The scope of this page includes communication and swallowing disorders in patients with tracheostomy tubes or endotracheal tubes (ETTs), both with and without mechanical ventilator dependence, across the life span.
See the Tracheostomy and Ventilator Dependence Evidence Map for summaries of the available research on this topic.
Speech-language pathologists (SLPs) with appropriate training contribute to the communication and swallow assessment and management of patients with tracheostomy tubes or ETTs, both with and without mechanical ventilator dependence, in cooperation with an interprofessional team.
A tracheotomy is a surgical procedure that involves an incision in the trachea and placement of a tube to create an artificial airway. A tracheostomy is the opening (tracheostoma) into the trachea created by the tracheotomy through which the tracheostomy tube can be inserted. Tracheostomy tubes can also be inserted using a technique called percutaneous dilation tracheostomy. A tracheostomy tube is a curved tube inserted into the tracheostoma to maintain an airway. An ETT is a tube that is inserted through the mouth that passes through the vocal folds into the trachea to maintain an airway. Some tracheostomy patients, and most ETT patients, require mechanical ventilation, a form of ventilation that uses a machine to help deliver oxygen to a patient. This machine may also help remove carbon dioxide.
Patients have diverse experiences in the type and severity of communication and swallowing difficulties due to the wide variety of medical conditions that may necessitate a tracheostomy (with or without mechanical ventilation). Individualized assessment and management require interprofessional collaborative practice. A tracheostomy team may include (but is not limited to) an otolaryngologist, a pulmonologist, a respiratory therapist, nurses, and an SLP.
This team may consult with additional professionals (e.g., physical therapists and occupational therapists) as necessary. SLPs may have to advocate for their inclusion on teams in facilities where their expertise with trach/vent patients is underutilized (S.D. Davis et al., 2021; Freeman-Sanderson et al., 2011).
Positive patient and health care organizational outcomes—including reductions in cannulation times, shorter duration to communication, 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 et al., 2017; Brenner et al., 2020; Chorney et al., 2021; Ninan et al., 2023; Whitmore et al., 2020). See ASHA’s resource on interprofessional education/interprofessional practice (IPE/IPP).
Other ASHA Practice Portal pages that are applicable to this topic include Adult Dysphagia, Pediatric Feeding and Swallowing, Voice Disorders, Head and Neck Cancer, and Augmentative and Alternative Communication.
Incidence of tracheostomy refers to the number of new cases identified with new tracheostomy in a specified time period.
Prevalence of tracheostomy refers to the number of people living with tracheostomy in a given time period.
In the United States, approximately 40% of pediatric and 20%–40% of adult intensive care unit (ICU) patients require mechanical ventilation (Society of Critical Care Medicine, n.d.). Of those who require ventilation, 6.2% of individuals require it for a prolonged period of time (i.e., over 21 days of ventilation for at least 6 hours a day; Lone & Walsh, 2011).
The annual incidence rate for tracheostomy placements is approximately 28.4–39.7 cases out of every 100,000 adults in the United States (Abril et al., 2021). Pediatric tracheostomies occur much less frequently, with a reported annual incidence rate of 6.0–7.1 cases per 100,000 individuals under the age of 18 years (Muller et al., 2019). Individual statistics regarding the rates of tracheostomy within specific diagnoses are not readily available.
Estimates of the incidence and prevalence of tracheostomy seen in commonly associated clinical populations are as follows:
Acquired brain injury: Approximately 21%–47% of mechanically ventilated adults with severe acquired brain injury require tracheostomy (Wahlster et al., 2021).
Acute respiratory distress syndrome (ARDS): It is estimated that 5%–15% of adults with ARDS admitted to the ICU require tracheostomy (Abe et al., 2018; Wahlster et al., 2021).
Amyotrophic lateral sclerosis (ALS): It is estimated that 16.4%–31.3% of adults with ALS undergo tracheostomy; however, estimates may differ based upon the degree of disease progression and patient preferences regarding end-of-life decisions (Segura et al., 2023; Spataro et al., 2012).
Burn injuries: Approximately 0.9% of adult patients admitted with burn injuries require tracheostomy (Mourelo et al., 2015), with an increased rate of 30.9% for those requiring ICU-level care (Janik et al., 2021).
COVID-19: Approximately 12.2%–16.4% of adults receiving ICU-level care secondary to COVID-19 require tracheostomy (Mahmood et al., 2021; Martin-Villares et al., 2021).
Head and neck cancer: Reported rates of tracheostomy for adults requiring surgery due to head and neck cancer range from 17% to 20.3% (COVIDSurg Collaborative, 2021; Siddiqui et al., 2016).
Respiratory failure: Each year, an average of 9.1%–9.6% of hospitalized adults requiring mechanical intervention due to respiratory failure receive tracheostomy (Abril et al., 2021; Mehta, Syeda, Bajpayee, et al., 2015).
