October 19, 2004 Features

Managing Adults With Tracheostomies and Ventilator-Dependence

Current Concepts

The role of the SLP in the care of adults with tracheostomies and ventilator-dependence has evolved as the medical management of these complex patients has changed. The development of tracheostomy intermittent positive pressure ventilation (TIPPV) and its expanded use during the polio epidemics of the 1950s was one of the first major changes in treatment of these patients that prolonged their lives. Further advances in the area of mechanical ventilation (both noninvasive and invasive), in conjunction with the ability to treat infections and manage chronic pulmonary conditions, have resulted in many patients living out a significant part of their remaining lifespan as ventilator dependent.

At one time, adults with tracheostomies and ventilator-dependence were found only in hospitals, in intensive or acute care beds. Financial considerations and the need for available beds in hospitals led to the development of specialty care units and the transfer of such individuals to different levels of care. These patients are no longer found solely in intensive care units of hospitals, but may progress to long-term acute care, subacute, extended care, and community (home care) settings.

Concurrent with changes in medical management is increased awareness of the special needs of this population, including quality-of-life issues of communication and oral intake. The speech-language pathology community is creating more literature and presentations on the topic of tracheostomy and ventilator dependence. ASHA has developed relevant position and guideline papers and SLPs are experiencing greatly increased caseloads in multiple settings. The role of the SLP on the treatment team has expanded, as have the issues that the treating clinician must handle on a daily basis. Some relevant references are provided on the ASHA Web site. See end of article.

Competencies of the Clinician

A clinician who manages patients with tracheostomies and ventilator-dependence deals with a challenging, stimulating population. Optimally, the clinician will work as a team member with a variety of health care practitioners, including physicians, respiratory care practitioners, nurses, rehabilitation personnel, registered dieticians, social workers, and others. However, supportive personnel and resources, the presence of a team, and the role of the SLP vary widely from facility to facility.

The experience and training of SLPs providing services, and the type of services provided, also vary. As in other areas in our field, appropriate competencies and training are vital. Very few clinicians enter, or even complete their clinical fellowship year with the knowledge and skills needed to evaluate and treat patients with tracheostomies and ventilator-dependence. ASHA's Code of Ethics makes clear that it is the responsibility of treating clinicians to be competent in the services they provide. This has created conflicts for some clinicians who work in settings where patients with tracheostomies and ventilator-dependence were not previously admitted.

One example is a nursing home that is designating beds for these patients in response to a new need in the facility's catchment area. The clinician providing services in the facility receives a consult for speech and swallowing assessment. Ideally, the SLP would be part of the team planning the resources needed to admit and manage these individuals. Personnel needed for effective care could be identified, and training needs discussed. For example, during the development of what is now a 48-bed unit for patients with tracheostomies and ventilator-dependence, we, along with a pulmonologist, respiratory care practitioner, and nursing supervisor visited an established subacute facility. The investment of one day in observation and discussion was invaluable for all team members.

Our facility has provided similar opportunities for other groups. As SLPs, we have the dual responsibility of both advocating for the communication and swallowing needs of adults with tracheostomy and ventilator-dependence, and obtaining the necessary education and training to provide services in this area.

In general, SLPs who work with this population must have familiarity with anatomy and physiology of the respiratory and phonatory systems (normal and disordered), normal respiratory and metabolic values, airway management techniques, endotracheal and tracheostomy tubes, and mechanical ventilators (invasive and noninvasive). The Tracheostomy Tubes sidebar provides some definitions of terminology for the SLP. The clinician should understand the potential impact of tracheostomy and ventilator dependence on communication and in some cases, swallowing.

While SLPs do not select airway management techniques or modify ventilator settings, they must realize that a particular type of tracheostomy tube can affect candidacy for a one-way speaking valve use for voice restoration. In addition, because the adult with a tracheostomy and ventilator-dependence is typically medically fragile and clinically complex, understanding the patient's mode of mechanical ventilation can guide the timing of a speech and swallowing evaluation.

Certain ventilator settings and laboratory values reflect the overall health status of the patient as well as their respiratory status. For example, clinicians can check the oxygen saturation of hemoglobin in the blood with a noninvasive technique called pulse oximetry. A light-emitting probe is placed on a well-oxygenated area of the body, and a value called SP02 is obtained that correlates with oxygen saturation in the blood. A patient with a low SP02 despite respiratory intervention may not be ready for active treatment, and the clinician may defer intervention until the SP02 reaches acceptable limits.

The assessment and management process is very individualized, and discussion with other team members involved in the patient's care can greatly facilitate the SLP's intervention. See The ASHA Leader Online for a sample of normative values helpful to a clinician when evaluating a person with a tracheostomy and ventilator-dependence.

