When therapy becomes personal

How did you come to select this profession, and when and why did your specialisation become a vocation?

Hans Schwegler: I started as a primary school teacher and then while at the school I came into contact with speech therapy. It fascinated me and I decided to study speech therapy. Shortly before the end of the course I did a practicum working with adult voice patients. As a result I applied for a position in the phoniatry department of the Lucerne cantonal hospital. From 1990 to 1997 I worked in the phoniatry department with voice patients and also patients with laryngectomy. I came into contact with the Swiss Paraplegic Centre (SPZ) through an ENT specialist who was working in ENT consulting in Nottwil. He was always in contact with patients who required speech therapy there and from January 1995 I started at the SPZ once a week and worked not only with dysphonia and dysarthria patients but also patients with dysphagia, frequently in connection with tracheal cannulas.

 

At that time continuing education with tracheal cannulas was virtually unavailable, which meant that I was learning on the job with patients, and unfortunately also from mistakes. From 2000 I had so many patients that a part-time position became full time. One thing came to another, and I began to concentrate on the topic of tracheal cannulas - and over time in connection with ventilation.

I loved the challenges and enjoyed learning something new, and still do today. I found this field very exciting and varied. There was and still is so much to optimise and improve for the patients. This is how a profession became a vocation. Fate could not have done better with me.

Your name is closely connected with tracheal cannula management through your book and your many lectures. What do you find so fascinating about that?

Hans Schwegler: The wide range of possibilities for change and opportunities for improvement. We are also close to basic human needs: communication, swallowing, breathing, eating. They are essential basic human needs, which means that my work is very closely involved with easily visible effects. In these fields I have been able to achieve many successes with patients, giving me the feeling that I get at least as much benefit for the effort that I have invested in the therapy.

If you have the privilege of experiencing how much pleasure it can give to swallow a bit of water or to be able to talk to family on the telephone while on ventilation, they are wonderful events and I consider them the best "payment".  I have had so much back from patients, for which I am very grateful. I often hear from patients even years later: "You know, the sorbet right at the start - that was so wonderful!" Things that healthy people accept as normal acquire a special significance in different circumstances. They become more valued.

 

What are the specific challenges that you see in your work (speech therapy) with tracheotomised patients and how can we meet them?

Hans Schwegler: I believe that a current problem now is that the expertise that is now available in tracheal cannula management is still not accepted or implemented by decision-makers and generally in the professions that are involved with it. This is why one of the greatest challenges remains with the communication of the knowledge and the training courses for the relevant professional groups. Of course, this extends beyond acute hospitals and rehabilitation clinics to associated institutions such as care homes, ventilation group homes or outpatient services (referred to as "Spitex" here in Switzerland), where treatment and care must be improved. We as speech therapists also have a duty here. I still unfortunately experience again and again great insecurity in the field of tracheotomy and tracheotomy cannula management. This reminds me of the case of a young patient in outpatient care, who had a small cannula without cuff fitted and was under BIPaP ventilation. Although the tracheotomy was years ago, neither the cannula nor the ventilation had ever been adjusted.

 

In the meantime the patient was an adult and the anatomical conditions had changed. The background to such cases in my experience is primarily lack of knowledge.

Iris Geiseder: I often find that tracheotomy cannula management is considered a status. However, it is actually a process, something that must be continuously checked and adjusted. This seems to be overlooked by many people. That is exactly what I find most interesting with this topic.

Hans Schwegler: That's exactly how I feel! Even years after the tracheotomy there are still aspects that must be considered. You could say that we are never finished. This is why it is so important to have enough people with the right experience and knowledge.

On the topic of tracheal cannulas: Are there functions of a cannula that you find particularly good?

Hans Schwegler:  I consider that multifunction cannulas with subglottal suction tubes are particularly helpful for ventilated patients with serious swallowing disorders. Secretions can be atraumatically drained without unblocking or highly mobilised by blowing air into the pharynx or mouth region. The subglottal suction tube can also be used to enable speech with Above Cuff Vocalisation (ACV). In addition, the air input is also particularly important for swallowing.

Another request from a therapeutic point of view for all who place tracheostomata would be the placement of dilatative rather than surgical stomata. Dilatative stomata compress the air with speaking valves or subsequently sealing caps when deflecting the air. The high loss of air with the surgical stomata (often too large) is in many cases a disaster for the patient in the course of subsequent tracheotomy cannula management, because functions such as phonation, coughing and swallowing are seriously affected.

Annette Hamann: In Germany and Austria the recommendation is still always for the patient to have a surgical stoma on discharge to the outpatient clinic.

Hans Schwegler: We should always resist this. Cannulas in dilatative stomata can also be replaced without difficulty. Dilatative stomata are also more stable over time.

Annette Hamann: Is the danger of granulation greater with dilatative stomata?

Hans Schwegler: Unfortunately yes. But this must be considered with the disadvantages. The loss of air is simply the greater problem.

In contrast, in my opinion cannulas with phonation openings should be used only very rarely. The openings are mostly in the wrong position in the tracheostoma channel. If cannulas of this type are inserted, the position of the phonation openings must always be checked by endoscopy. They are very often not only incorrectly positioned in the tracheostoma channel and are therefore non-functional but they also cause complications such as granulation tissue, bleeding and pain. In my opinion, cannulas that are too large are often inserted. Where possible, I prefer downsizing the cannula to enable setup of the physiological air flow beside the unblocked cannula.

 

 

 

SPIRAFLEX^® UNI CUFF SUCTION

 

On the topic of decannulation: What steps do you consider essential with decannulation management?

Hans Schwegler: In my view, decannulation management cannot be separated from tracheotomy cannula management. Decannulation starts simultaneously with the tracheotomy. The treatment with the cannula has an influence on tracheotomy cannula management right from the start and thus on the option or the time of decannulation¹. The revision of my book is now complete. With my new co-authors Sarah Stierli and Stephan Mayer we have made significant additions. There are new training films that can be accessed by QR code. The main chapter, tracheotomy cannula management with invasive ventilation, has been completely rewritten. I myself have of course learnt a lot during this process. I have recently become aware that another step is required after decannulation – post-operative care.

At the time of removal the success of a decannulation is not completely obvious. The success - or failure - only become clear over time. Was the decannulation successful if the patient needs to be intubated again three weeks after decannulation due to restricted ability to cough with pulmonary complications? Or were the criteria for decannulation not even met? Post-operative care, particularly with continuing restricted ability to cough, is absolutely essential. The ability to cough and productive coughing must be considered to a much greater extent with reference to secretion management and throughout the entire process of decannulation.

We are currently working on a study with 150 patients to record the progress for up to three months after decannulation to determine whether the criteria for decannulation can be improved further.