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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
tongue base helps to propel the bolus
inferiorly into the esophagus and also
directs it away from the opening of the
airway.
Lastly, the laryngeal structures, including the true vocal folds and the
ventricular folds, close during deglutition, which effectively seals off the
airway as the bolus passes through the
pharynx and into the esophagus. Alittle puff of air that occurs as the vocal
folds close also directs the bolus up
and off the opening to the airway. The
epiglottis acts like a lid above the true
vocal folds and closes down over the
entrance to the upper airway.
Any disruption of these airway protection mechanisms can lead to compromised airway protection and aspiration. Neuromuscular disease that
results in muscular weakness or palsies
of the muscles involved in structural
movements needed for airway protection are obvious causes of dysphagia
risk, but airway protection mechanisms can be disrupted by many other
pathologies such as bulky masses or
tumors, strictures or scarring (common
after head and neck radiation therapy),
or the need for an artificial airway or
tracheostomy tube. The placement of a
tracheostomy tube potentially disrupts
upward and forward movement of the
hyolaryngeal complex by tethering the
trachea to the skin of the lower neck.
PULMONARY RISK FACTORS
Patients with preexisting pulmonary
disease who become dysphagic have a
diminished ability to tolerate even mild
aspiration. Aspiration insults are very
poorly tolerated by an already compromised pulmonary system. Pulmonary
diseases include all the smoking-related
lung diseases
sema, chronic obstructive pulmonary
disease (COPD), chronic bronchitis,
and lung cancer. Patients with cardiopulmonary pathologies such as cardiomyopathies, pulmonary hypertension,
and other cardiovascular diseases are
also at heightened risk for pulmonary
complications from dysphagia.
— for example, emphy-
ASPIRATION PNEUMONIA
True aspiration pneumonia has a typical radiographic pattern. The pattern
demonstrates infiltration or consoli
dation most commonly in the right
lower lobe, next most often in the right
upper lobe, and less frequently in the
left lower lobe. Rarely are all three lobes
involved at the same time. This distribution is a consequence of the angle of
the tracheobronchial takeoff into the
parenchyma of the right lung. The right
lower lobe represents a straight line of
descent from the trachea to the right
main stem bronchus. In a patient who
is supine, or lying on the right side,
the right upper lobe takeoff from the
right main stem bronchus represents
a dependent position. The left lobe is
in a dependent position in the left sidelying position. Therefore, the common
sites of aspiration are influenced largely
by gravity and human anatomy.
The diagnosis of aspiration pneumonia in a patient relies on both clinical and
radiographic signs. Clinical findings of
aspiration include fever, shortness of
breath, weakness, and cough. Sputum
may be thick, colored, and difficult to
expel by coughing. Chest auscultation
may reveal rhonchi in the large airways,
and breath sounds are decreased over
-
12. AIRWAY CONSIDERATIONS IN DYSPHAGIA
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275
the consolidated lung (solidification of
the lung secondary to pneumonia) and
may even sound hollow (Yoshimatsu
et al., 2022). Chest x-ray will demonstrate consolidation of the involved
portion of the lungs. To ensure appropriate treatment, pneumonia related
to dysphagia, or difficulty eating and
drinking, must be differentiated from
a pneumonia related to a single aspiration event or a community acquired
pneumonia from other etiologies.
Aspiration pneumonia may be a
result of material entering the lungs in a
single aspiration event during a period
of altered level of consciousness, such
as can occur in trauma, diabetic coma,
or acute myocardial infarction with
loss of consciousness. Under general
anesthesia, or even conscious sedation,
the patient is unable to fully protect
the airway. During a surgery under
anesthesia, reflux of stomach contents
may occur as the lower esophageal
sphincter is relaxed, leading to the
potential for aspiration. This risk is
increased if the patient has eaten close
to the time of the surgery. Similarly,
individuals who have eaten a meal and
then experience a traumatic event leading to unconsciousness are at very high
risk for aspiration. This type of aspiration may be preceded by vomiting and
may have devastating consequences for
the lungs.