When discussing specific communication and swallowing management skills, SLPs must have a knowledge of vocal and non-vocal communication methods, swallowing management including post-tracheotomy anatomy and potential impact of tracheostomy and ventilator dependence on swallowing, an awareness of co-morbidities that can affect swallowing function, and skills with clinical and instrumental dysphagia assessment. In addition, any clinician working with this population should have basic competencies in the management of respiratory emergencies. While specific to facility practice, such training would typically include oral and tracheal suctioning (as permitted by state licensure laws), and basic ventilator troubleshooting, such as the ability to recognize a ventilator disconnect or failure alarm. In our facility, where adults who are ventilator-dependent regularly attend rehabilitation sessions and therapeutic recreation events, such training is essential. The key is annual training with the demonstration of return competencies to a qualified instructor such as a staff development nurse or a respiratory therapist.

While facility specific, many SLPs participate on ventilator teams and have input into tracheostomy weaning and decannulation protocols. We are part of our subacute facility respiratory care committee, which meets monthly. Policies and procedures, treatment protocols, and new products and equipment for the respiratory unit are discussed during these meetings. The group is chaired by the director of respiratory therapy and includes members from administration, nursing, medicine, pulmonology, speech-language pathology, social work, therapeutic recreation, and finance.

Speech-language pathology also assisted in the development of an interdisciplinary tracheostomy and weaning protocol. The role of speech-language pathology in this process includes the placement of a one-way speaking valve as a first step in capping, or plugging, the tracheostomy tube, and the assessment of swallowing, especially airway protection. In a recent example, a primary care physician requested pulmonary and speech-language pathology evaluations for a patient she felt was borderline for decannulation due to impaired cough and reduced airway protection. While the physician will make the ultimate determination for decannulation, the input from the pulmonologist and SLP provided useful information in making the decision.

Clinician Responsibilities

In some instances, SLPs working with adults with tracheostomy and ventilator-dependence may find themselves asked to perform tasks they feel are outside their scope of practice. Clinicians should carefully evaluate the request and monitor their practice. For example, SLPs do not modify the settings of a mechanical ventilator or change tracheostomy tubes, although they may recommend that these steps be taken during a patient's treatment program. However, SLPs in most states can perform oral and tracheal suctioning during their treatment sessions, when properly trained.

It is the responsibility of the individual clinician to be aware of state licensure laws and to obtain the necessary training. In fact, SLPs should feel empowered to seek such training if they are asked to work with adults with tracheostomy and ventilator-dependence. In terms of education and training, colleagues are excellent sources of information. These authors are fortunate to have worked with many physicians, respiratory care practitioners and nurses who have assisted us in our clinical practice.

Companies that make specific products, such as tracheostomy tubes or one-way speaking valves, are typically happy to share information and references about their products. Continuing education courses and facility in-service training are essential for all clinicians. ASHA has several self-study products available in this area. ASHA has also developed clear and useful knowledge and skills documents for clinicians actively working with, or interested in working with patients with tracheostomies and ventilator-dependence. One example is "Use of Voice Prostheses in Tracheostomized Persons With or Without Ventilator Dependence," adopted by the ASHA Legislative Council in 1992. This document addresses scope, education and training, knowledge and skills, safety and infection control, and patient education and outcomes.

Maintaining awareness in current practice mandates that clinicians read literature on the topic of tracheostomy and ventilator dependence. Frequent literature reviews are helpful, and will keep the clinician aware of new information and trends.

Dysphagia Management

One relevant area to any clinician working with this population is dysphagia management. Dysphagia represents the majority caseload of most clinicians in acute, subacute, and even long-term care facilities. Consults for adults with tracheostomies and/or ventilator-dependence often include a request to assess swallowing safety. There are a number of studies that discuss swallowing impairment in the patients with tracheostomies and ventilator-dependence. Chapters in the two textbooks listed in the references with this article contain relevant information.

Although a causal relationship has not been clearly established, most clinicians working with this population will encounter varying degrees of disordered swallowing. This finding may be related to the complications inherent in tracheostomy and ventilator-dependence, associated procedures, or the co-morbidities that actually precipitated the respiratory failure. For example, individuals with severe obstructive pulmonary disease, an intrinsic lung disorder, may have difficulty swallowing due to changes in lung volumes that affect the finely coordinated processes of deglutition and respiration. These individuals may manage their oral diets with self-adjustments of texture and eating style until an exacerbation of their condition leads to respiratory distress, intubation, mechanical ventilation, and eventual tracheostomy. The potential physiologic and mechanical impact of the tracheostomy tube and mechanical ventilator may overwhelm an already stressed system, and the patient is unable to manage an oral diet. In contrast, a patient with a more acute condition such as an obstructed airway, who requires an emergency tracheostomy, may not show the same impact. As with all persons with dysphagia, a thorough history, a comprehensive clinical and instrumental swallow assessment, and an understanding of the systems affected will guide the clinician's management.

