Trach & Swallowing Flashcards
There is a complex interrelationship between ___________ and ___________.
Deglutition & respiration
Is there potential for the presence of the trach tube to impact swallowing?
Yes, however, it is not absolute.
Is there potential for the occlusion status of the trach tube to impact swallowing?
Yes, however, it is not absolute.
Factors influencing airway protection in patients with pulmonary disease include: (3)
- Alterations in the timing of airway closure
- Interruption of the normally well timed pattern of swallowing & breathing
- Diminished respiratory defenses (ex: cough, airway clearance)
When respiratory system is stressed, the duration of the inspiratory phase is _______ and the time requirement for airway closure is _________.
Reduced; disrupted
Patients with ____ ______ pulmonary disease may required a ___________ ____.
more severe; tracheotomy tube
What is the normal pattern of swallowing and breathing in the average patient?
95% of all swallow were followed by an exhalation
What is the pattern of swallowing and breathing in patients with a CVA?
CVA patients inhaled immediately after the swallow
Role of expiratory airflow: timing of the swallow within the expiratory airflow
- Assists w/airway clearance in removing pharyngeal and laryngeal residue
- When pulmonary air is not available for clearance, aspiration may be more likely
- Patients on a vent, during VFSS, observed aspirated material clear airway upon exhalation
When alone could be the main contributing factor to a swallowing disorder?
Underlying medical condition in the 1st place alone could be the main contributing source of the swallowing disorder (ex: pulmonary conditions, neurological diseases, etc.)
What are the mechanical impacts of a trach tube? (2)
- Reduced laryngeal excursion
- Saliva & secretion management
Mechanical impact of the trach: reduced laryngeal excursion (4)
- Anchoring effect
- Decreased BOT movement (deconditioning)
- Weight of equipment
- Cuff inflation/over inflated cuff
Mechanical impact of the trach: saliva & secretion management
-Medication side effects
What are the physiologic impact of the trach on swallowing? (2)
- Disruption of airway pressure
- Reduction of airflow through the glottis
Physiologic impact of the trach: disruption of airway pressure
-Occlusion status
Physiologic impact of the trach: Reduction of airflow through the glottis
- Without expiration through the glottis, redued ability to clear residual materials from airway
- Loss of laryngeal sensation
- Glottis closure response - reduced coordination
Suiter et al. found what about cuff deflation for incidence & severity of aspiration
Cuff deflation DID NOT reduce incidence or severity of aspiration as compared w/the cuffed or one-way valve
Suiter et al. found what about cuff deflation and hyolaryngeal excursion?
An increase in extent of hyoid maximal anterior movement was observed w/cuff deflation. However, No significant increase in maximal laryngeal elevation was noted.
Suiter et al. found what about one-way valves and aspiration?
Use of one-way valve REDUCED incidence & severity of aspiration of thin liquids
What is the potential reason for improvement in swallow due to one way valve?
Re-establishment of sub glottal air pressure – really, remains unclear though
Suiter CONCLUSION: Patients who are able to tolerate cuff deflation and one-way valve placement MAY …
benefit from eating w/a one-way valve in place.
Suiter CONCLUSION: May see improvement with patients with …
difficulty with thin liquids
Suiter CONCLUSION: Use of valve will…
NOT ALWAYS improve swallow function
Does an inflated cuff prevent aspiration?
NO
If the cuff is over-inflated, you have a potential for…
tracheal wall breakdown
At times, patients may be permitted to eat w/an inflated cuff given a variety of other factors that may come into play (2)
- Individual / case by case situation
- Recommended proper suctioning protocols
Pre & post trach effect:
- 12/12 subjects who aspirated before the trach also aspirated after
- 7/8 subjects who did NOT aspirate before the trach also did NOT aspirate after
Is there is casual relationship between trach and aspiration status?
Confirmation of NO casual relationship between trach & aspiration status
trach effect: removal of the trach
-No differences in aspiration status w/the trach tube in, removed with the tracheostoma gently covered, or with an open tracheostoma
Does research (Terk, Ledler & Burrell) show evidence to support that the trach tube tethers the larynx during the swallow?
No evidence under the following 3 conditions:
- Trach tube in w/inflated cuff
- Trach tube in w/capped w/deflated cuff
- Trach tube out (decannulated)
Swallowing following prolonged endotracheal intubation (>48 hours)
~36%-70% aspiration
Effects of mechanical vent on swallowing: Terzir – swallowing on / off the vent
Reduced swallowing time per bolus & number of swallows per bolus when swallowing ON the mechanical ventilator
Effects of mechanical ventilation on swallowing: Vitacca – Swallowing may ________ work of respiratory muscles where mechanical ventilation had the ________ effect.
Swallowing may INCREASE work of respiratory muscles where mechanical ventilation had the OPPOSITE effect.
Effects of mechanical ventilation on swallowing: Vitacca – Mechanical ventilation maintains a _______ subglottic pressure to ______ the risk of aspiration.
Mechanical ventilation maintains a POSITIVE subglottic pressure to REDUCE the risk of aspiration.
Vent dependent & Trach: aspiration present in ___% of patients. (___% was silent)
Davis & Stanton: 41.4% aspiration - 83.3% silent
Leder: 33% aspiration - 82.3% silent
Vent dependent & trach: compensatory strategies alleviated aspiration in ___% of the patients.
63.8%
vent dependent & tach: aspirations were _____ and _____ days post-trach
Older & fewer days post-trach (73 y/o vs 59 y/o – 14 days vs 23 days)
Types of blue dye (5)
- Evan’s blue dye
- Methylene blue dye
- Isosulfan blue dye
- FD & C Blue No. 1 **
- FD & C Blue No. 2
What is the most common type of dye used for enteral feedings to detect for pulmonary aspiration?
