Role of speech-language pathologist in tracheostomy care – A case study
A “tracheotomy” refers to the surgical procedure that creates an opening between the trachea and the midline skin surface of the neck. Indicators for a tracheostomy tube include maintenance of airway, protection of the airway from aspiration, removal of tracheal secretions, to wean from ventilation, and for long-term mechanical ventilation. Other indications include neurological deficit, craniofacial anomaly, cardiopulmonary insufficiency, neuromuscular indication, bilateral vocal cord paralysis, and subglottic stenosis. The presence of a tracheostomy tube may lead to reduction of anterior-superior movement of the larynx, tracheal irritation at rest and during swallowing, reduced laryngeal closure, subglottic air pressure and laryngeal sensitivity, reduction or elimination of airflow through the glottis and blunting of the reflexive cough. The complex interrelationships between respiration, swallowing, and communication dictate that speech and language pathologists (SLPs) to play an integral role in assessment and management of subsystems, swallowing and speech in patients with a tracheostomy as a part of the multidisciplinary team.
A 41-year-old was diagnosed with right cerebellopontine angle meningioma using magnetic resonance imaging by the neurologist for which he underwent retrosigmoid, suboccipital craniotomy, and excision of lesion was done. Tracheostomy was done since the client had stridor and wheezing, 3 days post-surgery and breathing were initially supported by the mechanical ventilation through tracheostomy tube, and feeding was aided through nasogastric tube. Language profile and cognition such as alertness and orientation were observed to be adequate.
Informal evaluation was done which revealed that the client had good attention and was emotionally stable. Sensory- motor abilities such as texture discrimination were present; the client is ambulatory and has pincer grasp. Memory of past and present events was good.
Respiration – through tracheostomy tube.
Breathing tolerance with occlusion – 3–5 min.
|Face||Eyelid closure – absent in right side, present in left side
Abnormal movements – absent
Drooling – absent
Mouth breathing – present
|Deviation to one side
Rising of eyebrows – right absent
Closing of eyes – right absent
|Lips||Drooling – present
Symmetry – deviation to left
Lip closure at rest – present
|Lip spread /i/ – inadequate
Lip rounding /u/ – adequate
Lip strength against resistance – reduced
Range of motion – restricted
|Teeth||Alignment – normal
Occlusion – normal
|Biting/chewing – present in left side|
|Tongue||Symmetry – deviation to right
Tongue coloration – normal
|Elevation, retraction, protrusion, lateral movements – inadequate
Range of motion – inadequate
Strength – inadequate
|Hard palate||Structure – normal
Color – normal
Arch height – normal
|Symmetry at rest|
|Soft palate||Structure – normal
Discoloration – absent
|Movement (elevation/depression) – could not be assessed
Hyponasality/hypernasality/nasal emission – could not be assessed
|Jaw||No deviation||Jaw movement – inadequate|
|V trigeminal||SENSORY – reduced sensation (right)
MOTOR – inadequate
|VII facial||Elevation right eyebrow – absent
IOBP – absent
Taste sensation reduced on right
|IX glossopharyngeal||Weak cough, absent gag reflex
Tongue sensation – reduced on right side
|X vagus||Absent gag reflex, weak cough, voicing present with reduced loudness|
|XII hypoglossal||Restricted tongue movement|
Swallowing profile (baseline assessment)
At present, the client is under nasogastric tube for feeding. He is a known case of tracheostomy. Drooling was absent. Biting and chewing were observed and reported to be present. Swallowing screening was carried out using honey. Gurgitation and weak cough observed to be present. Laryngeal elevation was absent. Similar findings were observed for saliva swallow test.
Repeated saliva swallow test – <3 times within 30 s.
Modified water swallow test – failed to swallow with choking noted.
The client reported that saliva and honey were struck in lower throat and chest region. Hence, further food consistencies were not attempted suggestive of oral transit dysphagia.
Modified barium swallow test was recommended. During testing, oral and nasal regurgitation occurred and hence procedure was stopped.
It is recommended to do detailed audiological evaluation, to continue non-oral feed, and to attend swallowing therapy.
Goals worked on
The client will be able to establish abdominal breathing pattern adequate for speech production through relaxed, regulated, and modified breathing exercises
Voluntary breath-holding maneuver will be carried out by occlusion of tracheostomy cannula which indirectly improves subglottic pressure and promotes best airway closure
Tongue base resistance exercises and Masako maneuver were carried out to improve tongue retraction and improve epiglottis excursion
To work on improving the range of motion, strength, and coordination of active articulators – lips, tongue, and mandible through isotonic and isometric exercises and to improve the intraoral breath pressure
To work on swallowing through maneuvers.
Progress in swallowing post therapy is shown in Table 3.
|Swallowing profile||Pre-therapy||Post-therapy (after 8 sessions)|
|Breathing tolerance with occlusion||3–5 min||2–3 h|
|Repeated saliva swallow test||<3 times within 30 s||>3 times swallow in 30 s|
|Modified water swallow test||Failed to swallow with choking noted||Failed to swallow, choking present|
SLP plays an important role in decision-making process for cuff deflation, tracheal decannulation and in management of swallowing, voice, and establishing a means of communication. Despite its relevance, lack of a universally accepted protocol for decannulation continues to plague this vital transition. More often assessments are based on subjective clinical impression of the physician. Protocolized decannulation may guarantee consistency and objectivity of care. Warnecke et al. in their study performed a mandatory step of fiberoptic endoscopic examination of swallowing in their decannulation process. Similarly, subjective assessment of coughing is the usual norm. Six strategies have been described to facilitate effective communication with individuals with a tracheostomy including establishing a communication- friendly environment, assessing functional skills, anticipating the individual’s needs, facilitating lip- reading, augmentative and alternative communication and educating the person with a tracheostomy, and family and staff about communication strategies. Swallowing and voicing can be re-established through appropriate rehabilitative exercises.
Assessment and management with tracheostomy involves a comprehensive multidisciplinary team approach. Speech Language Pathologist role is to identify risk factors for dysphagia, examination of upper respiratory system, Oral structure and function and perform detailed cranial nerve examination. Based on the findings appropriate manoeuvres or compensatory startegies should be chosen along with family counselling.
Declaration of patient consentThe authors certify that they have obtained all appropriate patient consent.
Financial support and sponsorshipNil.
Conflicts of interestThere are no conflicts of interest.
- Crit Care Med. 2013;41:1728-32Standardized endoscopic swallowing evaluation for tracheostomy decannulation in critically ill neurologic patients.
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