Repeated aspiration may occur in a
cognitively intact and awake patient
with an ongoing inability to protect the airway during oral nutrition
due to ineffective airway protection
mechanisms (i.e., dysphagia). “Silent”
aspiration (when a patient does not
respond to aspiration with a cough)
may go undetected (Horner & Massey,
1988; Splaingard et al., 1988). Patients
who chronically aspirate may become
undernourished and unable to maintain their weight and are diagnosed as
failing to thrive. Immunological risk is
heightened because of the lack of adequate protein, albumin, and fat stores to
maintain normal body function. Laryngeal cancer patients often initially present with aspiration and cachexia. Both
occurring at the same time portend for
a poor outcome as both fat and protein stores are depleted (Esper & Harb,
2005) (Table 12–1).
Under normal circumstances, the
pulmonary system clears aspiration
events with a cough to expel aspirated
material. In addition, the mucociliary
blanket lining the trachea and bronchi
consists of cilia covered by a blanket
of mucus that traps aspirated materials and moves them up and out of the
Table 12–1. Risk Factors for Aspiration
Single Aspiration Event Recurrent Aspiration
Decreased level of consciousness Feeding tube
Supine position Feeding tube malposition in esophagus
General anesthesia Bolus feeding
Intubation and mechanical ventilation Neurologic disorder
Vomiting Diabetes
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
airway through the beating of the cilia.
Repeated aspiration leads to pneumonia when the airway is unable to adequately maintain its normal physiologic
hygiene and clearing. Long-term endotracheal intubation heightens a patient’s
risk for repeated aspiration by the presence of an artificial tube that interferes
with the normal cough, impairs the ciliary action of the lining of the trachea,
and precludes the normal filtration and
humidification of the nose and mouth.
In addition, the presence of an artificial
airway changes the normal bacterial
flora in the mouth. Even with cuffed
endotracheal and tracheostomy tubes,
micro- and macro-aspiration into the
tracheobronchial tree occurs. This is a
consequence of the constant expansion
and contraction of the trachea during
normal respiration and subsequent
movement of the artificial airway cuff
in the lumen of the trachea. Aspirated
material sitting above the inflated cuff
will unavoidably leak around the cuff
and into the airway. The primary cause
of pneumonia in patients on ventilators
is the ongoing micro-aspiration around
the cuff of the artificial airway. Poor
oral care and changes in oral flora with
bacterial overgrowth and poor dentition also increase the risk of ventilatorassociated pneumonias (VAPs) via this
mechanism (Minei et al., 2006; Munro &
Grap, 2004; Niederman & Craven, 2005;
Trieger, 2004).
An episode of severe, acute aspiration or chronic, repeated aspiration can
cause pneumonia, which is best treated
with appropriate antibiotics combined
with aggressive respiratory therapy.
Coughing, deep breathing, oxygen,
and medication support are indicated.
If not treated promptly or with the
correct antibiotic regimen, the patient
can become dangerously ill. Today, an
increase in antibiotic-resistant microorganisms makes some pneumonia variants more difficult to treat. In a patient
whose immune system has been threatened as a consequence of chemotherapy,
significant deconditioning, or AIDS,
pneumonia of any origin may be lethal.
If aspiration pneumonia is diagnosed, the dysphagia team must be
able to differentiate between aspiration
caused by an inability to protect the airway during eating and swallowing due
to motor and/or sensory factors and
aspiration from other causes. Whatever
the etiology, early correct detection is
tantamount to correct treatment and,
ultimately, to recovery.
ASPIRATION PRECAUTIONS
Aspiration precautions are a set of recommendations designed to minimize
the risk of aspiration for a given patient
during and in between meals. Aspiration precautions are indicated in many
settings such as acute care hospitals,
nursing homes, and at home. Precautions must be modified for each individual patient to match their type of
dysphagia, nutritional needs, and treatment plan. Again, continual diligence
is required to ensure aspiration precautions are effective because many dysphagic patients aspirate without giving any external sign of food or liquid
entering the airway (Logemann, 1986).
Inpatient aspiration precautions may
include the following:
Oral Feeding:
n
Do not allow patient to eat unat-
tended or unobserved.
