Tracheostomy And Speech Therapy: How To Assess & Treat Dysphagia

Over 50% of patients with tracheostomies may have dysphagia (Liu et al., 2024; Skoretz et al., 2020). 

While working with these patients may be intimidating at first, we have you covered!

In this article, you’ll learn all about tracheostomy and speech therapy dysphagia treatment, including: 

• What to expect
• What to look for when assessing people with tracheostomies
• Compensatory swallowing strategies & other treatment areas

Tracheostomy and Speech Therapy: What To Expect 

Studies show that as many as 80+% of people with a tracheostomy will experience dysphagia (Liu et al., 2024; Skoretz et al., 2020). This is largely due to how the tracheostomy tube impacts airway protection during the swallow.

These patients are especially at risk for aspiration pneumonia due to increased residue in the pharynx and subglottic structures (Liu et al., 2024).

That said, not every patient with a tracheostomy will present with dysphagia.

Here’s a quick review of the whats, whys, and hows of tracheostomy and speech therapy.

What Is A Tracheostomy?

A tracheotomy is a surgical procedure in which an opening is made into the anterior neck between the second and third tracheal rings. 

A tracheostoma is the opening into the trachea created by the tracheostomy. In other words, it’s a surgically made hole in the patient’s neck. 

A tracheostomy tube is placed after the tracheostomy/tracheostoma is made (Suiter & Gosa, 2019; American Speech-Language-Hearing Association, 2024). 

Tracheostomy tubes are typically placed after endotracheal intubation. Some patients will require a form of mechanical ventilation, in which a machine provides oxygen to a patient (American Speech-Language-Hearing Association, 2024).

Why A Tracheostomy?

A patient may need a tracheostomy if they have:

• Obstruction in the upper airway
• Airway stenosis
• Trouble managing secretions
• And/or a difficult-to-maintain airway (Suiter & Goza, 2019)

Injuries to the larynx and trachea often result in prolonged intubation. Swallowing deficits due to injury may include diminished adductor vocal fold movement, increased risk of silent aspiration, and diminished cough reflex.

Tracheostomies themselves may also affect the typical breath-swallow sequence (Suiter & Goza, 2019).

When evaluating and treating your patient with a tracheostomy, be sure to work as part of a multidisciplinary team (Bonvento et al., 2017). This may include a respiratory therapist, dietitian, nurse(s), occupational therapist, physical therapist, ENT, GI, physicians, and social work.

Tracheostomy Speech Therapy Assessment 

Once you get the referral, complete a clinical swallow evaluation (aka CSE) that’s tailored to tracheostomies. Here’s how.

1. Chart Review For Tracheostomy

First, review the patient’s medical chart to learn about their past and current medical history. Here’s what to look for when doing a chart review for tracheostomy:

• Primary diagnosis or reason for admission
• Why the patient had a tracheostomy placed
• If they require mechanical ventilation, and if they’re currently or recently on oxygen
• When the tracheostomy was placed
• The size of the tracheostomy
• If it is cuffed or cuffless
• How they are tolerating their secretions
• If they’ve done speaking valve trials
• Past medical history (as applicable to dysphagia)
• Labs, imaging, vital signs
• Allergies
• Recent instrumental assessments (VFSS, FEES)
• Current diet level and any speech therapy notes
• Precautions (hip precautions, isolation precautions, etc.)

Next, consult with the nurse and respiratory therapist to determine if the patient is medically stable enough for a CSE. Ask if they notice any difficulties swallowing or breathing and about their voice and communication abilities.

If possible, coordinate your CSE with a respiratory therapist. The RT can monitor oxygen status and manage secretions (suctioning as needed). They will also be knowledgeable about the patient’s tracheostomy cuff (if present), if they can tolerate cuff deflation, and about speaking valve trials.

2. Patient & Care Partner Interview for Tracheostomies

• Confirm the patient’s name, date of birth, and ask how they want to be addressed (i.e., name, nickname)
• Verify details of their medical history and symptoms
• Explain the reason for your assessment and what it will look like 
• Ask what their swallow was like before their tracheostomy and how it has changed since the tracheostomy. Be sure to ask what foods or liquids they avoid or have difficulties swallowing
• Ask how they take their medications (i.e., whole with water, in applesauce)  

It may be helpful to bring in swallowing surveys, like the EAT-10, MASA, or PILL-5.

If the patient has a communication and/or voice disorder, make sure they have a way to communicate, such as writing, text-to-speech, or other AAC. This will also be a primary goal in your plan of care.

3. Oral Mechanism Examination For Tracheostomies

During your OME, check for symmetry of the cranial nerves and oral-motor structures. Note any asymmetry, weakness, and other red flags of cranial nerve involvement (hypernasality, lack of sensation). Assess cough strength and effectiveness, breath coordination and control, and ability to manage secretions. 

The presence of a cuffed or cuffless tracheostomy tube will also play a role in respiration and secretion management.

Visit Tracheostomy Education’s website to learn more about Cuffed Versus Cuffless Tracheostomy Tubes.

Refer to neurology, gastroenterology, or otolaryngology for underlying structural or neurological issues.

