Part of being a competent speech-language pathologist is knowing about and using the evidence that supports or refutes what we do with our patients and clients. One service provided by SLPs—managing patients with dysphagia who have tracheostomy tubes—may be particularly challenging and therefore might be an especially important area in which to consult available evidence.
In addition to understanding the clinical considerations typical for all patients—such as medical comorbidities, current medical status, and mental state—an SLP needs to be aware of additional factors pertaining to a patient’s tracheostomy. These factors include the presence of a cuff and the effects of cuff inflation status; the size of the tracheostomy tube in relation to the patient’s probable tracheal diameter; whether mechanical ventilation is in use; the ventilation mode and patient progress toward weaning; the patient’s tolerance of expiratory occlusion and success in establishing exhalation airflow to the larynx and oral-nasal exits; the patient’s tolerance of a one-way speaking valve; and secretion management. As clinicians, how do we know which of these factors will positively or negatively affect a patient’s swallowing function? How do we know whether these factors will result in impaired biomechanics that lead to aspiration and associated morbidity? How can we determine through assessment, and minimize through intervention, the likelihood of any adverse effects?
Which of our assessment procedures most accurately predicts or identifies aspiration? Multiple studies have demonstrated high rates of silent aspiration in patients breathing through a tracheostomy tube (Ding & Logemann, 2005; Davis et al., 2002; Davis et al., 2004; Elpern et al., 2000). Is stand-alone clinical testing sufficiently robust, how sensitive are these clinical screening tools in predicting aspiration, and should they stand alone as diagnostic studies for this population? Many argue that identification of aspiration is best accomplished by instrumental testing (e.g., Elpern et al., 2000; Ding & Logemann, 2005), but which instrumental test is superior?