Do patients with a cuffed tracheostomy (trach) tube need to be nothing by mouth (NPO)?

Cuffed Tracheostomy Tubes Do Not Require NPO Status

Patients with cuffed tracheostomy tubes do not automatically need to be NPO, but swallowing function must be formally assessed before initiating oral intake, as the presence of a cuff—whether inflated or deflated—does not reliably prevent aspiration. 1, 2

Key Principle: The Cuff Does Not Protect Against Aspiration

• An inflated cuff does not prevent aspiration of oral secretions or food. Material can pool above the cuff and leak around it into the lower airway, particularly in patients with dysphagia. 3
• The American Thoracic Society identifies chronic translaryngeal aspiration as a specific indication for using cuffed tubes, not as something the cuff prevents. 1, 2
• Cuffed tubes are indicated primarily for mechanical ventilation with positive pressures and for patients requiring only nocturnal ventilation, not for aspiration prevention. 1, 2

Mandatory Swallowing Assessment Before Oral Intake

• All patients with tracheostomy tubes require multidisciplinary swallowing assessment before cuff deflation or initiation of oral intake. 3
• Research demonstrates that inappropriate cuff deflation or tube changes without documented swallowing assessment has resulted in dangerous aspiration requiring cuff reinflation or reinsertion of cuffed tubes. 3
• Current UK practice shows that approximately half of facilities lack formal swallow screening protocols for tracheostomy patients, contributing to suboptimal and varied care. 4

Clinical Algorithm for Oral Intake Decision-Making

Step 1: Assess ventilatory requirements

• If the patient requires positive-pressure ventilation or high pressures, the cuff must remain inflated and the patient should remain NPO. 1, 2
• If the patient is weaned from mechanical ventilation and breathing spontaneously, proceed to Step 2. 1

Step 2: Conduct formal dysphagia screening

• Patients with neurological diagnoses and tracheostomy should be referred directly to speech-language therapy. 4
• For patients at low risk for dysphagia, consider blue dye testing as an alternative to more invasive assessments. 1
• For high-risk patients, flexible endoscopic evaluation of swallowing (FEES) or videofluoroscopic swallow study (VFSS) may be necessary despite being aerosol-generating procedures. 1

Step 3: Trial cuff deflation if swallowing assessment permits

• The American Academy of Otolaryngology-Head and Neck Surgery recommends that cuff deflation should only occur when the patient is considered low risk for requiring mechanical ventilation. 1
• Once the patient tolerates cuff deflation or transition to a cuffless tube, one-way speaking valves or capping can facilitate speech and oral intake. 1, 2

Common Pitfalls to Avoid

• Never deflate the cuff or initiate oral intake based solely on clinical impression without formal swallowing assessment. Six documented cases showed patients were found to be aspirating after inappropriate cuff deflation, requiring emergency reinflation. 3
• Do not assume an inflated cuff protects the airway during oral intake. This is a dangerous misconception that can lead to aspiration pneumonia and death. 3
• Avoid changing from a cuffed to uncuffed tube without multidisciplinary team evaluation. Research shows this decision requires documented assessment of both swallowing function and ventilatory needs. 3, 5

Cuff Management During Oral Intake Trials

• If oral intake is attempted with a cuffed tube, the cuff should typically be deflated to allow translaryngeal airflow and more normal swallowing mechanics. 1, 5
• Cuff pressure must be maintained between 20-30 cmH₂O when inflated to prevent tracheal injury while maintaining adequate seal. 1, 2
• For patients requiring nocturnal ventilation only, the cuff can be inflated at night and deflated during the day to allow speech and oral intake. 1, 2, 6

Multidisciplinary Team Approach

• The American Thoracic Society emphasizes that dysphagia management in tracheostomy patients requires a multidisciplinary approach including speech-language pathology, nursing, respiratory therapy, and physician input. 3
• Bedside assessment of laryngeal function should rely initially on clinical skills, with endoscopy reserved for cases where upper airway pathology is suspected. 1
• Earlier tracheostomy tube changes (before day 7) are associated with earlier tolerance of speaking valves and oral intake, though this should be coordinated with the multidisciplinary team. 7