Tracheostomies - Types, Swallowing, and Communication
Suzie Getz, Jill Londrigan, and Rodney Smith
 

What is a Tracheostomy?
 

A temporary or permanent opening made by an incision through the second, third, fourth or fifth tracheal ring
Hole is called a stoma
A tube is inserted to allow air to pass through the stoma and for secretions to be more easily removed  (Aaron's Tracheostomy Page, 1997)

 

Why have one?
  Upper airway obstruction above the level of the true vocal folds
Potential upper airway obstruction from edema following surgery (Logemann, J.A. 1983. Evaluation and Treatment of Swallowing Disorders, Pro-Ed.)

 

Types of Trache Tubes
  can be made of plastic, metal or silicone
cuffed, uncuffed, fenestrated
Parts outer tube
inner tube (cannula)
obturator
 
  Tracheostomy: Swallowing

 

Possible Difficulties restriction of laryngeal elevation
decreased laryngeal sensitivity
decreased glottal pressure
interrupts the cricopharyngeus
causes difficulty in expelliing air

 

Preliminary Evaluation what is current diagnosis and reason for being tracheostomized?
how long has patient been tracheostomized?
what type of tracheostomy tube has been inserted? un/cuffed? un/fenestrated?
current medications that may alter cognition?
does patient currently have or have history of aspiration pnemonia?
can cuff be deflated and for how long?

 

Swallowing Exam suction orally
deflate cuff (inflated cuff may prevent laryngeal elevation or press into the espohagus. deflate either partially or fully by inserting a 5-10 ml syringe into cuff pilot balloon and withdraw air slowly. slow deflation allows positive lung pressure to push secretions upward from the bronchi.)
patient should occlude trach tube with finger to establish near normal trach pressure
clinician should do a four finger swallow (feel posterior tongue, hyoid bone and laryngeal movement)
practice a few dry swallows to feel laryngeal elevation
administer consistencies with blue dye
phonate to check for gurgly voice or pant to shake loose material collected in pyriform sinuses or valeculae to prevent from falling into airway
suction orally and trach site to check for aspiration (blue dye)
reinflate cuff and check for leak free cuff seal
Exercises and Strategies Communication Options:
    * A main goal of the preoperative counseling needs to concentrate on developing an immediate and successful means of communication  
Non-vocal Communication Options to express basic needs and wants
    Types Picture or word communication board
Magic Slate writing board
Simple gestures with a corresponding key for staff/family to interpret
vital messages Facial expressions or eye gazing techniques for patients limited by mobility Simple utilization of a call system (call bell or light)
Any of the commercially available augmentative devices, must be]
immediately available and easy to utilize Dry erase board
Magnetic letters with a magnet board (can use a cookie sheet or pie pan
for a magnetic background).

 
Considerations

Patient participation in selecting method
Providing an immediate and successful communication system, the coping process of the aphonic status is initiated
Due to the chance of vocal cord damage, some patients may never regain vocal speech, therefore a nonvocal system may be vital to provide expression for those patients. Also, patients with severe upper airway obstruction or vocal cord paralysis in the adducted position may never be able to vocalize.
Vocal Communication Systems
    Pneumatic and electronic devices for vocalization
  Electrolarynges
Best to use postoperatively and not long-term
Problems extremely conspicuous
vocal quality poor, therefore decreased speech intelligibility
does not provide an opportunity for patients to use intact vocal cords
 
Types (see White, pg. 165-166; & Prater & Swift, pg. 260)

 

Fenestrated tracheostomy tubes
  Designed to reintroduce airflow into the upper air way.
Factors to consider may stimulate granulomas to grow and obstruct air way
fenestration ports may become clogged with secretions
can be used with an inflated tracheal cuff, but must consider the two previous factors
if misaligned, ports can become blocked with tracheal tissue
Must occlude end of the tube with finger for phonation- get the same effect if you use a down-size tube, this reduces the chance of granulomas or mucous plug
Tucker Tube (Piling Co.) inner cannula
used with a Tucker or Jackson metal tracheostomy tube
can become plugged with mucous
creates phonation without finger occlusion
used with cuffless tracheostomy tubes
one-way valve that remains open on inspiration and on expiration the valve closes forcing air through the trachea and upper airway, creating a voice
Talking tracheostomy tubes
    speech is produced by gas from an independent air source flowing through an airflow line just above the tracheostomy tube cuff
vocalization is supported by air flowing through the glottis
vocalization is produced by air flow over the vocal cords while maintaining a closed ventilatory system
cuff remains inflated
types The Communitrach by Spectrum of California, Inc. - a low pressure, high volume, single cuffed talking tracheostomy tube; air flow through eight fenestrations
The Portex "Talk" Tracheostomy Tube by Concord/Portex - double-lumened single-cuffed tracheostomy tube; air flow through a single opening
The Bivona Talking Tracheostomy Tube by Bivona Inc. - allows air to flow through an air port, directing air through the larynx to produce voicing; "foam cuff"; intended to maintain low pressure
use own vocal cords and air source
one-way valve that allows the flow of air in through the trachea and out of the mouth and nose.
fit on the end of the actual tracheal hub
patient considerations for use of one-way tracheostomy speaking valves medical stability
airway assessment
environment and level of care
motivation of patient and staff
types The Olympic Trach Talk by Olympic Medical - valve remains open except when exhaling, at which time the force of the breath closes the valve and diverts the air through the larynx, enabling vocalization The Montgomery Speaking Valve by Boston Medical Products, Inc. -one-way air flow using a thin silicone hinged diaphragm which is fully open during inspiration and closes upon expiration. has a cough resistant feature to prevent blowoff The Hood Speaking Valve by Hood Laboratories - one-way airflow with a floating ball that moves open and closed based on expiration and inspiration forces The Kistner One-Way Valve by The Pilling Co. - one-way valve that allows air to be taken in trough the tube on inhalation and closes upon exhalation, does not have a "cough resistant" feature   LINKS Aaron' Tracheostomy Page
Passy-Muir Web Site
The Great Big Respiratory Link Page
Dysphagia Resource Center
 
 

References:

Prater, R.J. & Swift, R.W. (1984). Manual of Voice Therapy. Austin, Tx: Pro-ed.

Voicing! (1994). Communication Approaches for Tracheostomized and Ventilator Dependent Patients.

White, P. (1997). Diagnosis and Management for the Speech-language Pathologist. Boston, MA: Butterworth-Heineman.