Another topic under recent discussion in the literature is the use of "blue dye" as part of the swallowing evaluation process with patients with tracheostomies and ventilator-dependence. Although protocols vary, the blue dye screen itself consists of the placement of blue food coloring on the patient's tongue or in a small bolus. The patient's tracheostomy tube is suctioned for presence of the dye, which would indicate aspiration into the trachea. Clinical concerns have included a very low reliability with instrumental assessment. For example, in one widely reviewed study by Thompson-Henry and Braddock (1995) 50% of patients who "passed" a blue dye screen without evidence of dye in the tracheal secretions were found to aspirate during an instrumental assessment.

In our own clinical work we found similar discrepancies in the use of blue dye in clinical swallowing evaluations compared to the findings of fiberoptic endoscopic evaluations of swallowing safety (FEESS). These findings point to blue dye as very unreliable in the assessment of airway protection problems. In addition, adverse outcomes, that is, severe illness and patient deaths associated with the use of blue dye in enteral, or feeding tube, contents, has been reported in the literature. Lucarelli et al (2004) discussed blue dye toxicity in critically ill patients given the dye in their tube feedings. In critical care settings, blue dye was commonly added to tube feedings for the detection of reflux and aspiration.

In these patients, especially those with sepsis, a severe and pervasive infection, the blue dye appears to have been systemically absorbed by the body leading to toxicity and in some cases, death. While the amounts used in enteral feedings are significantly greater than that used during dysphagia assessment, concerns for safety have been raised. In many facilities, the use of any food dye in swallowing assessment, even for FEESS, has been eliminated. Further research into the safety of small amounts of food dyes is needed. Alternative materials have been suggested and presented by various clinicians. SLPs using blue dye with their adults with tracheostomy and ventilator-dependence must weigh both the safety and utility of this process.

SLPs working with the adults with tracheostomy and ventilator-dependence will find themselves challenged on a daily basis by the clinical and medical questions that arise in their practice. They will also be greatly rewarded by assisting these individuals with their communication and swallowing needs.

Karen J. Dikeman, is assistant vice president of rehabilitation services at the Silvercrest Center. 

Marta S. Kazandjian, is the director of speech pathology at the Silvercrest Center for Nursing and Rehabilitation, Briarwood, New York, and New York Hospital Queens, Flushing, New York.  

cite as: Dikeman, K. J.  & Kazandjian, M. S. (2004, October 19). Managing Adults With Tracheostomies and Ventilator-Dependence : Current Concepts. The ASHA Leader.

Tracheostomy Tubes

Materials, Design, and Type

Button: decannulation plug for a tracheostomy tube also referred to as a cork, plug, or cap, depending upon the type of tube. Used during the weaning and decannulation process to assist the patient in learning to breathe through the upper airway, the button seals off the outer or inner cannula of the tracheostomy tube.

Cuff: the balloon-like part of an artificial airway (e.g., tracheosotmy tube) that is inflated in the trachea to provide a seal in the airway; usually used during mechanical ventilation to prevent air leaking out the upper airway. May also be used in the presence of copious secretions.

Fenestration: an opening or window. Fenestrations are placed in tracheostomy tubes (outer or inner cannula) to facilitate air passage through the tube and the upper airway.

Inner cannula: the internal portion of a trachesotomy tube that fits within the main or external structure of the tube. May be disposable or nondisposable.

Speaking valves: valves that are placed on the hub or end of a tracheostomy tube to allow air to enter on inspiration, and be directed around the tube and out the upper airway upon expiration. Facilitates voice and may assist with swallowing in some cases, for example, by restoring effective cough. Valves may be one-way or two-way dependent on manufacturer; only some valves may be used for patients on and off the ventilator.

Outer cannula: the portion of the tracheostomy tube that forms the actual body of the tube; the external structure of the tube in which the inner cannula fits.

Talking tracheostomy tube: a tracheostomy tube that has been adapted to permit phonation in the presence of an inflated cuff. Talking tracheostomy tubes contain an external air source that allows air to enter the airway above the level of the tracheostomy tube cuff. Usually used for ventilator dependent patients who cannot tolerate cuff deflation. 



