Swallowing disorders in tracheostomised patients: a multidisciplinary/multiprofessional approach in decannulation protocols

Abstract

Safe removal of tracheal cannula is a major goal in the rehabilitation of tracheostomised patients to achieve progressive independence from mechanical support and reduce the risk of respiratory complications. A tracheal cannula may also cause significant discomfort to the patient, making verbal communication difficult. Particularly when cuffed, tracheal cannula reduces the normal movement of the larynx which can further compromise the basic swallowing defect. A close connection between respiratory, phonating, swallowing and feeding abilities to be recovered, implies a strict integration among different professionals of the rehabilitation team. An appropriate management of tracheostomy cannula is closely connected with assessment and treatment of swallowing disorders in order to limit the development of severe pulmonary and nutritional complications, but at present there are no uniform protocols in the scientific literature. Furthermore, several studies report as an essential criterion for decannulation the presence of good patient consciousness, which is often altered in patients with tracheostomy, but a general agreement is lacking.

Frequency and outcome of post‐extubation dysphagia using nurse‐performed swallowing screening protocol

“…In other words, when considering dysphagia, interventions by a multidisciplinary team including doctors, nurses, SLPs, physical therapists, nutritionists and dental hygienists are necessary. The importance of multidisciplinary teams for the treatment of swallowing disorders in elderly patients and those with stroke or tracheostomy has been widely reported (Rofes et al, 2011;Gandolfi et al, 2014;Garuti et al, 2014;Aoki et al, 2016), but no such studies have been reported for critically ill patients. Even in the ICU, evaluations of swallowing function and interventions by a multidisciplinary team should be performed to promote oral intake after extubation, and the effects of such evaluations and interventions should be verified.…”

Decanulação: indicadores sociodemográficos, clínicos e fonoaudiológicos preditivos de sucesso

“…Presence of abundant secretions and need for frequent tracheal aspirations in a 24-hour period are considered contraindications to decannulation (13,16) . It is worth emphasizing that cuff deflation favors better functionality of the larynx, thus allowing airflow through the upper airway, improved laryngeal elevation and sensitivity, removal of lung secretions, protection of the lower airways, voice, and deglutition.…”

“…The following criteria are suggested for indication and success in decannulation: ability to tolerate cuff deflation for 24h (9,10) ; presence of respiratory muscle strength and resistance (11,12) ; effective cough with ability to remove lung secretions (7,(9)(10)(11)(13)(14)(15) ; voluntary and reflexive cough (7,10,11,13) ; intact upper airways (5,9,13,15) ; absence of glottic or subglottic stenosis (16,17) ; preserved swallowing capacity (7,9,(11)(12)(13)(15)(16)(17) ; performance of the Blue Dye test (6,11,13,18) ; absence of previous head and neck surgery (7,11) ; use of phonation valve (11,14) ; tolerance to tracheostomy occlusion, with or without need for oxygen therapy (9,11,12,15,17) ; stable oxygen saturation for longer than 24h after tube occlusion (7,(9)(10)(11)…”

“…Aiming to avoid or minimize functional complications resulting from tracheostomy, which generate significant emotional impact on the quality of life of patients and on family relationships (19) , the tube removal process should be initiated as early as possible, and speech-language pathology (SLP) assessment and monitoring are essential in identifying some criteria that contribute to the success in weaning, such as functional swallowing, ability to protect the lower airways (7,9,(13)(14)(15)20,21) , absence of pulmonary aspiration, spontaneous swallowing of saliva, and facilitation of verbal and non-verbal communication (12,19) .…”

Management of decanulation in the tracheostomized patient

“…Il existe d'autre part un intérêt démontré à la gestion des patients trachéotomisés par une équipe spécialisée, de même qu'à la réalisation de protocoles guidant la décanulation [18][19][20] : diminution du nombre d'obstructions et de détresses respiratoires sur canule, diminution des complications liées à la décanulation, délai de décanulation raccourci avec augmentation du taux de succès, durée d'hospitalisation et dépenses de santé diminuées... Un tel suivi permet certainement une réévaluation plus fréquente des critères de décanu-lation et pourrait éviter de laisser en place des trachéotomies devenues inutiles. Cette équipe est multidisciplinaire et peut se composer de médecins réanimateurs ou tout médecin en charge du patient, d'ORL, d'orthophonistes, de kinésithéra-peutes, d'infirmières, formés à ce type de prise en charge.…”