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C
URRENT
O
PINION
Managing dysphagia in trachesotomized patients:
where are we now?
Diane Goff
Purpose of review
Tracheostomized patients are medically complex and vulnerable. International attention is now focused on
improving the safety and quality of their care. This review summarizes recent evidence in hot-topic areas
pertinent to speech and language therapy (SLT) intervention for dysphagia management in tracheostomized
patients.
Recent findings
The management of tracheostomized patients requires a truly multidisciplinary team (MDT) approach.
Without this, patients remain tracheostomized and hospitalized for longer and have slower access to MDT
members. Patterns of SLT intervention are variable across the United Kingdom, and further work to achieve
consensus on best practice is required. Instrumental evaluation of swallowing provides vital information and
can facilitate well tolerated oral feeding even prior to cuff deflation. A systematic review suggests that
sensitivity of blue-dye testing is poor, but studies are methodologically flawed. The need for tracheostomy-
specific quality of life measures is being addressed by the development of a questionnaire.
Summary
In this review, the main research themes relevant to speech and language therapists (SLTs) working with
tracheostomized patients are discussed. This patient group poses significant challenges to robust study
design. However, recent advances in uniting MDT members globally to improve standards of care are
encouraging.
Keywords
dysphagia, speech and language therapist, swallowing, tracheostomy
INTRODUCTION
Tracheostomized patients are a medically complex
and vulnerable population. There are many indica-
tions for a tracheostomy, and patients who receive
one present with diverse causes and often multiple
comorbidities. It is essential care is well coordinated
and any effects of the tracheostomy itself are under-
stood. The consequences of inappropriate manage-
ment are far-reaching, especially given the high
numbers performed in critical care units [1], in
which prolonged stay due to increased morbidity
has significant financial implications.
In 2014, the National Confidential Enquiry into
Patient Outcome and Death (NCEPOD) published
the results of their UK survey that assessed the
organization of care and current practice for 2546
patients with a tracheostomy [2
&&
]. It coincided
with the publication of revised UK policy [3] and
the launch of an international forum designed to
share knowledge and pool resources/data [4
&&
]. This
highlights the growing desire among healthcare
professionals to drive up standards of care, improv-
ing quality and safety. The management of trache-
ostomized patients has become a priority concern
for healthcare providers.
The number of tracheostomies performed each
year is increasing globally, with current reports
suggesting around 12 –15 000 in the United King-
dom [2
&&
,5] and as many as 100 000 in the United
States [6]. Speech and language therapists (SLTs) are
an essential part of the team, managing the care of
Department of Speech, Voice and Swallowing,The Newcastle upon Tyne
Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon
Tyne, UK
Correspondence to Diane Goff, MClin Res, Department of Speech,
Voice and Swallowing, The Newcastle upon Tyne Hospitals NHS
Foundation Trust, Freeman Hospital, Freeman Road, High Heaton, New-
castle upon Tyne NE7 7DN, U K.
Tel: +44 0191 2137646; e-mail: diane.goff@nuth.nhs.uk
Curr Opin Otolaryngol Head Neck Surg 2017, 25:217– 222
DOI:10.1097/MOO.0000000000000355
1068-9508 Copyright ß2017 Wolters Kluwer Health, Inc. All rights reserved. www.co-otolaryngology.com
REVIEW
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
these patients given their training in anatomy and
physiology of the head and neck and their expertise
in managing communication and swallowing dis-
orders [2
&&
,7,8]. The interplay between a tracheos-
tomy and swallowing function is not well
understood. Agreed protocols of care for assessing
and managing swallowing disorders (dysphagia) do
not exist because of a weak evidence base.
Previous research of swallow physiology post-
tracheostomy has been focused around several key
areas: cause–effect of tracheostomy on specific swal-
low parameters; and timing and methods of assess-
ment, for example use of blue dye, timing of cuff
deflation, placement of a speech valve, instrumental
evaluation and effects of a multidisciplinary team
(MDT) approach.
The current article will review the recent evi-
dence for several of these key components of speech
and language therapy (SLT) management of dyspha-
gia for tracheostomized patients in an attempt to
harmonize approaches to care and highlight gaps in
knowledge. Due to the limited scope, only studies of
adults have been included, and service provision
detail is mostly specific to the United Kingdom,
although issues will be recognizable internationally.
REFERRAL TO SPEECH AND LANGUAGE
THERAPY
Key recommendations from the NCEPOD study
[2
&&
], included the need for early referral to SLT,
particularly for complex patients in the critical
care setting.
Intensive Care Society standards [3] acknowl-
edge that referral to SLT is essential when dysphagia
is suspected. However, identification of dysphagia
may not be timely, and referral practices to SLT
appear to be variable across the United Kingdom.
