The scope of this page includes communication and swallowing issues in patients with tracheostomy, both with and without ventilator dependence, across the lifespan.
See the Tracheostomy and Ventilator Dependence Evidence Map for summaries of the available research on this topic.
Individuals with artificial airways due to medical complications often experience compromised communication and swallowing function. Speech-language pathologists (SLPs) with appropriate training contribute to the communication and swallow assessment and management of patients with tracheostomies, both with and without ventilator dependence, in cooperation with an interprofessional team.
Definitions relevant to page content:
Due to the wide variety of medical conditions that may necessitate a tracheostomy (both with and without mechanical ventilation), patients have diverse experiences in type and severity of communication and swallowing difficulties. Individualized assessment and management require interprofessional collaborative practice. A tracheostomy team may include an otolaryngologist, a pulmonologist, a respiratory therapist, nurses, and the SLP. Positive patient outcomes—including reductions in cannulation times, hospital length of stay, adverse events, and cost of care—have been realized when patients with tracheostomy are managed with a multidisciplinary team approach (Bonvento, Wallace, Lynch, Coe, & McGrath, 2017; de Mestral et al., 2011; Garrubba, Turner, & Grieveson, 2009). See ASHA's page on Interprofessional Education/Interprofessional Practice (IPE/IPP).
A range of conditions (across the lifespan) may necessitate the placement and maintenance of an artificial airway, often leading to varying degrees of laryngeal injury and co-occurring communication and/or swallowing problems. A recent systematic review by Brodsky et al. (2018) found a high prevalence (83%) of laryngeal injury in adults who received endotracheal intubation with mechanical ventilation in the intensive care unit (ICU). Although the reasons for tracheostomy and severity of injuries varied across studies, dysphonia (76%), hoarseness (63%) and dysphagia (49%) were reported as common clinical symptoms post intubation. An additional systematic review by Skoretz, Flowers, and Martino (2010) reported the frequency of dysphagia in medical and surgical populations ranging from 3% to 62%, with higher frequencies noted with prolonged intubation (> 24 hours).
In the United States, it is also estimated that 800,000 people require mechanical ventilation each year (Mehta, Syeda, Wiener, & Walkey, 2015; Wunsch et al., 2010), with prolonged mechanical ventilation reported in approximately 250,000 (≥ 96 hours; Zilberberg, Luippold, Sulsky, & Shorr, 2008). As the aging population increases, these numbers are expected to rise with approximately 600,000 people requiring prolonged mechanical ventilation by the year 2020 (Stephan et al., 2013; Zilberberg, de Wit, & Shorr, 2012; Zilberberg & Shorr, 2008). Additional data revealed that 100,000 tracheostomies are performed each year on individuals requiring mechanical ventilation (Herritt, Chaudhuri, Thavorn, Kubelik, & Kyeremanteng, 2018; Shah et al., 2012).
SLPs play a central role in the screening, assessment, diagnosis, and treatment of persons with swallowing and/or communication disorders related to artificial airways, including tracheostomies, with and without ventilator dependence. The professional roles and activities in speech-language pathology include clinical/educational services (diagnosis, assessment, planning, and treatment), advocacy, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016b).
Assessment and treatment of persons with swallowing and/or communication disorders related to artificial airways, including tracheostomies, with and without ventilator dependence may require use of appropriate personal protective equipment.
Appropriate roles for SLPs include, but are not limited to, the following:
Safe intervention for the patient with a tracheostomy tube, with or without ventilator dependence, requires essential knowledge of the following:
As indicated in the Code of Ethics (ASHA, 2016a), SLPs who serve this population should be specifically educated and appropriately trained to do so.
SLPs may encounter patients with tracheostomy, both with and without ventilator dependence, in a variety of settings—including hospitals, skilled nursing facilities, rehabilitation centers, outpatient clinics, long-term acute care centers, schools, and home health care.
Patient populations requiring a tracheostomy (with or without the use of a mechanical ventilator) include those with diagnoses specific to lung disease, diagnoses impacting respiratory musculature, and/or diagnoses impacting structure and function of the respiratory tract, including the upper airway. Examples of patient diagnoses include the following:
Among patient populations requiring a tracheostomy, the reasons for surgical intervention are varied, and the type of tracheostomy tube selected by the surgeon is individualized.
Surgical intervention and placement of a tracheostomy tube may address the following:
The type of tracheostomy tube placed by the surgeon will depend on the specific needs, characteristics, and medical status of the individual patient. Consideration is taken regarding the advantages offered and/or disadvantages imposed by each type of tube and its components.
Figure 1: A tracheostomy tube in situ. From Communication and Swallowing Management of Tracheostomized and Ventilator-Dependent Adults (2nd ed) (p. 69) by K. J. Dikeman and M. S. Kazandjian, 2003, Clifton Park NY: Delmar Learning. Copyright 2003 by authors. Reprinted with permission.
