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Tracheostomy

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The Role of the Speech Pathologist in Tracheostomy Management: An Overview
Reasons for receiving a Tracheostomy
Decision-Making regarding Tracheostomy insertion
Swallowing with a Tracheostomy
Speech with a Tracheostomy
Weaning from a Tracheostomy
Tracheostomy Care
References

The Role of the Speech Pathologist in Tracheostomy Management: An Overview

Tracheostomy management is an area in which a speech pathologist may be involved in palliative care*.

Speech pathology management of tracheostomy patients is an area requiring detailed, specialized knowledge, a comprehensive description of which is beyond the scope of this website. The principles involved in tracheostomy management in the palliative care setting do not differ greatly from other clinical situations in which tracheostomy is encountered, with the aims of management being to optimise the client's swallowing and communication abilities. Speech pathologists working with tracheostomy management should be trained appropriately. It is recommended that speech pathologists new to working with tracheotomised patients seek management guidelines from the literature, professional association guidelines (Speech Pathology Australia, 2005) as well as guidance from clinicians who have skills in this area*.

The following sections outline the key areas which speech pathologists working in palliative care may need to understand in relation to tracheostomy.

Reasons for receiving a Tracheostomy

In palliative care, a common reason for receiving a tracheostomy is head and neck cancer with airway obstruction* (Barnett, 2005). Other reasons for which a patient may receive a tracheostomy include other types of airway blockages; severe dysphagia* (Barnett, 2005); the need for ongoing supported ventilation; weakened or paralysed chest muscles and diaphragm due to progressive neuromuscular disease (e.g. motor neurone disease; Barnett, 2005); injury to the head or neck (Barnett, 2005); or aspiration caused by sensory or muscular problems in the throat (Bissell, 2001a). The tube may be in place temporarily or for lengthy durations, ranging from weeks to years*. See www.tracheostomy.com/reasons.htm for a more comprehensive list of possible reasons for receiving a tracheostomy.

Decision-Making regarding Tracheostomy Insertion

A speech pathologist in palliative care may be faced with the issue of whether or not a given client should receive a tracheostomy tube, and if so, when to have the tube inserted (L. Brown, personal communication, October 21, 2005). There is a large amount of debate in the literature concerning mechanical ventilation via a tracheostomy tube in clients with progressive neurological disorders, particularly amyotrophic lateral sclerosis (ALS) (Farrero et al., 2005; Lechtzin, Schmidt & Clawson, 2005; Young, Marshall & Anderson, 1994). Lechtzin, Schmidt and Clawson (2005) acknowledge the advantages and disadvantages to long-term mechanical ventilation for such clients, stating that "While very few ALS patients opt for tracheostomy and long-term mechanical ventilation, for select patients, this can provide years of support with a preserved quality of life" (p. 168).

The decision to receive a tracheostomy and respiratory support should ultimately be made by the client themselves (Young, Marshall & Anderson, 1994). Factors considered by clients in making this decision may include quality of life, severity of their disability, availability of ventilation via a nasal mask, possibility of being able to discontinue mechanical ventilation, desire to live, and concern for the emotional and care demands placed on their families (Young, Marshall & Anderson, 1994).

The speech pathologist can help facilitate this decision-making by providing clear, unbiased information regarding the client's disease progression and the implications of having a tracheostomy inserted in terms of swallowing and communication function*.

Swallowing with a Tracheostomy

The presence of a tracheostomy tube has the potential to negatively impact on swallowing and increase risk of aspiration (Higgins & Maclean, 1997; Murray & Brzozowski, 1998), particularly if there are concurrent structural and/or neurological difficulties.

Assessment
Swallowing assessment for these clients will follow many of the same principles as a swallowing assessment with any client in a palliative setting* (see DYSPHAGIA section). The process may involve:

Bedside swallowing evaluation/observational dysphagia assessment*
Cranial nerve assessment*
Obtaining detailed case history information including type and size of tracheostomy tube; date of insertion; presence of a cuff; fenestration of the tube; and/or use of a speaking valve (Murray & Brzozowski, 1998)
Use of the Evan's Blue Dye Test* (Higgins & Maclean, 1997) or Modified Evan's Blue Dye Test* (Murray & Brzozowski, 1998). It must be noted that some clinicians surveyed reported not using this test due to its lack of strong evidence base*
Videofluoroscopy*

Management
Dysphagia management for a palliative care client with a tracheostomy may also involve many of the same strategies as with any client in a palliative setting* (see DYSPHAGIA section). Such management for tracheostomy clients may involve the following:

Giving strategies for improving swallowing function (Bissell, 1999).
Giving recommendations regarding appropriate dietary consistency, level of supervision required during feeding, safe swallowing strategies (see DYSPHAGIA section of this website), positioning, and cuff deflation and tracheal occlusion instruction (Murray & Brzozowski, 1998).
Collaborating with respiratory specialist and physician to determine necessary adjustments to a patient's ventilator settings (if they are receiving mechanical ventilation), to maximize swallowing safety (Murray & Brzozowski, 1998).