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277
n
If patient is taking an oral diet,
follow the diet recommendations
and restrictions generated by an
objective dysphagia assessment
plan. (Coordinate with the physician’s orders for consistency,
amount, and frequency.)
n
Position patient in optimally safe
upper body position as recommended, or 90 degrees in a chair
with head/neck flexion, if possible. Address head stability during
meals.
n
Observe for coughing, choking,
throat clearing, or struggle during
eating.
n
Minimize distractions (maintain
quiet environment, no television,
no talking during eating).
n
Continually assess the patient’s
pulmonary status for fevers, rales,
rhonchi, and clinical signs of aspiration.
Enteral Feeding:
n
Ensure placement of feeding tube
is confirmed by radiograph and
monitor for evidence of tube migration.
n
Observe reflux precautions (prop-
er positioning, limited nocturnal
feeds, elevated head of the bed).
n
Check gastric residuals before be-
ginning enteral feeding (Metheny
et al., 2012).
n
Improve oral care (Munro & Grap,
2004; Niederman et al., 2005).
Outpatient aspiration precautions are
similar and may include:
Oral Feeding:
n
Avoid eating/drinking when alone.
Minimize distractions (quiet en-
vironment, no television, no talking during eating).
n
Observe food consistency, amount,
and frequency recommendations
by the dysphagia team.
n
Observe optimally safe upper
body position as recommended,
or use 90-degree upper body position with chin tuck. Assess head
stability during eating.
n
Ensure that family/caregivers are
familiar with the Heimlich maneuver, CPR, and signs of aspiration.
n
Note cough, throat clear, “wet”
voice, voice changes, and struggle
associated with eating/drinking
that indicate possible aspiration
(Metheny, 2007).
n
Oral care before and after meals
(Munro & Grap, 2004).
Enteral Feeding:
n
Monitor tube position for evi-
dence that it has migrated.
n
Observe reflux positioning.
n
Check gastric residuals before
feeding (Metheny et al., 2012).
Monitor and document tolerance
or intolerance to the enteral feeding regimen.
REFLUX PRECAUTIONS
Patients with a history of reflux disease are at risk of aspiration of refluxed
materials from the stomach. Although
reflux presents a potential aspiration
risk, it should not be treated empirically in order to avoid treatment with
inappropriate medications and implementation of unnecessary reflux precautions. If reflux is suspected, a referral to a physician with expertise in the
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
diagnosis and management of reflux
disease is recommended.
Individuals whose primary mode of
nutrition is by feeding tube (NG, NJ,
GT/J) are still susceptible to aspiration from gastroesophageal reflux and
improper placement or migration of
the enteral tube. Gastrointestinal (GI)
reflux may occur with either continuous or bolus feeding and can also occur
with gastric secretions alone. Reflux
and potential aspiration in patients
with gastrostomy tubes can be caused
by lower esophageal sphincter (LES)
relaxation secondary to gastric distention of the stomach (Takahashi et al.,
1994b). These patients require rigorous
monitoring because this type of aspiration may be silent, and its symptoms are
elusive to cursory examination. Vomiting, coughing, retching, or pharyngeal
suctioning can cause the distal tip of a
feeding tube to migrate upward into
the esophagus or downward into the
duodenum. Additionally, the tube may
become coiled in the pharynx (Simons
& Abdallah, 2012).
Coughing following a feeding (especially bolus feeding), with a full stomach, is a strong indication of reflux and
potential aspiration. When feeding is
administered lower in the GI tract, via
jejunostomy, reflux of gastric acid after
feeding may still occur (Coben et al.,
1994; Sands, 1991). The acidity (pH <3)
of the gastric secretions can be extremely
damaging to the larynx and lungs.
Proper position and monitoring of
the enteral feeding tube are critical to
the correct administration of nutrition. Radiographic documentation of
tube placement prior to use is the standard of care (McClave et al., 2009). If
the patient is discharged home with an
enteral feeding tube, family members
should be taught assessment for placement. In the home, belly auscultation
with instillation of air through the tube,
measurement of tube length outside
the nose, and gastric content checks
are used to assess correct placement of
enteral tubes. A repeat radiograph may
be indicated if there is any concern
regarding the clinical ability to confirm
proper tube placement.