Traumatic brain injury: Approximately 29%–31.8% of adults with traumatic brain injury receiving ICU-level care require tracheostomy (Pelosi et al., 2011; Robba et al., 2020).
Spinal cord injury (SCI): It is estimated that 13.8%–17.7% of adults with acute traumatic cervical SCI require tracheostomy (Long et al., 2022; Mu & Zhang, 2019).
Stroke: Approximately 1.3%–1.9% of adults require tracheostomy following acute stroke (Chatterjee et al., 2018; Walcott et al., 2014), whereas 14%–20% of adults who require mechanical ventilation status after stroke receive tracheostomy (Pelosi et al., 2011).
SLPs play a central role in the screening, assessment, diagnosis, and treatment of persons with swallowing and/or communication disorders related to artificial airways. An artificial airway is a device that is used to facilitate ventilation and secretion management. These include the endotracheal tube (ETT)—a tube placed into the trachea via the mouth or nose to establish and/or maintain the airway and ventilation—and the tracheostomy tube. Artificial airways may be used to access mechanical ventilation. 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, 2016).
Appropriate roles for SLPs include, but are not limited to, the following.
Safe assessment and intervention for the patient with a tracheostomy tube, with or without mechanical ventilator dependence, requires knowledge of the following:
As indicated in the ASHA Code of Ethics (ASHA, 2023), SLPs who serve this population should be specifically educated and appropriately trained to do so. It is important to consider potential liability associated with tracheostomy-related procedures, such as deep suctioning, cuff inflation and deflation, and changing or capping tracheotomy tubes.
SLPs may encounter patients with tracheostomy, both with and without mechanical 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/upper airway obstruction. Examples of patient diagnoses include the following:
Among patient populations requiring a tracheostomy, the reasons for surgical intervention (i.e., tracheotomy) or bedside percutaneous placement are varied, and the type of tracheostomy tube selected by the surgeon is individualized.
The 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, anatomical variations, 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 Individuals (3rd ed., p. 39), by K. J. Dikeman and M. S. Kazandjian, 2022, Eat Speak Breathe Publishing. Copyright 2022 by authors. Reprinted with permission.
Figure 2. Parts of a standard tracheostomy tube. From Communication and Swallowing Management of Tracheostomized and Ventilator-Dependent Individuals (3rd ed., p. 58), by K. J. Dikeman and M. S. Kazandjian, 2022, Eat Speak Breathe Publishing. Copyright 2022 by authors. Reprinted with permission.
The components of a tracheostomy tube include the following:
The components of neonatal or pediatric tracheostomy tubes are similar to those of adults, with some exceptions. Some pediatric tracheostomy tubes are cuffless, and an inflated cuff is typically used during mechanical ventilation when the pediatric patient is on high ventilator settings. Whereas most adult cuffs are inflated with air, most pediatric cuffs are inflated with water. As with adults, some tracheostomy tubes are made with foam and cannot be deflated; therefore, a one-way speaking valve should not be used with patients with a foam-filled cuff.
Different types of tracheostomy tubes may include the following characteristics or specializations:
Clinicians should properly identify/differentiate patients with tracheostomy or laryngectomy to ensure proper airway management. Total laryngectomy patients have tracheostomy tubes that, from the outside, look identical to other tubes; however, these tubes have much shorter cannulas and are not to be used in patients who have a larynx. In addition, capping and one-way speaking valve placement on a laryngectomy tube would result in airway compromise due to a lack of connection between the larynx and the nose and mouth in these patients.
The type, size, and characteristics of a patient’s tracheostomy tube may require alterations because of anatomical growth, changes in the patient’s underlying condition, and facilitation of communication options; to optimize safety; or as part of the weaning process. Note that changes made to the tracheostomy tube may impact swallow function or the ability to participate in valving trials or capping.
The appropriate size and style of tracheostomy tubes are important when addressing communication and swallowing needs. Tracheostomy tubes may also be custom-made to fit. The tracheostomy team considers factors specific to each patient when determining the appropriate size (i.e., inner diameter, outer diameter, angle, length, etc.) of the tracheostomy tube. See Mitchell et al. (2013) and Sherman et al. (2000) for further information on patient-specific factors, including several of the following:
For further information, please see Mitchell et al. (2013) and Sherman et al. (2000).
Consideration of the tracheostomy tube cuff status requires input from the tracheostomy team, with attention to a patient’s medical status, a patient’s respiratory/ventilatory status, and the impact it has on the patient’s communication status and swallow function.
Most cuffs can be inflated or deflated by an SLP or other medical providers (e.g., respiratory therapist, registered nurse) as necessary or when indicated (such as placing a one-way speaking valve or conducting a swallowing evaluation); however, foam cuffs cannot be inflated or deflated and may not be used with a one-way speaking valve.
