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DOI: 10.1007/s00455-003-0022-x
Abstract. This study examined the eects of tracheostomy cu deation and one-way speaking valve
placement on swallow physiology. Fourteen nonventilator-dependent patients completed videouoroscopic swallow studies (VFSS) under three
conditions: (1) cu inated, (2) cu deated, and (3)
one-way valve in place. Four additional patients with
cuess tracheostomy tubes completed VFSS with
and without the one-way valve in place. All swallows
were analyzed for the severity of penetration/aspiration using an 8-point penetrationaspiration scale.
Seven preselected swallow duration measures, extent
of hyolaryngeal elevation and anterior excursion, and
oropharyngeal residue were also determined. Scores
on the penetrationaspiration scale were not signicantly aected by cu status, i.e., ination or deation. However, one-way valve placement signicantly
reduced scores on the penetrationaspiration scale
for the liquid bolus. Patients who are unable to tolerate thin liquids may be able to safely take thin
liquids when the valve is in place. However, one-way
valve placement may not be benecial for all patients.
Clinicians who complete VFSS with tracheostomized
patients should include several bolus presentations
with a one-way speaking valve in place before making
any decisions regarding the use of the valve as a
means to reduce aspiration.
Key words: Tracheostomy Deglutition
Aspiration Deglutition disorders.
285
Methods
Participants
Participants were recruited from the University of Tennessee
Medical Center, Knoxville. Twenty-two consecutive individuals
with tracheostomy tubes, who were referred by their attending
physician for a videouoroscopic swallowing study (VFSS) due to
suspected oropharyngeal dysphagia, completed an initial VFSS. Of
the 22 patients, 18 had cued tracheostomy tubes and four had
cuess tracheostomy tubes. Selection criteria were (1) nonventilator dependence, (2) ability to tolerate cu deation during the
VFSS, as determined by a respiratory therapist who monitored
oxygen saturation and heart rate throughout the testing session, (3)
Procedures
All participants completed a VFSS positioned upright and viewed
in the lateral plane. A U.S. one-cent coin was placed at the angle of
the left mandible to serve as a marker for measuring hyolaryngeal
movement. The oral cavity, pharynx, upper airway, and cervical
esophagus were radiographically visualized during the entire study.
Participants completed a total of 12 swallows in three conditions:
(1) cu inated, (2) cu deated, and (3) cu deated with the oneway valve in place. Two liquid boluses (E-Z Paque liquid barium,
EZEM, Westbury, NY) and two puree boluses (four parts unsweetened applesauce to one part barium powder, E-Z High
Density Barium Sulfate, EZEM, Westbury, NY) were presented
under each condition. Participants with cuess tracheostomy tubes
completed only eight swallows, as the cu-inated condition was
removed. To minimize order eects, presentation under the three
conditions was randomized. During the cu-inated condition, all
participants tracheostomy cus were fully inated (i.e., no leak).
This was conrmed by a respiratory therapist using a Posey Cufator (Posey Company, Arcadia, CA). The clinician that completed the VFSS fed each participant. All boluses were presented
via plastic spoon.
The uoroscopic image of the swallow was recorded
(General Electric, Model 152000G2, New York, NY) to allow for
real-time and slow-motion analyses. A 100-ms video timer (FOR.A
Corp, Model VTG-55, San Jose, CA) was used for detailed, frameby-frame, timed analysis of the measures employed. Images were
held for 3 s after the swallow to allow for viewing of any
postswallow aspiration.
Measurements
Two speechlanguage pathologists reviewed all videotapes in real
time and in slow motion. Videotapes were analyzed for the pres-
286
Participant
Diagnosis
Nutrition
Tracheostomy
tube size
Days with
tracheostomy
Days o
ventilator
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
COPDa
CHIc
COPD
CHI
CHI
CHI
COPD
CHI
s/p CABGe
s/p CABG
CHI
CHI
ARDSf
ARDS
ARDS
COPD
CHI
s/p AAA repairg
N-G Tubeb
N-G Tube
N-G Tube
N-G Tube
N-G Tube
PEGd Tube
N-G Tube
N-G Tube
N-G Tube
N-G Tube
N-G Tube
N-G Tube
N-G Tube
N-G Tube
N-G Tube
N-G Tube
N-G Tube
N-G Tube
6
6
6
8
6
6
6
6
4
6
6
6
6
6
6
4
6
8
20
9
21
14
15
17
15
5
11
7
13
19
25
26
25
18
14
29
4
6
8
4
3
5
7
2
9
3
2
4
14
19
14
15
4
11
Results
Three separate comparisons were completed for the
14 participants with cued tracheostomy tubes: (1)
cu inated versus cu deated, (2) cu inated
versus one-way valve, and (3) cu deated versus
one-way valve. Only one comparison was completed
for the four individuals with cuess tracheostomy
tubes: no one-way valve versus one-way valve. The
95% level of condence was selected as statistically
signicant.
