tracheostomy management

Level 2 / 11-19 Bank Place T 61 3 9642 4899 [email protected] Melbourne Victoria 3000 F 61 3 9642 4922 www.speechpathologyaustralia.org.au

The Speech Pathology Association of Australia Limited ABN 17 008 393 440

Position Paper

Tracheostomy Management

Copyright 2005 The Speech Pathology Association of Australia Limited

Disclaimer: To the best of The Speech Pathology Association of Australia Limited’s ("the

Association") knowledge, this information is valid at the time of publication. The Association makes no warranty or representation in relation to the content or accuracy of the material in

this publication. The Association expressly disclaims any and all liability (including liability for negligence) in respect of use of the information provided. The Association recommends you seek independent professional advice prior to making any decision involving matters outlined in this publication.

Speech Pathology Australia

Tracheostomy Management Position Paper i Copyright © The Speech Pathology Association of Australia Ltd 2005

Contents

1.0 Position Statement 1 2.0 Origin and Aims of this Paper 2 3.0 Definitions and Patient Groups 2

3.1 Definition ................................................................................................................... 2 3.2 Patient Groups .......................................................................................................... 2

4.0 Service Delivery 3 4.1 Role of the Speech Pathologist ................................................................................ 3 4.2 Role of the Team....................................................................................................... 4

5.0 Management and Intervention 4 5.1 Assessment............................................................................................................... 4 5.2 Management ............................................................................................................. 4 5.3 Education and Counselling ....................................................................................... 5

6.0 Skill Development 5 6.1 Basic Skills ................................................................................................................ 6 6.2 Specialist Clinicians/Advanced Skills ....................................................................... 6 6.3 Management of Ventilator Assisted Patients............................................................ 7

7.0 Protocols and Procedures 8 7.1 Safety Guidelines ...................................................................................................... 8 7.2 Risks in Tracheostomy Management........................................................................ 8

8.0 Documentation 9 9.0 Paediatric Population 9

9.1 Patient Groups ........................................................................................................ 10 9.2 Diagnostic Categories............................................................................................. 10 9.3 Management and Intervention ................................................................................ 10 9.4 Ventilator Assisted Paediatric Patients ................................................................... 11

10.0 Medico Legal and Ethical Responsibilities 12 10.1 Code of Ethics......................................................................................................... 12 10.2 Duty of Care ............................................................................................................ 12 10.3 Seeking Guidance ................................................................................................... 12 10.4 Job Descriptions ..................................................................................................... 12 10.5 Standard of Care..................................................................................................... 13 10.6 Proxy Intervention ................................................................................................... 13 10.7 Consent for Treatment ............................................................................................ 13 10.8 Informed Consent ................................................................................................... 13 10.9 Testamentary Capacity ........................................................................................... 13 10.10 Indemnity Cover and Insurance ............................................................................ 13 10.11 Summary ............................................................................................................... 13

11.0 Current Issues 14 11.1 Evidence Based Practice (EBP) .............................................................................. 14 11.2 Scope of Practice.................................................................................................... 14

11.2.1 Suctioning..................................................................................................... 14 11.2.2 Changing of Tracheostomy Tubes ............................................................... 14

11.3 Use of Single versus Double Lumen Tracheostomy Tubes.................................. 15 11.4 Progression to Decannulation............................................................................... 15 11.5 Managing Swallowing ............................................................................................. 16

11.5.1 Use of One-way Valves and Swallowing...................................................... 16 11.5.2 Use of Blue Dye............................................................................................ 16

12.0 Tracheostomy Training and Education 17 12.1 Clinical Competency ............................................................................................... 17 12.2 University Training................................................................................................... 17 12.3 Research ................................................................................................................. 17


Tracheostomy Management Position Paper ii Copyright © The Speech Pathology Association of Australia Ltd 2005

13.0 Further Reading and Resources 18 Chris Stone Professional Standards National Coordinator 20 References 21


Tracheostomy Management Position Paper Page 1 Copyright © The Speech Pathology Association of Australia Ltd 2005

1.0 Position Statement

Tracheostomy Management

• This paper seeks to reflect current best practice in tracheostomy management and where possible, to identify evidence based practice (EBP). In some areas, little clinical

consensus exists amongst experts and there is a paucity of research available.

• This paper addresses the major issues in tracheostomy management at the time. It is not intended to provide an exhaustive review. This work should serve to direct clinicians

towards understanding in depth review on specific topics.

• Involvement in the evaluation and management of patients with tracheostomy tubes is within the scope of practice of speech pathology. However, practising within this area is seen as a specialist skill and management of patients with tracheostomy should not be

undertaken by those without additional and specialist training.

• The involvement of a speech pathologist in tracheostomy management will be determined by the policies and procedures of their employing organisation. Speech pathologists

need to adhere to the policies and procedures of their organisation and any relevant state or federal legislation.

• No single discipline is adequately prepared to manage all aspects of care required by a patient with a tracheostomy. A multidisciplinary team approach provides optimal care for

patients with tracheostomy. The Speech Pathologist needs to liaise with the treating doctor and other team members concerning ongoing management issues.

• Management of a patient with a tracheostomy is not a competency expected of a new

graduate nor is it appropriate for a new graduate to practice in this area. It is the responsibility of the speech pathologist to obtain basic tracheostomy management competency. Competency should be obtained through reading, workshops, directly supervised clinical experience and discussions with specialist clinicians.

• Treating ventilator assisted patients is an advanced skill and should only be undertaken by specialist speech pathologists.

• Speech pathologists working in the area of tracheostomy management must maintain

and update their knowledge and skills on a regular basis.

• Speech pathologists must adhere to the safety guidelines of their organisation and be aware of and manage the risks involved in tracheostomy care.

• Consistent, accurate recording and documentation of all areas of patient management

should occur.

• Projects on tracheostomy management should be incorporated into general departmental

quality assurance and quality improvement programs.


Tracheostomy Management Position Paper 2 Copyright © The Speech Pathology Association of Australia Ltd 2005

2.0 Origin and Aims of this Paper This paper is a revision of the original Tracheostomy Tube Management Position Paper (1996). Since that publication, the role of the speech pathologist working with the tracheostomised population has expanded and changed. This paper will address these changes and document the available evidence. The intent of this revision is to address broader and more specialised areas than the initial paper including the increasing role of the

speech pathologist in the process of decannulation, management of paediatric patients and the management of ventilator assisted patients.

Management and intervention will vary according to clinical setting and patient needs. This paper does not provide a “how to” manual detailing specific instructions and procedures for

assessment and management of patients with tracheostomy. It is recognised that there are areas of differences, even controversy, within the profession regarding tracheostomy management (see 11.0 Current Issues).

3.0 Definitions and Patient Groups

3.1 Definition A tracheotomy is a surgical or percutaneous incision made in the trachea to create a patent

airway. To prevent this incision from closing and to maintain easy access to the lungs, a hollow tube is inserted into the opening. This tube is called a tracheostomy tube. Reasons for insertion of a tracheostomy tube include: airway obstruction, inability to protect the airway, the need for prolonged ventilatory support, and/or removal of tracheal secretions.