A study of UK-based clinicians (SLTs, nurses and
physiotherapists) working with tracheostomized
patients has identified key concerns regarding SLT
services currently provided [9
&&
]. The authors inves-
tigated the use of screening tools to identify dys-
phagia and explored clinicians’ views on the
effectiveness of current practice. Questionnaires
were returned by 221 participants, the majority
(62%) of whom were SLTs. Unfortunately, a
response rate was not calculable, and the findings
may be diluted because professions other than SLT
were included. There was an even split between
those screening and those not. Of the 121 respond-
ents without a screening protocol, approximately
one-third referred all patients to SLT, one-third
allowed patients to eat and drink with close
monitoring and the remaining third referred only
‘high-risk’ groups or when a problem had been
identified. More than half of respondents thought
that their current system was ineffective in identi-
fying risk. Semistructured interviews were carried
out with 11 clinicians. Four main themes emerged
from the interview: identification of patients need-
ing swallow assessment, patient safety and well-
being and balancing risk against resources and
MDT working. This mixed-methods approach adds
depth to the survey findings and allows for further
interpretation of results. When combined with an
earlier study surveying clinical consistency in tra-
cheostomy management among UK SLTs [10], these
results are invaluable in establishing current prac-
tice and highlighting inconsistencies across the
country. There are a range of service models in
use across the United Kingdom. Referral of all
patients with a tracheostomy to SLT is standard
practice in some units. The evidence for adoption
of this approach is lacking, and with the growing
number of patients but depletion of funding and
resources, services may need to consider altern-
atives, for example a dysphagia screening protocol.
Research into the value of screening tools in this
population would provide a framework for SLTs to
engage other MDT members in the appropriate and
timely identification of patients requiring the
specialist assessment of an SLT.
CAUSE–EFFECT
The lack of agreement regarding assessment of
patients stems from conflicting evidence of how/if
the presence of a tracheostomy tube alters swallow-
ing mechanics. There are numerous theoretical ways
a tracheostomy could negatively impact on swallow
KEY POINTS
SLTs demonstrate variable consistency in
clinical practice.
The development of a robust screening protocol is
needed to ensure timely and appropriate referrals to
SLT services.
Coordinated MDT working is crucial to high-quality,
safe care for tracheostomized patients. SLTs are a core
member of such teams.
Fibreoptic endoscopic evaluation of swallowing is
advocated, especially for cuff-inflated patients, and SLTs
should interpret results of the modified Evans blue dye
test with caution.
Objectively measuring quality of life is important, and
a tracheostomy-specific questionnaire is under
development.
Speech therapy and rehabilitation
218 www.co-otolaryngology.com Volume 25 Number 3 June 2017
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
function. Several studies have attempted to investi-
gate this but many are methodologically flawed, and
synthesis of their results is not possible due to the
diverse patient groups studied, lack of standardized
outcome measures and difficulty controlling vari-
ables in a critically unwell population.
Two recent studies have added to this body of
research:
Kim et al. [11] assessed five parameters of swal-
lowing using videofluoroscopy 1 month prior to and
1 month postdecannulation. All patients (n¼17)
were in a brain injury rehabilitation unit and had
long-term tracheostomies. Patients were assessed on
one consistency (3 ml semisolid porridge). Results
showed no statistical difference in laryngeal
elevation, pharyngeal transit time or aspiration.
There were significant improvements in pharyngeal
residue (P<0.001) and upper oesophageal (UES)
width (P<0.001) postdecannulation. This last result
is interesting considering that there was no
improvement in laryngeal elevation, which is part
of the mechanism of opening UES. High-resolution
manometry is improving our understanding of pres-
sure profiles of the UES during specific swallowing
conditions [12]. Future research into the physiologi-
cal basis for using high-resolution manometry in
tracheostomized patients may be helpful in explor-
ing Kim et al.’s finding.
The second study aimed to investigate the
potential for ‘reversibility’ of dysphagia as well as
analysing possible influence of underlying disease
[13]. This observational, prospective study screened
patients admitted with a tracheostomy for either
neurological or pulmonary rehabilitation and
recruited 187/557 patients admitted over a 36-
month period. Videofluoroscopy was used to assess
seven swallowing parameters soon after admission
and again 1 month after a period of individually
tailored swallow rehabilitation.
The results of this study suggest the neuroreha-
bilitation patients significantly improved (P<0.03)
in all parameters except epiglottic inversion and onset
of reflex, whereas pulmonary rehabilitation patients
only improved in aspiration rates (P<0.03). They
also conclude that laryngeal elevation is not affected
by the presence of a tracheostomy as impairment
was recorded in only 4– 18% of the videofluoroscopy
studies. The findings helpfully describe the dyspha-
gia features seen for each of the two conditions and
the potential effects of swallow rehabilitation in
diminishing these. However, the effect of the tra-
cheostomy being in situ is difficult to determine
because of the large volume of data presented. All
patients undergoing repeat videofluoroscopy assess-
ment had a speech valve in situ, compared with none
in the first videofluoroscopy. Placement of a speech
valve has been shown to improve swallow function
[14,15]. The presence of the speech valve is therefore
a confounding variable, and the two study con-
ditions (videofluoroscopy prerehabilitation and
postrehabilitation) were not equal.
