive adult, postoperative head and neck cancer patients were prospectively evaluated with fiberoptic endoscopic evaluation of swallowing (FEES) under three conditions: (1) tracheotomy tube present, (2) tracheotomy tube removed and tracheostoma covered with gauze sponge; and (3) tracheotomy tube removed and tracheostoma left open and uncovered. For each condition, the endoscope was first inserted transnasally to determine aspiration status during FEES and then inserted through the tracheostoma to corroborate aspiration status by examining the distal trachea inferiorly to the carina. Three experienced examiners determined aspiration status under each condition and endoscope placement. RESULTS There was 100% agreement on aspiration status between FEES results and endoscopic examination through the tracheostoma. Specifically, 13 of 22 patients (59%) swallowed successfully and nine of 22 (41%) aspirated. There was also 100% agreement on aspiration status for tracheotomy tube present, decannulation and tracheostoma covered by gauze sponge, and decannulation and tracheostoma left open and uncovered. CONCLUSIONS Neither presence of a tracheotomy tube nor decannulation affected aspiration status in early, postsurgical head and neck cancer patients. The clinical impressions that a tracheotomy or tracheotomy tube increases aspiration risk or that decannulation results in improved swallowing function are not supported. Rather, need for a tracheotomy indicates comorbidities (eg, respiratory failure, trauma, stroke, advanced age, reduced functional reserve, and medications used to treat the critically ill) that by themselves predispose patients for dysphagia and aspiration.
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Affiliation(s)
- Steven B Leder
- Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, P.O. Box 208041, New Haven, CT 06520-8041, USA.
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22
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Ross J, White M. Removal of the tracheostomy tube in the aspirating spinal cord-injured patient. Spinal Cord 2003; 41:636-42. [PMID: 14569265 DOI: 10.1038/sj.sc.3101510] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Four related case reports, occurring within a 10-month time frame during 2001. OBJECTIVES Aspiration is commonly reported in the literature as a contraindication to decannulation. We report four examples of successful removal of the tracheostomy tube in the presence of aspiration by an experienced team, utilising a risk management approach. SETTING Victorian Spinal Cord Service (VSCS), Austin Hospital, Melbourne, Australia. METHODS Four individuals in our unit with traumatic spinal cord injury, three quadriplegic and one paraplegic, presented with aspiration identified by a positive modified Evan's blue dye test or constant coughing, gagging and oxygen desaturation during cuff deflation trials. In three of the four cases, the tracheostomy tube had been in situ for a prolonged period and the patients had failed to progress towards decannulation. A decision was made to decannulate these four patients in spite of the presence of traditionally held contraindications for decannulation. The multidisciplinary team carefully compared the inherent risks of premature decannulation against those of prolonged tracheostomisation. Given the risk associated with this procedure, a closely monitored decannulation protocol was instituted. RESULTS All four patients were successfully decannulated with improved quality of life, eating between 1 and 4 days and communicating immediately after decannulation. None experienced respiratory deterioration. CONCLUSION It is possible to safely decannulate aspirating spinal cord injured individuals in some instances, using a risk management approach.
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Affiliation(s)
- J Ross
- Physiotherapy Department, Austin Hospital, Melbourne, Australia
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23
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24
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The use of speaking valves with ventilator-dependent and tracheostomy patients. Curr Opin Otolaryngol Head Neck Surg 2001. [DOI: 10.1097/00020840-200106000-00005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Affiliation(s)
- P F Dunn
- Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston 02114, USA
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Goldsmith T. Evaluation and treatment of swallowing disorders following endotracheal intubation and tracheostomy. Int Anesthesiol Clin 2001; 38:219-42. [PMID: 10984854 DOI: 10.1097/00004311-200007000-00013] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- T Goldsmith
- Department of Speech Language Pathology, Massachusetts General Hospital, Boston 02114, USA
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Elpern EH, Borkgren Okonek M, Bacon M, Gerstung C, Skrzynski M. Effect of the Passy-Muir tracheostomy speaking valve on pulmonary aspiration in adults. Heart Lung 2000; 29:287-93. [PMID: 10900066 DOI: 10.1067/mhl.2000.106941] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We determined instances of aspiration in adults with tracheostomies and investigated the effect of the Passy-Muir tracheostomy speaking valve on occurrences of aspiration. METHODS Adults with tracheostomies scheduled for videofluoroscopic swallowing examinations who met inclusion criteria were enrolled. According to study protocol, 6 presentations of thin liquids were recorded, 3 with and 3 without the Passy-Muir tracheostomy speaking valve. If a cuffed tube was present, the cuff was deflated fully for all presentations. RESULTS Seven of 15 subjects aspirated material on 1 or more presentations of thin liquid. Five subjects aspirated material only with the Passy-Muir tracheostomy speaking valve off, whereas 2 subjects aspirated material with and without the valve. No subject aspirated material while the valve was on exclusively. Aspiration was significantly less frequent with the Passy-Muir tracheostomy speaking valve on than with it off. CONCLUSIONS Clinically unapparent aspiration occurs commonly in patients with tracheostomies. An expiratory occlusive valve can reduce, though not eliminate, occurrences of aspiration. CLINICAL IMPLICATION The benefit of the Passy-Muir tracheostomy speaking valve should be evaluated in selected patients who aspirate liquid.