3.2 Patient Groups Speech pathologists manage patients with tracheostomy across the continuum of care. Tracheostomy can be performed in individuals of all age groups (from infants through to the elderly). Patients with tracheostomy are seen across a wide variety of medical units and settings. They may be treated in acute care settings, rehabilitation or extended care

facilities, or community settings including home or residential care facilities. Clinicians may manage patients with tracheostomy during the following stages:

• short term tracheostomy with assisted ventilation (usually Intensive Care Unit (ICU),

High Dependency Unit (HDU) or specialised weaning unit)

• short term tracheostomy with no assisted ventilation (usually ICU or hospital ward)

• long-term tracheostomy with or without assisted ventilation (hospital, home or nursing

home).

Diagnostic categories for patients with tracheostomy include:

1. Neurological, including:

• stroke

• acquired/traumatic brain injury

• progressive neurological disease, e.g. Motor Neurone Disease

• encephalitis/ meningitis

• tumour

• congenital neuromuscular disorder, e.g. Duchenne’s Muscular Dystrophy

2. Post-surgical, including:

• head and neck

• neurosurgery

• spinal

• craniofacial



• impaired supraglottic function, e.g. oedema

• laryngeal dysfunction, e.g. stenosis 3. General medical, including:

• local trauma, e.g. spinal, laryngeal, pulmonary

• connective tissue disorders, eg. scleroderma

• medically complex- e.g. liver transplant, burns 4. Respiratory, including:

• acute/chronic obstruction pulmonary disease ( COPD)

• cardiothoracic/thoracic

Patients with Laryngectomy

This paper does not address patients with laryngectomy and permanent tracheostoma.

Paediatric Patients (Refer to Section 9.0 Paediatric Population)

This paper will address the management of adults with tracheostomy in situ, with the exception of Section 9.0 Paediatric Population. In many regards the management of older children and adults with tracheostomy tubes in situ are similar. However, there are several critical differences and unique considerations

that must be understood by clinicians treating infants and younger children. These issues will be addressed in a separate section of this paper. Those working with paediatric patients should read this paper in its entirety and not assume that the paediatric section alone addresses all aspects of care for this population.

4.0 Service Delivery

4.1 Role of the Speech Pathologist

Speech pathology assessment and intervention should occur as part of a multidisciplinary team. The complex interrelationships between respiration, swallowing and voicing dictate that experienced Speech Pathologists play an integral role in managing patients with tracheostomy. The role includes the assessment and management of airway protection (the ability to safely

swallow oropharyngeal secretions initially and oral intake eventually), communication and the tracheostomy weaning/decannulation process. Specialist clinicians with advanced experience assume the role of tracheostomy team leader in some facilities (Dikeman & Kazandjian, 2003). Professional roles and boundaries should be investigated and understood at the organisational level. Roles will vary across organisations.

The Speech pathologist's role will be dependent upon the:

• level of expertise of the treating speech pathologist

• patient setting

• facilities/resources available

• client needs

• specialty skills of other team members

• policies and procedures of the organisation

It may include one or more of the following:

• team member, assisting in the management of clients with a team of professionals

• clinician undertaking speech pathology patient assessment and treatment



• consultant, providing assessment information and advice on management of the client

to other health professionals and carers

• educator, imparting theoretical and clinical information on tracheostomy management

• researcher, addressing clinical and research issues

• patient advocate

4.2 Role of the Team

A team of health professionals must be involved in the management of patients with tracheostomy. If a speech pathologist is asked to assess a patient in isolation he/she should make every

effort to form a team. The team must include the treating Doctor, and may also include

Nurses, Physiotherapist, Occupational Therapist, Dietician, Ear Nose and Throat Surgeon (ENT), Neuropsychologist, Respiratory Doctor, Intensive Care Unit (ICU) Doctor and other medical specialists.

There are numerous variations in the composition of teams across facilities. The literature on tracheostomy management makes frequent references to the discipline of Respiratory Therapy (RT). This specialist discipline does not exist in Australia. In Australia, specialist Nurses, Doctors, Physiotherapists, and Respiratory Scientists perform this role. It is essential that the speech pathologist establishes a clear understanding of the roles and skill

level of the professionals involved in tracheostomy management at their organisation.

5.0 Management and Intervention

5.1 Assessment

• management of oral secretions

• airway protection

• swallowing function pertaining to oral intake

• cough and airway clearance in conjunction with Physiotherapist/Nurse

• upper airway patency

• communication status (voice, articulation, language)

• choice of appropriate tracheostomy tube (in conjunction with team)

• cognitive status (memory, insight, judgement)

• impact of patient’s anxiety on management

• readiness for decannulation in conjunction with team

5.2 Management

• cuff status, including monitoring cuff pressures, cuff inflation/deflation (in conjunction

with Physiotherapist/nurse)

• above cuff suctioning (as appropriate) (Refer to 11.2.1 Suctioning)

• use of one way speaking valves and/or talking tracheostomy tubes

• swallowing ability/dysphagia and oral intake

• communication options including Augmentative and Alternative Communication (AAC)

• airway patency issues (in conjunction with ENT Surgeon)

• phonation



5.3 Education and Counselling

• The speech pathologist may be called upon to educate and counsel patients and family

prior to and post insertion of the tracheostomy tube.

•

• Topics that are covered in education/counselling will vary according to the patient’s

medical status, whether the tracheostomy is short or long term, and the roles and skills of other team members.

•

• Topics may include: components of the tracheostomy tube, anatomical and

physiological changes caused by the tracheostomy tube, cuff management, communication options, above cuff and oral suctioning, use of inner cannula, coughing for airway clearance, use of speaking valves, communication backup system when voicing is not available, decannulation process.

•

• Anxiety frequently interferes with the ability of a patient to tolerate changes in management. Clinicians must be sensitive to this issue, strive to reassure the patient,

utilise sound clinical judgement, educate frequently, consult with team regularly and support family members. At times when anxiety is high it may be appropriate to withhold treatment in order to ensure future success.

•

• The resources available to assist patients in the community either at home or in a residential care facility should be carefully investigated/considered by the team at all stages of management in order to ensure that accurate information is conveyed to

medical staff and family.

•

• Upon discharge from an acute or rehabilitation facility, the Speech Pathologist should

liaise with other hospital and community teams as well as outpatient support services.

6.0 Skill Development Tracheostomy management is a specialty area. It is not a competency required of or appropriate for new graduate speech pathologists (Competency Based Occupational

Standards (CBOS), 2001). General comments regarding tracheostomy training and the specific skills required to obtain basic and advanced skills are addressed in this section.

• The area of tracheostomy management is currently not covered in detail by university

programs (Refer to 12 Tracheostomy Training and Education, and 12.1 Clinical Competency).

