Should a patient with a tracheostomy (trach) and a history of swallowing difficulties or aspiration risk undergo a modified barium swallow study before decannulation?

Should a Patient Get a Modified Barium Swallow Study Before Removing Trach?

A pharyngolaryngeal examination (typically fiberoptic endoscopic evaluation) should be performed at or before decannulation rather than routinely ordering a modified barium swallow study, though MBSS may be indicated if oropharyngeal dysmotility, penetration, or aspiration is specifically suspected after initial assessment. 1

Primary Recommendation: Pharyngolaryngeal Examination First

The French Intensive Care Society and French Society of Anaesthesia and Intensive Care Medicine recommend that a pharyngolaryngeal examination should probably be performed at or following decannulation (GRADE 2+, Strong Agreement). 1 This approach is superior to routine clinical assessment alone because:

• Over one-third of tracheostomized patients who pass clinical swallowing assessment will fail fiberoptic endoscopic evaluation, demonstrating penetration or aspiration risk. 2 The negative predictive value of clinical assessment alone is only 64%, meaning clinical assessment misses significant aspiration risk in a substantial proportion of patients. 2

• Among 100 neurological patients in one cohort, endoscopic evaluation allowed successful decannulation in 27 patients for whom clinical assessment had predicted failure, with a recannulation rate of only 1.9%. 1

• Pharyngolaryngeal examination comprises sequential assessments of salivary stasis, silent inhalation, spontaneous swallowing, and laryngeal sensitivity before considering swallowing tests with paste and liquid. 1 No patient who passed these three assessments had difficulty swallowing in subsequent food consistency tests. 1

When Modified Barium Swallow IS Indicated

MBSS should be performed specifically when oropharyngeal dysmotility is suspected, particularly with concerns for swallowing dysfunction, penetration, or aspiration. 3 The American College of Radiology defines MBSS as a videofluoroscopic procedure performed with a speech-language pathologist to evaluate oropharyngeal swallow and examine effectiveness of rehabilitation strategies. 1

Specific indications for MBSS in tracheostomy patients include:

• Patients exhibiting coughing while swallowing, nasal regurgitation, or feeling of food getting stuck. 4

• Patients with neurologic conditions or those who have undergone head and neck cancer treatment. 4

• When pharyngolaryngeal examination reveals abnormalities requiring detailed functional assessment of oral and pharyngeal phases of swallowing. 1

• Patients with oropharyngeal etiology for tracheostomy (oropharyngeal or laryngeal tumor, surgery, or infection) have 3.4 times greater odds of aspiration. 5

High-Risk Features Requiring Swallowing Assessment

59% of patients with new tracheostomies aspirate on at least one consistency during instrumental swallowing evaluation, and 81% of those who aspirate do so silently. 5 Risk factors demanding evaluation include:

• Uncapped tracheostomy status: odds of aspiration are twice as high compared to capped/speaking valve status, and odds of silent aspiration are 4.5 times greater. 5

• Prolonged mechanical ventilation: higher incidence of swallowing dysfunction occurs in tracheostomized patients ventilated for extended periods. 1

• Silent aspiration is particularly concerning: 55% of patients who aspirate demonstrate absent protective cough reflex. 1

Critical Pitfalls to Avoid

• Do not rely solely on clinical bedside swallowing assessment before decannulation. The positive predictive value is 91% (reliable when failed), but negative predictive value is only 64% (unreliable when passed). 2

• Do not use MBSS to evaluate retrosternal esophageal dysphagia. MBSS focuses on oral cavity, pharynx, and cervical esophagus only and does NOT evaluate the entire esophagus. 1, 3

• Do not attempt MBSS in delirious or severely impaired patients who cannot cooperate with the assessment. 4 The patient must be able to participate and follow recommendations. 4

• Do not delay decannulation unnecessarily. Prolonged tracheostomy increases risk of inhalation and pharyngolaryngeal lesions. 1

Recommended Algorithm for Decannulation Assessment

1. Ensure prerequisite met: weaning from mechanical ventilation 24 hours daily. 1

2. Deflate tracheostomy tube cuff when patient is breathing spontaneously (GRADE 2+). 1 Cuff deflation reduces decannulation failure, shortens mechanical ventilation weaning, and decreases tracheostomy-related complications. 1

3. Perform pharyngolaryngeal examination (fiberoptic endoscopic evaluation) to assess:

   • Salivary stasis and silent inhalation 1
   • Spontaneous swallowing 1
   • Laryngeal sensitivity 1

4. If pharyngolaryngeal examination reveals concerns for oropharyngeal dysfunction, penetration, or aspiration, proceed to MBSS with speech-language pathologist. 1, 4, 3

5. MBSS allows testing of varying barium consistencies and barium-impregnated food to assess swallowing ability and introduce rehabilitation strategies including postural changes, sensory enhancement, and swallow maneuvers. 1, 6

Multidisciplinary Protocol Requirement

A multidisciplinary decannulation protocol should be available in intensive care units, written and applied routinely by all team members, defining neurological examination and pharyngolaryngeal examination requirements. 1 Use of weaning protocols shortens weaning time, reduces decannulation failure rate, and decreases complication rate. 1