Dysphagia
The number of tracheostomised, dysphagic patients in clinical and outpatient settings and the associated need for treatment is continuously increasing.1 As early as 2015, the Deutsche interdisziplinäre Gesellschaft für Dysphagie e.V. (DGD)[German Interdisciplinary Society for Dysphagia] stated that there were 5 million people suffering from dysphagia in Germany. The National Foundation of Swallowing Disorders speaks of 15 million people in the United States of America.
Swallowing is a semi-reflective skill that one uses up to 2,000 times every day. This highly complex process involves 56 pairs of muscles and (in addition to central control) at least five pairs of cranial nerves and five cervical nerves.2 The term swallowing disorder, referred to as dysphagia, is derived from the Greek word "phagein" = to eat and the prefix "dys" = disturbed, therefore strictly speaking it means eating disorder.3 In general, however, it is understood to imply difficulty or even the inability to swallow saliva, food and/or liquids safely and effectively. Depending on the severity, aspiration can occur, which describes the penetration of liquid and/or solid matter into the airways.
Swallowing disorders occur with a high prevalence in almost all neurological diseases. In addition to malnutrition and dehydration, they lead to serious complications such as aspiration pneumonia, which represents one of the most frequent causes of death in neurological patients. Early dysphagia management therefore not only significantly improves the patient's quality of life, but also reduces mortality.4
Dysphagia in tracheostomised and ventilated patients.
In addition to neurological causes, there are also other causes linked to dysphagia. For example, the placement of a tracheostoma with an inserted tracheostomy tube can also predispose to dysphagia.
Whether and to what extent dysphagia is present after placement of a tracheostoma with a (blocked) tracheostomy tube basically depends on the causes that led to the tracheotomy. If the tracheostomy tube is not unblocked and fitted with a speaking valve in the therapeutic setting, then dysphagia can worsen or even develop in the first place. The tracheostomy tube should therefore be unblocked as soon as possible, always performed by an experienced therapist and following consultation with the prescribing physician.
If the tracheostomy tube is blocked, patients cannot cough up the secretions that enter the windpipe (trachea) through the larynx and which accumulate above the cuff. In the long term, this inevitably leads to habituation to secretions in the trachea and thus to a reduction in sensitivity. During physiological swallowing, the larynx is pulled upwards and forwards, thus pulling the entrance to the oesophagus open and transporting the food towards the stomach. The blocked cuff of the tracheostomy tube forms an unwanted anchor function and thus restricts the range of movement of the larynx during the process of swallowing.
Tracheal cannula management and the
provision of a speaking valve
To achieve an improvement in swallowing ability in the case of an already existing swallowing disorder (dysphagia), it is essential that the tracheostomy tube is unblocked as early as possible in speech therapy and that breathing is redirected via the upper airways using a speaking valve. This not only promotes sensitivity and perception, but also increases the swallowing frequency. In parallel, this also enables voice formation. Being able to speak gives patients back an enormous amount in terms of quality of life.
This procedure is not only important for neurological patients, but also for cannulated patients in general, for them to be able to maintain sensitivity, ideally to enable oral nutrition to be started as well as possibly to aim for decannulation. For the diagnosis and treatment of existing dysphagia, it is crucial to unblock the tracheostomy tube as early as possible and use a speaking valve to direct exhalation via the physiological airways again, at least temporarily. The speech therapist treating the patient, but also the nursing staff, should always bear in mind that some dysphagia patients do not feel when they choke. Consequently, there is also no cleansing cough to remove the aspirate from the lower airways. This is referred to as silent aspiration and can possibly lead to aspiration pneumonia (inflammation of the lungs).
Unblocking and treatment with the speaking valve improves sensitivity and also restores the ability to cough, both reflexively as well as voluntarily. This protective mechanism is important within the context of dysphagia, as it allows the negative consequences of impaired swallowing ability (residues, penetrations, aspirations) to be either corrected reflexively or improved therapeutically using voluntary cleansing techniques.2
Our speaking valves
Sources:
1 Ledl, C., Frank, U., Dziewas, R., Arnold, B., Bähre, N., Betz, C. S., ... & Graf, S. (2024). Curriculum „Trachealkanülenmanagement in der Dysphagietherapie “. Der Nervenarzt, 1-11
2 Zylka-Menhorn, V., (28. März 2014), „Dysphagie. Wenn Schlucken eine Tortur ist“. Deutsches Ärzteblatt, Jg. 111, Heft 13
3 Prosiegel, M., & Weber, S. (2018). Dysphagie: Diagnostik und Therapie. Ein Wegweiser für kompetentes Handeln. Springer-Verlag.
4 Labeit, B., Muhle, P., Warnecke, T. et al. Dysphagiemanagement verbessert Lebensqualität und senkt Mortalität. InFo Neurologie 21, 36–47 (2019). doi.org/10.1007/s15005-019-0026-1