Figure 2. Parts of a standard tracheostomy tube. From Communication and Swallowing Management of Tracheostomized and Ventilator-Dependent Adults (2nd ed) (p. 86) by K. J. Dikeman and M. S. Kazandjian, 2003, Clifton Park NY: Delmar Learning. Copyright 2003 by authors. Reprinted with permission.
Different types of tracheostomy tubes may include the following characteristics or specializations:
The type, size, and characteristics of a patient's tracheostomy tube may require alterations as a result of anatomical growth, changes in the patient's underlying condition, and/or facilitation of communication options.
The components of a tracheostomy tube include the following:
An appropriately sized tracheostomy tube is important for addressing the communication and swallowing needs of patients with tracheostomy tubes. Tracheostomy tubes may be custom fit. When determining the appropriate size (i.e., inner diameter, outer diameter, length) of the tracheostomy tube, the tracheostomy team considers the following patient specifics:
(Mitchell et al., 2013; Sherman et al., 2000)
Consideration of tracheostomy tube cuff status requires input from the tracheostomy team with attention to a patient's medical status, respiratory/ventilatory status, and the impact it has on the patient's communication status and swallow function. It is important to note that an inflated cuff does not prevent aspiration. If there is liquid at the level of the cuff, the patient has already aspirated as the cuff is located below the true vocal folds. Leakage around the cuff is possible; an inflated cuff does not provide a watertight seal.
Benefits of cuff deflation may include the following:
The timing of the initial tracheostomy tube change may have an impact on patient progress. For example, changing the tube within a week of the tracheotomy procedure may result in earlier use of a speaking valve and earlier oral intake in adult patients (Fisher et al., 2013). Deutsch (1998) concluded that most pediatric tracheostomy tubes can be safely changed 3–4 days after surgery and that shorter intervals between surgery and the first tracheostomy tube change may be beneficial (e.g., shorter hospital stays).
Mechanical ventilators are utilized with various modes and settings, which may require modifications as a patient's status or condition changes. Decisions made by the physician (e.g., pulmonologist) about the ventilator modes and/or settings are carried out by trained medical professionals.
Mechanical ventilation is used to address compromised breathing, which impacts the ability to move air in and out of the lungs and/or for the lungs to complete the necessary gas exchange. Respiratory or ventilatory failure (or impending failure) is an indicator of the need for mechanical ventilation. Respiratory failure may be hypoxemic (i.e., abnormally low levels of oxygen in the blood) or hypercapnic (i.e., excess carbon dioxide in the blood). There are many and various etiologies of respiratory failure, including the following:
Mechanical ventilation may also be used with patients who undergo anesthesia (e.g., during surgery).
Ventilator settings (the characteristics of ventilation provided) and modes (representing the method—the how and when—of inspiratory support), as well as any modifications of the same, are determined and managed by the physician (or the respiratory therapist/nurse/trained professional under physician's orders).
The primary mechanical ventilator settings include the following:
Ventilator modes can be either volume controlled (VC) or pressure controlled (PC), referring to which aspect(s) of the breath that are pre-set and controlled by the ventilator. Commonly used modes of mechanical ventilation include the following:
A mechanical ventilator may be used when the tracheostomy tube cuff is inflated or deflated.
Possible benefits of inflated cuff with mechanical ventilation (Dikeman & Kazandjian, 2003):
Possible benefits of deflated cuff, both with and without mechanical ventilation (Dikeman & Kazandjian, 2003):
Tracheostomy tube placement, both with and without mechanical ventilation, may impact the patient's swallow function and communication ability in various ways. Medically complex patients may have multifactorial causes of communication and swallow problems.
The assessment and treatment of dysphagia in patients with a tracheostomy (with or without ventilator support) does involve special considerations; however, the processes, procedures, approaches, and techniques used by the clinician are comparable. See the information on assessment and treatment in the ASHA Practice Portal pages on Adult Dysphagia and Pediatric Dysphagia as well as the summaries of available research in the Dysphagia (Adults) Evidence Map and the Dysphagia (Pediatrics) Evidence Map for more detailed information.
It is important to obtain answers to practical questions (as relevant to the age and developmental status of the patient) at the outset of a swallowing assessment and/or examination of feeding issues. Such questions may include the following:
An association between dysphagia (e.g., aspiration/silent aspiration) and tracheostomy placement (both with and without ventilator dependence) has long been documented (Cameron et al., 1973; Davis & Stanton, 2004; Elpern et al., 1994; Leder, 2002; Tolep et al., 1996). A dysphagia screening may help determine the likelihood that dysphagia exists and inform decisions on further swallowing assessment. The goal of a dysphagia screening for patients with a tracheostomy/ventilator support is to identify key factors such as level of arousal and cooperation, oral motor skills, secretion management, and volitional swallow and cough ability that can help determine a patient's readiness for clinical and/or instrumental evaluations. It is not necessary for a patient to be weaned from the ventilator to begin the swallow assessment process.