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Affiliation(s)
- E H Elpern
- Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL 60612, USA
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Leder SB, Ross DA. Investigation of the causal relationship between tracheotomy and aspiration in the acute care setting. Laryngoscope 2000; 110:641-4. [PMID: 10764011 DOI: 10.1097/00005537-200004000-00019] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the causal relationship, if any, between tracheotomy and incidence of aspiration in the acute care setting. STUDY DESIGN Prospective, consecutive. PATIENTS AND METHODS Twenty adult patients evaluated between February 1997 and October 1999 participated. Criteria for inclusion were a dysphagia evaluation before tracheotomy, subsequent tracheotomy and placement of a tracheotomy tube, and then a repeat dysphagia evaluation after tracheotomy prior to decannulation. This permitted the causal relationship between tracheotomy and incidence of aspiration to be investigated. Differences between duration of tracheotomy placement and age were analyzed with the Student t test and for non-parametric nominal data the chi2 test was applied. RESULTS No causal relationship between tracheotomy and aspiration was exhibited, as 19 of 20 (95%) subjects exhibited the same aspiration status before and after tracheotomy. All 12 (100%) subjects who aspirated before tracheotomy also aspirated after tracheotomy and 7 of 8 (88%) subjects who did not aspirate before tracheotomy also did not aspirate after tracheotomy (P > .05). In addition, no significant differences were observed between aspiration status and days since tracheotomy or age (P > .05). CONCLUSION In the acute care setting, no causal relationship between tracheotomy and aspiration status was exhibited.
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Affiliation(s)
- S B Leder
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA.
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Kirshblum S, Johnston MV, Brown J, O'Connor KC, Jarosz P. Predictors of dysphagia after spinal cord injury. Arch Phys Med Rehabil 1999; 80:1101-5. [PMID: 10489016 DOI: 10.1016/s0003-9993(99)90068-0] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To quantify the incidence of swallowing deficits (dysphagia) and to identify factors that predict risk for dysphagia in the rehabilitation setting following acute traumatic spinal cord injury. DESIGN Retrospective case-control study. SETTING Freestanding rehabilitation hospital. PATIENTS Data were collected on 187 patients with acute traumatic spinal cord injury admitted for rehabilitation over a 4-year period who underwent a swallowing screen, in which 42 underwent a videofluoroscopic swallowing study (VFSS). MAIN OUTCOME MEASURES VFSS was performed on patients with suspected swallowing problems. Possible antecedents of dysphagia were recorded from the medical record including previous history of spine surgery, surgical approach and technique, tracheostomy and ventilator status, neurologic level of injury, ASIA Impairment Classification, orthosis, etiology of injury, age, and gender. RESULTS On admission to rehabilitation 22.5% (n = 42) of spinal cord injury patients had symptoms suggesting dysphagia. In 73.8% (n = 31) of these cases, testing confirmed dysphagia (aspiration or requiring a modified diet), while VFSS ruled out dysphagia in 26.2% (n = 11) cases. Logistic regression and other analyses revealed three significant predictors of risk for dysphagia: age (p < .028), tracheostomy and mechanical ventilation (p < .001), and spinal surgery via an anterior cervical approach (p < .016). Other variables analyzed had no relation or at best a slight relation to dysphagia. Tracheostomy at admission was the strongest predictor of dysphagia. The combination of tracheostomy at rehabilitation admission and anterior surgical approach had an extremely high rate of dysphagia (48%). CONCLUSION Swallowing abnormalities are present in a significant percentage of patients presenting to rehabilitation with acute traumatic cervical spinal cord injury. Patients with a tracheostomy appear to have a substantially increased risk of development of dysphagia, although other factors are also relevant. Risk of dysphagia should be evaluated to decrease the potential for morbidity related to swallowing abnormalities.