Benefits of cuff deflation and cuffless tracheostomy tubes may include
It is important to note that an inflated cuff does not prevent aspiration as the cuff is below the level of the vocal cords.
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.
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.
Mechanical ventilators are used 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 mechanical ventilator modes and/or settings are carried out by trained medical professionals (e.g., respiratory therapists, nurses).
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). Patients receive mechanical ventilation via an ETT or a tracheostomy. When a patient fails extubation (i.e., removal of the ETT), a tracheotomy may be performed to allow the patient to continue to receive mechanical ventilation.
There are many and various etiologies of respiratory failure, including, but not limited to, the following:
Mechanical ventilation may also be used with patients who undergo anesthesia (e.g., during surgery).
Mechanical ventilators have different settings (the characteristics of ventilation provided) and modes (representing the method—the how and when—of inspiratory support). Any changes or modifications to setting or mode are determined and managed by the physician (or the respiratory therapist/nurse/trained professional under a physician’s orders).
The primary mechanical ventilator settings include the following:
Mechanical ventilator modes can be either volume controlled (VC) or pressure controlled (PC), referring to which aspect(s) of the breath are preset 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; however, in most cases, the cuff will remain inflated.
Possible benefits of an inflated cuff with mechanical ventilation (Dikeman & Kazandjian, 2022) include the following:
Placement and maintenance of an artificial airway may lead to laryngeal injury. Such injuries are often mild but may lead to persistent airway abnormalities, dysphonia, and dysphagia (Brodsky et al., 2021; Kelly et al., 2023).
Medically complex patients may have multifactorial causes of communication and swallowing problems.
Dysphagia is associated with tracheostomy placement (L. A. Davis & Stanton, 2004; Elpern et al., 1994; Leder, 2002; Tolep et al., 1996) with or without mechanical ventilation (Skoretz et al., 2020). Tracheostomy and/or intubation may impact airway patency and function by damaging or impairing the larynx (Wallace & McGrath, 2021). As such, patients with tracheostomy, especially those with uncapped tracheostomy, may be at increased risk for silent aspiration (Marvin & Thibeault, 2021).
Instrumental swallowing evaluations such as the Fiberoptic/Flexible Endoscopic Evaluation of Swallowing (FEES) and the Videofluoroscopic Swallow Study (VFSS) are the only reliable method to detect silent aspiration and to predict some risk factors for aspiration (e.g., pharyngeal residue).
The assessment and treatment of dysphagia in patients with a tracheostomy (with or without mechanical ventilator support) involves special considerations; however, the processes, procedures, approaches, and techniques used by the clinician are comparable to those used with other populations. See the information on assessment and treatment in the ASHA Practice Portal pages on Adult Dysphagia and Pediatric Feeding and Swallowing as well as the summaries of available research in the Dysphagia (Adults) Evidence Map and the Pediatric Feeding and Swallowing Evidence Map for more detailed information.
The goal of dysphagia screening for patients with a tracheostomy (with or without mechanical ventilation) is to identify key factors that can help determine a patient’s readiness for clinical and/or instrumental evaluations such as level of arousal, oral motor skills, secretion management, and volitional swallow and cough ability. Screening may be conducted by an SLP or members of other trained professions.
The modified Evans blue dye test is occasionally administered at bedside on tracheostomy patients to detect potential aspiration; however, it should be conducted with caution due to inconsistent reports of its diagnostic accuracy (Béchet et al., 2016).
A clinical swallowing assessment may be useful in identifying signs and symptoms of feeding and swallowing difficulty and in determining a patient’s readiness for instrumental assessment. It is not necessary for a patient to be weaned from the mechanical ventilator or decannulated to begin the swallowing assessment process.
SLPs consider many details that may impact a patient’s ability to reliably participate in swallowing or feeding assessment or that may influence the assessment plan. Such considerations may include the patient’s
Clinicians use instrumental swallowing assessments to more comprehensively assess the physiology/pathophysiology of the patient’s swallow and the effectiveness of potential treatment strategies. FEES and VFSS may detect the presence or absence of aspiration, silent aspiration, and/or residue as well as the patient’s response to any residue and/or aspiration. When possible, completing instrumental evaluations under a variety of conditions (i.e., with the cuff inflated or deflated, on or off the mechanical ventilator, with or without a one-way speaking valve) can inform recommendations regarding multiple conditions in which a person may be able to eat and drink. Reassessment may be warranted on an ongoing basis, based on the results of treatment and goals of care.