• Tracheostomy management carries several inherent risks (Refer to 7.2 Risks in

Tracheostomy Management). The Speech Pathologist should demonstrate competency in dysphagia, neurological disorders, respiratory disorders, voice disorders and the field of AAC prior to managing patients with tracheostomy.

• It is essential that basic tracheostomy competency be obtained before the speech

pathologist independently manages patients with tracheostomy.

• It is the responsibility of the speech pathologist and his/her manager to ensure

adequate training is obtained prior to managing patients with tracheostomy.

• It is recommended that organisations support speech pathologists working with

patients with tracheostomy to access training and supervision.

• It is recommended that organisations develop tracheostomy competency training programs for staff.



6.1 Basic Skills Basic tracheostomy competency skills should be obtained through professional reading, tracheostomy courses/workshops, and supervised clinical contact.

The speech pathologist should have knowledge and demonstrated skills in:

• the speech pathologist's role and roles of other team members

• indications for insertion/use of tracheostomy tubes

• types of tracheostomy tubes

• tracheostomy tube design and function, e.g. cuffs, fenestrations, cannulas

• anatomical and physiological changes following tracheostomy

• complications and risks of tracheostomy (Refer to 7.2 Risks in Tracheostomy

Management)

• oral suctioning and above cuff suctioning with tubes designed for this purpose (Refer to 11.2.1)

• communication options including use of talking tracheostomy tubes, speaking valves and AAC

• assessment and management of swallowing impairment including indications and limitation of use of blue dye (Refer to 11.5.2 Use of Blue Dye)

• signs of respiratory distress/failure

• decannulation process (Refer to 11.4 Progression to Decannulation)

• types of suctioning and humidification devices

• emergency procedures and universal precautions

• the policy and procedures of the Speech Pathology Department and the organisation,

including infection control and emergency procedures

6.2 Specialist Clinicians/Advanced Skills

A specialist clinician would be recognised by peers as having a number of years of specific experience and/or additional education/training in the assessment and management of the patient with a tracheostomy. This may involve some of the following:

• expertise with specialist clinical populations; for example, acute neurosurgery, intensive

care units, head and neck surgery, ventilator assisted patients

• contribution to the development of policy and procedure statements for use within the

persons organisation and in the community and external agencies

• skill in complex specialised and/or invasive assessment and treatment techniques

• knowledge and use of instrumental examination (e.g. nasendoscopy) including the

ability to;

− identify and recommend appropriate types of assessment

− use these in conjunction with other relevant health professionals

− interpret information from such examinations

− document and communicate examination findings and recommendations

• maintenance of standards of care, including;

− development and maintenance of programs to improve tracheostomy service

delivery

− participation as a key member in the team who manage patients with

tracheostomy

− development and documentation of policy and procedures within the team

• teaching/supervision of speech pathologists, other health professionals and students,

including;

− identifying education and clinical teaching needs

− demonstrated skill in education techniques and supervisory methods

− participation in professional development teaching, training and planning



• contribution to the knowledge and methods of assessing and managing patients with

tracheostomy

• development and facilitation of pertinent research projects

6.3 Management of Ventilator Assisted Patients It is within the scope of practice of the speech pathologist to be part of the team that manages patients who have a tracheostomy and are ventilator assisted. This area constitutes an advanced level of skill. Skills must be obtained through literature review, training programs, observation and direct clinical experience with skilled clinicians from the

professions of medicine, registered nursing, speech pathology, and physiotherapy. It is recommended that speech pathologists adhere to and participate in the development of policies and procedures for the management of ventilator assisted patients.

In addition to the basic tracheostomy management the following clinical skills are required:

Team

• knowledge of the roles and skill base of all team members in a variety of settings. For

example, the Speech Pathologist should establish which professional (Physician, Physiotherapist or Nurse) will adjust and monitor ventilator settings/modes at his/her organisation

Population

• knowledge of patient populations requiring assisted ventilation (e.g. surgical, cardiothoracic, brain injury, neuromuscular disease, spinal cord injury, metabolic disturbances)

• knowledge of the progression of medical conditions that may require increasing dependence on assisted ventilation (e.g. advancing lung disease, obesity, neurological

disease)

• recognition of the medical complexity and fragile nature of some patients requiring

ventilator assistance

Respiratory Issues

• basic knowledge of objective respiratory monitoring methods and norms including spirometry, pulse oximetry, capnography and arterial blood gas studies

• knowledge of the evolution of respiratory failure in a variety of patient populations

• (e.g. progressive neurological, Chronic Obstructive Pulmonary Disease)

• knowledge of protocols for weaning from assisted ventilation

• basic knowledge of sleep related issues (e.g. nocturnal hypercapnia)

• thorough knowledge of potential effects that speech pathology interventions may have on ventilation and respiratory status

• ability to recognise signs of respiratory fatigue, increased work of breathing, respiratory distress and respiratory failure

• familiarity with all emergency procedures to call for help in the event of respiratory or medical deterioration

Assisted Ventilation Technology

• basic knowledge of methods of assisted ventilation including non-invasive (positive

pressure ventilation via nasal or full face mask or negative pressure ventilation via Iron Lung, rocking bed or Cuirass) and invasive ventilation (e.g. positive pressure ventilation via endotracheal or tracheostomy tube)

• basic knowledge of modes of ventilation (Assist Control, Synchronised Intermittent Mandatory Ventilation [SIMV], Continuous Positive Airway Pressure [CPAP], Bi-level

Positive Airway Pressure [BiPAP], Positive End Expiratory Pressure [PEEP])

• understanding volume cycled versus pressure cycled ventilation



• basic knowledge of ventilator components including assisted ventilation status

measurements (e.g. Tidal Volume, Respiratory Rate and Peak Inspiratory Pressure readings); Alarms (e.g. high and low pressure, exhale tidal volume); circuits (e.g. tubing, connections and expiration ports)

• basic knowledge of types of ventilators used in one’s workplace

Communication and Swallowing

• thorough knowledge of the physiological effects of assisted ventilation on voicing and swallowing

• management options for communication and swallowing including cuff deflation,

ventilator assisted speech, use of one-way speaking valves, talking tracheostomy tubes, and AAC options

• knowledge of positioning and mobility restrictions due to ventilator equipment

Other Considerations

• links with expert clinicians within the organisation, and the wider speech pathology, physiotherapy, nursing and medical professions

• liaison with patient advocates, Social Workers, psychosocial supports

• ethics involved in making end of life decisions

7.0 Protocols and Procedures

It is strongly recommended that speech pathologists be involved in formulating tracheostomy protocols and procedures within their organisation. These documents should address care in all environments in which patients are seen. It is legally incumbent on Speech Pathologists to adhere to the protocols and procedures within their working environment or community.

