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.