Dyphagia How Best to Treat

Dyphagia

How best to treat a patient with severe neurogenic dysphagia as well as a tracheotomy becomes even more critical during the period of neurologic rehabilitation. However, according to Frank and colleagues (2007), there has been little research conducted on how to set proper criteria and establish decision charts to follow for the safe and fast removal (decannulation) of the tracheotomy tube from patients with severe dysphagia. Similarly, the literature on describing treatment procedures for weaning dysphagic patients from the tracheotomy tube is minimal.

In this study, which was based on current knowledge about neurophysiology and learning theory, a tracheotomy removal decision chart with the FOTT (Face and Oral Tract Therapy) principles was the basis for a multidisciplinary swallowing and weaning protocol. One part of the FOTT concept is a swallowing intervention approach that integrates the modification of tonus (muscle contraction), posture, movement, and function.

Patients with a tracheotomy and tube for severe dysphagia have high incidence of saliva aspiration. Cuffed tubes are used with dysphagic patients due to their life-preserving function. However, at the same time, these types of tubes sometimes have negative effects on swallowing and communication. It is therefore important for a multidisciplinary team to wean these patients from the tracheotomy tube as quickly and Lipp and Schlaegel (1997) earlier introduced a weaning and decannulation protocol adapted from the FOTT concept. In this method, the tracheal tube is first deflated in increasing intervals. Next, the patient is supplied with a cuffless fenestrated tube that is capped in therapy sessions for stimulation of physiologic respiration through the upper airway and swallowing and coughing functions. Finally, the patients are decannulated temporarily, and after rhinolaryngoscopic examination, permanent decannulation follows.

The importance of this approach, in addition to the slower weaning process, is the fact that it is multidisciplinary. The speech pathologist is an integral part of this team approach, because he/she determines (at times with the nurse) the progression of each stage in the weaning process (see below)

Speech Pathologist:

1. Patient can be positioned upright, on the side, or in prone position so that saliva can be swallowed or let drool

2. Cleaning of oral tract and teeth is possible

3. During cuff deflation intervals, only minimal secretions from above the cuff have to be suctioned

4. During cuff-deflation and tube-occlusion intervals, the patient can breathe spontaneously and sufficiently through the upper airway for a minimum of 20 minutes with sufficient and stable oxygen saturation (minimum 95% ± 5%)

5. Patient can swallow his secretions spontaneously or with light stimulation

6. Efficient spontaneous coughing with subsequent swallowing

7. Improved vigilance

8. Exclusion of reflux and frequent vomiting

9. If necessary, fiberoptic endoscopic evaluation of swallowing (FEES)

Nurse (in addition to speech pathologist_s criteria):

1. Decreasing need for tracheal suctioning

2. Secretions are liquid and whitish

3. Patient tolerates a mask for respiratory assistance if necessary

4. Positioning to support respiration and secretion management is possible

5. No anesthesia/operations planned for the following week