Speech-Language Pathology: Tracheostomy and Swallowing
Surgical Airways: Tracheostomy vs. Laryngectomy
Tracheostomy: A surgical airway created through an incision in the neck into the trachea, typically below the level of the larynx. It involves inserting a tube to maintain an open airway and can be temporary or permanent.
Laryngectomy: Surgical removal of the larynx (voice box). This procedure results in a permanent stoma in the neck for breathing. Total laryngectomy involves removing the entire larynx, while partial laryngectomy may remove only a portion of it.
Pre and Post Laryngectomy
Pre-Laryngectomy:
Structures present: Velum (soft palate), base of tongue, pharynx, larynx, esophagus, epiglottis, hyoid bone, arytenoid cartilage, false vocal cord, true vocal cord, trachea. The patient breathes through the nose and mouth, and the larynx is responsible for voice production and protection of the airway during swallowing.
Post-Laryngectomy:
Structures remaining: Velum (soft palate), base of tongue, pharynx, tongue, esophagus. The upper aerodigestive tract remains intact, but the connection to the lower respiratory tract via the larynx is eliminated.
Stoma: Opening in the neck for breathing; replaces the function of the nose and mouth for breathing. Air enters and exits the lungs directly through the stoma, bypassing the upper airway's warming, humidifying, and filtering functions.
Patients with Tracheostomy
Low volume of patients across the age continuum (0-10 patients with surgical airway in-hospital at any given time). Despite the relatively low numbers, these patients require significant resources and specialized care.
High acuity, medically-complex, and medically vulnerable patients requiring specialized care. These patients often have multiple comorbidities and are at increased risk for complications.
Patients with chronic tracheostomies may be admitted to units or facilities less familiar with their care. This can lead to inconsistencies in care and potential safety risks.
SLP Responsibility
Considerations for SLP:
Patient populations with tracheostomy: Understanding the underlying conditions that led to the tracheostomy is crucial for effective management.
Reasons for tracheostomy: Different etiologies can impact the patient's overall prognosis and rehabilitation potential.
How the tracheostomy was placed (surgical vs. percutaneous): The method of placement can influence the risk of certain complications.
What type of hardware is in the airway: Different types and sizes of tracheostomy tubes have implications for airflow, secretion management, and communication.
Impact of tracheostomy on swallowing, voicing, breathing, and cough: Tracheostomy can disrupt the normal physiology of these functions, requiring targeted interventions.
When SLP has a direct role: SLPs are involved in various aspects of tracheostomy management, including swallowing assessment and rehabilitation, communication strategies, and ventilator weaning.
Patient Populations Requiring Tracheostomy
Head and neck cancer: Tracheostomy may be necessary to maintain an airway after surgery or radiation therapy.
Seizure disorders: Patients with frequent or severe seizures may require a tracheostomy to protect the airway.
Medically complex/fragile patients: Patients with multiple medical problems may need a tracheostomy for long-term airway management.
Stroke: Tracheostomy may be indicated in patients with severe dysphagia or impaired cough reflex following a stroke.
Infection: Meningitis or sepsis can cause airway obstruction and necessitate a tracheostomy.
Developmental disorders: Cerebral Palsy often involves swallowing and respiratory difficulties that may require tracheostomy.
Congenital defects/disorders: Subglottic stenosis, laryngeal cleft, Treacher Collins syndrome can cause airway obstruction from birth.
Neurodegenerative diseases: Parkinson's Disease (PD), Myasthenia Gravis (MG), Muscular Dystrophy (MD), Multiple Sclerosis (MS), Amyotrophic Lateral Sclerosis (ALS) can lead to progressive respiratory muscle weakness and the need for tracheostomy.
Spinal cord injury: High-level spinal cord injuries can impair respiratory function and necessitate a tracheostomy.
Guillain-Barré Syndrome: This autoimmune disorder can cause paralysis of respiratory muscles, requiring temporary or permanent tracheostomy.
Pulmonary disease: COPD (airway), PNA (alveoli), Sarcoidosis (interstitium) can lead to chronic respiratory failure and the need for long-term tracheostomy.
Traumatic Brain Injury: TBI can result in impaired consciousness, respiratory dysfunction, and the need for airway management with a tracheostomy.
Brain tumor: Tumors in the brainstem or other areas controlling respiration can cause airway compromise and the need for tracheostomy.
Indications for Tracheostomy
General intent: Achieve a stable, patent, and secure airway. Ensure adequate ventilation and oxygenation while minimizing the risk of aspiration.
Primary indications:
To bypass an obstructed upper airway: Conditions such as tumors, trauma, or severe swelling can block the upper airway, necessitating a tracheostomy.
To clear and remove secretions from the airway: Patients with impaired cough or excessive secretions may require a tracheostomy to facilitate suctioning and prevent pneumonia.
