Working with Tracheostomy and Ventilator Dependent Adults and Children
Breathing is necessary for life. Communication is vital to our well-being. Food is love.
Eating, drinking, and talking are the basics of our humanity. It is how we get to know each other, celebrate, and even mourn. Imagine a holiday gathering without food or drink where no one communicates! Furthermore, parents want to nurture and feed their children. The cry of a baby can be music to the ears of the family that has longed to hear their voice. Unfortunately, when a person requires a tracheostomy tube for breathing, communication and eating are often suspended.
Roxann Diez Gross
When I began my career as a speech-language pathologist (SLP), there was no guidance or available information that could help me to understand how a tracheostomy tube worked, what was inside, and what I could do to help my patients speak again. There was a lack of information and a lot of confusion surrounding the management of tracheostomy tubes. At the rehabilitation hospital where I worked, I was told by one physician that the patient had a “talking tube” and all that I had to do was occlude the hub and the patient could talk. It turned out that the tube was a fenestrated tube (holes in the main shaft). The inner cannula within the main shaft did not have holes, so when I occluded the tube with my finger—he couldn’t breathe! I decided that I was going to have to teach myself about tracheostomy tubes, so I contacted the various manufactures and asked for samples and information.
At the same time, the Passy-Muir Speaking Valve had just appeared on the market, but since most physicians were not familiar with it, they were resistant to order them for my patients. To convince the doctors of the safety and benefits, I was able to use my sample tracheostomy tubes to demonstrate the advantages of cuff deflation and speaking valve use. Not only were our tracheostomy and ventilator patients speaking and actively participating in their care, we started to observe that secretion management and swallowing function appeared to improve.
I next worked at an acute care hospital with head and neck cancer patients, only to find out that speaking valve use was prohibited (of course, I always kept a speaking valve in the pocket of my lab coat, hoping for the right opportunity). Worse yet, swallowing evaluations could not be conducted until the tracheostomy tube was removed and the stoma was healed! The stated reason from the ear, nose, and throat (ENT) doctors was that subglottic air pressure was necessary for safe swallowing. I searched the literature and found no mention of this.
My opportunity to place the valve came when, during a modified barium swallow study, I was unable to find a compensatory strategy to stop or reduce an outpatient’s aspiration of liquids during the swallow. I called her ENT doctor and said that placing a speaking valve might enable the build up of subglottic air pressure while the tracheostomy tube was still in place. Incredibly, I received the verbal order to try the valve. When I placed it, she immediately stopped aspirating! When I took it off, she aspirated again. When I put it back on, she stopped aspirating again! I could literally control the situation. The patient then agreed to come to my lab so that I could measure the subglottic pressures with and without the valve while she swallowed. We discovered that with an open tracheostomy tube, there was no subglottic pressure present during a swallow and she aspirated. With the Passy-Muir Valve in place, we measured a subglottic pressure of 9.3 cm of H2O with no aspiration (Eibling & Gross, 1996). Subsequently, the study of subglottic air pressure and swallowing relationships as well as educating others in the area of management of persons with indwelling tracheostomy tubes became the focus of my career.
Kristin A. King
When I began my career in speech-language pathology, I knew I wanted to have a focus on the medical side of our profession. Early in my adult life, I was a high school English teacher. I found that it did not quite fit my personal goals, and I returned to school to get my master’s degree in speech-language pathology. Since I was in the schools previously, I convinced our placement director to provide me with two placements in a local level 1 trauma center. As a graduate student completing my externships, I quickly learned that the medical setting was definitely for me. It was here that my love of all things medical, including tracheostomy and mechanical ventilation, took hold.
As a student initially working in a rehabilitation area of the hospital, I did not get much exposure to patients with tracheostomies. However, when my supervisor called in sick, I was shifted to another SLP who worked in acute care. That fateful call cemented the rest of my career as an SLP. It was my first foray into the acute setting. I followed an SLP who was well-known for being hard but fair on students, and she was an exceptional instructor. My very first visit to an intensive care unit (ICU) began inauspiciously when I started to follow her and she asked, “Where’s your pen and paper? You will be taking notes.” I quickly grabbed them and off we went to a surgical ICU to see a patient for whom the SLP had orders for a “speaking valve evaluation.”