7.1 Safety Guidelines

• the speech pathologist should refer to relevant departmental and organisational policies

and procedures in the areas of Occupational Health & Safety and Infection Control

• the speech pathologist must receive adequate training to recognise respiratory distress

and to be able to action appropriate procedures to ensure patient safety

• tracheostomy management procedures, including cuff deflation and dysphagia

assessments, should be conducted in environments where appropriate safety equipment such as oxygen, suction, and trained staff are available

• in the event of a blocked tube, self decannulation or failed decannulation appropriate equipment and spare tracheostomy tubes should be available

• emergency procedures of the organisation should be understood by all team members

7.2 Risks in Tracheostomy Management

Speech pathologists must be aware of possible risks and complications inherent in tracheostomy management. The specific policies of the organisation regarding tracheostomy tube management should be adhered to at all times.

The treating speech pathologist must be aware of, assess and manage risk in the following

areas:

Airway Protection

• benefits and risks of cuffed and cuffless tracheostomy tubes

• risk of aspiration of oral secretions in the presence of tracheostomy

• risk of aspiration of oral intake in the presence of tracheostomy



Airway Patency

Sources of potential upper airway obstruction include:

• a large tracheostomy tube which fills more than two thirds of the tracheal lumen

• inadequate airway between the tracheostomy tube and the tracheal wall when using a

one way speaking valve

• failure to deflate the cuff when using a one way speaking valve

• corking /capping/spigotting (see 12.4 Progression to Decannulation)

• inadvertent corking of a non-fenestrated tube or when the cuff is not deflated

• presence of copious secretions, oedema, granulous tissue, sputum plug,

tracheomalacia, tracheal stenosis, adducted position of the vocal folds, laryngeal dyskinesia, upper airway tumour

• blocked lumen of the tracheostomy tube

Airway Clearance

• patients who are unable to cough well enough to clear oral or tracheal secretions from

the airway are at risk for sputum retention and/or plugging

• inadequate humidification is another source of risk leading to sputum plugging.

• patients are at risk of chest infections secondary to increased pulmonary secretions

Other Complications

• emergency reintubation, inability to re-insert tracheostomy tube, e.g.; rapid stomal closure, airway collapse

• infection of tracheostomy site

• infection of sputum e.g.MRSA

• excessive bleeding during cannulation/decannulation procedures

• respiratory arrest secondary to decannulation

• vagal stimulation with potential to lead to acute cardiac dysfunction

• suctioning trauma

8.0 Documentation Documentation should be in accordance with Speech Pathology Australia Competency Based Occupational Standards (CBOS) (2001) and Principles of Practice (2001) and the organisation’s policies and procedures.

Specific documentation for patients with tracheostomy should include:

• type and size of tracheostomy tube

• cuff status prior to and post speech pathology intervention

• communication options including AAC, speaking valves

• any management changes, together with rationale for change, e.g. initiation or cessation of cuff deflation, initial one way valve trial

• results of therapeutic intervention, particularly where outcome has been adverse, e.g.

aspiration of trialled substances, lack of tolerance of speaking valve

• pre and post decannulation entries

9.0 Paediatric Population

The paediatric population with tracheostomy, and in particular long-term tracheostomy, is increasing. Indications for tracheostomy in infants and young children continue to change with advances in medical treatment, technology and airway management. In addition to the information presented in this paper, a number of issues are uniquely pertinent to the paediatric population. Neonates, infants and older children have specific issues and general problems not seen in the adult patient.



9.1 Patient Groups Speech pathologists manage paediatric patients with tracheostomy across the continuum of care. They may be managed in acute care settings, rehabilitation or extended care facilities, community care settings including home or educational setting.

Speech pathologists manage paediatric patients during the following stages:

• short term tracheostomy with assisted ventilation (usually Neonatal Intensive Care

(NICU), Paediatric Intensive Care (PICU), Special Care Nurseries (SCN), or specialised weaning units)

• short term tracheostomy with no assisted ventilation (usually PICU, surgical or

rehabilitation wards)

• long-term tracheostomy with or without assisted ventilation (PICU, surgical or

rehabilitation wards, home, community or educational settings)

9.2 Diagnostic Categories 1. Neurological, including:

• neonatal maturation conditions (e.g. central hypoventilation syndrome)

• neonatal injury (e.g. hypoxic ischaemic encephalopathy, intracranial haemorrhage, cerebral palsy)

2. Structural, including:

• tracheoesophageal anomalies (e.g. tracheoesophageal fistula)

• craniofacial anomalies and syndromes (e.g. Pierre-Robin sequence, Crouzon’s, Opitz-

Frias, Goldenhaar, Treacher-Collins)

• laryngeal or pharyngeal neoplasms (e.g. haemangioma)

• tracheal stenosis

• respiratory papilloma

3. Respiratory, including:

• bronchopulmonary dysplasia (BPD)

• chronic neonatal lung disease (CNLD)

• acute respiratory infections (e.g. croup, epiglottitis)

• cardiopulmonary disorders (e.g. congenital heart disease)

9.3 Management and Intervention Speech pathologists working with this population must be knowledgeable about:

• structure of the aerodigestive tract, development of the structure and physiology of the

pulmonary system and gastrointestinal health in neonates, infants and young children.

• normal development of feeding, swallowing and communication skills in infants and children and their importance in the assessment and management of children with tracheostomy tubes.

• signs and symptoms of respiratory distress unique to each age group including neonates, infants and children

• disease processes in infants and children

• indications for tracheostomy in paediatric populations including; ventilation/respiratory disorders, airway obstructive disorders, secretion clearance problems, neuromuscular

disorders

• types of paediatric tracheostomy tubes used in specific age groups (neonates, infants,

young children, older children and adolescents)

• specific effects of having a tracheostomy tube in situ on the development of laryngeal

and tracheal structures in infants

• paediatric use and contraindications for using one way speaking valves. Monitoring of

tolerance including respiratory patterns, infant cues and signs of distress is essential



9.4 Ventilator Assisted Paediatric Patients This area of practice requires additional competency and is regarded as a specialist/advanced skill (Refer to 6.2 Specialist/Advanced Skills) In caring for ventilator assisted children clinicians must gain specific knowledge of:

• ventilation support methods used with infants and young children including facial

masks, nasopharyngeal tubes, endotracheal tubes, tracheostomy tubes and ventilators and specific ventilation modes

• different equipment (e.g. ventilator tubing, etc.) utilised with ventilator-assisted infants

and children, their relative effects on the paediatric airway and implications for use with speaking valves

• effect of speaking valves on positive end expiratory pressure (PEEP) and the need to monitor/ adjust ventilator settings with pulmonary/intensive care physicians

• effect of ventilation equipment on the growth and development of head and neck anatomy, core stability and movement

• specific issues relating to decannulation in infants and children including ‘decannulation panic’

• the effects of a tracheostomy tube on developmental and adaptive skills, behavioural

development, communication skills, swallowing skills, phonation and respiratory status

Management

Additional aspects of the speech pathologist's management specific to paediatric patients with tracheostomy include:

Clinical

• assessment of oral sensorimotor development

• prevention and management of oral sensorimotor dysfunction and maintenance of oral sensorimotor development

• evaluation and management of developmental feeding and swallowing skills and independent feeding skills across a range of food and fluid textures including age

appropriate clinical and instrumental evaluations

• management of communication problems and maintenance of optimal communication

skills across the age continuum (i.e. developmentally appropriate receptive and expressive language, motor speech, voice, fluency and pragmatics)

• prevention and management of other developmental and behavioural issues impacting

on communication (e.g. parent-child bonding, psychosocial development, cognition, attention, interaction, general sensorimotor development, adaptive skills, environment and play)

• identification of crucial stages for intervention in children with long-term tracheostomy in the light of communication and sensorimotor development

Education, awareness and counselling

• education of parents and caregivers regarding long-term tracheostomy (e.g. feeding,

communication, developmental, psychosocial and behavioural aspects)

• education and support for staff and respite-carers within the child's educational setting

regarding tracheostomy

• maintaining parent, medical and educational staff awareness of developmental issues,

the effects of tracheostomy and long-term hospitalisation on the infant and young child

• education and counselling of parents/family regarding developmental consequences of tracheostomy

Advocacy

• for appropriate health service delivery, respite care and funding options for children with

long-term tracheostomy

• for entry to appropriate developmental programs and educational placements for

children with tracheostomy



10.0 Medico Legal and Ethical Responsibilities The following points should be considered by speech pathologists working with patients who

have tracheostomies in situ.

10.1 Code of Ethics

Speech pathologists should adhere to the Speech Pathology Australia Code of Ethics (2000) and to the codes of the employing organisation.

10.2 Duty of Care "Duty of care" is a legal concept and term from Law of Torts describing the relationship, in this case, between the patient and the speech pathologist. The speech pathologist owes a Duty of Care to his/her patient/client. Speech pathologists should be aware that they could be liable in a civil action for a claim for damages (compensation) if they breach that Duty of Care. A breach of Duty of Care may result from specific action taken by the speech

pathologist, a failure to act when action was required, or simply a statement made that in the eyes of the law amounts to a "negligent misstatement." The duty involves using the same degree of care that a "reasonable" speech pathologist would exercise in the circumstances. Whether or not there has been a breach would be determined by what other speech pathologists working in the same field would have done in the circumstances and may involve being aware of the recent literature on the subject, being aware of current practices

carried out by peers, and being familiar with the Speech Pathology Australia Code of Ethics (2000).

10.3 Seeking Guidance It is recommended that the speech pathologist dealing with a person with a tracheostomy tube in situ have knowledge of and the skills to meet the standards for management of patients with tracheostomy as documented in this paper (See 9.0 Skill Development). The

level of skill required may need to be identified by the organisation or service purchaser prior

to appointment. CBOS (2001) Range Indicator Statement page 3) indicates that when a patient presents with multiple features that combine to require specialist speech pathologist intervention (including tracheostomy in the ICU setting), it is essential to have supervision by a senior speech pathologist.

The speech pathologist should also be familiar with all the documents that relate to managing patients with tracheostomy at their organisation. He/she should undertake any mandatory training required by the workplace, for example, occupational health and safety training, non-nursing CPR training.

When any of these skills or minimum requirements cannot be met, the courts would expect a speech pathologist who is aware that he/she lacks the desired level of skill in an area of tracheostomy management to seek guidance before managing a patient. This could be in the form of requesting the support of more experienced colleagues or seeking the support of an employer to obtain further training. This support should be documented.

10.4 Job Descriptions The responsibilities of individual speech pathologists for patients with tracheostomy tubes may be identified in their job descriptions, or within the policies and procedures of their

department.



10.5 Standard of Care

The situation applicable to medical practitioners by the courts will be comparable to that for speech pathology. It is essential that the speech pathologist be aware of the expected standard of care upheld by their organisation.

10.6 Proxy Intervention Where a speech pathologist does not carry out the treatment but has instructed and supervises someone else carrying out the treatment, the law would hold the

advising/supervising speech pathologist liable just as if they were carrying out the intervention themselves. The law refers to this as "vicarious liability." In other words, the same standard of care would be required if the speech pathologist was holding him/herself out as the person with the knowledge and skills. The fact that he/she did not actually carry out the treatment would be irrelevant in the eyes of the law.

10.7 Consent for Treatment This may vary with different population types (such as acute, chronic, palliative, paediatric, aged) and across health care facilities.

10.8 Informed Consent Where mental capability allows, the law requires that consent be obtained from an adult

patient/client or parents if the patient/client is under 16 years. The speech pathologist must give sufficient information as to the procedure and possible risks involved with the procedure. There may be state variation in legislation regarding medical treatment.

10.9 Testamentary Capacity This relates to the mental capability of a person to make informed decisions such as at the time of writing a will. If mental abilities are limited at the time in question, the person may be unable to make a valid will or give informed consent to procedures. In the medical profession, the opinion of two doctors is required to describe a patient/client's testamentary

capacity.

10.10 Indemnity Cover and Insurance

It is the responsibility of the speech pathologist to ensure that they have appropriate professional indemnity cover. For those employed in the Public Service or other organisations, this could be determined by consultation with their employer/organisation. Professionals should be aware that there may be instances where the employing body may not necessarily indemnify them for their actions. It is recommended that all practising Speech Pathology Australia members have personal indemnity insurance. Speech

pathologists must be fully aware of the conditions of the insurance such as notification procedures.

10.11 Summary In summary, a speech pathologist working with patients who have tracheostomy should:

• adhere to the Speech Pathology Australia Code of Ethics (2000)

• keep the client and carers well informed of the treatment program including any possible complications that may arise

• if possible, obtain the client's consent to the treatment program

• seek advice from experienced speech pathologists and/or fellow professionals

• not undertake treatment that is outside experience or expertise as a professional



• not overstate expertise

• work as part of a team in patient management

• keep up to date with professional developments

• keep accurate records

• ensure that all advice given to the client, professionals or staff is in writing

• keep up to date with report writing

• ensure the clinical environment is safe

• ensure at all times that there is adequate professional indemnity insurance cover

11.0 Current Issues Tracheostomy management as a multidisciplinary practice has evolved considerably over the past decade (Dikeman & Kazandjian 2003). The role of the speech pathologist and the specialisation of tracheostomy management have expanded considerably since the initial

Speech Pathology Australia Tracheostomy Position Paper (1996).

11.1 Evidence Based Practice (EBP)

In tracheostomy management there are numerous instances where practice varies across organisations, disciplines and individuals. When searching for evidence speech pathologists may find that little consensus exists in the literature or between experts in some areas. Russell and Matta (2004) state:

“Where possible we have based our management plans on high quality evidence

and research. However, in many instances, such data is lacking and the treatment plans we have provided are inevitably tinged with local bias.” (Russell and Matta, 2004, pg xi)

Speech pathologists seeking to acquire best practice knowledge may be frustrated in their search to establish the “right approach”. There may not be a single best approach to some of the questions that arise. Speech pathologists should accept this reality but continue to expand their expertise.