Normal Values to Remember

Values

Normal Range

Acid-Base Balance (pH) 7.35-7.45
End Tidal Carbon Dioxide 35-45 mmHg *
Oxygen Saturation 90-100 % *
Albumin 3.5-5.5
Respiratory Rate <28 bpm
Heart Rate < 120 bpm
Negative Inspiratory Force -20-30 > 50%, >-30=100%

* These numbers are typically patient specific-persons with severe lung disease may have higher carbon dioxide values than those with healthier lungs.



ASHA Resources

ASHA Products and Resources

  • Managing Communication and Swallowing Impairments in Tracheostomized and Ventilator Dependent Adults
    Examine the potential impact of the loss of upper airway usage and analyze management techniques that maximize the potential for the restoration of upper airway flow in this self-study videoseminar (item #0112182). Available for .4 ASHA CEUs.
  • Upper Airways and Artificial Airways
    This audioseminar examines the anatomy and physiology of the upper aerodigestive tract and discusses artificial airways and mechanical ventilation (item #0112025). Available for .6 ASHA CEUs.

ASHA Policy Documents

  • Use of Voice Prostheses in Tracheotomized Persons With or Without Ventilatory Dependence: Position Statement
  • Use of Voice Prostheses in Tracheotomized Persons With or Without Ventilatory Dependence: Guidelines


Glossary

Albumen: a protein found in mammals, often measured in a blood analysis to determine an individual's nutritional needs. A low albumen level can impede the ventilator weaning process by decreasing inspiratory muscle strength and reducing the ability to breathe on one's own.

Acid-base balance (pH): measure of hydrogen ions in the blood reflecting balance of oxygen and carbon dioxide. Abnormalities in this value may indicate a change in respiratory or metabolic status. An example of a metabolic change would be sepsis, a severe infection that can affect multiple body organs and eventually lead to respiratory failure.

End tidal carbon dioxide (PetCO2): the amount of carbon dioxide in exhaled air; a measure that should correlate with levels of carbon dioxide in the lungs. Assists in assessing the adequacy of ventilation and the tolerance of modifications to the ventilator or tracheostomy tube (e.g., speaking valve placement).

Oxygen saturation: amount of oxygen in the blood (hemoglobin), measured most accurately in samples of arterial blood (blood gases); also reflected in a noninvasive measure such as pulse oximetry. Helpful in measuring trends in blood oxygen saturation and tolerance of ventilator or tracheostomy tube modifications.

Mechanical ventilation (ventilator dependence): mechanical assistance in the breathing process; it may be used to augment the efforts of a patient who has spontaneous, but weak, breaths or for individuals who cannot breathe on their own.

Respiratory rate: the number of breaths per minute. May be spontaneous or delivered by a ventilator. An abnormally high, sustained respiratory rate may indicate an underlying respiratory or metabolic problem and impending respiratory failure.

Heart rate: number of beats per minute of the heart, reflected in the patient's pulse and potentially reflective of increased stress on the patient's system.

Negative inspiratory force: a maximum inspiratory effort that can be produced by a patient; greater values are a positive prognostic factor for ventilator weaning.

Tracheostomy: an artificial airway; the tube used to secure the opening or stoma created by a tracheotomy, or surgical creation of an opening in the trachea.

Weaning: the process of removing a patient from mechanical ventilation. Reduction of support may be gradual or more rapid, dependent on patient tolerance. May also refer to the process of removing a tracheostomy tube.



Selected Readings

American Speech-Language-Hearing Association. (1993). Position statement and guidelines for the use of voice prostheses in tracheostomized persons with or without ventilator dependence. ASHA, 35, (Suppl. 10), pp. 17-20.

Belozerco-Tracey, L., Harris, A., Dikeman, K., Kazandjian, M., Schembari, M., Tracey, C., Berding, J., Fleming, R., & Zamora, A. (2002). An interdisciplinary approach to tracheostomy capping and decannulation. Poster presented at the Annual Convention of the American Speech-Language-Hearing Association, Atlanta, GA.

Dikeman, K. J., & Kazandjian, M. S. (2003). Communication and swallowing management of the tracheostomized and ventilator dependent adult. Thomson Delmar Learning: Clifton Park, NY.

Lucarelli, M. R., Shirk, M. B., Julian, M. W., & Crouser, E. D. (2004) Toxicity of food drug and cosmetic blue No. 1 dye in critically ill patients. Chest, 125, 793-795.

Thomson-Henry, S., & Braddock, B. (1995). The modifed Evan's blue dye procedure fails to detect aspiraiton in the tracheostomized patient: Five case reports. Dysphagia, 10, 172-174.

Tippett, D. C. (Ed.), (2000). Tracheostomy and ventilator dependency: Management of breathing, speaking and swallowing. New York: Thieme Medical Publishers.



  

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