How should oral water intake be managed in a patient with a tracheostomy (tracheal tube) and a history of respiratory issues?

Managing Oral Water Intake in Tracheostomy Patients with Respiratory History

Oral water intake should not be initiated in tracheostomy patients until the cuff is deflated or a cuffless tube is in place, swallowing safety is formally assessed, and the patient demonstrates adequate secretion management—with cuff deflation only occurring when mechanical ventilation is no longer required. 1, 2

Critical Safety Prerequisites Before Any Oral Intake

Cuff Management Requirements

• The tracheostomy cuff must be deflated before attempting any oral intake, as an inflated cuff prevents translaryngeal airflow and significantly increases aspiration risk. 1
• Cuff deflation should only occur when the patient is considered low-risk for requiring mechanical ventilation and can breathe spontaneously without positive pressure support. 1, 2
• If the patient requires positive-pressure ventilation or high pressures, the cuff must remain inflated and the patient should remain NPO (nothing by mouth). 2
• Cuff pressure must be maintained at 20-30 cmH₂O when inflated to prevent tracheal injury while maintaining adequate seal. 2

Mandatory Swallowing Assessment

• A formal dysphagia screening must be conducted before initiating any oral intake, as tracheostomy patients have altered motor and sensory functions that decrease swallowing efficiency. 2, 3
• For low-risk patients, a blue dye test can be performed to minimize aerosol generation rather than more invasive assessments. 1, 2
• For high-risk patients or those with suspected dysphagia, flexible endoscopic evaluation of swallowing (FEES) or videofluoroscopic swallow study (VFSS) is necessary. 1, 2
• The inability to manage oral secretions is a red flag indicating unsafe swallowing and requires immediate multidisciplinary evaluation before any oral intake attempts. 1

Secretion Management Capability

• The patient must demonstrate adequate cough effectiveness and ability to manage their own oral secretions before oral intake trials. 1
• Do not advance to oral intake trials if the patient cannot manage their own oral secretions, even with cuff deflation, as this predicts aspiration. 1
• Excessive oral secretions pooling in the mouth or requiring frequent suctioning indicates inadequate secretion management and unsafe swallowing. 1

Step-by-Step Algorithm for Oral Intake Initiation

Step 1: Assess Ventilation Status

• Confirm the patient is weaned from mechanical ventilation and breathing spontaneously without requiring positive pressure support. 2
• For patients requiring only nocturnal ventilation, the cuff can be inflated at night and deflated during the day to allow oral intake. 2

Step 2: Deflate Cuff or Transition to Cuffless Tube

• Deflate the cuff when the patient no longer requires positive pressure ventilation. 1
• Monitor for respiratory distress during cuff deflation trials. 1

Step 3: Apply One-Way Speaking Valve

• Once cuff deflation is tolerated, apply a one-way speaking valve to optimize swallowing safety by allowing air to pass through the vocal cords during exhalation, creating positive subglottic pressure that helps clear residual material from the larynx. 1
• 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

Step 4: Perform Risk-Stratified Swallowing Assessment

• Conduct blue dye testing for low-risk patients or instrumental evaluation (FEES or VFSS) for high-risk patients. 1
• Clinicians should use N95 mask with goggles/fluid shield or PAPR when performing FEES or VFSS. 1

Step 5: Initiate Oral Intake with Monitoring

• Begin with texture-adapted food if dysphagia is present but swallowing is deemed safe. 4
• If swallowing is proven unsafe, enteral nutrition (EN) should be administered instead of oral intake. 4

Essential Supportive Care During Oral Intake Trials

Humidification Management

• Maintain proper humidification using HME with viral filter when not using speaking valve to prevent secretion thickening that could impair swallowing. 1
• Heat and moisture exchangers (HMEs) with viral filters are recommended as first-line for active patients not using speaking valves. 1
• Active heated humidification systems are recommended when secretions become thick despite HME use. 1

Oral Care Protocol

• Implement an 8-hourly oral care protocol consisting of tooth brushing with toothpaste, chlorhexidine gluconate 0.12% solution application, and saliva replacement gel to prevent aspiration pneumonia. 1
• This protocol mechanically removes bacterial colonization and maintains mucosal integrity to prevent xerostomia. 1

Continuous Monitoring Requirements

• Assess the patient daily for adequacy of nutrition, swallowing efficiency, signs of aspiration, and oral secretion management. 1
• Pulse oximetry monitoring is mandatory to detect early signs of tube obstruction from mucus plugging. 5
• Daily discussion with speech and language therapists should occur at every shift change for patients attempting oral intake. 1

Critical Pitfalls to Avoid

• Never attempt oral intake with an inflated cuff, as this eliminates translaryngeal airflow and dramatically increases aspiration risk. 1, 2
• Never bypass formal swallowing assessment before initiating oral intake, as inappropriate cuff deflation without documented swallowing assessment can result in dangerous aspiration and death. 3
• Do not use routine saline instillation into the tracheostomy tube, as this decreases oxygen saturation and contaminates lower airways. 1
• Do not neglect PPE during oral care procedures, particularly eye protection, as oral secretion management involves contact with potentially infectious material. 1
• Avoid routine tracheostomy changes or cleaning during the pandemic or high-risk periods unless medically necessary. 4

Nutritional Support When Oral Intake Is Inadequate

• In non-intubated patients not reaching energy targets with oral diet, oral nutritional supplements should be considered first, then enteral nutrition if supplements are insufficient. 4
• For patients with dysphagia and very high aspiration risk, postpyloric EN or temporary parenteral nutrition should be considered. 4
• Early enteral nutrition (within 48 hours of ICU admission) should be performed in patients with respiratory issues including those receiving ECMO, traumatic brain injury, or stroke. 4

Timeline Expectations

• Median time to continuous cuff deflation is approximately 7.5 days post-tracheostomy insertion. 6
• Median time to commencement of oral intake is approximately 10.5 days post-tracheostomy insertion. 6
• Earlier tracheostomy tube change (before day 7) is associated with earlier ability to tolerate oral intake (10 days vs 20 days). 7
• Increased time to commencement of oral intake correlates with increased time to decannulation and increased hospital length of stay. 6