4. Food and Liquid Trials For Tracheostomies

There are a few important things to do before starting food and liquid trials for tracheostomies:

• Check if the patient had an instrumental swallowing evaluation 
• Complete proper oral care before PO trials
• Check if the patient wears a tracheostomy cap or speaking valve when eating and drinking

Read our detailed guide on how to present food and liquid trials.

5. Making Recommendations For Tracheostomies

After completing PO trials, it’s time to make your recommendations!

You will recommend a diet/liquid level, swallowing strategies, swallowing exercises, an instrumental assessment, and/or make any necessary referrals.

Ask what your patient’s goals are for speech therapy. For example, what diet do they hope to advance to?

Given the higher incidence of silent aspiration in this population, an instrumental swallowing assessment is highly recommended to guide your treatment planning (Suiter & Gosa, 2019)

6. Tracheostomy and Speech Therapy Education

Educating your patients and their care partners is a crucial step of your CSE, especially for patients with tracheostomies.

Provide handouts to help explain what dysphagia is, what caused it, and the strategies and exercises you recommended. Offer verbal explanations and handouts about tracheostomies and how they affect swallowing.

How To Treat Dysphagia in Patients With Tracheostomies 

If your CSE determined that the patient is a candidate for dysphagia treatment, they will likely benefit from compensatory strategies and/or rehabilitative exercises.

Below, we’ll review dysphagia goal areas and treatments for people with tracheostomies.

Compensatory Strategies For Tracheostomies

Depending on your patient’s swallowing deficits, you may recommend compensatory strategies. These include modifications to the bolus, like altered diet textures and liquid consistencies.

Other swallowing compensatory strategies for tracheostomies may include:   

• Small bites and sips
• Single bite and/or sip at a time
• Alternating bites and sips
• No straws
• Chin tuck
• Head turn or tilt
• Swallow twice
• Eat and drink slowly
• Breath-hold and swallow (supraglottic)
• Energy conservation
• Positioning

Many of these strategies should only be recommended after an instrumental assessment.

Rehabilitative Exercises For Tracheostomies

It’s best practice to use the results of an instrumental assessment (FEES or VFSS) to guide your recommendations for swallowing exercises.  

Patients with tracheostomies often need to work on breath support and control. Expiratory Muscle Strength Training (EMST) can be an effective exercise for these patients, especially those on mechanical ventilation (Rodrigues et al, 2015). 

Based on the patient’s swallow deficits, you may recommend other rehabilitative exercises. Read How To Treat Dysphagia for a step-by-step guide to treating dysphagia, including effective exercises.

Other Goal Areas for Tracheostomies

Secretion management and improving cough effectiveness are common goal areas for patients with tracheostomies. This will depend on whether their tracheostomy is cuffed or cuffless.

A speaking valve may improve swallowing in patients with tracheostomies (Passy Muir, n.d.) If they have a tracheostomy cuff, make sure that it’s deflated and have a respiratory therapist present to assess oxygenation and respiratory status during trials.

Read How To Use A Speaking Valve for a guide to doing speaking valve trials.

Passy-Muir® is a great resource for speaking valves.

Evidence-Based Dysphagia Materials

Visit our shop for evidence-based dysphagia handouts for your speech therapy patients.

If you’re transitioning to adult speech therapy from pediatrics or returning after a long break, we made it easier for you! Learn more about The Adult Speech Therapy Roadmap Course. Eligible for 1.55 ASHA CEUs.

References

• American Speech-Language-Hearing Association. (n.d.). Tracheostomy and ventilator dependence [Practice portal]. Retrieved November 23, 2024 from https://www.asha.org/Practice-Portal/Professional-Issues/Tracheostomy-and-Ventilator-Dependence/
• Bonvento, B., Wallace, S., Lynch, J., Coe, B., & McGrath, B. A. (2017). Role of the multidisciplinary team in the care of the tracheostomy patient. Journal of multidisciplinary healthcare, 10, 391–398. https://doi.org/10.2147/JMDH.S118419
• Brewer, C., Aparo, M. (2021) The Adult Speech Therapy Starter Pack. Harmony Road Design Publishing.
• Liu, C.; Yang, S.; and Hsiao, M. (2024) Management of Dysphagia in Tracheostomized Patients: A Narrative Review, Rehabilitation Practice and Science: Vol. 2024: Iss. 1, Article 1. DOI: https://doi.org/10.6315/3005-3846.2229
• Passy Muir (n.d.) Passy Muir Valve. https://www.passy-muir.com/valves_page/
• Rodrigues, K. A., Machado, F. R., Chiari, B. M., Rosseti, H. B., Lorenzon, P., & Gonçalves, M. I. (2015). Swallowing rehabilitation of dysphagic tracheostomized patients under mechanical ventilation in intensive care units: a feasibility study. Revista Brasileira de terapia intensiva, 27(1), 64–71. https://doi.org/10.5935/0103-507X.20150011
• Skoretz, S.A., Anger, N., Wellman, L. et al. A Systematic Review of Tracheostomy Modifications and Swallowing in Adults. Dysphagia 35, 935–947 (2020). https://doi.org/10.1007/s00455-020-10115-0
• Suiter, D.M. & Gosa, M.M. (2019). Assessing and treating dysphagia: A lifespan perspective. New York, NY: Thieme. ISBN-9781626232143