Using ventilators for speaking and swallowing

The Feasibility, Utility, and Safety of Communication Interventions With Mechanically Ventilated Intensive Care Unit Patients: A Systematic Review

Purpose The aim of this study was to conduct a systematic review of the literature relating to the feasibility, utility, and safety of augmentative and alternative communication (AAC) interventions and tracheostomy-related communication interventions with mechanically ventilated adult patients in the intensive care unit (ICU). Method MEDLINE, Embase, and PsycINFO databases were searched for relevant articles. Studies were included if (a) they were performed in the ICU, (b) they involved participants > 18 years of age, (c) > 85% of participants were mechanically ventilated, and (d) they reported on content that related to the feasibility and/or utility and/or safety of AAC intervention and/or tracheostomy-related communication intervention. Studies were extracted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The levels of evidence for included studies were assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) guidelines. Results Forty-eight studies met the inclusion criteria. Different communication interventions relating to intubated and tracheostomized mechanically ventilated patients were reviewed, including (a) communication boards, (b) electrolarynx, (c) high-technology AAC devices, (d) tracheostomy tubes with communication-enabling features, (e) one-way valve in line with the ventilator, (f) ventilator-adjusted leak speech, (g) ventilator adjustments and one-way valve, and (h) multiple interventions. Forty-seven of 48 studies examined the feasibility and utility of the interventions. Sixteen studies examined the safety of the interventions. The included studies were composed of randomized controlled trials (n = 2), quasi-experimental studies (n = 7), cohort studies (n = 8), case-control (n = 1), case series (n = 23), and case reports (n = 7). The levels of evidence varied and ranged from high (n = 2), moderate (n = 7), low (n = 9), and very low (n = 30). Conclusions There is developing evidence that communication interventions with mechanically ventilated ICU patients are feasible, have utility, and are safe. Further research is warranted to guide speech pathologist-directed intervention to improve patient outcomes and the patient experience in the ICU.

Swallowing rehabilitation of dysphagic tracheostomized patients under mechanical ventilation in intensive care units: a feasibility study

Objective

The aim of the present study was to assess the feasibility of the early implementation of a swallowing rehabilitation program in tracheostomized patients under mechanical ventilation with dysphagia.

Methods

This prospective study was conducted in the intensive care units of a university hospital. We included hemodynamically stable patients under mechanical ventilation for at least 48 hours following 48 hours of tracheostomy and with an appropriate level of consciousness. The exclusion criteria were previous surgery in the oral cavity, pharynx, larynx and/or esophagus, the presence of degenerative diseases or a past history of oropharyngeal dysphagia. All patients were submitted to a swallowing rehabilitation program. An oropharyngeal structural score, a swallowing functional score and an otorhinolaryngological structural and functional score were determined before and after swallowing therapy.

Results

We included 14 patients. The mean duration of the rehabilitation program was 12.4 ± 9.4 days, with 5.0 ± 5.2 days under mechanical ventilation. Eleven patients could receive oral feeding while still in the intensive care unit after 4 (2 - 13) days of therapy. All scores significantly improved after therapy.

Conclusion

In this small group of patients, we demonstrated that the early implementation of a swallowing rehabilitation program is feasible even in patients under mechanical ventilation.

Tracheostomy management in the chronically ventilated patient

Tracheotomy is a fundamentally important technique for managing patients who require long-term mechanical ventilation. Appropriate application of tracheotomy requires a skilled approach for timing the procedure, selecting the appropriate tracheostomy tube appliance, caring for the artificial airway once it is in place, and assisting patients with their specialized needs, such as articulated speech, airway humidification, and oral nutrition. Preparing patients for airway decannulation after they have weaned from mechanical ventilation requires a similar level of skill and attention to detail.

Swallowing in patients with tracheotomies

Swallowing and respiration are well-coordinated and interdependent functions. When one of these processes is impaired, the ramifications may be negative for the other. This article describes the mechanics of normal swallowing, the disorders of swallowing, the effects of tracheotomy and mechanical ventilation on swallowing, and the procedures used to assess and treat swallowing. Combining a basic understanding of these concepts with practical management can increase safe and efficient oral intake in patients with artificial airways.

Scintigraphic quantification of aspiration reduction with the Passy-Muir valve

The Passy-Muir "speaking" tracheostomy valve has been noted to aid in swallowing, based on videofluoroscopy to assess aspiration. In this study scintigraphy was used to quantify the amount of material aspirated. Eleven patients were studied who currently had a tracheostomy in place and were either known to aspirate or were suspected of aspirating. Most were post-treatment head and neck cancer patients who were tumor free at the time of testing. Swallowing was evaluated using videofluoroscopy and scintigraphy. Videofluoroscopy was performed to assess anatomy and determine whether aspiration had occurred. Scintigraphic testing was then performed when the patient had the one-way valve on, and again with it off and tracheostomy open. Following a swallow, the amount (%) of aspirate with the valve in place was found to be significantly less than with the tracheostomy open. A one-way valve can be helpful in reducing aspiration in patients who are at risk for aspiration and who require that their tracheostomy be open.

Dysphagia and expiratory air flow

Expiratory air flow preserves the freedom of the upper airway from foodway contamination in patients with dysphagia. Valving the tracheostomy cannula, "quad coughing," the Heimlich maneuver, the "supraglottic swallow," and coupling to a ventilator each has a place among the measures used for treating aspiration.