The following briefly addresses some of the differences of opinion, controversy or lack of clarity around issues that currently exist.

11.2 Scope of Practice

Some organisations have supported speech pathologists to perform roles outside of the Speech Pathology Australia Scope of Practice. In these instances speech pathologists are strongly advised to seek formal approval, credentialing, ongoing training and support and legal advice from their employer.

11.2.1 Suctioning

Suctioning of the oral cavity or suctioning secretions from above the cuff via an above the cuff suction line is within the scope of practice for speech pathologists. Suctioning via the nasopharynx, pharynx and trachea is outside of the scope of practice of the speech pathologist.

11.2.2 Changing of Tracheostomy Tubes Changing a tracheostomy tube is outside of the Speech Pathology Australia Scope of Practice This procedure is a medical, nursing or physiotherapy role. It is recommended that speech pathologists who participate in changing tracheostomy tubes:



have appropriate training in all procedural and safety aspects of tracheostomy tube change (documentation of this training must be kept by the speech pathologist) have access to immediate medical, nursing and physiotherapy assistance strictly adhere to their employing organisation's policies and procedures

11.3 Use of Single versus Double Lumen Tracheostomy Tubes

Most large facilities have standard practices surrounding the use of single or double lumen tubes. There are pros and cons to use of both tube types. In general, most organisations choose to use inner cannulas for ease of cleaning and to prevent tracheostomy tube occlusions (Russell, 2004). However, speech pathologists must be aware that an inner cannula reduces the inner diameter by approximately 1–1.5mm, which increases the work of breathing (Cowen, Holt, Gegenheimer, Izenberg and Kukarni, 2001). Some organisations

prefer to use single lumen tubes with adequate humidification to avoid increased work of breathing and optimise voice and swallowing.

11.4 Progression to Decannulation

Weaning from tracheostomy is the process of moving towards removal of the tracheostomy tube. The act of removing the tube is referred to as decannulation. The goal of tracheostomy management is to remove the tube as quickly as is safely possible. The team treating the patient must weigh the risks of removing the tube too early against the risks of leaving the tube in for longer than necessary (Ross and White, 2003).

Weaning and decannulation processes vary across organisations. The speech pathologist must consider the individual patient status and the policies and procedures of the organisation. There are several techniques that are used to wean a patient from a tracheostomy. These include: downsizing the tube, using a fenestrated tube, occluding (spigotting or capping) the

tube for increasing periods of time, toleration of cuff deflation for 24-48 hours prior to removal, use of cuffless tubes, use of one-way valves and then removing the tube and the use of trache buttons to keep the stoma open to allow for removal of tracheal secretions. The speech pathologist must understand and critically review each method in order to optimally assist the team and patient.

The concept of downsizing involves the placement of a tracheostomy tube with a smaller outer diameter. When the cuff is down the smaller tube allows more room for the patient to expire through the upper airway around the tube. With a smaller tube in situ the patient is required to inspire through a smaller lumen which results in increased airway resistance and work of breathing (Dikeman and Kazandjian, 2003).

The process of capping involves placing a spigot or cap on the hub of the tracheostomy tube. Capping also increases the work of breathing. Some speech pathologists view the ability to tolerate capping and/or downsizing as an indicator for readiness to decannulate (Dikeman &Kazandjian, 2003). Godwin and Heffner (1991) suggest however that not all patients can tolerate increased airway resistance and work of breathing.

The use of one-way valves during decannulation introduces a degree of resistance but not as much as capping. With a one-way valve on the tracheostomy tube a patient can inspire through the tracheostomy during the decannulation process. The valve redirects air around the tube and through the upper airway upon exhalation. Le, Aten Chiang and Light (1993) report greater patient comfort for those using speaking valves rather than capping.

Thompson–Ward, Boots, Frisby, Bassett and Timm (1999) evaluated weaning via downsizing and capping versus 24-48 hours of successful cuff deflation. They found the process of cuff deflation rather than downsizing and capping to be safe and more efficient in facilitating earlier tracheostomy removal.



11.5 Managing Swallowing

Sound clinical skills and judgement are required to manage the multiple swallowing issues that patients with tracheostomy may present with. The serious potential consequences inherent in cuff deflation and swallowing trials must be recognised. Dikeman and Kazandjian (2003) and Hales (2004) review the causes of swallowing impairments in patients with tracheostomy. Dikeman and Kazandjian (2003) divide the issues into mechanical impact (reduced laryngeal excursion, saliva and secretion issues, medication side effects) and

physiological impact (disruption of airway pressures, reduction of airflow through the glottis). Dikeman and Kazandjian (2003) also include a section on the effects of mechanical ventilation on swallowing. In general, it is accepted that oral intake should be deferred in acutely ill patients who have tracheostomy tubes with inflated cuffs (Dikeman and Kazandjian, 1995). Based on clinical

judgements, some patients with tracheostomy and inflated cuffs receive oral intake after careful assessment by an expert team. Suiter, McCullough & Power (2003) found no significant effect of cuff inflation versus cuff deflation using an aspiration/penetration scale in fourteen non ventilated patients with tracheostomy. Further research is required. Tippett (1991) reports that aspiration in ventilated patients with the tracheostomy cuff down

may be reduced because the ventilator provides additional expiratory support to assist in clearing the upper airway. However, patients with tracheostomy and ventilation have greater respiratory compromise than patients without tracheostomy and ventilation. Clinicians treating patients on a ventilator must work extremely closely and communicate extensively with treating Physician and team.

11.5.1 Use of One-way Valves and Swallowing The evidence regarding use of valves to assist swallowing is mixed. Several authors report that use of a one-way speaking valve restores airflow through the upper airway, voice, cough, sensation and may also improve swallowing function (Elpern, Scott, Petro, & Ries,

1994; Dikeman and Kazandjian 2003). Leder and Ross (2000), however, failed to find a causal relationship between aspiration and tracheostomy. In a series of articles Leder challenges the notion that occlusion of the tracheostomy tube and the use of one-way speaking valves prevents aspiration (Leder, 1996; Leder, Ross, Burrell & Sasaki 1998; Leder, Cohen & Moller, 1998; Leder 1999). More recently

Suiter (2003) reports that the use of one way valve placement significantly reduced scores on an aspiration-penetration scale for the liquid bolus.

11.5.2 Use of Blue Dye

The use of blue dye in enteral feeds has resulted in episodes with serious complications including death (Medwatch Notification October/2003-10-29). Speech pathologists have utilised blue dye to screen for aspiration of oral secretions or food/liquid in tracheostomised patients. There have been conflicting reports on the validity of the technique (Logemann, 1994; Thompson-Henry & Braddock, 1995). In addition due to the high false-negative rate it is only suitable as a screening tool (Belafsky, Blumenfield, LePage & Nahrstedt, 2003; Brady,

Hildner & Hutchins, 1999). In light of the controversy and confusion surrounding blue dye it is advisable for Speech Pathology Departments to establish policies to clarify their position on this issue.