TRACHEOSTOMY
Tracheostomy tubes bypass the upper
aerodigestive tract and create an opening directly into the pulmonary system
via an opening in the trachea below
the larynx (Figure 12–1). They can be
Figure 12–1. Position of tracheostomy tube
relative to other aerodigestive tract structures. Blue arrow: air flow into the tracheostomy bypassing the upper airway.
12. AIRWAY CONSIDERATIONS IN DYSPHAGIA
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279
a temporary or long-term requirement
and usually heal spontaneously after
removal of the tube with very little permanent impact. In patients with an artificial airway in place such as a tracheostomy, the disease process necessitating
the artificial airway, as well as the presence of the appliance, may influence the
patient’s ability to swallow.
Tracheostomies are often performed
in individuals who require mechanical
ventilation for longer than approximately 10 days. The presence of an
orally or nasally placed endotracheal
tube in the upper airway and through
the larynx for a longer period of time
than 10 days is associated with laryngeal scaring due to injury of those tissues by the endotracheal tube (Whited,
1984) (Figure 12–2). Removing the
endotracheal tube and replacing it with
a tracheostomy tube protects upper airway tissues, is more comfortable for the
patient and allows less patient sedation,
and is associated with faster weaning
from the ventilator (Bosel et al., 2013;
Zheng et al., 2012). Ongoing mechanical ventilation requires that the tracheostomy tube have an inflated cuff in
the trachea.
It must be kept in mind that vocalization requires exhaled air to pass
through the vocal folds. With a cuffed
tracheostomy tube, exhalation of air
around the cuff and through the vocal
folds is not possible and patients will
not be able to vocalize. Exhaled air will
pass out of the tube rather than through
the vocal folds (Figure 12–3).
In addition, the inflated cuff will not
prevent aspirated material from entering the lower airways and may further
impede normal swallowing mechanisms. An inflated endotracheal tube
cuff may impinge on the esophagus as
the trachea is supported by C-shaped
rings that encompass the anterior and
lateral sides of the trachea while the
Figure 12–2. Orotracheal intubation results in pressure on the posterior laryngeal
tissues.
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
Figure 12–3. A cuffed tracheostomy allows positive pressure ventilation without leak
of air out the upper airway but also prevents air flowing through the vocal folds as is
required for speech.
posterior wall of the trachea is mucosa
only. Inflation of the cuff may protrude
into the adjacent esophagus because of
this lack of support of the posterior tracheal wall.
Another indication for placement of a
tracheostomy tube is obstruction of the
upper airway that prevents adequate
ventilation. By bypassing the upper airway, the tracheostomy tube allows air
to be inhaled directly into the lungs. In
this situation, the patient may be able to
breathe without the need for mechani-
cal ventilation so a cuffed endotracheal
tube is not needed. The tube can be
sized so that it does not completely fill
the airway and exhaled air may pass
around the tube and through the vocal
folds for vocalization (Figure 12–4). Air
will flow out of the lungs preferentially
through the passage of least resistance
(the tracheostomy) so a finger or valve
over the tracheostomy tube opening
must be used to force exhaled air to
flow around the tracheostomy tube
and through the vocal folds for speech
12. AIRWAY CONSIDERATIONS IN DYSPHAGIA
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281
tube and into the trachea. B. During exhalation, if the opening of the tracheostomy tube is blocked by a finger or speaking valve,
Figure 12–4. Illustration of a cuffless tracheostomy tube within the airway. A. With inhalation, air passes through the tracheostomy
air passes around the tube and through the vocal folds to allow vocalization.
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
rather than out the low-resistance tracheostomy tube.
All tracheostomy tubes require an
inner cannula (Figure 12–5A). Mucus
and secretions that normally flow up
and out of the trachea via the mucociliary blanket and are usually swallowed will likely be coughed out of
the tracheostomy tube directly. Mucus
catches in the tracheostomy tube and
may obstruct the tube, interfering with
air passage. Frequent suctioning of the
tube is required to keep the tracheostomy free of mucus and secretions. The
inner cannula can be quickly removed
to reestablish an open airway in the
case the tracheostomy becomes completely obstructed by mucus.
