dysphagia related to tracheostomy & ventilation · replaced every 28-30 days ... inflated cuff...

1

Presented By:

Lisa H. Renfroe, M.C.D., CCC-SLP

February 21, 2014

DYSPHAGIA RELATED TO TRACHEOSTOMY &

VENTILATOR DEPENDENCE

Ventilation

Ventilation Indications

Disruption of normal air exchange into and out of lungs

Causes of respiratory failure:

Respiratory illness

Cardiac events

Neurological injury

Neuromuscular disease

Trauma

Environmental contamination

Airway obstruction

Dysphagia Related to Tracheostomy & Ventilator

Dependence


February 21, 2014

Ventilation Associated Complications

Lung barotrauma

Oxygen toxicity

Atelectasis

Nosocomial pneumonia

Decreased venous return

Decreased cardiac output

Hypotension

Gastrointestinal bleeding

Malnutrition

Decreased urine

output/altered renal

function

Altered fluid balance

Increased intracranial

pressure

Respiratory alkalosis

Accidental disconnect of

ventilator/power loss

Loss of airway pressure


Dependence


February 21, 2014

Artificial Airways

Artificial Airway Purposes

Maintain patent airway

Connect to mechanical ventilation

Provide access to lungs for pulmonary toilet

Control ventilation

Control oxygenation

Circumvent airway obstruction

Reduce aspiration potential


Dependence


February 21, 2014

2

Endotracheal Intubation

Insertion of endotracheal tube into airway

Somewhat flexible but retains shape in airway

Used for short-term:

To provide artificial airway

To connect to mechanical ventilation for airway protection and

ventilation

May stabilize severe facial fractures

May not be possible with tracheal stenosis and tumors


Dependence


February 21, 2014

Orotracheal Intubation

Orotracheal: Inserted into mouth, passing through pharynx and vocal

folds into trachea


Dependence


February 21, 2014

Nasootracheal Intubation Nasotracheal: Inserted into nose, passing into pharynx and vocal

folds into trachea


Dependence


February 21, 2014

Short-Term Endotracheal Intubation

Complications

Trauma

Otitis media

Damage to vocal folds or recurrent laryngeal nerve

Hypoxemia

Improper positioning

Esophageal intubation or rupture

Cardiac complications

Traumatic extubation with cuff inflated

Increased intracranial pressure


Dependence


February 21, 2014

Long-Term Endotracheal Intubation

Complications

Pressure necrosis

Granuloma

Stenosis

Laryngeal web

Glottic incompetence


Dependence


February 21, 2014

Cricothyroidotomy

Emergency surgical opening into

cricothyroid membrane

Potential complications:

Chronic vocal changes

Injury to:

Trachea

Larynx

Vocal cords

Esophageal perforation

Subglottal stenosis


Dependence


February 21, 2014

3

Tracheotomy

Surgical opening directly into trachea

May be maintained as long as needed


Dependence


February 21, 2014

Tracheotomy

Surgical or endoscopic

procedure

Between 2nd and 3rd

tracheal rings

Horizontal vs. vertical

incision Thyroid Cartilage

Tracheal Rings Cricoid Cartilage


Dependence


February 21, 2014

Tracheostomy Materials

Disposable:

Can retain bacteria

Should be discarded and

replaced every 28-30 days

Non-disposable: Must be

sterilized routinely


Dependence


February 21, 2014

Tracheostomy Materials: PVC

Disposable

Inexpensive

Widely used

More rigid than silicone

Soften in heat


Dependence


February 21, 2014

Tracheostomy Materials: Silicone

Disposable or non-disposable

Flexible

Softer than PVC or metal

May weaken and collapse over

time

Contains fewer chemical additives

Properties reduce encrustation of secretions and tendency of

bacteria to adhere to tube


Dependence


February 21, 2014

Tracheostomy Materials: PVC/Silicone Mix

Commonly used

Strength of PVC with bacteria resistance of silicone


Dependence


February 21, 2014

4

Tracheostomy Materials: Metal

Silver or stainless steel

More sanitary

Not typically used for individuals

requiring ventilation

Less comfortable

Often used at home


Dependence


February 21, 2014

Tracheostomy Size

Often denoted on flange

Typically measured in French sizes

Determined based on age, weight, and height

Goal:

Tube with sufficient airflow but not too large

Fill no more than ⅔-¾ of tracheal lumen


Dependence


February 21, 2014

Tracheostomy Components

1. Outer Cannula

2. Cuff

3. Pilot Line

4. Pilot Balloon

5. 15 mm hub

6. Flange

7. Obturator

8. Button

9. Inner cannula

10. Syringe 1 2

3 4

5

6

7

8 9

10


Dependence


February 21, 2014

Tracheostomy Components: Flange

Allows tube to be held in place with

string ties

Prevent:

Tube from advancing into trachea

Accidental decannulation

Often denotes some features


Dependence


February 21, 2014

Tracheostomy Components: Outer

Cannula

Provides basic structure

Remains in place to maintain airway

Single lumen tubes:

Have only outer cannula

Least airway resistance


Dependence


February 21, 2014

Tracheostomy Components: Inner

Cannula

Can be removed: For cleaning

Quickly if obstructed

Smaller lumen increases work of breathing

May be disposable or non-disposable


Dependence


February 21, 2014

5

Tracheostomy Components:

Fenestration

Windows/holes in body of outer or

inner cannula

Allows air to pass from trachea to vocal

folds

Not used in individuals at high risk for

aspiration

Often used as part of weaning process

Improperly aligned fenestration may

result in:

Granulation

Occlusion Dysphagia Related to Tracheostomy & Ventilator

Dependence


February 21, 2014

Tracheostomy Components:

Fenestration

Non-Fenstrated

Inner Cannula Fenstrated Inner

Cannula Dysphagia Related to Tracheostomy & Ventilator

Dependence


February 21, 2014

Tracheostomy Components: Cuff

Cuff:

Internal balloon surrounding body of

tracheostomy tube

Compensates for area in tracheal

lumen not filled by tube

Soft plastic molds to tracheal walls

Prevents air from escaping around

tube, especially during ventilation

Reduces risk of aspirated material

immediately entering trachea

Cuffless: Allows air to escape around

body of outer cannula to upper airway


Dependence


February 21, 2014


High volume, low pressure

Low volume, high pressure

Pressure-controlled

Foam


Dependence


February 21, 2014


Inflated Cuff & Pilot Deflated Cuff & Pilot


Dependence


February 21, 2014

Tracheostomy Components: Pilot

If tracheostomy is cuffed:

Pilot line: pathway for air

to inflate and deflate cuff

Pilot balloon:

Indicates amount of air in

cuff

Prevents air escape from

cuff


Dependence


February 21, 2014

6

Tracheostomy Components

Obturator

Button:

Closes tracheostomy

Used during

weaning/decannulation

process


Dependence


February 21, 2014

Tracheostomy Benefits (Compared to

ET tube)

Decreased risk of accidental decannulation

Improved secretion management

Larynx is not involved in procedure

Decreased airflow resistance

Increased comfort

Decreased physical restriction

Increased options for oral feeding and communication

Options for transfer out of intensive care unit


Dependence


February 21, 2014

Tracheostomy Complications Pneumothorax

Bleeding

Inadvertent decannulation

Cardiorespiratory arrest

Thyroid injury

Recurrent laryngeal nerve damage

Cuff rupture

Discomfort

Infection at stoma

or in trachea

Tracheal web

Pneumonia

Aspiration

Ineffective cough

Dysphagia

Tracheal granuloma

Tracheomalacia

Tracheal stenosis

Fistulae


Dependence


February 21, 2014

Swallowing Physiology

Impact

Swallow may or may not be affected by presence of

tracheostomy

Potential for dysphagia is increased due to:

Tracheostomy tube presence

Surgical procedures

Neurological/respiratory impairments

Risk of aspiration is increased by presence of tracheostomy

Consequences of aspiration are more serious

Impaired smell and taste


Dependence


February 21, 2014

Impact: Laryngeal Excursion

Reduced due to:

Fixation of muscles

Weight of equipment and tubing

Cuff inflation anchors tracheostomy tube

Results in:

Decreased tongue base movement and propulsion force

Dragging along walls during attempts at elevation

Inflated cuff partially obstructing esophagus


Dependence


February 21, 2014

7

Impact: Laryngeal Excursion

Esophageal

Bulge Cuff in Place


Dependence


February 21, 2014

Impact: Secretions

Disturbance in saliva and secretion management due to:

Airflow disruption

Medication side effects

Thick secretions

Infections

Interruption of filtration and hydration

Results in:

Insufficient saliva

Excess saliva


Dependence


February 21, 2014

Impact: Airway Pressure

Decreased subglottic pressure:

When normal, prevents oropharyngeal contents from entering

airway

Valsalva maneuver

Results in: accumulation of residue in pharynx

Mechanical ventilation may result in less aspiration than

spontaneous breathing with tracheostomy


Dependence


February 21, 2014

Impact: Glottic Competence


Dependence


February 21, 2014

Impact: Glottic Competence

Decreased glottic closure response:

Gradual loss of laryngeal sensation

Eliminates reflexive cough and throat clear

Reduced cough effectiveness

May use expiratory airflow of ventilator for airway

clearance if cuff is deflated

Incoordination of glottic closure with swallow

Disruption of apneic interval when ventilator is required

Protective function does not immediately return once cuff

is deflated


Dependence


February 21, 2014

Normalizing Airway Pressure During swallow, nearer normal pressure can be attained by: Digital occlusion

One-way valve

Capping

Individuals who are ventilator-dependent: Often swallow worsens when on ventilator

Tidal volume may be increased to compensate for lost volume and to provide increased subglottic pressure

Must learn to time swallow with ventilator cycle of expiration

With ventilator, instruct in glottic control to compensate for air leak during cuff deflation


Dependence


February 21, 2014

8

Cuff Deflation for Swallow

Cuff Deflation

At least partial cuff deflation should be attained prior to

swallow assessment and feeding:

Cuff deflated sufficiently for air to move through larynx

Allows brief occlusion of tracheostomy

Cuff must be at least partially deflated to identify

potential aspiration

Full cuff deflation is goal


Dependence


February 21, 2014

Cuff Deflation

Partial Deflation Full Deflation


Dependence


February 21, 2014

With Cuff Inflation

Fully inflated cuff should not completely seal against tracheal

walls

Aspirated material can pool on top of cuff and may:

Fall into airway when cuff is deflated even with proper

suctioning after cuff deflation

Fall between trachea and cuff, especially as cuff slides with

movement of larynx

Become bacterially colonized


Dependence


February 21, 2014

With Cuff Inflation

With fully inflated cuff, individual cannot cough through

larynx to clear laryngeal vestibule

With repetitive swallow movements, inflated cuff rubbing

on tracheal walls can cause tracheoesophageal fistula

Without cuff deflation, only oral stage and ability to trigger

swallow can be assessed

Individuals who are so medically fragile as to preclude cuff

deflation are usually not candidates for significant oral intake


Dependence


February 21, 2014

With Cuff Inflation Material Above and

Around Cuff


Dependence


February 21, 2014

9

With Cuff Inflation

Oral intake should be deferred until at least partial cuff

deflation is achieved

If medical clearance cannot be attained:

Fully explain and document limitations and dangers of

swallowing in presence of inflated cuff

If physician has been educated and still desires individual eat

with fully inflated cuff, recommendations made during

dysphagia assessment are useless


Dependence


February 21, 2014

Suctioning and Cuff Deflation


“…Clinicians must be competent to perform any activity by virtue of education, training, and experience”

Appropriate training and support is necessary to undertake any activity in which SLP is not already competent

SLP may perform suctioning and cuff deflation if accepted under State Licensure and fully trained

“Suctioning is complicated and can be a life threatening procedure. The procedure should always be done by those who are properly trained and know the complications and the individual.”