12.0 Tracheostomy Training and Education

12.1 Clinical Competency The Speech Pathology Australia Code of Ethics (2000 Section 5.3) highlights that it is the

responsibility of speech pathologists to:

• recognise and acknowledge the limits of their professional competence

• maintain and extend clinical competence

• not practise professionally beyond the scope of their competence given their level of education, training and experience

• not misrepresent training and competence

It is recommended that speech pathologists approach their employer to seek further training if required. Currently it is challenging for Speech Pathologists to obtain training in tracheostomy management, particularly in rural settings. Clinical training opportunities are being offered at a growing number of organisations, however they are still limited. Specialist

speech pathologists and special interest groups including newsletters, currently provide a forum for clinical discussion.

12.2 University Training Universities provide graduates with CBOS entry-level competency in the range of indicators of swallowing and voice. In addition to those the following topics could be covered to give graduates a very basic understanding of tracheostomy management:

• knowledge of the post-tracheostomy anatomy

• the physiological implications with regard to communication and swallowing

• knowledge of the principles of assessment and management of both communication

and swallowing issues in patients with tracheostomy

• skills in research design and analysis

12.3 Research The need for further research in the areas of tracheostomy and ventilator assisted patients is great. This is an emerging field with a small but growing body of literature. Research is encouraged in the majority of the areas covered in this paper. The team

approach required to manage a patient with a tracheostomy precipitates the need for multidisciplinary research. Recent publications such as Tracheostomy, A Multiprofessional Handbook (Russell and Matta, 2004) are an encouraging sign that this multidisciplinary

aspect is appearing in the literature. It is recommended that speech pathologists strive to implement clinical research into their daily practice. This may be assisted via developing collaborative relationships with

universities.



13.0 Further Reading and Resources

Austan, T. (1992), Ventilator assisted patient vocalisation with positive end expiratory pressure and tracheostomy cuff leak. A brief report, Heart Lung, 21(6), 575-577.

Bach, J.R., & Alba A.S. (1990), Tracheostomy ventilation: a study of efficacy with deflated cuffs and cuffless tubes. Chest, 97, 679-783. Byrick, R.J. (1993), Improved communication with the Passy-Muir valve: the aim of

technology and the result of training, Critical Care Medicine, 21, 483-484. Dolenska, S., Dalal, P. Taylor, A. Essentials of Airway Management(2004) Greenwich -

Medical Media Limited, London Frattali, C., & Worrall, L.E. (2001), Evidence based practice: applying the science to the art of clinical care, Journal of Medical Speech-Language Pathology, 9(1), ix-xiv.

Hoit, J.D., Banzett, R.B., Lohmeier, H.L., Hixon, T.J., & Brown, R. (2003), Clinical ventilator adjustments that improve speech, Chest, 124, 1512-1521.

Hussey, J.D., & Bishop, M.J. (1996), Pressures required to move gas through the native airway in the presence of a fenestrated versus a non-fenestrated tracheostomy tube, Chest,110, 494-497.

Reilly, S., Douglas, J. & Oates, J. (Eds) (2004), Evidence Based Practice in Speech Pathology.

Whurr Publishers, London. Speech Pathology Australia Position Paper(2004), Dysphagia.

Tippet, D. (2000), Tracheostomy and Ventilator Dependency: Management of Breathing, Speaking and Swallowing. Thieme, New York.

Myers, E.N., Johnson J.T., & Murray, T. (Eds) (1998), Tracheotomy, Singular Publishing

Group, Inc., San Diego, London Paw, H. G. W., Bodenham, A.R. Percutaneous Tracheostomy A Practical Handbook (2004)

Greenwich Medical Media Ltd. London Passy, V., Baydur, A., Prentice, W., & Darnell-Neal, R. (1993), Passy-Muir tracheostomy speaking valve on ventilator-dependent patients, Laryngoscope, 108, 663-658.

Sparker, A.W., Robbins, K.T., Nevlud, G.M., Watkins, C.N., & Jahrsdoefer, R.A. (1987), A prospective evaluation of speaking tracheostomy tubes for ventilator assisted patients. Larygoscope, 97, 89-92.

Tracheostomy Interest Group Australia (TIGA) Editor: Moira Solley, [email protected] Worrall, L.E., & Bennet, S. (2001), Evidence based practice: Barriers and facilitator for

Speech-Language Pathologists, Journal of Medical Speech-Language Pathology, 9(2), xi-xvi.



Paediatric Further Reading Abraham, S.S., & Wolf, E.L. (2000), Swallow physiology of toddlers with long-term tracheostomies: A preliminary study, Dysphagia, 15, 206-212.

Abraham, S.S. (2003), Babies with tracheostomies: The challenge of providing specialized clinical care. The ASHA Leader, March 18, pages 4,5,26.

Arvedson, J.C., & Brodsky, L. (1992), Pediatric tracheotomy referrals to speech-language pathology in a children’s hospital, International Journal of Pediatric Otorhinolaryngology, 23, 237-143.

Bleile, K.M. (1993), The Care of Children with Long-Term Tracheostomies, Singular Publishing Group, San Diego.

Black, R.J., Baldwin, D.L., & Johns, A.N. (1984), Tracheostomy ‘decannulation panic’ in children: Fact or fiction? The Journal of Laryngology and Otology, 98, 297-304. Driver, L.E., Nelson, V.S., & Warschausky, S.A. (1997), The Ventilator-Assisted Child. A

Practical Resource Guide, Communication Skill Builders, Texas

Engleman, S.G., & Turnage-Carrier, C. (1997), Tolerance of the Passy-Muir Speaking Valve ™ in infants and children less than 2 years of age, Pediatric Nursing, 26(6), 571-575.

Gray, R.F., Wendell, T.N., & Jacobs, I.N. (1998), Tracheostomy decannulation in children: Approaches and techniques, Laryngoscope, 108, 8-12.

Hoit, J.D., & Banzett, R.B. (1997), Simple adjustments can improve ventilator –supported speech, American Journal of Speech – Language Pathology, 6, 87-96.

Hoit, J.D., Shea, S.A., & Banzett, R.B. (1994), Speech production during mechanical ventilation in tracheostomised individuals, Journal of Speech and Hearing Research, 36, 53-63.

Kertoy, M. (2002), Children with Tracheostomies Resource Guide, Delmar Singular Publishing Group, Canada.

Mallory, G.B., Reilly, J.S., Motoyama, E.K., Mutich, R., Kenna, M.A., & Stool, S.E. (1985), Tidal flow measurement in the decision to decannulate the paediatric patient, Annals of Otology, Rhinology and Laryngology, 94, 454-457.