To deliver oxygen to the lungs more easily and safely and maintain respiratory/pulmonary status: Tracheostomy allows for direct delivery of oxygen and positive pressure ventilation, improving respiratory function.
Anatomy of Tracheostomy
Key structures:
Epiglottis: A leaf-shaped cartilage that covers the larynx during swallowing to prevent aspiration.
Hyoid Bone: A U-shaped bone in the neck that provides attachment for muscles of the tongue and larynx.
Thyrohyoid Membrane: A ligament that connects the thyroid cartilage to the hyoid bone.
Thyroid Cartilage: The largest cartilage of the larynx, forming the Adam's apple.
Superior Thyroid Artery: A major blood vessel that supplies the thyroid gland and surrounding structures.
Internal Jugular Vein: A large vein in the neck that drains blood from the brain and face.
Cricothyroid Ligament: A ligament that connects the cricoid and thyroid cartilages; often used for emergency airway access (cricothyrotomy).
Middle Thyroid Vein: A vein that drains blood from the thyroid gland.
Cricoid Cartilage: A ring-shaped cartilage that forms the base of the larynx.
Subcricoid Space: The area below the cricoid cartilage.
Vagus Nerve: A cranial nerve that innervates the larynx, pharynx, and other structures involved in swallowing and voice.
1st, 2nd, and 3rd Tracheal Rings: Cartilaginous rings that support the trachea.
Right Recurrent Laryngeal Nerve: A branch of the vagus nerve that innervates the muscles of the larynx responsible for voice production.
Brachiocephalic Vein and Artery: Major blood vessels in the chest that can be encountered during tracheostomy.
Internal Carotid Artery: A major artery that supplies blood to the brain.
Anterior Scalene Muscle: A muscle in the neck that can be a landmark during tracheostomy.
Left Vagus Nerve: The vagus nerve on the left side of the body.
Left Recurrent Laryngeal Nerve: The recurrent laryngeal nerve on the left side of the body.
Tracheostomy Procedures
Open (Surgical) Procedure: Traditional surgical dissection involving an incision in the neck to expose the trachea and create an opening for the tracheostomy tube. This is typically performed in the operating room under general anesthesia.
Percutaneous (Dilatational) Procedure: Minimally-invasive technique using a single tapered dilator over a guide wire. This procedure is often performed at the bedside in the ICU under bronchoscopic guidance.
Advantages:
No transport needed: The procedure can be performed at the patient's bedside, eliminating the need for transport to the operating room.
Decreased local infection: Minimally invasive nature reduces the risk of wound infection.
Less bleeding: Smaller incisions lead to less bleeding during and after the procedure.
Less cosmetic deformity: Results in a smaller scar compared to open tracheostomy.
Usually done at the bedside in the intensive care unit under bronchoscopic guidance: Allows for real-time visualization of the trachea during the procedure.
Can be done in 5-10 minutes, rarely more than 15 minutes: This is a faster procedure compared to open tracheostomy.
Lower cost: Percutaneous tracheostomy is generally less expensive than open tracheostomy.
Advantages of Open Procedure:
Dissection under direct vision: Allows the surgeon to directly visualize the anatomical structures, reducing the risk of complications.
Can avoid aberrant vessels: Important for patients with unusual anatomy or vascular abnormalities.
Better for difficult cases (e.g., high riding innominate artery): Provides better control and precision in complex cases.
Time-honored: Traditional approach with a long history of success.
Best control of the airway: Surgeon has complete control over the airway during the procedure.
Lower complication rate: In certain situations, open tracheostomy may have a lower risk of specific complications.
Complications of Tracheostomy
Granulomas or granulation tissue: Formation of inflammatory tissue around the stoma site.
Ulceration: Open sores or lesions around the stoma.
Tracheoesophageal fistula: An abnormal connection between the trachea and the esophagus.
Tracheomalacia: Softening of the tracheal cartilage, leading to collapse of the trachea.
Tracheal and subglottic stenosis: Narrowing of the trachea or subglottic region, causing airway obstruction.
Parts of Tracheostomy
Faceplate: Secures the trach tube to the neck, preventing dislodgement.
Pilot balloon: Indicates cuff inflation; allows for monitoring of cuff pressure.
Valve: Used for cuff inflation, deflation, and pressure measurement; ensures proper cuff management.
Outer cannula (cuffed): Main tube inserted into the trachea; provides the airway passage.
Obturator: Used for insertion of the outer cannula; facilitates smooth and atraumatic insertion.
Disposable inner cannula: Inserted into the outer cannula; can be removed for cleaning to maintain airway patency.
Features of Tracheostomy Hardware
Material: Plastic or metal; affects biocompatibility and durability.
Size/Dimensions: (e.g., New Shiley "Flex" Trach Hardware Ref 6 = Tracheostomy tube size, 7.5 mm I.D. = Inner diameter without disposable inner cannula, 6.5 mm I.D. = Inner cannula diameter); appropriate sizing is crucial for optimal airflow and comfort.