ASHA's Code of Ethics


Dependence


February 21, 2014


Mississippi Department of Health is silent, stating “it is a

scope of practice issue”

It is advisable for each facility to develop written policy that

addresses:

Level of involvement of SLP

Training required

Mechanism for verifying competency


Dependence


February 21, 2014

Suctioning Indications

Inability to effectively clear secretions

Need to remove material from airway to prevent obstruction

Respiratory conditions


Dependence


February 21, 2014

Suctioning Material Above Cuff

Foreign materials collect in airway above

level of cuff

Suctioning through tracheostomy tube

with inflated cuff does not remove

material above cuff

Materials above cuff are cleared by

suctioning via mouth and through vocal

folds or after cuff deflation


Dependence


February 21, 2014

http://www.asha.org/docs/html/ET2010-00309.html

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Suctioning Complications

Mucosal trauma

Cardiac arrhythmia

Hypoxemia due to oxygen being removed from lungs

Laryngospasm


Dependence


February 21, 2014

Cuff Deflation


Dependence


February 21, 2014

Partial Deflation

Full Deflation

Cuff Deflation


Dependence


February 21, 2014

Medical clearance by physician is necessary before any

attempt at deflation

Some individuals are not candidates for deflation

Ventilation With Cuff Deflation Benefits


Dependence


February 21, 2014

Improves access to upper airway during suctioning

Normalizes airflow through upper airway for airway

protection reflexes

Air escapes on inspiration and travels through upper airway

instead of remaining in closed loop between ventilator and

individual

Reduces trauma to mucosal tissue

Decreases interference with laryngeal elevation during

swallowing

Clinical Assessment

History


Dependence


February 21, 2014

Additional information which is useful:

Intubation:

Date

Planned vs. emergent

Associated trauma

Extubation:

Date

Associated trauma

Tracheostomy information

Secretions

Ventilator history

11

Contraindications to Assessment

Decreased alertness

Extreme agitation

Severe cognitive impairment

Medical instability

Extreme fragility

Inflated cuff


Dependence


February 21, 2014

Clinical Assessment

Valuable but limited information is gathered

Rarely is final step in tracheostomy dysphagia assessment:

Typically leads to instrumental assessment

Only if completely confident of individual’s ability to manage

oral intake should recommendation for oral feeding be made

based solely on clinical assessment

More often, stand0alone when already eating and there are

questions regarding management of particular diet or when

aspiration is overt

May require multiple sessions


Dependence


February 21, 2014

Clinical Assessment Procedure

Oro-motor assessment

Suction

Deflate cuff

Digital occlusion or one-way valve placement:

Phonate

Cough

Clear throat


Dependence


February 21, 2014


Dry test swallow:

Prior to advancing to trial swallows, consider if individual

can:

Swallow

Phonate

Clear throat

Expectorate secretions


Dependence


February 21, 2014


Trial swallows:

Assess with tracheostomy unoccluded and with tracheostomy

occluded during swallow

Provide controlled bolus sizes and types


Dependence


February 21, 2014


Observe:

Oral transit/control

Initiation speed

Pharyngeal swallow

Vocal quality changes

Cough: cough may occur unrelated to swallow due to changes in

sensations and pulmonary status

Increased secretions or need for suctioning

Typical signs of dysphagia and aspiration


Dependence


February 21, 2014

12


Encourage cough or throat clear if needed

Suction, rest, re-suction

Re-inflate cuff and return to baseline ventilator settings, if

needed


Dependence


February 21, 2014

Clinical Assessment Reliability

Limitations

Possible loss of cough reflex

Changes in vocal quality or inability to phonate

Secretion management differences

General decreased reliability of clinical assessment in

identifying aspiration

Cannot assess:

Cause of aspiration

Compensatory strategies


Dependence


February 21, 2014

Cervical Auscultation

Tracheal sounds observed with tracheostomy differ from those without tracheostomy


Dependence


February 21, 2014

Blue Dye Test Used to enhance ability to discern bolus from surrounding

mucosa or secretions

May identify aspiration of more than trace amounts

May not effectively identify trace aspiration

Optimally performed over several sessions during 48-72 hour period


Dependence


February 21, 2014

Blue Dye Test Protocol Place 2-3 drops of sterile water mixed with blue food

coloring on tongue

Suction trachea immediately and at 15-minute intervals over 1 hour period, recording presence of any blue material in tracheal secretions

Can repeat secretion testing every 4 hours over 48-hour period

Does not compromise individual, as individual only aspirates own secretions


Dependence


February 21, 2014

Blue Dye Test Protocol If no evidence of aspiration of saliva, can mix blue dye with

food consistencies

Proceed one consistency at time, waiting at least 4-6 hours between consistencies

Positive result: Presence of blue material in any tracheal suctioning

Alerts to presence of aspiration

Dictates conservative approach to further assessment

Negative result:

Absence of dye

Allows further test swallows


Dependence


February 21, 2014

13

Blue Dye Test Protocol Alert nursing and respiratory care staff that blue dye test is in

progress

Cuff status should be noted during presentations and suctioning

Bedside tracking sheet assists with documentation of suctioning results


Dependence


February 21, 2014

Blue Dye Test Tracking Sheet

DATE

TIME

CONSISTENCY

PRESENTED

CUFF

STATUS

DYE PRESENCE

None Min. Mod . Sev.

INITIALS

Name:___________________ Date:______________

SLP: _____________________ Phone #: ____________


Dependence


February 21, 2014

Blue Dye Test Limitations

Up to 50% false-negative error rate

Subjective grading of degree of dye present

Unable to determine:

Cause of aspiration

Timing of aspiration

Quantity of aspiration

Effectiveness of compensatory strategies

Should be interpreted conservatively and not used exclusively to determine candidacy for oral feeding


Dependence


February 21, 2014

One-Way Valve Use

One-Way Speaking Valves


Dependence


February 21, 2014

“It is the role of the speech-language pathologist, following

referral from and in collaboration with medical specialists,

to determine the need for and appropriate type of voice

prostheses. The speech-language pathologist also assesses the

effectiveness of these communication devices and provides

rehabilitation to help the individual obtain an optimum level

of communication function.”

One-Way Speaking Valves


Dependence


February 21, 2014

Function:

Allows air to enter tracheostomy tube on

inspiration

During expiration, valve is closed, and air is

directed into trachea and upward to vocal

folds

Can be used with individuals using

oxygen, humidified air, or ventilator

Entire team should be aware of purpose

and use of valve One-Way

Valve

14

One-Way Speaking Valve Benefits


Dependence


February 21, 2014

Normalizes airflow

Restores more normalized

physiology

Design inhibits secretions from

entering tracheostomy

One-Way Speaking Valve Requirements


Dependence


February 21, 2014

Awake and alert

Tolerance of full cuff deflation:

Proper size of tube relative to tracheal

lumen

48-72 hours after tracheostomy initially

performed or tracheostomy change to

allow for decrease in edema

Airflow with One-Way Valve

and Cuff Inflated

One-Way Speaking Valve

Contraindications


Dependence


February 21, 2014

Inflated cuff

Tracheostomy tube with sponge or foam-filled cuff

Airway obstruction that affects airflow through upper airway even when tracheostomy size is adjusted and cuff deflated

Bilateral adductor vocal cord paralysis

Severe tracheal/laryngeal stenosis

Unstable medical/pulmonary status

Reduced lung elasticity which may create air trapping

Unmanageable, thick, copious pulmonary secretions

Endotracheal tube

Unconscious; comatose; sleeping

Laryngectomy

One-Way Speaking Valve Cautions


Dependence


February 21, 2014

Respiratory treatments or medications should not be

administered during valve use

Caution should be taken with:

End-stage pulmonary disease

Heat moisture exchange device

One-Way Speaking Valve Procedure


Dependence


February 21, 2014

Position individual optimally

Instruct with procedure for deflation and speaking valve

placement

Suction appropriately (tracheal and oral)

Deflate cuff:

Allow acclimation prior to initial placement of valve

Make necessary changes to ventilator settings

Cuffless tracheostomy is ideal and should be considered

Monitor continually

Remove T-Piece if needed



Dependence


February 21, 2014

Attempt digital occlusion

If digital occlusion tolerated place valve

If inner cannula of tracheostomy has grasp ring:

Ensure ring does not extend beyond hub of tracheostomy tube

If ring does impede valve movement, remove inner cannula

15



Dependence


February 21, 2014

Observe for:

Adequate airflow around tube

Signs of respiratory distress

Prolonged, excessive coughing

If any distress (or at completion of trial):

Remove valve

Replace T-piece

Re-inflate cuff

Return to original ventilator settings

Swallow Treatment

Treatment After assessment, treatment can proceed similarly to

individuals without tracheostomy

If swallow is not elicited, treatment focus is on indirect treatment to elicit swallow until individual consistently swallows independently

Therapeutic feeding trials: considerations same as with clinical assessment with tracheostomy

When full cuff deflation is not possible: Some exercises can be used to strengthen and prepare for swallow

Repeated laryngeal elevation required by some exercises increases potential for tracheo-esophageal fistulae

Consider each exercise individually


Dependence


February 21, 2014

Compensatory Techniques

Changes in posture:

Chin tuck

Head turn

Chin tuck & turn

Head tilt

Head back

Reclined

All may be physically difficult due to equipment in place


Dependence


February 21, 2014


Diet modifications:

Non-oral options

Changes in consistency of liquids

Changes in consistency of solids

Teach digital occlusion during swallow and for several

seconds after swallow


Dependence


February 21, 2014


Changes in bolus presentation:

Bolus size

Rate

Placement

Clearance

No straw

Liquid by spoon

No talking

Moisten mouth prior to meal

Can proceed as without tracheostomy


Dependence


February 21, 2014

16


Increased sensory input:

Temperature

Pressure

Flavor

Texture

Can proceed as without tracheostomy


Dependence


February 21, 2014

Facilitation Strategies (Caution with

Full Cuff Inflation)

Effortful Swallow

Mendelsohn Maneuver: Often used in individuals with tracheostomy

Supraglottic Swallow Maneuver: Difficult to maintain breath hold unless digital occlusion or one-way valve is in place

Super-Supraglottic Swallow Maneuver: Difficult to maintain breath hold unless digital occlusion or one-way valve is in place


Dependence


February 21, 2014

Therapeutic Techniques Oral motor exercises

Tongue base exercises

Pharyngeal exercises: Masako: Caution with full cuff inflation

Laryngeal elevation exercises: Contraindicated with full cuff inflation

Laryngeal closure exercises: Breath hold difficult to maintain unless digital occlusion or one-way valve is in place

Thermal-tactile stimulation

Sour bolus swallows

VitalStim: Adjustments are made to electrode positioning

DPNS: Contraindicated


Dependence


February 21, 2014

Other Issues

Endotracheal Intubation First meal after extubation, individual

is at high risk for aspiration

Greatest risk of aspiration is within 24 hours following extubation

Greatest risk of respiratory distress and re-intubation is within 4-6 hours after extubation

Immediately after extubation, individual often exhibits hoarseness, spontaneous coughs, and congestion, making clinical observations unreliable


Dependence


February 21, 2014

Consider

Goal is to reduce risk for clinical decompensation

Must consider when treating individuals with tracheostomy:

Aspiration characteristics

Condition of individual

Underlying lung condition

Systemic factors can interfere with compensation

Continued monitoring is crucial, since individuals with

tracheostomy often demonstrate more rapid and frequent

changes in tolerance of feedings than other populations


Dependence


February 21, 2014

17

References

American Speech-Language-Hearing Association. (1993). Position statement and guideline for the use of voice prostheses in tracheotomized persons with or without ventilator dependence. ASHA, 35, Suppl. 10: 17-20: [Position Statement]. Available from www.asha.org/policy.

