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.
Communication and Swallowing Management of Tracheostomized and Ventilator Dependent Adults
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).
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.
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.
We conducted a retrospective case series on patients with COVID-19 who had a tracheostomy. We included patients who had undergone mechanical ventilation for 14 days or longer, had a surgical tracheostomy, been discharged from intensive care to a medical unit, and received PT and SLP referrals. We compiled retrospective data from electronic medical records, analyzing days from tracheostomy to achievement of PT and SLP functional milestones, including mobility, communication, and swallowing. Of six critically ill patients with COVID-19 who had tracheostomy placement at our facility, three met inclusion criteria: patient 1, a 33-year-old woman; patient 2, an 84-year-old man; and patient 3, an 81-year-old man. For all patients, PT interventions focused on breathing mechanics, secretion clearance, posture, sitting balance, and upper and lower extremity strengthening. SLP interventions focused on cognitive reorganization, verbal and nonverbal communication, secretion management, and swallowing function. Intensity and duration of the sessions were adapted according to patient response and level of fatigue.
We found that time to tracheostomy from intubation for the three patients was 23 days, 20 days, and 24 days, respectively. Time from tracheostomy insertion to weaning from ventilator was 9 days for patient 1, and 5 days for patient 2 and patient 3. Regarding time to achieve functional PT and SLP milestones, all patients achieved upright sitting with PT prior to achieving initial SLP milestone of voicing with finger occlusion. Variations in progression to swallowing trials were patient specific and due to respiratory instability, cognitive deficits, and limitations in production of an effortful swallow. Patient participation in therapy sessions improved following establishment of oral verbal communication. 2ff7e9595c
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