Single lumen or double lumen (lumen = cannula): Double lumen tubes allow for easier cleaning and maintenance.
Cuffed or uncuffed: Cuffed tubes provide a seal in the trachea, preventing aspiration and allowing for mechanical ventilation.
Cuff features: Air-filled vs. saline-filled vs. foam-filled; cuff status when deflated; different cuff types have different pressure characteristics and may be better suited for specific patients.
Cannula length: Standard vs. XL (proximal vs. distal); appropriate length ensures proper placement and minimizes the risk of complications.
Airway Alert Sign
Important information to include:
Type/Size of Tracheostomy or Laryngectomy Tube: Ensures correct tube replacement in case of accidental decannulation.
Whether the patient can be intubated orally (Yes/No): Critical information for emergency airway management.
Presence of upper airway abnormality (Yes/No): Alerts medical staff to potential difficulties with intubation or ventilation.
Date the tracheostomy was placed or changed: Helps track the age of the tracheostomy and identify potential problems.
Whether an inner cannula is present (Yes/No): Important for routine care and emergency situations.
Cuff type (Air/H2O / NA): Informs proper cuff management protocols.
Instructions for accidental decannulation: Provides clear steps to take in case the tracheostomy tube comes out.
Suction depth: Prevents trauma to the tracheal mucosa during suctioning.
Rationale for Multi-disciplinary Teaming
A well-identified plan and process to manage, progress to the least-restrictive hardware, and possible progression to remove the trach has not been well-identified. A collaborative approach ensures comprehensive care and optimal outcomes.
Surgical Airway Clinical Team
Nursing: Stoma care and dressings; monitor for infection and skin breakdown.
Respiratory Care: Trach/Laryngectomy Hardware (tubes, valves, caps, humidification); manage ventilation and oxygenation.
Speech-Language Pathology: Swallowing and Communication; assess and treat dysphagia and communication disorders.
Tracheostomy and Swallowing
When a trach cuff is inflated, a "Forgotten Airway" is created. Secretion collection occurs due to sensation and motor blunting. This can increase the risk of aspiration and pneumonia.
SLP Role with patients with Tracheostomy
Collaborate with RT toward cuff deflation and candidacy for one-way speaking- swallowing valve. Cuff deflation improves airflow and enhances swallowing function.
Evaluate patients both on continuous trach collar or on chronic vent. SLPs need to be able to assess swallowing and communication in both ventilated and non-ventilated patients.
Evaluate swallowing (secretions) and voicing. Assess the patient's ability to manage secretions and produce voice.
Assess candidacy toward resuming P.O. diet via peripheral oral-pharyngeal swallowing evaluation, VFSS as indicated. Instrumental assessments like VFSS can help determine the safety and efficiency of swallowing.
Weigh in on least-restrictive trach/valve/capping hardware. SLPs provide expertise in selecting the most appropriate hardware to optimize swallowing and communication.
Provide input toward decannulation. SLPs play a critical role in determining when a patient is ready to have their tracheostomy removed.
Participate in weekly Surgical Airway Clinical Team Rounds (virtual vs. bedside) and reporting. Collaboration with the medical team ensures coordinated and effective care.
Communicate with patient, family, caregivers, and medical team. Effective communication is essential for patient education and shared decision-making.
Criteria to Provide SLP Intervention
Basic criteria for manipulation of tracheostomy hardware to assess candidacy for one-way speaking/swallowing valve:
Fully weaned from vent OR
Tolerating continuous trach collar trials of 4 hours x 3 consecutive days; OR
Tolerating weaning mode on vent (CPAP) for 12 continuous hours x 3 consecutive days
AND is being suctioned every 4 hours or less frequently – i.e, managing secretions
Meeting criteria aids in confirming patient has reached the level of respiratory/pulmonary stability to tolerate manipulation of trach hardware/possible placement of speaking/swallowing valve. These criteria help ensure that the patient is medically stable enough to tolerate changes in their tracheostomy hardware.
One-way Speaking Swallowing valves
Passy Muir: A popular brand of speaking valve that allows air to enter the trachea during inspiration but closes during expiration, redirecting airflow through the vocal cords for speech.
Shikani: Another type of speaking valve with similar functionality to the Passy Muir valve.
Shiley Phonate: A speaking valve designed for use with Shiley tracheostomy tubes.
Caps and corks: Devices used to occlude the tracheostomy tube, forcing air through the upper airway for speech and swallowing.
Solid inner cannula: An inner cannula without fenestrations, which can be used to redirect airflow through the upper airway.
Laryngectomy Tube Features
Standard (solid tube) VS Fenestrated: Fenestrated tubes have openings that allow for some airflow through the upper airway, potentially improving voice and secretion management.
Heat-moisture exchange (HME)
Laryngectomy tube and H