Special considerations in the treatment of dysphagia in patients with a tracheostomy (with or without ventilator dependence) include the following:
There are specific considerations when assessing, managing, and optimizing communication for 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, including, but not limited to, the following:
Communication choices for people with artificial airways may include both high- and low-tech 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):
For further information, please see Ten Hoorn et al. (2016), Rose et al. (2021), and Wallace et al. (2023).
Verbal communication options may require modification to the current tracheostomy tube (or a change in the type of tube), cuff inflation status, and/or mechanical ventilator settings. These changes involve input from the tracheostomy team members (e.g., SLP, registered nurse, respiratory therapist, physician). It can be helpful for a patient with a tracheostomy tube to have a nonoral backup system of communication to meet diverse communication needs of communication partners and across contexts.
One-way speaking valves enable individuals with a tracheostomy tube to use voice and speech to communicate. A variety of one-way speaking valves are available, and each speaking valve may look and work somewhat differently from the others. In general, one-way speaking valves open on inhalation and close on expiration to redirect expired air through the upper airway and vocal folds. Some one-way speaking valves can be placed in line with a mechanical 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 et al., 2016). Candidacy for speaking valve use must be carefully established.
Candidacy requirements for safe and effective one-way speaking valve placement and use include the following (Hess & Altobelli, 2014):
Candidacy considerations may also include the following (Hess & Altobelli, 2014):
Benefits of one-way speaking valve use may include the following:
For further information, see Wallace et al. (2023).
Prior to one-way speaking valve placement, the airway should be cleared of secretions, and the cuff should be deflated. If the patent displays signs of respiratory distress (e.g., increased respiratory rate, diminished oxygen saturation, increased heart rate) following placement of the speaking valve, then the one-way speaking valve should be removed immediately, and the team should assess airway patency and evaluate for possible causes of difficulty (Hess & Altobelli, 2014; Sutt et al., 2021).
Contraindications for one-way speaking valve use include the following:
Infants and children have different airway anatomy, physiology, and size than adults (Singh & Zubair, 2023). Due to these differences, the typical surgical incision for pediatric patients is vertical through the third and fourth tracheal rings, rather than the horizontal incision typically used in adults between the second and third tracheal rings. Pediatric tracheostomy tubes and mechanical ventilator settings may differ from those typically used with adults. For instance, manufacturers produce smaller tracheostomy tubes specifically for use with pediatric and neonatal populations. These tubes can be cuffed or cuffless. Additionally, in contrast to adult populations, pediatric tracheostomy tubes are often single lumen, with no removable inner cannula. SLPs should also consider anatomical and physiological differences between pediatric and adult populations when conducting a swallow evaluation. Premature infants who are status post prolonged intubation may have limited per os (PO) experience, and the suck–swallow–breathe sequence in infants on mechanical ventilation may be discoordinated.
Uncuffed/cuffless tracheostomy tubes are generally preferred over cuffed tracheostomy tubes in the pediatric population; however, much like adult patients, cuffed tracheostomy tubes may be necessary in certain patient populations with comorbidities such as secretion management difficulties, like those with severe pulmonary disease or neuromuscular disease.
The mechanical ventilator modes used for pediatric patients may also differ significantly from those used with adults. There are a variety of mechanical ventilator modes available for neonatal and pediatric use, each with benefits and drawbacks but with no definitive indications or protocols for use (Kollisch-Singule et al., 2021).
SLPs should also be aware that reasons for tracheostomy may differ between adults and infants. For instance, infants often need tracheostomy tube placement due to complications from prematurity (chronic lung disease) or aerodigestive conditions (subglottic stenosis, other laryngeal abnormalities). Primary indicators for pediatric tracheostomy may also include prematurity, cardiopulmonary disease, neurological impairment, airway obstruction, craniofacial abnormalities (e.g., Treacher Collins syndrome, Pierre Robin sequence), and traumatic injury (Gergin et al., 2016). For further information, please see Singh and Zubair (2023).
Clinicians may rely on nonverbal signs to detect pain and discomfort (e.g., cries, facial expressions, unusual postures, agitated movements) when limited communication is present. A delay in remediating pain or discomfort can result in instability in heart rate, respiration, tone, or other physiologic function. SLPs may provide education to family members about interventions to reduce pain and discomfort (e.g., swaddling, nonnutritive sucking).
Tracheostomy tube placement and mechanical ventilator dependence can impact social development in pediatric populations. SLPs may need to make modifications to the environment, patient positioning, and patient handling to improve social interactions. Physical therapy and occupational therapy may be consulted as necessary. SLPs provide counseling and education to family members regarding the developmental status of communication, swallowing, voice, articulation, and related functions as appropriate.
As with all patients, holistic, interprofessional, and patient/family-centered care is important to achieving the best treatment outcome.
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]. https://www.asha.org/Practice-Portal/Professional-Issues/Tracheostomy-and-Ventilator-Dependence/