Specific feeding recommendations/strategies provided by a speech pathologist to enhance a client's ease and safety of oral intake may include (Murray & Brzozowski, 1998):

Dry swallow after every bite to help clear residue in the pharynx
Series of single swallows instead of continuous/consecutive swallows, to allow breathing time in between swallows
Have frequent rest breaks during meals because of the extra effort of breathing while eating

An inflatable cuff around the tracheostomy tube may minimize aspiration of secretions or food/fluid. However, this method is not entirely effective, as material can pass the vocal folds and sit on top of the cuff (Murray & Brzozowski, 1998). Regular cuff deflation and suctioning of aspirated secretions may help protect the lower airway from secretions and other materials, although efficacy of this technique requires objective testing (Murray & Brzozowski, 1998).

Speech with a Tracheostomy

Presence of a tracheostomy can alter or minimize a patient's ability to use their voice to speak (Bissell, 2001b). In a study by Forbes (1997), 15 out of 20 palliative clients with head and neck cancer and a tracheostomy indicated that communication was a problem. See www.tracheostomy.com/speech.htm for a more detailed explanation of how a tracheostomy affects an individual's ability to use speech.

Assessment
Speech pathologists use mostly informal observation to assess a client's speech when working in palliative care* (see the SPEECH section of website). When working with a client in palliative care who has a tracheostomy in place, the speech pathologist may use observational assessment to determine the client's communication ability and suitability for a speaking valve, and/or augmentative and alternative communication (AAC) device* (see COMMUNICATION section of website).

Management
The speech pathologist's role in speech intervention for palliative clients with a tracheostomy may include:

Communication assessment and giving recommendations regarding an appropriate method of communication*
Provision of augmentative and alternative communication (AAC) devices if speech is not an option* (Bissell, 2001b). See COMMUNICATION section of this website.
Recommendation regarding the type of tracheostomy tube used*
Advice as to whether use of a speaking valve is appropriate*

Specific ways to achieve or improve a client's ability to speak with a tracheostomy may include the following (Bissell, 2001a). Adapted from www.tracheostomy.com/speech.htm:

Use of a finger, the patient's chin, or a cap to occlude the tracheostomy tube for short periods during voicing.
A one-way tracheostomy speaking valve (e.g. a SpeakEZ), which allows air in through the external stoma, but then directs expired air through the vocal folds and out the mouth, allowing speech. These cannot be used when the airway is completely obstructed.
Fenestrated tracheostomy tube.
Electrolarynx or Artificial larynx. See the LARYNGECTOMY section of this website.
A talking tracheostomy tube, with which an outside air source forces air through the vocal cords.

Weaning from a Tracheostomy

The procedure of weaning a client from a tracheostomy tube and associated assisted ventilation has been promoted for clients in sub-acute care (Shrivastava, Kapre & Gray, 2003; Rumbak et al., 1999). However, this process was not mentioned by speech pathologists who were surveyed about their role with tracheostomy in palliative care. This is presumably because management of a palliative client is focused on maintaining comfort and quality of life, rather than on having the client return to a pre-morbid level of functioning.

Tracheostomy Care

While a speech pathologist's role may involve educating caregivers or staff regarding cleaning and maintenance of the tracheostomy tube, tracheostomy care is primarily the role of an experienced nurse* (Barnett, 2005; Wilson, 2005). An adequately trained nurse may be called on to perform duties such as suction or irrigation when necessary; humidification; daily cleaning of the stoma; inspection of the stoma site for skin damage; securing the tracheostomy tube; changing the tapes daily; and changing the tracheostomy tube at least weekly (Barnett, 2005; Wilson, 2005). For specific guidelines on caring for tracheostomy site see www.tracheostomy.com/care.htm (Bissell, 2003).

