Basics about trachs and vents

I remember learning about tracheostomies and ventilators in my graduate classes, but did not really think much of it. However, since working in a hospital for 4 months, I have quickly learned that it is important for an SLP to not only be well versed in the basics of trachs and vents, but also be aware of how the influence swallowing. 

Let's review: 

A tracheotomy is the surgical opening in the trachea (between the second and third tracheal rings).The subsequent opening resulting from a tracheotomy is called a tracheostomy. A tracheostomy tube is then inserted in the airway, which serves as an air passage to help patients breathe when the usual route for breathing is obstructed or impaired. Tracheostomies are often needed when patients require mechanical ventilation in order to assist in breathing. A ventilator is a machine that is used to get oxygen in the lungs, remove carbon dioxide from the body, and/or either partially or fully support breathing. 

Conditions warranting tracheosomies and/or ventilation include diseases (head/neck cancers, COPD, etc.) and trauma (spinal cord injury, head injury, respiratory failure, etc.) that compromise a patient's airway.

There are a lot of components of a trach tube. 

The outer cannula is placed in the airway and an inner cannula sits within this. The inner cannula can be removed and replaced. Some, but not all cannulas have one or more fenestration or hole to allow air to flow through the patient's vocal folds. The cuff at the bottom of the cannula can be inflated and deflated via the cuff inflation valve/line. You can easily see if the cuff is inflated or deflated by looking at the pilot balloon as it matches the condition of the cuff. When the cuff is inflated (see the first picture), air is forced through the trach tube, meaning that the patient is breathing through the tracheostomy but air is unable to move up through the larynx and vocal folds so the patient can speak and breath through their mouth. However when the cuff is deflated, air can travel through the trach tube AND around the trach and up through the patient's vocal folds and mouth so the patient can speak. It is important to note that sometimes, the cannulas have one or more fenestration to allow air through the vocal folds and the trach tube. 

So why do trachs and vents matter to an SLP? Trachs and vents often times negatively influence speaking and swallowing. 

First, let's discuss speaking. As mentioned before, patients with trachs initially cannot speak as air no longer is able to flow through the vocal folds. However, many patients are able to wean off the ventilator with hope of having the trach removed. While this is a complex process that will be discussed in a later post, it is possible for patients to have their cuff deflated to allow air to move through the vocal folds/mouth, which will allow for some vocalizations. Further, patients on a ventilator can use a speaking valve, which is a one-way valve (meaning the valve is always in the closed position until the patient inhales) that allows air to be redirected through the vocal folds, mouth, and nose, again allowing the patient to talk. 

Further, trachs also complicate swallowing. During a functional swallow, the vocal folds close and prevent air from leaving the lungs during the swallow, which creates subglottic pressure. This subglottic pressure is not achieved when the open trach tube allows air to leave the lungs. Additionally, If the cuff is inflated, it presses against the esophagus which can be problematic. Further, hyolaryngeal elevation is reduced with a trach. Again, the speaking valve can improve swallowing as well as speech.

Your job as an SLP is to determine the patient's expressive language skills and swallowing function and risk of aspiration throughout each step of the trach and ventilation. 

Happy treating! 

Mallory

Sources: 

http://www.mayoclinic.org/tests-procedures/tracheostomy/home/ovc-20233993

https://www.nhlbi.nih.gov/health/health-topics/topics/trach

http://www.livingwithavent.com/pages.aspx?page=Basics/What

http://www.practicalslpinfo.com/swallowing-with-a-tracheostomy.html