American Speech-Language-Hearing Association. (2004). Role of the speech-language pathologist in the performance and interpretation of endoscopic evaluation of swallowing guidelines [Guidelines]. Available from www.asha.org/policy.

American Speech-Language-Hearing Association. (2010). Code of ethics [Ethics]. Available from www.asha.org/policy.

Conway, N. (1994). Speech evaluation of the individual with a tracheostomy tube. Imaginart. Bisbee, AZ.

Crary, M. A., Groher, M. E. (2003). Introduction to adult swallowing disorders. Butterworth Heinemann. St. Louis.

Dikeman, K. J., Kazandjian, M. S. (1995). Communication and swallowing management of tracheostomized and ventilator dependent adults. Singular Publishing, San Diego.


Dependence


February 21, 2014

Dougherty, D. (2009). Bedside evaluation of the dysphagia individual. Cross Country Education.

Feldman, S. A., Deal, C. W., Urquhart, W. (1966). Disturbance of swallowing after tracheotomy. Lancet, 1: 954-955.

Finucane, B. T., Tsui, B. C. H., Santora, A. H. (2011). Principles of airway management. New York: Springer.

Fornataro-Clerici, L., Roop, T. A. (1997). Clinical management of adults requiring tracheostomy tubes and ventilators: A reference guide for healthcare practitioners.

Groher, M. E. (1984). Dysphagia: Diagnosis and management. Butterworth Publishers. Boston.

Logemann, J. (1992). Management strategies during videofluoroscopy. Course III.

Logemann, J. A. (1993). Manual for the videofluorographic study of swallowing, Second Edition; Pro-Ed.


Dependence


February 21, 2014

Logemann, J. A. (1998). Evaluation and treatment of swallowing disorders.

Pro-Ed. Austin, Tx.

Murray, J, Sullivan, P. A. (2006). FEES and modified barium swallow (MBS)

for fragile individuals. ASHA Health Care 2006.

Nash, M. (1988). Swallowing problems in the tracheostomized individual.

Otolaryngologic Clinics of North America, 21(4): 701-709.

NMMC Policy & Procedure. (2005).Tracheostomy care of site.

NMMC Acute Rehabilitation Services-Speech-Language Pathology Policy &

Procedure. (2011). Bedside swallow assessment.

Passy-Muir Inc. (2008). Passy-Muir tracheostomy & ventilator swallowing

and speaking valves instruction booklet.

Siddharth, P., Mazzarella, L. (1985). Granuloma associated with fenestrated

trachestomy tubes. American Journal of Surgery, Vol. 150: 279-280.


Dependence


February 21, 2014

Sottille, F. D., Marrie, T. J., Prough, D. S., Hobgood, C. D., Gower, D. J.,

Webb, L. X., Coserton, J. W., Gristina, A. G. (1986). Nosocomial pulmonary

infection: Possible etiologic significance of bacteria adhesion to endotracheal

tubes. Critical Care Medicine, 14(4): 265-270.

Sullivan, P. A. (2006). Aspiration syndromes and polypharmacy in critically

ill individuals. ASHA Health Care 2006.

Tippett, D., Siebens, A. (1991). Using ventilators for speaking and

swallowing. Dysphagia, 6: 94-99.

Weymuller, E. A. (1992). Prevention and management of intubation injury of

the larynx and trachea. American Journal of Otolaryngology 13(3): 139-144.


Dependence


February 21, 2014

http://www.asha.org/policy



dysphagia related to tracheostomy & ventilation · replaced every 28-30 days ... inflated cuff...

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