Both studies demonstrate flaws that are fre-
quently encountered when investigating this patient
group:
(1) Use of nonvalidated scales
(2) Lack of description of tube type
(3) Inconsistent presence of speaking valve
(4) Variable data collection points
(5) Sample size
(6) Heterogeneous patient group
The effects of a tracheostomy on specific
swallowing parameters require further investi-
gation, and a causal relationship with aspiration
risk is yet to be proven [16].
CUFF STATUS
Some SLT services will not accept referrals to assess
the swallowing of patients with a tracheostomy who
cannot yet tolerate cuff deflation [9
&&
,10]. This is due
to conflicting research into the effects of swallowing
with an inflated tracheostomy cuff [14,17 – 21], and
as yet there is no clear guidance regarding appro-
priacy of assessment. An inflated cuff prevents
airflow through the larynx, which could affect the
coordination of respiration/swallowing, glottic
sensation, preventing timely adduction during
swallowing and weakened cough response. Bedside
assessment of swallowing is therefore more chal-
lenging as important markers of dysfunction cannot
be evaluated (voice quality and attempts to cough).
Presence of an inflated cuff does not increase
aspiration risk but silent aspiration (i.e. no reflexive
cough is triggered) is more prevalent in cuff-inflated
patients [14,16,22]. Therefore, more objective
methods of evaluating swallowing are essential.
Patients do not necessarily need to wait until their
cuff has been deflated to successfully commence
oral intake as several studies have demonstrated
[23
&
,24,25], and further research is indicated [2
&&
]
to inform service provision. Clinicians need to
evaluate swallowing on a case-by-case basis, and a
holistic team approach is required.
ASSESSMENT
Bedside evaluation of swallowing function is routine
practice [10], and the SLT will rely on mostly
subjective measures to determine appropriacy of
oral intake. Instrumental assessment provides more
Managing dysphagia in tracheostomized patients Goff
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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
detailed information and is now increasingly acces-
sible to SLTs [10].
Fibreoptic endoscopic evaluation of swallowing
(FEES), in which the patient is given food/drink to
swallow whilst a nasendoscope is in situ in the
pharynx, has a growing evidence base in the trache-
ostomized population [25– 29]. A view of anatom-
ical structures, assessment of secretion management
and visualization of residues are some useful
strengths.
Videofluoroscopy complements a nasendo-
scopic view, providing more information about
the oral phase of swallowing, depth of aspiration
and upper oesophageal sphincter function. Both
assessments are valuable but not readily available
on daily basis for most SLTs. FEES can be performed
at the patient’s bedside, which is generally necessary
in the critical care setting.
Wallace [24] performed FEES on 33 tracheos-
tomized patients in the ICU to assess aspiration risk.
All patients were cuff-inflated and were tested on
fluids, syrup fluids and modified diet. Aspiration was
identified in 23/33 patients, and of these, 19 were
silently aspirating. FEES changed the feeding recom-
mendations in 55%. Seven patients had been kept
nil by mouth (NBM) by the medical team when no
aspiration was identified. Conversely, 10 patients
who had been started on liquids were aspirating and
placed NBM.
Other research has demonstrated the value of
FEES in progressing oral intake appropriately, avoid-
ing enteral feeding and facilitating discharge from
the ICU [30] and identifying occult laryngeal dis-
order [27].
BLUE DYE TESTING
One component of swallowing assessments with
tracheostomized patients is the modified Evans blue
dye test (MEBDT), which uses blue dye to stain
secretions/food/fluids and assess for evidence of
blue from material suctioned via the tracheostomy.
First described by Cameron et al. [31], the sensitivity
of this test has been challenged, and its use has since
been withdrawn in some services but not all
[9
&&
,10,17,32–36].
The first systematic review of the evidence for
diagnostic accuracy of the MEBDT was recently
published [37
&&
]. Six studies met the inclusion
criteria. Studies were excluded in which the authors
were unable to retrieve data in cases of mixed popu-
lations. Their flowchart identifies 17 studies that
were excluded at the screening stage, though
reasons are not provided. Meta-analysis was not
feasible given the diversity of the six included stud-
ies. Sensitivity ranged from 38 to 62% and specificity
79–100%. No definite conclusions could be drawn
regarding accuracy in detecting aspiration. In
addition, there were discrepancies in MEBDT pro-
tocols employed in the studies. The limitations of
this tool are now widely acknowledged [36,38], and
SLTs are urged to use it cautiously and adjunctively.