Reliability
Repeated viewing of the videotapes were allowed so
that each judge could make the most accurate ratings
possible. Neither judge was aware of tracheostomy
tube occlusion status. The two judges independently
rated the presence or absence of aspiration, timing of
aspiration, severity of penetration/aspiration, amount
of oral and pharyngeal residue, and all swallow duration measures. Each judge was blinded to the ratings of the other judge.
In order to determine intrajudge reliability,
one judge reviewed 20% of the videotapes, which
were randomly selected, twice. This judge was unaware of ratings from the previous viewing.
Pearsons product moment correlations were
computed for all duration measures. Kendalls tau
correlations were computed for scores on the penetrationaspiration scale and for oropharyngeal residue. Correlations for interjudge reliability ranged
from 0.915 to 1.000. Correlations for intrajudge
reliability ranged from 0.906 to 1.000.
287
tion (PTD) [F(1,13) = 5.487, p = 0.036] and duration of hyoid maximum anterior excursion
(DOHMAE) [F(1,13) = 4.719, p = 0.049] were signicantly longer for the cu-deated condition than
for the cu-inated condition. Duration of cricopharyngeal opening (DOCPO) was signicantly
shorter for the cu-deated condition than for the
cu-inated condition [F(1,13) = 4.719, p = 0.005].
There was no signicant eect of bolus.
Hyolaryngeal Excursion
Mean maximum laryngeal elevation for the liquid
bolus was 9.853 mm (SE = 0.763) for the cuinated condition and 9.656 mm (SE = 0.944) for the
cu-deated condition. Mean maximum laryngeal
elevation for the pureed bolus was 9.023 mm (SE =
0.717) for the cu-inated condition and 8.942 mm
(SE = 0.408) for the cu-deated condition. A 2 2
(condition bolus) univariate repeated-measures
ANOVA revealed no signicant eect of condition.
Mean maximum hyoid anterior excursion for
the liquid bolus was 11.350 mm (SE = 0.635) for the
cu-inated condition and 12.076 mm (SE = 1.002)
for the cu-deated condition. Mean maximum hyoid
anterior excursion for the pureed bolus was 9.314 mm
(SE = 0.908) for the cu-inated condition and
11.055 mm (SE = 0.642) for the cu-deated condition. A 2 2 (condition bolus) univariate repeatedmeasures ANOVA revealed a signicant main eect
for condition [F(1,13) = 7.960, p = 0.014]. Mean
maximum hyoid anterior movement was signicantly
greater for the cu-deated condition than for the
cu-inated condition. In addition, there was a signicant eect of bolus [F(1,13) = 32.379, p < 0.001].
Hyoid anterior movement was signicantly greater for
the liquid bolus than for the pureed bolus.
Residue
A two-factor (condition and bolus) doubly multivariate repeated-measures ANOVA revealed no
signicant eect of condition or bolus.
PenetrationAspiration Scale
The number of penetration and aspiration occurrences for liquid and pureed boluses are presented in
Tables 2 and 3, respectively. As with the previous
analysis, the majority of aspiration occurrences were
silent and during the swallow.
288
1st bolus
a
A
A
A
A
A
A
A
A
A
A
A
A
A
A
N/A
N/A
N/A
N/A
Cu deated
2nd bolus
A
P
A
A
P
P
P
A
N/A
N/A
N/A
N/A
1st bolus
A
P
No P-A
A
A
P
A
A
A
A
No P-A
A
A
A
No P-A
A
A
A
One-way valve
2nd bolus
No P-A
A
A
No P-A
A
A
No P-A
A
A
A
1st bolus
No
No
No
P
No
A
No
A
P
P
No
No
A
No
No
No
No
No
P -A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
2nd bolus
No
No
No
No
No
No
No
No
A
No
No
No
No
No
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
A = Aspiration.