Simon, B.M., & Handler, S.D. (1981), The speech pathologist and management of children with tracheostomies, The Journal of Otolaryngology, 10(6), 440-448

Simon, B.M., & Silverman McGowan, J. (1989), Tracheostomy in young children: Implications for assessment and treatment of communication and feeding disorders, Infants and Young

Children, 1(3), 1-9.



Appendix 1: Task Group

Project Officer

Tanis Cameron Manager, Tracheostomy Review and Management Service, Senior Speech Pathologist Austin Health, Heidelberg, VIC

Members of Working Party

Bridget Brisdee Senior Speech Pathologist, Royal Hobart Hospital, Hobart, TAS

Noni Bourke Speech Pathologist, Royal Darwin Hospital, Darwin, NT

Kim Brookes Speech Pathology, Head of Department, Sir Charles Gardiner Hospital, Nedlands, WA

Claire Dodd Speech Pathologist, Austin Health, VIC

Judy Dixon Senior Speech Pathologist, Alfred Hospital, Melbourne, VIC

Amanda Scott Senior Speech Pathologist, Alfred Hospital, Melbourne, VIC

Marion Fisher Acting Area Director Speech Pathology, CSAHS, Royal Prince Alfred Hospital, Camperdown NSW 2050

Kate Starick Manager Acute Support Speech Pathology and Lead Professional, The Canberra Hospital, Canberra ACT

Maura Solley Speech Pathologist, Princess Alexandra Hospital, Woolloongabba, QLD

Melanie Sonsee Senior Speech Pathologist, Sir Charles Gairdner Hospital, Nedlands, WA

Sarah Woon Manager, Speech Pathology Department, The Queen Elizabeth Hospital, Woodville South, SA

Kelly Weir Speech Pathologist, Royal Children’s Hospital, Herston, QLD

Speech Pathology Australia Representatives

Stacey Baldac Position Paper Coordinator

Philippa Davis Professional Standards National Coordinator

Chris Stone Professional Standards National Coordinator

This paper has been reviewed by members of Speech Pathology Australia who work in the area of tracheostomy management. Every Branch had a representative on this task force.

Each member of the Working Party contributed to this project on the basis of his/her particular work context, and the Working Party as a whole was considered to be representative of the range of contexts in which speech pathologists work with persons with tracheostomies.



References

Belafsky, P.C., Blumfield, L., LePage, A., & Nahrstedt, K. (2003), The accuracy of the modified Evan’s blue dye test in Predicting Aspiration, Laryngoscope, 113, 1969-1972. Brady, S.L., Hildner, C.D., & Hutchins, B.F., (1999), Simultaneous videofluoroscopic swallow

study and modified Evans blue dye procedure: An evaluation of blue dye visualisation in cases of Known Aspiration, Dysphagia, 14, 146-149.

Cowan, T. Holt, T.B., Gegenheimer, C., Izenberg, S., & Kulkarni, P. (2001), Effect of Inner Cannula Removal on the Work of Breathing Imposed by Tracheostomy Tubes: A Bench Study, Respiratory Care, 46 (5), 460-465.

Dikeman, K.J. & Kazandjian, M.S. (2002) (2nd Ed), Communication and Swallowing Management of Tracheostomised and Ventilator Assisted Adults, Singular Publishing Group,

California. Elpern, E.H., Scott, M.G., Petro, L., & Ries, M.H. (1994), Pulmonary aspiration in mechanically ventilated patients with tracheostomies, Chest, 105 (2), 563-6.

Godwin, J.E., & Heffner, J.E. (1991), Special critical care considerations in tracheostomy management, Clinics in Chest Medicine, 12, 573-583.

Hales, P. (2004), Swallowing. In Russell, C. & Matta, B. Tracheostomy A Multiprofessional

Handbook, Greenwich Medial Media Limited, London. Le, H.M., Aten, J.L., Chiang, J.T., & Light, R.W. (1993), Comparison between conventional cap and one-way valve in the decannulation of patients with long –term tracheostomies,

Respiratory Care, 38 (11), 1161-1167. Leder, S.B. (1999), Effect of a one-way tracheotomy speaking valve on the incidence of

aspiration in previously aspirating patients with tracheotomy, Dysphagia, 14 (2), 73-7. Leder, S.B., Cohn, S.M., & Moller, B.A. (1998), Fibreoptic endoscopic documentation of the high incidence of aspiration following extubation in critically ill trauma patients, Dysphagia,

13, 208-212. Leder, S.B., Joe, J.K., Hill, S.E., & Taube, M. (2001), Effect of tracheostomy occlusion on

upper esophageal sphincter and pharyngeal pressures in aspirating and nonaspirating patients, Dysphagia, 16, 79-82. Leder, S.B. & Ross, D.A., (2000), Investigation of the casual relationship between

tracheostomy and aspiration in the acute care setting, Laryngoscope, 110, 641-644. Leder, S.B., Tarro, J.M. Burrell, M.I., & Sasaki, C.T. (1998), Tracheostomy Tube Occlusion

Status and Aspiration in Early Postsurgical Head and Neck Cancer Patients, Dysphagia, 13(3), 167-171. Logemann, J.A. (1994), Management of dysphagia poststroke. In Chapey, R. (Ed), Language

Intervention Strategies in Adult Aphasia (3rd ed.). Williams & Wilkins, Sydney.

Medwatch Notification Date Accessed October/2003-10-29). http://www.fda.gov/medwatch/SAFETY/2003/safety03.htm#FDCblue Site revised Jan 2, 2004 Ross, J. &White, M. (2003), Removal of the tracheostomy tube in the aspirating spinal cord-

injured patient, Spinal Cord, 41, 636-642.



Russell, C. (2004), ‘Tracheostomy Tubes’, in Tracheostomy: A Multiprofessional Handbook,

Russell, C. & Matta, B., Greenwich Medical Media Limited, London. Russell, C. and Matta, B. (2004), Tracheostomy: A Multiprofessional Handbook, Greenwich

Medical Media Limited, London. Speech Pathology Australia (1996), Tracheostomy Tube Management.

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Speech Pathologists.

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Suiter, D.M., McCullough, G.H., & Powell, P.W. (2003), Effects of cuff deflation and one-way tracheostomy speaking valve placement on the swallow physiology, Dysphagia, 18, 284-292.

Thompson-Henry, S. & Braddock, B. (1995), The modified Evan's blue dye procedure fails to

detect aspiration in the tracheotomized patient: five case reports, Dysphagia, 10, 172-174. Thompson-Ward, E., Boots, R., Frisby, J., Bassett, L., & Timm, M. (1999), Evaluating suitability for tracheostomy decannulation: a critical evaluation of two management protocols, Journal of Medical Speech-Language Pathology, 7(4), 273-281.

Tippet, D., & Siebens, A. (1991), Using ventilators for speaking and swallowing, Dysphagia, 6(2), 94-99.

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