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Effects of Tracheotomy on Swallowing
- Reduced laryngeal elevation- the larynx is tethered down from the cuff of the tracheostomy and therefore does not elevate to the same degree as prior to tracheostomy
- Desensitivation of the larynx- If the cuff of the tracheostomy tube is inflated there is poor airflow through the trachea and oral cavity. Since there is limited airflow, the patient has reduced pharyngeal and laryngeal sensation. If the patient does aspirate, he/she may not feel it and therefore, not produce a normal cough reflex. The patient is at greater risk of silent aspiration.Consider the patient’s respiratory status. If they are breathing quickly or in distress, the patient will likely have difficulty swallowing due to his respiratory status. This is true of patients without tracheostomy tubes as well.
- Muscle Disuse Atrophy- this is not due to the tracheostomy itself, but due to the patients illness. Patients in ICU lose about 2% of muscle mass a day during their illness, resulting in severe physical disability. Rebuilding muscles losses can take over a year and patients may be so weak that they struggle to feed themselves. Their cough power is greatly reduced and they may have poor control over their swallowing and upper airways with risk of aspiration.
Complications of Tracheostomy Tube Placement
- Absence of airflow through nose and nouth = loss
- of taste and smell
- Foreign object in body = increase in secretions
- Tracheal granuloma (growth of inflammatory
- Trachemalacia= degeneration of tissue
- Tracheal stenosis- narrowing of trach
- Decreased laryngeal elevation with a cuffed
- trach = aspiration
Voicing with a trach
- 1. Use of a finger, the patient’s chin, or a cap to occlude the tracheostomy tube for short periods during voicing.
- 2. A one-way tracheostomy speaking valve (passymuir)
- 3. Fenestrated tracheostomy tube:- similar to other tracheostomy tubes but has a ‘hole’ in the outer cannula-allows for airflow from your lungs, through the tracheostomy tube and up through the vocal folds and oral cavity for speech-may be a step towards decannulation
- 4. Electrolarynx or Artificial larynx-Talking tracheostomy tube-An outside air source forces air through the vocal fold-Cuff does not need to be deflated for useBlom Tracheostomy Tube- This is a new patented design in which the cuff does not need to be deflated and the tracheostomy tube is fenestrated to allow for airflow through the tracheostomy and up into the oral cavity.
Suggested Protocol for placement of a speaking valve
- 1. Normal oral motor exam
- 2. Attempt to communicate (adequate cognition)
- 3. Alert for at least 2 consecutive days
- 4. Tracheostomy tube in place at least 24 hours for healing
- 5. Normal laryngeal examination by ENT-- rule out vocal fold pathology
- 6. Cuff deflation
- 7. Assessment of viscosity of secretions: Thick secretions= risk for obstruction
- 8. Assessment of upper airway (tracheal or glottal stenosis, granualtion tissue)
- 9. If valve is used with a ventilator, physician must apporve delation of cuff and modify vent volumes. Increase in tidal volume may be needed to accomadate new air leakage around the deflated cuff