FD & C No. 1
FD & C No. 1 is relatively non-toxic as less than ___ is absorbed systematically.
5%
Acceptable daily human intake of FD & C Blue No. 1 is ___ milligrams per kilogram of body weight
12.0 milligrams / kilogram of body weight
Patients who are risk for the use of FD & C Blue No 1. have increased _______________ __________.
Gastrointestinal permeability (ex: sepsis, burns, shock, multiple trauma, renal failure, inflammatory bowel disease, surgical intervention, bowel disease / celiac sprue disease)
No adverse reports published regarding using blue dyed foods with ________________ patients during ___________________.
Non-critically ill patients; swallowing evaluations
At this time, the FDA (has/has not) come out with a specific warning against using blue food coloring during swallow evaluations.
HAS NOT
Is green dye any safer than blue?
NO
Who was the first to investigate the efficacy of dying enteral feedings blue as a mean to detect pulmonary aspiration?
Potts et al (1993)
Potts et al (1993) - inspecting tracheal secretion ______ to detect most episodes of known aspiration.
FAILED
Methany et al. (2002) used animal model how?
Using rabbits and forcing small-volume pulmonary aspiration
The efficacy of blue dye with tracks was first described by…
Cameron et al (1973)
Blue Dye Swallow Clinical Swallow Screening (Steps)
- 3-5 drops of blue food coloring placed into a 4oz cup of puree / liquid
- Complete standard clinical swallow eval (chart review, oral mech, cog status, etc)
- Deflate cuff if possible
- Occluse end of trach tube if possible
- Have suction set up
- Provide pt w/1 consistency of food/liquid that hs been dyed
- Observe pt’s reaction to bolus presentation
- Provide w/additional presentations of same consistency (3-5)
- Provide suctioning and observe for blue tinged secretions
- Change trach dressing around stoma site and observe for blue discoloration / tinged mucus
- If pt has dual cannula system: remove inner cannula to look for blue content
- Return pt to baseline occlusion & cuff status
- Document exact steps / results
How do you know if the blue dye test has positive findings?
If you see blue in the suctioning catheter, around the stoma site, or on the inner cannula of the trach tube.
How long after the blue dye swallow screen do you monitor suctioning records for?
Monitor suctioning records for the next 8-24 hours.
Blue dye test showed an overall false-negative error rate of __% for the detection of aspiration when compared to VFSS & FEES
50%
(100% accurate to detect aspiration in gross amount -VFSS study — 67% accurate to detect aspiration in gross amount -FEES study)
The blue dye test is NOT sensitive to detect _______________, only sensitive to detect ________________.
microaspiration; gross aspiration
Current evidence suggest that the blue dye test should, at best, be viewed only as a ___________ for the presence of gross amounts of aspiration.
Screening tool
The blue dye test is like what for a patient with a trach or someone is NPO?
A clinical bedside swallow eval
If the patient has a positive blue dye test, what are some things to consider?
Take them for an instrumental to see how much they’re aspirating, to trial compensatory strategies, and test consistencies
If the patient has a negative blue dye test, what are some things to consider?
Do NOT recommend a diet based on this result - you’d still want an instrumental assessment to confirm they are not aspirating
Trach Effect? - Removal of the trach on the swallow - procedure:
- pt provided with 3 boluses of puree WITH the trach tube in place
- Trach removed & stoma covered w/gauze & gentle hand pressure
- Pt presented with 3 boluses of puree WITHOUT the trach tube in place
- Subglottal viewing also completed
Trach Effect? - Removal of the trach on the swallow - Results:
Aspiration status was in agreement with and without the trach in place in __% of the subjects.
95%
Trach Effect? - Removal of the trach on the swallow - Results:
Aspiration occurred with the trach tube in place in __% of subjects
8%
Trach Effect? - Removal of the trach on the swallow - Results:
Aspiration occurred with the trach tube removed in __% of the patients
13.5%
Trach Effect? - Removal of the trach on the swallow - Results:
The 2 patients who demonstrated a different swallowing pattern with regard to aspiration, only demonstrated aspiration when the trach was _______.
Removed.
Trach Effect? - Removal of the trach on the swallow - Results:
Laryngeal penetration occurred in ___% of the subjects with and without the trach
67.6%
Trach Effect? - Removal of the trach on the swallow - Results:
Laryngeal penetration status was in agreement w/ and w/out the trach in place in __% of the subjects.
78%
4 pts. did better with the trach, 4 pts did better without the trach
Trach Effect? - Removal of the trach on the swallow
For a majority of the patients, the removal of the trach tube made ___________ in the incidence of aspiration/laryngeal penetration.
No difference
Do the results of the trach effect (removal of the trach) study support the clinical notion that swallow function will improve with the removal of the trach tube?
NOPE
What is one limitation of the trach effect study? (removal of the trach)
Only puree consistencies were evaluated - may see a difference when it comes to liquids
Durational analysis for swallow initiation time and duration of laryngeal closure (were / weren’t) significantly different by occlusion status or after the removal of the tracheotomy tube.
WERE NOT
MarionJoy results regarding occlusions condition and swallowing:
Open: 16% demonstrated increased airway invasion
Finger: 10.7%
Capped: 5.35%
*No clear pattern though - multifactoral problem
Patients should be evaluated under ________________________ to determine the optimal conditions to facilitate a safe swallow in this patient population.
a variety of conditions