Direct suctioning of the airway
through a tracheostomy tube is an
effective means of assisting in pulmonary toilet. Patients may have a tracheostomy tube placed to allow for suctioning of material from the lungs and
not due to the need for mechanical ventilation or to bypass an upper airway
obstruction. This is particularly helpful
in patients with severe primary pulmonary disease who have difficulty managing normal pulmonary secretions.
Suctioning through a tracheostomy
tube may cause a patient to cough,
and the increased intrathoracic pressure generated during a cough may
cause reflux. Consequently, suctioning
should be effective to remove secretions but gentle to prevent the reflexive coughing, particularly if aspiration
is suspected during a reflux episode.
Following suctioning, a patient may
be asked to cough voluntarily, without
suction, to further determine if there is
refluxed material in the airway, but this
is not always a reliable indicator.
In a patient with a tracheostomy
and a feeding tube, blue vegetable dye
placed in a very small amount of the
tube feeding formula can be a useful
test for reflux of the feedings and subsequent aspiration. If secretions suctioned
from the tracheostomy turn blue, aspiration is confirmed (Metheny et al.,
2002). The presence of food (or enteral
feeding in the case of a tube-fed patient)
A B
Figure 12–5. Cuffed and cuffless tracheostomy tubes have an inner cannula and an
obturator to aid in tube placement through the surgical opening. © 2023 Medtronic.
All rights reserved. Used with the permission of Medtronic.
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in a tracheostomy or of endotracheal
secretions is an obvious indicator of
aspiration or reflux and aspiration.
This observation requires an immediate response from the treatment team
to manage an aspiration event. Patients
with an artificial airway in place should
be immediately suctioned in the event
of a witnessed aspiration.
TRACHEOSTOMY TUBES
Clinicians involved in the care of the
person with dysphagia must have an
intimate knowledge of the kinds, uses,
and complications of artificial airways
used in their patient population. The
following is an overview of some of
the types of tracheostomy tubes used
in the acute care setting.
Cuffed tracheostomy tubes (Figure
12–5B) are used to seal the airway for
positive pressure ventilation. Intracuff
pressures are established at no more
than 20 to 30 mm Hg in order not to
exceed end capillary pressures of the
tracheal walls causing necrosis of the
tracheal tissues (McGuinnis et al., 1971).
These tubes are typically used in critical
care settings and with patients on positive pressure ventilators or during surgical procedures requiring anesthesia.
Cuffed endotracheal and tracheostomy
tubes do not prevent aspiration of food
and secretions and should not be used
with the intent to avoid aspiration in
patients with dysphagia.
Patients are infrequently sent home
with cuffed tracheostomy tubes. Cuffed
tubes are appropriate for outpatients
only if they require positive pressure
ventilation, such as the patient with
end-stage amyotrophic lateral sclerosis
(ALS). When a patient does not require
positive pressure ventilation and is
breathing independently, the cuff is
always deflated as soon as possible
to avoid pressure and scarring of the
tracheal walls (tracheal stenosis). Cuff
deflation is the precursor to replacing
the cuffed tube with a noncuffed tube.
Uncuffed/cuffless tracheostomy
tubes (see Figure 12–5A) are used to
provide an airway when the patient
is able to breathe on their own but
still requires assistance with secretion
removal or to bypass upper airway
obstruction. These tracheostomy tubes
are typically used for short- or longterm airway support. The impact of a
tracheostomy tube on swallowing function is a subject of much debate. There
is a concern, however, that a tracheostomy tube may tether the larynx and
interfere with its normal elevation during swallow, further impairing swallowing ability in patients (Skoretz, et al.,
2020). The goal is to use the smallest
tube possible that allows the patient to
ventilate with maximum tidal volume
without restriction.
Fenestrated tubes (Figure 12–6) are
rarely used. They were initially developed with the idea they might be helpful for weaning and decannulation and
are generally smaller in diameter than
tubes used for traditional airway maintenance. Fenestrated tubes have a series
of openings or fenestra on the superior
horizontal portion of the tube with the
idea that air can flow through the fenestra, allowing for vocalization and some
use of the upper airway for respiration.
When the inner cannula is removed and
the tube is capped, the patient is breathing via the fenestra, as well as around
the tube. Fenestrated tubes are not left
in place for long periods of time, no
more than 3 to 5 days, because of the
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