A clinical swallow evaluation may be useful in identifying gross aspiration and overt signs and symptoms of feeding and swallowing difficulty and in determining a patient's readiness for follow-up instrumental measures, such as fiberoptic endoscopic evaluation of swallowing (FEES) and videofluoroscopic swallowing study (VFSS). Clinicians use instrumental swallow measures to fully assess the physiology/pathophysiology of the patient's swallow, including the presence or absence of (silent) aspiration, and to determine the appropriateness and effectiveness of a variety of treatment strategies. Reassessment may be warranted on an ongoing basis, as results will guide treatment. The ASHA Practice Portal pages on Adult Dysphagia and Pediatric Dysphagia provide in-depth information on both instrumental and clinical (noninstrumental) dysphagia assessments. See the Tracheostomy and Ventilator Dependence Evidence Map for summaries of the available research on swallow assessment in this population.
When working with the population of patients with tracheostomy (both with and without ventilator dependence), the clinician addresses the following questions before, during, and after the assessment process (as appropriate to the age and developmental status of the patient):
Special considerations in the treatment of dysphagia in patients with a tracheostomy (with or without ventilator dependence) include the following (dependent upon the patient's age and developmental status):
ASHA's Code of Ethics stipulates that clinicians must be competent in any area in which they practice. ASHA's Scope of Practice in Speech-Language Pathology is broad and does not address specific procedures; however, procedures should be related to the assessment and treatment of patients with communication or swallowing disorders. Some facilities (e.g., hospitals) have a process in place for “credentialing” staff in suctioning procedures and may provide training to SLPs in these procedures. It is important to consider potential liability associated with tracheostomy-related procedures, such as changing or capping tracheotomy tubes.
State licensure laws vary. Some states may provide specific guidance, whereas others do not. It is the clinician's responsibility to be aware of laws and guidelines applicable to each situation. See also ASHA's Position Statement on Multiskilled Personnel and Technical Report on Multiskilled Personnel.
There are specific considerations when assessing and treating communication in individuals with tracheostomy (with or without ventilator dependence). Depending on the patient's diagnoses, age, needs, strengths/weaknesses, and goals, the information on assessment and treatment in the following ASHA Practice Portal pages may be helpful: Acquired Apraxia of Speech, Aphasia, Augmentative and Alternative Communication, Pediatric Traumatic Brain Injury, and Traumatic Brain Injury in Adults.
The approach to providing a communication assessment to a patient with a tracheostomy, with or without ventilator dependence, involves special considerations. These considerations may be addressed by answering/considering the following questions (as appropriate to the patient's age and developmental status):
The approach to providing communication treatment to patients with tracheostomy, with or without ventilator dependence, involves special considerations.
Communication choices for people with artificial airways may include both high-tech and low-tech augmentative and alternative communication (AAC) options as well as both oral and nonoral options. Several options may be appropriate for a patient, depending upon their situation. Options include the following (as appropriate for the patient's age and developmental status):
Verbal communication options may require modification to the current tracheostomy tube (or a change in type of tube), cuff inflation status, and/or ventilator settings. These changes will involve input from the tracheostomy team members (e.g., SLP, nurse, respiratory therapist, physician). It is always prudent for a patient with a tracheostomy tube to have a nonoral backup system of communication.
One-way speaking valves enable individuals with a tracheostomy tube to use voice and speech to communicate. A variety of speaking valves are available. Although each available speaking valve may look and work somewhat differently, in general, they close on expiration and redirect expired air through the upper airway and vocal folds. Some speaking valves can be placed in line with a ventilator. Early speech intervention and voice restoration for a patient with mechanical ventilation may lead to increased participation in their care and improved quality of life (Freeman-Sanderson, Togher, Elkins, & Phipps, 2016). Candidacy for speaking valve use must be carefully established.
Candidacy requirements for safe and effective speaking valve placement and use include the following (Hess & Altobelli, 2014):
Candidacy considerations may also include the following (Hess & Altobelli, 2014):
Benefits of speaking valve use may include the following:
Contraindications for speaking valve use include the following:
When working with pediatric populations, including infants and neonates, SLPs must be aware of the following special considerations:
As with all populations (and especially relevant to pediatric populations), providing holistic, interprofessional, and patient/family-centered care is crucial in achieving the best outcomes.
This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.
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Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Tracheostomy and Ventilator Dependence page:
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association (n.d.) Tracheostomy and Ventilator Dependence. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Professional-Issues/Tracheostomy-and-Ventilator-Dependence/.