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Affiliation(s)
- S Kirshblum
- Spinal Cord Injury Services, Kessler Institute for Rehabilitation, and Outcomes Research, West Orange, NJ, USA
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Logemann JA, Pauloski BR, Colangelo L. Light digital occlusion of the tracheostomy tube: a pilot study of effects on aspiration and biomechanics of the swallow. Head Neck 1998; 20:52-7. [PMID: 9464952 DOI: 10.1002/(sici)1097-0347(199801)20:1<52::aid-hed8>3.0.co;2-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND This study examined the effects of digital occlusion of the tracheostomy tube versus no occlusion on oropharyngeal swallowing in head and neck cancer patients. METHODS Eight treated head and neck cancer patients were studied, six of whom had undergone surgical treatment for oral or laryngeal cancer and two who had undergone high-dose chemotherapy and radiotherapy for laryngeal cancer. Videofluorographic studies of oropharyngeal swallowing were accomplished on 3-mL boluses of liquid in seven patients and 3-mL boluses of paste in three patients, first with the tracheostomy not occluded and then with it lightly digitally occluded by the patient. Videofluorographic studies of swallow were examined for observations of aspiration and residue. Biomechanical analysis of each liquid swallow was also completed. RESULTS Four of the seven patients aspirated on thin liquids with the tube unoccluded. Aspiration was eliminated with the tracheostomy digitally occluded in two of these four patients. One of the patients also aspirated on paste with the tube unoccluded, and the aspiration was eliminated with the tube occluded. A third patient who aspirated on thin liquid had no change when the tube was occluded, and one patient's swallow worsened with the tube occluded on liquid. There were significant changes in five measures of swallow biomechanics on liquids with the tube occluded: (1) duration of base of tongue contact to the posterior pharyngeal wall was reduced, (2) maximal laryngeal elevation increased, (3) and (4) laryngeal and hyoid elevation at the time of initial cricopharyngeal opening increased, and (5) onset of anterior movement of the posterior pharyngeal wall relative to the onset of cricopharyngeal opening began later. CONCLUSION Light digital occlusion of the tracheostomy tube appears to be a safe procedure, because most biomechanics of swallow are positively affected, perhaps because of the increased resistance provided by the closed trachea. However, not all patients received benefit from tube occlusion, indicating that each patient must be evaluated individually to determine whether or not tube occlusion improves their swallow.
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Affiliation(s)
- J A Logemann
- Department of Communication Sciences and Disorders, Northwestern University, Evanston, Illinois 60208, USA
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Abstract
Pulmonary aspiration of gastric contents can cause a spectrum of sequelae that spans from relatively minor to rapidly lethal disease. To emphasize the extent of this spectrum and to encompass both noninfectious complications and infection, we use the term “aspiration-induced pulmonary injury” rather than “aspiration pneumonia.” In this article we review the relevant literature, focusing on more recent insights into the pathogenesis of lung injury, the natural history of aspiration, risk factors, the relationship between aspiration and infection, and recommendations for management. The relevance to human disease of studies using intra-airway acid instillation in animals is questioned. We discuss the difficulties in predicting the clinical course after aspiration. We identify risk factors for aspiration-induced pulmonary injury that are commonly encountered in the intensive care unit, and discuss in detail factors of special interest to the intensivist, including the impact of tracheal intubation; the effects of enteric intubation, particularly the comparison between pre- and postpyloric routes of enteric feeding administration; and the relative risks associated with particular feeding protocols. We conclude with recommendations regarding treatment and prevention strategies.
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Affiliation(s)
- Judith E. Nelson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mount Sinai School of Medicine, New York, NY
| | - Marvin Lesser
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mount Sinai School of Medicine, New York, NY
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Abstract
Until recent years, pulmonary aspiration attracted remarkably little clinical investigation. Although aspiration was considered a common occurrence in hospitalized individuals, with serious and even fatal consequences, clinicians had limited scientific data to guide practice. Consequently, approaches to this problem were based largely on unsystematic observations, intuition, and tradition. Recent investigations on the subjects of aspiration have increased our understanding of patients at risk for aspiration, the value of diagnostic methods, and the efficacy of interventions to prevent or limit aspirations. Results of these studies call to question many time-honored adages and practices. Considerable uncertainty remains and more investigation is necessary before management decisions can be characterized clearly and clinical strategies defined. This review focuses on pulmonary aspiration and enteral feeding in the critically ill adult. Factors implicated in aspiration in this population are highlighted and evidence to support the application of interventions prescribed commonly is presented.
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Affiliation(s)
- E H Elpern
- Advanced Lunge Disease and Lung Transplant Program, Rush-Presbyterian-St Luke's Medical Center, Chicago, IL, USA
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