As we entered, the first thing that hit me was the smell, then the sight. The patient had had a radical neck dissection, tracheostomy, and nasogastric feeding tube. I had not been exposed to this level of medical complexity and severity before. I learned shortly afterward that the patient also had pseudomonas, contributing to the smell. As I stood to observe, I went to the foot of the bed. The supervisor advised me to move to one side as “things might come flying out,” and then began the suctioning. As a new student, unexposed to anything relative to a tracheostomy, the sights, sounds, and smells were overwhelming. I took notes with the tablet on my knee, bent over, as I became dizzy with all that was happening. But when the patient said a simple hello and then called his wife for the first time in in 2 months, I was hooked. The session completed, without me fainting, and we exited the patient’s room. Even though I was overwhelmed and, to be honest, a bit disturbed, I also was fascinated and enthralled. It was in those moments, in that room, when that patient spoke, that I knew acute care, critical care, trach/vent patients were my future path. Following this introduction, I spent my clinical career in hospitals.
From a medical setting to academia, it was important for me to help my future colleagues find their path and to provide strong education in evidence-based practice and experiential experience to be the best clinicians they could be. However, I discovered limited resources. I eventually moved into industry but still working, helping, and educating on tracheostomy and mechanical ventilation.
Tracheostomy and Mechanical Ventilation
The number of adult and pediatric patients with tracheostomies is growing each year secondary to advancements in medical care and interventions to sustain life, more so than seen historically. In a study conducted in 2008, it was estimated that by the year 2020, there would be over 600,000 adult patients requiring prolonged mechanical ventilation (Zillerberg et al., 2008). But little did that author know that, in 2020, a pandemic would change the face of medical care. It was estimated that in 2020, 965,000 people would require mechanical ventilation due to COVID-19, not including other disease and injury processes (Halpern et al., 2020). Just considering COVID-19 patients, the potential incidence of tracheostomies is thought to be much higher than the prediction given in 2008.
The placement of a tracheostomy tube and prolonged mechanical ventilation with an inflated cuff causes a disconnect between the upper and lower airway. The lack of airflow through the upper airway can often lead to multiple negative changes affecting speech and swallowing: reduced subglottic pressure; decreased sensation to the pharynx and glottis; reduced laryngopharyngeal reflex; decreased ability to manage secretions, requiring more frequent suctioning; decreased sense of taste and smell; inability to vocalize; increased aspiration risk; and muscle disuse and atrophy (Brooks et al., 2020; Eibling & Gross, 1996; O’Connor et al., 2019). A disconnect between respiration and swallowing may also negatively impact the ability to coordinate breathing and swallowing. For pediatrics, long-term tracheostomy placement has also been associated with delayed acquisition of language, delayed social development, and risk of impaired parent-child bonding (Cowell et al., 2013).
With tracheostomies, changes in the aerodigestive system become evident through these impacts on voice, swallowing, cough, and other functions. The prevalence for these aerodigestive challenges, which may lead to feeding and swallowing difficulties, is high. The complexity and prevalence of this patient population requires a strong knowledge base and evidence-based practice.
Our new book, Tracheostomy and Ventilator Dependence in Adults and Children: Learning Through Case Studies, came into being because we share in the mission to provide the best possible care for anyone with a tracheostomy tube. In an area where it is difficult to conduct well-controlled research studies, we both know that with the right knowledge, products, and team members, combined with persistence and creativity, we can greatly enhance the quality of life for patients and their families. The book provides detailed case studies from around the world, in all patient care settings, with a wide-range of ages and diagnoses. The thought-provoking treatments contain excellent examples for clinical practice, teaching, and learning.
References
Brooks, L., Figueroa, J., Edwards, T., Reeder, W., McBrayer, S., & Landry, A. (2020). Passy muir valve tolerance in medically complex infants and children: Are there predictors for success? The Laryngoscope, 130(11), E632–E939. https://doi.org/10.1002/lary.28440
Cowell, J., Schlosser, D., & Joy, P. (2013). Language outcomes following infant tracheostomy. Asia Pacific Journal of Speech, Language, and Hearing, 5(3), 179–186. https://doi.org/10.1179/136132800805576942
Eibling, D. E., & Gross, R. D. (1996). Subglottic air pressure: A key component of swallowing efficiency. Annals of Otolaryngology, Rhinology, and Laryngology, 105(4), 253–258. https://doi.org/10.1177/000348949610500401
Halpern, N. A., & Tan, K. S. (2020). United States resource availability for COVID-19. Society for Critical Care Medicine, 3, 1–16. https://sccm.org/Blog/March-2020/United-States-Resource-Availability-for-COVID-19
O’Connor, L., Morris, N., & Paratz, J. (2019). Physiological and clinical outcomes associated with use of one-way speaking valves on tracheostomised patients: A systematic review. Heart & Lung, 8(4), 356–364. https://doi.org/10.1016/j.hrtlng.2018.11.006
Zilberberg, M. D., & Shorr, A. F. (2008). Prolonged acute mechanical ventilation and hospital bed utilization in 2020 in the United States: Implications for budgets, plant and personnel planning. BMC Health Services Research, 8(1), 242. https://doi.org/10.1186/1472-6963-8-242