As there is always a risk of a tracheostomy tube becoming blocked, dislodged or removed completely, it has been recommended that all staff learn the appropriate procedures for resuscitation of a tracheostomy client (Wilson, 2005). However, in cases where the care is palliative, all staff, including the speech pathologist, must also be aware of the client's decision concerning whether or not they wish to be resuscitated should a complication arise (Rady & Johnson, 2004; Young, Marshall & Anderson, 1994).

References

Barnett, M. (2005). Tracheostomy management and care. Journal of Community Nursing, 19(1), 4-7.

Bissell, C. (2003, 20th Sep). Tracheostomy care. Retrieved September 18, 2005, from http://www.tracheostomy.com/care.htm

Bissell, C. (2001a, 25th May). Reasons for a tracheostomy. Retrieved September 18, 2005, from http://www.tracheostomy.com/reasons.htm

Bissell, C. (2001b, 11th Feb). Speech with a Tracheostomy. Retrieved September 22, 2005, from http://www.tracheostomy.com/speech.htm

Bissell, C. (1999, 25th Aug). Eating with a Tracheostomy. Retrieved September 22, 2005, from http://www.tracheostomy.com/eating.htm

Farrero, E., Prats, E., Povedano, M., Martinez-Matos, J.A., Manresa, F., & Escarrabill, J. (2005). Survival in amyotrophic lateral sclerosis with home mechanical ventilation: The impact of systematic respiratory assessment and bulbar involvement. Chest, 127(6),2132-2138.

Forbes, K. (1997). Palliative care in patients with cancer of the head and neck. Clinical Otolaryngology, 22, 117-122.

Higgins, D., & Maclean, J. (1997). Dysphagia in the patient with tracheostomy: Six cases of inappropriate cuff deflation or removal. Heart and Lung, 26(3), 215-220.

Lechtzin, N., Schmidt, E., & Clawson, L. (2005). Approach to the patient with amyotrophic lateral sclerosis. Clinical Pulmonary Medicine, 12(3), 168-176.

Murray, K., & Brzozowski, L. (1998). Swallowing in Patients with Tracheotomies. American Association of Critical-Care Nurses, 9(3), 416-426.

Rady, M., & Johnson, D. (2004). Admission to intensive care unit at the end-of-life: Is it an informed decision? Palliative Medicine, 18(8), 705-711.

Rumbak, M. J., Walsh, F. W., Mc Dowell Anderson, W., Rolfe, M. W., & Solomon, D. A. (1999). Significant Tracheal Obstruction Causing Failure to Wean in Patients Requiring Prolonged Mechanical Ventilation: A Forgotten Complication of Long-term Mechanical Ventilation. Chest, 115(4), 1092-5.

Shrivastava, D. K., Kapre, S., & Gray, R. (2003). Weaning is facilitated by use of non-fenestrated tracheostomy tubes in chronically ill tracheostomized subacute care patients. Chest, 124(4), S205.

Speech Pathology Australia (SPA) (2005). Tracheostomy management: Position paper. Melbourne: The Speech Pathology Association of Australia Limited. Retrieved October 21, 2005, from http://www.speechpathologyaustralia.org.au/library/Trache%20Position%20Paper%202005.pdf

Wilson, M. (2005). Tracheostomy management. Paediatric Nursing, 17(3), 38-43.

Young, J., Marshall, C., & Anderson, E. (1994). Amyotrophic lateral sclerosis patients' perspectives on use of mechanical ventilation. Health and Social Work, 19(4), 253-260.

Please note: Asterisk (*) indicates that information is based on the survey responses of 13 experienced speech pathologists working in palliative care in Victoria.

Disclaimer: The purpose of this website is to provide speech pathologists with a summary of the available evidence-base and current practice when dealing with patients in palliative care. The guidelines provided may be used as a guide for providing palliative care; however, cases will undoubtedly arise for which our findings may not be readily applied. The information contained in the website is not intended to prescribe specific procedures to use with palliative patients referred to speech pathology, but rather aims to assist speech pathologists by outlining the available evidence base and current practice methods used in the area. Information regarding current practice in palliative care was obtained from surveying thirteen speech pathologists with experience working in palliative care. It must be noted that not all speech pathologists surveyed contributed equally to all sections of this website.

© Copyright 2005.
Website developed by forth year speech pathology students Jane-Frances Gooden, Courtney Jones, Alyssa Mann, Marita McDowall and Jo Shugg. Supervised by Louise Brown.
School of Human Communication Sciences, La Trobe University, Melbourne, Australia.