P = Penetration.
= Participant did not complete this trial.
b
289
Cu deated
Subject no.
1st bolus
2nd bolus
1st bolus
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
Aa
P
No P-A
A
P
P
No P-A
A
No P-A
No P-A
No P-A
No P-A
No P-A
No P-A
N/A
N/A
N/A
N/A
P
No P-A
P
No P-A
No P-A
No P-A
No P-A
No P-A
No P-A
No P-A
N/A
N/A
N/A
N/A
No
No
No
A
A
P
P
A
No
No
No
No
No
No
No
A
No
No
Pb-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
One-way valve
2nd bolus
1st bolus
2nd bolus
No
No
No
A
A
No
No
No
No
No
No
No
No
No
No
No
No
P
P
A
No
A
No
No
No
No
No
No
No
A
No
No
No
No
P
No
No
No
No
No
No
No
No
No
No
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
P-A
A = Aspiration.
P = Penetration.
= Participant did not complete this trial.
b
290
Residue
A two-factor (condition and bolus) doubly multivariate repeated-measures ANOVA revealed no
signicant eect of condition.
Discussion
We found that cu status, i.e., inated versus
deated, had no eect on penetration or aspiration.
However, one-way valve placement signicantly reduced scores on the penetrationaspiration scale for
the liquid bolus when compared to the cu-inated
and cu-deated conditions. Most patients (8 of 10)
who aspirated thin liquids with their cus inated or
deated were able to safely take thin liquids when the
one-way valve was in place.
Deating the Cu
Results indicate that cu deation did not reduce
incidence or severity of aspiration compared with the
cued or one-way valve conditions. One reason that
the deated cu did not improve aspiration status is
that subglottal pressure cannot be restored by cu
deation alone. Decreased subglottal air pressure has
been identied as a primary mechanism responsible
for aspiration in tracheostomized patients [26]. It has
been demonstrated that subglottal pressure restoration can be improved in the presence of a one-way
valve. Thus, lack of subglottal pressure restoration
may contribute to the lack of signicant eect in
aspiration severity in the deated cu condition.
Another reason that cu deation alone did
not reduce aspiration severity is because both
inspiratory and expiratory air is largely exchanged via
the tracheostomy tube bypassing the upper airway. It
has been demonstrated that the adductor vocal fold
reex sensitivity decreases in the presence of tracheostomy tubes [8], presumably because of the lack of
291
Future Research
To better determine the eects of tracheostomy tubes
on swallowing physiology, three areas of future research are suggested. First, the eect of the one-way
valve on pharyngeal and laryngeal sensitivity needs to
be assessed. Second, determining the eects of oneway valve placement on subglottal pressure might
elucidate the eects of valve placement on
penetration/aspiration. In the current study, aspiration was most frequently noted with thin liquids. We
observed an increase in residue when the one-way
valve was in place. It is possible that one-way valve
placement may not have as signicant an eect on
aspiration with patients who aspirate pureed textures.
Previous research has indicated that this is the case
[17]. Future research should also examine the eects
of the one-way valve on larger numbers of participants who aspirate thicker consistencies.
By examining these three areas, perhaps we
can gain a more realistic picture of how one-way
valve placement aects swallow physiology.
References
1. Bone DK, Davis JL, Zuidema GD, Cameron JL: Aspiration
pneumonia: Prevention of aspiration in patients with tracheostomies. Ann Thorac Surg 18:3037, 1974
2. Elpern EH, Jacobs ER, Bone RC: Incidence of aspiration in
tracheally intubated adults. Heart Lung 16:527531, 1987
3. Elpern EH, Scott MG, Petro L, Ries MH: Pulmonary aspiration in mechanically ventilated patients with tracheostomies.
Chest 105:563566, 1994
4. Pannunzio TG: Aspiration of oral feedings in patients with
tracheostomies. AACN Clin Issues 7:560569, 1996
5. Bonnano PC: Swallowing dysfunction after tracheostomy.
Ann Surg 174:2933, 1971
292