Dysphagia Exam 2: Tracheostomy and Swallowing

• Insertion of tube into mouth or nose passing through pharynx and vocal folds into trachea
• Artificial airway to connect to mechanical vent
• Airway protection & mechanical vent.
• Temp.; 14-21 days

• Trauma to lips, gums, lips, tongue, pharynx, larynx
• Vocal fold damage: direct, cuff overinflation
• Hypoxemia: Lack of oxygen to tissues
• Left lung collapse
• Esophageal intubation (putting in wrong way, distension)
• Rupture of esophagus
• Cardiac complications

• Trauma
• Otitis media and conductive hearing loss
• Pressure necrosis (skin breakdown)
• Granulomas (lumps forming into polyp)
• Stenosis (narrowing)
• Laryngeal web (membranous formation)
• Glottic incompetence (protection)
• Endotracheal tube cuffs
• Tracheal stenosis (narrowing of trachea)

• Surgical placement of plastic or metal tube into trachea to create an airway
• Decannulation risk
• Secretion removal
• Reduced risk of laryngeal complications 
• Improved weaning from mech. vent.
• Comfort
• Increased options for oral communication and feeding

• Paralysis of muscles affecting swallow causing danger of aspiration
• Prolonged intubation
• Subglottic stenosis from prior trauma
• Obstruction from obesity for sleep apnea
• Congenital abnormality of larynx or trachea
• Severe neck/mouth injuries
• Inhalation of corrosive material smoke or steam
• Presence of large foreign body that occludes airway
• long term unconsciousness or coma

• General anesthesia
• Incision at 2nd or 3rd tracheal ring
• Tube size based on age, weight, height

• Related to abrasion at stoma site (58%)
• Softening of cartilage of trachea due to erosion of tracheal rings
• Narrowing that occurs with healing (infection, tube changes, tugging on tube, large stoma)
• Necrosis of tracheal and esophageal wall which forms passageway between GI tract & airway

• PVC- single use
• Silicone- sterilized and reused
• PVC mixed with silicone
• Metal (nondisposable)

• outer and inner cannula
• Flange (neck plate, holds tube in place)
• Obturator (eases insertion)
• Button (occludes tube used for weaning)
• Cuff (prevent air escape)

• Cuffed or cuffless, single or multiple fenestrations, allows air to pass from trachea through fenestrations to vf, improves phoantion, not used for those high risk of aspiration, use in decannulation
• Attached to inflation line leading to pilot balloon, used during mech. vent., reduces risk of aspirated secretions entering trachea, fenestratrated/nonfenestrated, high volume, low pressure 
• Single-outer cannula only, provides least airway resistance
• Double- Used with outer and inner--standard tube
• Extra long- Single, special needs patients (stenosis, malacia, anatomy changes, burns)

• Size, tube angle, cuffs (high volume low pressure, shape, fit to tube), Flange (swivel, shape, material), inner cannula (texture, connection)
• Talking trach tube--vent dependent, can't tolerate cuff deflation; external air tube connected to compressed air, provides continuous airflow for speech
• Tracheal buttons- maintain open stoma after trach removal; maintains opening in trach wall

1-way valve allows air to enter trachea on inspiration, valve closes on expiration directing air upward through vf; phonation or cough/clear throat

• Complications inherent in population who may need trach
• Reduced laryngeal excursion (horizontal incision, decreased BOT--pressure and disuse, weight of equipment, cuff inflation (drags tracheal wall over, partial esophageal obstruction, disruption of esophageal pressures due to changes in timely CP relaxation and opening)

• Medications specific to trach and ventilator dependent patients may lead to xerostomia
• Increased secretions (upper airway filtering and humidification bypassed), chronic lung disease, lack of fluid intake (dehydration)

• Disruption of airway pressures resulting in pharyngeal residue (1-way valves normalized pressures for less impact) 
• Reduction of airflow through glottis (elimination of expiratory airflow to clear residue from airway, loss of laryngeal sensation, disco ordination of glottic closure response--w/in 3 months)

• Disruption of normal apneic interval (vent may force air in when vf closure is occurring, disruptions swallow sequence)
• Tube feedings/intubation (premorbid dysphagia patients more at risk, difficulty tolerating extubation due to decreased airway protection; feeding tubes increase aspiration risk; NPO increases potential for bacteria (ORAL CARE)
• GI bleeding from stress ulcers (physical and emotional stress)

Aspiration: Cuff inflation does NOT prevent aspiration--incomplete seal, accumulation of aspirated material at top of cuff, destruction of cilia (remove mucus and aspirated contents, destroyed at cuff inflation site)