A tracheostomy tube provides an alternative means of respiratory ventilation and reduces the need for prolonged endotracheal intubation. A tracheostomy creates an opening within the trachea and is generally accepted as a safe procedure that provides meaningful benefits to patients which include a secure airway and facilitating pulmonary toileting (Cheung & Napolitano, 2014). In 2014 the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) estimated that in the UK approximately 12000 patients a year had a tracheostomy inserted.
Skoretz and colleagues (2020) highlight the interdependency of swallowing and respiration. The NCEPOD (2014) reported swallowing impairments were the third most common associated complication of a tracheostomy and up to 51.6% (n= 425) of inpatients with a tracheostomy had a swallowing disorder. However, there is limited knowledge regarding patients in the community with a tracheostomy and long term swallowing needs.
The medical term for swallowing disorder is oropharyngeal dysphagia. This is an impairment of motor and/or sensory components of the swallowing mechanism in which food/fluid transfers from the oral cavity into the pharynx and through the upper oesophageal sphincter (Walshe, 2019) and can lead to aspiration: food or fluid entering the airway and passing below the vocal cords often into the lungs. Healthy adults have a degree of aspiration, however persistent aspiration can lead to aspiration pneumonitis a potentially life threatening infectious process where aspirated material is colonised by pathogenic bacteria resulting in a chest infection (Marik, 2001).
In the past, the presence of a tracheostomy tube was considered to be a primary cause of an oropharyngeal dysphagia. For instance, Bonanno (1971) suggested that a tracheostomy tube resulted in tethering of the larynx and subsequently lead to aspiration. However it is now widely recognised that dysphagia is the cause of an underlying condition of which there could be multiple reasons. This is substantiated by Wallace, McGowan and Ginnelly (2016) who argued that the presence of a tracheostomy tube does not necessarily in isolation cause an oropharyngeal dysphagia, however they do recognise that it could contribute to dysphagia. Moreover, in two separate studies completed by Leder and Ross (2000; 2010), they reported that there was no causal relationship between tracheostomy and aspiration status. It is the role of the speech and language therapist (SLT) to work closely with people with a tracheostomy to provide detailed assessment and therapy intervention of swallowing due the impact and interconnection of dysphagia and tracheostomies (McRae et al, 2020).
Research in the field of conducting dysphagia assessment in adults with a tracheostomy is well reported (Brodsky et al., 2019). However, despite recommendations in the literature for intervention post assessment, Brodsky and colleagues (2019) note the lack of scientific based consensus for when and how intervention can begin post tracheostomy placement. Regardless of tracheostomy status, dysphagia assessment aims to support an intervention programme that is goal centred such as minimising the risk of aspiration and increase quality of life (Brodsky et al, 2019). In their scoping review, Skoretz and colleagues (2020) investigated swallowing and tracheostomy following critical illness. Based on their protocol they were able to include 85 appropriate studies of which 25% (n=21) of the papers looked at interventions. In the results the authors provided an overview of intervention type. They used the term “intervention” broadly to refer to instrumentation, traditional dysphagia exercises and manipulation of tracheostomy (e.g. deflation of the cuff and use of one-way valve to restore subglottic pressures required for swallowing). They noted that compared to the other domains of their research content (e.g. dysphagia frequency) there were relatively fewer studies available and thus acknowledge paucity in the literature regarding intervention for adults with dysphagia and tracheostomies.
Intervention, rehabilitation, management and exercise are some of the terms used to describe oropharyngeal dysphagia therapy. Therapy is a multimodal approach which aims to restore swallow function (Crary & Carnaby, 2014; Smithard, 2016). Examples may include ‘effortful swallowing’ targeting the contact between base of tongue and posterior pharyngeal wall (Logemann, 1991); ‘Mendelsohn manoeuvre’ for laryngeal elevation (Mendelsohn et al, 1987) and the ‘head lift’ to improve hyoid displacement (Shaker et al., 1997). Compensatory strategies may include adaptation of bolus delivery and/or environmental factors (e.g. posture/position) (Brodsky et al., 2019). In patients with progressive neurological disorders gains were seen in functional swallowing tasks with oral trials and swallowing related quality of life measures (Athukorala et al., 2014). Behavioural interventions can lead to improved swallowing ability, reduced number of patients with dysphagia at the end of the trial, and had greater outcomes than other interventions such as acupuncture, electrical stimulation and drug therapies (Bath, et al, 2018). Technological advances have delivered new approaches as well as interventional tools to aid delivery of behavioural interventions e.g. surface electromyography to provide biofeedback (Archer et al., 2020). In recent years, neuromuscular electrical stimulation (NMES)/transcutaneous electrical stimulation (TES) and pharyngeal electrical stimulation (PES) have gained prominence as dysphagia therapeutic interventions (Dziewas, et al, 2018). These methods use electrodes that are either placed externally on submental muscles (NMES/TES) or internally via electrodes on a catheter along the posterior pharyngeal wall (PES) to provide electrical stimulation which results in musculature and/or cortical changes (Ludlow, et al, 2010; Vasant et al, 2016).
Dysphagia therapies have been evaluated and scrutinized in differing patient cohorts including but not limited to, stroke, Parkinson’s disease, respiratory conditions and a variety of head and neck cancers. Dysphagia therapy is an accepted means of supporting patients to return to oral intake. Functional outcomes (e.g. increasing oral intake) after a programme of swallowing therapy have been noted on repeat videofluoroscopy assessments (Huang et al., 2014; Kang et al., 2012). Despite these gains, the evidence supporting the use of dysphagia therapy in patients with a tracheostomy is limited. One possible reason for this could be that developing a therapeutic protocol in this patient cohort is challenging due to the complex interaction of dysphagia and tracheostomies.
Swallowing in patients that have a tracheostomy has been considered a fundamentally important role in patient outcomes (NCEPOD, 2014). From Skoretz and colleagues’ (2020) scoping review it is clear that therapeutic intervention is an area that needs further exploration. No published scoping review has extrapolated information secondary to dysphagia therapy in tracheostomised patients when considering treatment type, dosage and frequency. This detailed understanding of the scope and effectiveness of dysphagia therapy in this population cohort will help develop the evidence base, provide scientific knowledge to work towards a consensus in dysphagia therapy for people with a tracheostomy and support robust therapeutic trials in this population.
This scoping review aims to:
- Describe the existing published literature on oropharyngeal dysphagia therapy used in an adult population that have a tracheostomy at the time of reporting.
Developing the research question:
There is paucity in the literature regarding swallowing therapy in adults that have a tracheostomy (Skoretz et al, 2020). Further understanding of this area, including therapy type and dosage, can provide support to clinicians working with patients that have a tracheostomy and guide robust research in this area.
The research question posed is: What is known from the existing literature about dysphagia therapy that people with a tracheostomy are receiving. This question was used to conduct a literature search to gain up to date information about treatment methods available in adult populations. This protocol is specifically interested in participants with a tracheostomy that receive dysphagia therapy including: surgical, pharmaceutical, cortical and peripheral stimulation, alternative therapies and direct oropharyngeal exercises.
Manipulation of the tracheostomy including taking the cuff down and placing a speaking valve are synonymous with dysphagia therapy. This protocol agrees with these sentiments, however a thorough scoping review has recently been completed which minimises the knowledge gap in this area (Skoretz, Anger, Wellman et al, 2020) and therefore inclusion within this protocol is not required.