SWALLOW REHABILITATION
Rodrigues et al. [39] investigate the effects of swallow
rehabilitation in 16 patients of mixed aetiology in
a Brazilian ICU setting. The study is titled as a
feasibility study, yet there appear to be no feasibility
outcomes included, for example compliance with
therapy and acceptability to patients/ICU staff.
The authors detail nonsignificant improvements
in nonvalidated dysphagia ratings as well as need
for enteral feeding. Interestingly, patients with the
most severe dysphagia (gross aspiration) were
excluded, though no justification for this is pro-
vided.
These studies of the rehabilitation that SLTs
provide are much needed, but methodological flaws
preclude transference of findings into clinical prac-
tice. Effectiveness of SLT intervention is important
to investigate. Early mobilization of ICU patients
produces improved outcomes [40]; therefore, the
timing of intervention for swallowing warrants fur-
ther study. In another patient group, the ‘use it or
lose it phenomenon’ has been identified following
prolonged periods of gastrostomy feeding versus
patients who continued small amounts of oral
intake [41].
MULTIDISCIPLINARY TEAM
NCEPOD [2
&&
] recommended a concerted MDT
approach as have other experts in succinctly
described ‘best-practice’ models [42,43].
Several studies have attempted to evaluate the
effectiveness of a specialized tracheostomy MDT. A
systematic review concluded that only low-quality
evidence was available to support the notion that
MDTs reduce overall duration of tracheostomy and
hospital length of stay and increase speaking valve
use [44].
The most recent study to emerge is from a
Canadian team [45
&
] who retrospectively compared
outcomes following the implementation of an
MDT. They specifically evaluated time to SLT refer-
ral, although sample sizes were small (n¼20 pre-
intervention, n¼24 postintervention). They found
a nonsignificant improvement in the weaning time
from mechanical ventilation to SLT referral (7.8 days
faster, P¼0.27) and a significant improvement
in referral to SLT posttracheostomy insertion
Speech therapy and rehabilitation
220 www.co-otolaryngology.com Volume 25 Number 3 June 2017
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
(25.5 days faster, P¼0.01). Another retrospective
study of 126 patients found that timing of oral
intake commencement was strongly correlated
with time to decannulation across the total cohort
[23
&
]. These studies support the role of early SLT
intervention with tracheostomized patients and
reiterate the benefits for both patient and health-
care provider in adopting a coordinated and collab-
orative approach to care. Future research should
consider collecting specific outcomes that demon-
strate the implications of a faster SLT referral time,
for example number of enteral feeding/NBM days.
Such data would be valuable when considering the
funding implications of increased need for SLT
resources.
QUALITY OF LIFE
Qualitative research has shown the complexity of
physical and emotional effects experienced by
patients with a tracheostomy [46 – 48]. It is essential
that clinicians are aware of such effects in order that
patients can be offered appropriately targeted inter-
ventions. Many studies of tracheostomized patients
fail to incorporate any patient-reported outcome
measures most likely due to the lack of validated
tool.
Development of a tracheostomy-specific quality
of life (QOL) questionnaire is underway [49
&
]. The
authors describe three phases of item generation:
semistructured interviews with patients to identify
concerns, item review and scale construction and
piloting of the tool with 37 patients. Initial validity
and reliability testing appears positive. Despite only
being in the pilot stages, the robust development
and evaluation of the tool shows promise in address-
ing a gap in our understanding and measurement of
how a tracheostomy affects health-related/disease-
specific QOL.
CONCLUSION
Tracheostomized patients have complex, often mul-
tifactorial swallowing disorders, and the effects of
the presence of a tracheostomy tube remain uncer-
tain. SLT services are inconsistent, with regard to the
criteria for accepting referrals and the timing and
methods of assessment of swallow function.
Ongoing research to validate instrumental evalu-
ations, screening tools and QOL measures will
greatly enhance clinicians’ understanding of best-
practice intervention. In the absence of rigorous
evidence for specific effects of a tracheostomy on
swallowing parameters, clinicians need to evaluate
cases individually to tailor rehabilitation and inform
patients and MDT colleagues.
The evidence described in this review highlights
the challenges of designing a robust study of dys-
phagia in patients with a tracheostomy. Researchers
are faced with the difficulty of sacrificing potential
recruitment numbers for a homogenous cohort and
there are many uncontrollable variables. There is a
need for collaborative research to inform practice.
Recent advances in bringing together the inter-
national community of MDT professionals working
with this population [2
&&
,4
&&
] are both exciting
and promising.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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Speech therapy and rehabilitation
222 www.co-otolaryngology.com Volume 25 Number 3 June 2017
