Trach and Vent Patient

Posted by | November 22, 2010 | Dyphagia Evaluation, Trach and Vent Articles

cuff inflated

TRACHEOSTOMY AND VENTILATER DEPENDENT PATIENTS

Terms used for the trach and/or vent dependent patient:

Artificial Airway
An artificial airway may be needed if a patient is unable to move air into and out of the lungs effectively.  It is indicated to maintain a patent, or open, airway. Artificial airways are also necessary when a patient requires mechanical ventilation and to facilitate the removal of secretions.

Endotracheal Tubes
These tubes enter the trachea after passing through the oral or nasal cavities.

Intubation
Intubation is the process of an endotracheal tube being placed in a patient’s airway.  Orotracheal intubation is when the endotracheal tube is placed in the patients oral cavity.  Nasotracheal intuation involves placement of the tube into the nasal cavity.

Complications of intubation that may affect swallowing:

  • Laryngeal trauma
  • Pulmonary aspiration
  • Nasal, oral, or pharyngeal soft tissue injuries
  • Tracheal injury
  • Laryngospasm

Tracheotomy
Tracheotomy is a surgical incision directly into the anterior aspect of the trachea. Tracheotomy signifies a temporary opening, whereas tracheostomy is a permanent opening. A tracheostomy tube is placed into the tracheal opening to maintain the airway.
A tracheotomy is performed to bypass airway obstruction at or above the trachea or manage the airway for long-term ventilatory support. Airway obstruction can be due to a variety of reasons such as tumors, edema, infection, stenosis. It can be used to treat severe obstructive sleep apnea or facilitate pulmonary toilet in a patient who chronically aspirates.

Benefits of a tracheostomy tube over intubation include:

  • Improved patient comfort/less need for sedation
  • Lower work of breathing and faster waning from mechanical ventilation
  • Improved safety
  • Improved oral hygiene and oral intake
  • Less long-term laryngeal damage
  • Lower VAP rates
  • Lower mortality
  • Reduced ICU and overall LOS
  • Earlier ability to speak and improved participation in care

Tracheotomy, however, does not prevent aspiration. The presence of a tracheostomy tube contributes to the risk of aspiration. This is increased further if a cuffed tracheostomy tube is present (Logmann, 1983).

Cuffed Tracheostomy Tube

Complications of tracheotomy that may affect swallowing:

  • Injury to laryngeal nerves
  • Tracheoesophageal fistula- an abnormal connection between the esophagus and trachea.

Cuffed Tracheostomy Tube
A cuff is a balloon shaped extension from the endotracheal or tracheostomy tube. It seals off the trachea and minimizes airflow around the inflated cuff. This is important during the delivery of mechanical ventilation to allow for the lungs to receive most of the ventilation without leaking through the trachea and out of the oral/nasal cavities. Deflating the cuff allows for some the of air to pass around the tracheostomy tube, through the vocal folds and out of the oral cavity. This allows for some voicing, and the ability to cough to clear the airway.

Cuffs also aid in reducing gross aspiration. Potential aspirate can be reduced by the cuff against the wall of the trachea. However, the cuff is below the level of the vocal folds. Also there is not an airtight seal and material can still fall between the cuff and the trachea.  So it may slow down gross aspiration, but the material will still fall around the cuff.  The cuff appears to have more harm than good if the patient is able to clear his or her airway effectively.

While it is often assumed that an inflated cuff will prevent aspiration, Elpern et al (1987) found that an inflated trach tube cuff was associated with an increased incidence of aspiration. In a study of long-term ventilator dependent patients receiving oral feedings, Elpern (1994) found that 50% of the 83 subjects aspirated and that 77% of these aspirations were “silent.” Silent aspiration means that there were no overt signs of aspiration, such as coughing or choking. The study also found that the mean age of the aspirators (72.5) was significantly higher than the non-aspirators (64.8).

A study of efficacy with cuff deflated and cuffless tubes

Another study demonstrated that when the cuff was inflated, the aspiration rate was higher than when the cuff was deflated. Aspiration was 2.7 times higher (17.8% versus 6.5%) for the cuff inflated subjects. Therefore, it may be safer to feed a patient with the cuff deflated (Davis, 2002).

Patients who have tracheostomies and/or on mechanical ventilation are medically fragile. They need special attention and consideration when deciding critical decisions such as if a speaking valve is appropriate or taking food by mouth. The timing of a swallow evaluation should be considered based on the patient’s medical stability, gastrointestinal issues, cognitive/linguistic issues, psychosocial, etc.

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