Swallowing Management Post-Tracheostomy

Cuff Management for Swallowing

Deflating the tracheostomy cuff or transitioning to a cuffless tube before initiating swallowing trials is recommended, as an inflated cuff prevents translaryngeal airflow, increasing aspiration risk, according to the American Academy of Otolaryngology-Head and Neck Surgery 1, 2
Cuff deflation should only occur when the patient is considered low-risk for requiring mechanical ventilation, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 1

Applying a one-way speaking valve once cuff deflation is tolerated can optimize swallowing safety by allowing air to pass through the vocal cords during exhalation, creating positive subglottic pressure that helps clear residual material from the larynx, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1
An open tracheostomy tube without a heat moisture exchanger (HME), speaking valve, or cap increases aerosolization risk and reduces protective airflow through the upper airway, according to the American Academy of Otolaryngology-Head and Neck Surgery 1

For patients at low-risk for dysphagia, performing a blue dye test rather than flexible endoscopic evaluation of swallowing (FEES) can minimize aerosol generation, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1, 2
FEES involves nasolaryngoscopy, is an aerosol-generating procedure, and requires close physical proximity to the patient, according to the American Academy of Otolaryngology-Head and Neck Surgery 1, 2
Videofluoroscopic swallow study (VFSS) is an alternative but may require patient transport, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 1, 2
Clinicians should use N95 mask with goggles/fluid shield or PAPR when performing FEES or VFSS, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1, 2

Assessing readiness for swallowing trials requires the patient to tolerate cuff deflation without respiratory distress and have adequate cough/secretion management, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 1, 2
Deflating the cuff or transitioning to a cuffless tube when the patient no longer requires positive pressure ventilation is recommended, according to the American Academy of Otolaryngology-Head and Neck Surgery 1
Applying a one-way speaking valve or cap can restore translaryngeal airflow and subglottic pressure, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1
Performing risk-stratified swallowing assessment, such as a blue dye test for low-risk patients or instrumental evaluation (FEES or VFSS) for high-risk patients, is recommended, according to the American Academy of Otolaryngology-Head and Neck Surgery 1, 2
Maintaining proper humidification using HME with viral filter when not using speaking valve can prevent secretion thickening that could impair swallowing, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 1, 2

Thick, tenacious secretions are a major complication in tracheostomy patients and can lead to life-threatening tube obstruction, highlighting the importance of proper humidification using HME with viral filter when not using the speaking valve 3

The National Tracheostomy Safety Project emphasizes daily discussion with speech and language therapists regarding swallowing assessment and adequacy of nutrition, and this should occur at every shift change for patients attempting oral intake, involving speech-language pathologists, respiratory therapists, nursing staff, and physicians 4

Assess the patient daily for adequacy of nutrition, swallowing efficiency, signs of aspiration, and oral secretion management, and perform oral care every 8 hours including tooth brushing and saliva replacement to reduce bacterial colonization that could lead to aspiration pneumonia 4

The National Tracheostomy Safety Project recommends implementing an 8-hourly oral care protocol consisting of tooth brushing with toothpaste, chlorhexidine gluconate 0.12% solution application, and saliva replacement gel to prevent aspiration pneumonia and maintain oral hygiene in tracheostomized patients 5, 6
Essential components of the 8-hourly protocol include tooth brushing with toothpaste to mechanically remove bacterial colonization, chlorhexidine gluconate 0.12% solution application, and saliva replacement therapy and oral gel application to maintain mucosal integrity and prevent xerostomia 5, 6

The inability to manage oral secretions is a red flag indicating unsafe swallowing and potential upper airway pathology requiring immediate multidisciplinary evaluation, according to the American Thoracic Society 7

Keep the cuff inflated at 20-30 cmH2O initially when patients cannot manage oral secretions, as deflation increases aspiration risk by eliminating the mechanical barrier, as recommended by the American College of Chest Physicians 5, 6

Heat and moisture exchangers (HMEs) with viral filters are recommended as first-line for active patients not using speaking valves, according to the American Association for Respiratory Care 6
Active heated humidification systems are recommended when secretions become thick despite HME use, particularly common in prolonged tracheostomy, as suggested by the American Thoracic Society 6

Inadequate humidification requiring adjustment may be indicated by excessive oral secretions pooling in the mouth or requiring frequent suctioning, according to the American Association for Respiratory Care 6
Unsafe swallowing requiring NPO status and speech-language pathology consultation may be indicated by the presence of excessive oral secretions, as recommended by the American Speech-Language-Hearing Association 7

Do not advance to oral intake trials if the patient cannot manage their own oral secretions, even with cuff deflation, as this predicts aspiration and requires instrumental swallowing evaluation, according to the American Gastroenterological Association 7
Do not use routine saline instillation into the tracheostomy tube, as this decreases oxygen saturation, fails to thin mucus, and contaminates lower airways, as recommended by the American Thoracic Society 8
Do not neglect PPE during oral care procedures, particularly eye protection, as oral secretion management involves contact with potentially infectious material, according to the Centers for Disease Control and Prevention 5, 7