What is the recommended approach to swallowing post tracheostomy (surgical creation of an airway in the trachea) to minimize the risk of aspiration?

Swallowing Management Post-Tracheostomy

The recommended approach to minimize aspiration risk in tracheostomy patients is to use a one-way speaking valve or cap with a deflated cuff during swallowing assessment and oral feeding, as this significantly improves laryngeal clearance and reduces penetration risk. 1, 2

Cuff Management for Swallowing

Deflate the tracheostomy cuff or transition to a cuffless tube before initiating swallowing trials. 1

• An inflated cuff prevents translaryngeal airflow, which is essential for effective laryngeal clearance of residual material and increases aspiration risk 1, 2
• Patients with uncapped tracheostomy have twice the odds of aspiration compared to those with cap or speaking valve in place 3
• Odds of silent aspiration are 4.5 times greater with an uncapped tracheostomy 3
• Cuff deflation should only occur when the patient is considered low-risk for requiring mechanical ventilation 1

One-Way Speaking Valve Placement

Apply a one-way speaking valve once cuff deflation is tolerated to optimize swallowing safety. 1, 2

• One-way speaking valves significantly improve laryngeal clearance and reduce the incidence of penetration during swallowing 2
• The valve allows air to pass through the vocal cords during exhalation, creating positive subglottic pressure that helps clear residual material from the larynx 2
• 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 1
• If the patient cannot tolerate cuff deflation or speaking valves due to increased secretions, offer augmentative communication options instead 1

Swallowing Assessment Approach

For patients at low-risk for dysphagia, perform a blue dye test rather than flexible endoscopic evaluation of swallowing (FEES) to minimize aerosol generation. 1

• FEES involves nasolaryngoscopy, is an aerosol-generating procedure, and requires close physical proximity to the patient 1
• Videofluoroscopic swallow study (VFSS) is an alternative but may require patient transport 1
• Patients at high-risk for dysphagia (oropharyngeal etiology for tracheostomy, head injury, prolonged intubation) require instrumental evaluation despite aerosol risk 3, 4
• When performing FEES or VFSS, clinicians should use N95 mask with goggles/fluid shield or PAPR 1

High-Risk Populations Requiring Enhanced Monitoring

Patients with oropharyngeal etiology for tracheostomy have 3.4 times greater odds of aspiration and warrant instrumental swallowing evaluation. 3

• Trauma patients with head injuries exhibit 41% aspiration rate and 68% dysphagia rate 4
• Overall, 59% of hospitalized patients with new tracheostomy aspirate on at least one consistency 3
• Silent aspiration occurs in 81% of patients who aspirate, making bedside clinical evaluation unreliable 3, 5
• Aspiration rates are similar whether or not a tracheostomy is present (35-36%), but the tracheostomy itself does not independently increase aspiration risk 4, 6

Critical Pitfall to Avoid

Do not assume that removing the tracheostomy tube will improve swallowing function. 6

• Kinematic analysis shows no significant difference in laryngeal elevation or pharyngeal constriction before versus after decannulation 6
• The tracheostomy tube does not cause an "anchoring effect" that impairs laryngeal elevation during swallowing 6
• Dysphagia in tracheostomy patients is typically related to the underlying condition requiring tracheostomy rather than the tube itself 4, 6

Practical Implementation Algorithm

1. Assess readiness for swallowing trials: Patient must tolerate cuff deflation without respiratory distress and have adequate cough/secretion management 1

2. Deflate cuff or transition to cuffless tube when patient no longer requires positive pressure ventilation 1

3. Apply one-way speaking valve or cap to restore translaryngeal airflow and subglottic pressure 1, 2

4. Perform risk-stratified swallowing assessment: Blue dye test for low-risk patients, instrumental evaluation (FEES or VFSS) for high-risk patients 1, 3

5. Monitor for silent aspiration as clinical signs alone are insufficient to detect aspiration in this population 5, 3

6. Maintain proper humidification using HME with viral filter when not using speaking valve to prevent secretion thickening that could impair swallowing 1