Secretions, occlusion status, and swallowing in patients with a tracheotomy tube: a descriptive study.

Abstract

We conducted a prospective, descriptive study of 40 tracheotomized patients to investigate the relationships between (1) levels of accumulated oropharyngeal secretions and laryngeal penetration/aspiration status, (2) secretion levels and tube-occlusion status, and (3) tube-occlusion status and aspiration status. Assessments of secretion status were quantified with the use of a 5-point rating scale. All evaluations were made by fiberoptic endoscopic evaluation of swallowing. We found that patients with higher secretion levels were more likely to aspirate than were patients with lower secretion levels. Also, patients who tolerated placement of a tube cap had the lowest mean secretion level, and those who tolerated only light finger occlusion had the highest; likewise, most patients with normal secretion levels tolerated a capped tube, and a plurality of patients with profound secretion levels tolerated only light finger occlusion. Finally, no significant differences were observed with respect to occlusion status and aspiration rates.

Introduction

Reductions in the amount of oropharyngeal secretions and possible improvement in swallowing ability are two of the reported secondary benefits of occluding a tracheotomy tube and using a one-way speaking valve. (1-9) Reductions in the amount of secretions in such circumstances have been described by Passy and colleagues, although their findings were based largely on anecdotal reports from patients and clinicians. (1,2) Manzano et al also reported reductions in the amount of secretions in ventilator-dependent patients following the use of a one-way speaking valve. (3) They also reported reductions in the frequency of tracheal suctioning, although they provided no objective data to support this finding, and no direct visualization of the airway was performed.

Lichtman et al studied the effects of a one-way speaking valve on secretion accumulation by measuring the amount of content that was suctioned from the oral cavity and tracheotomy tube over a 24-hour period. (4) They were the first to quantify the effects of a speaking valve on secretions, but their study was limited by the small sample size (N = 7). Also, they provided no clear description of their suctioning technique or the frequency with which they performed suctioning under various conditions; in fact, suctioning was performed according to a patient's needs rather than at comparable times under speaking-valve and nonoccluded conditions. Finally, they did not perform direct visualization of the accumulated oropharyngeal secretions.

The relationship between the presence of accumulated oropharyngeal secretions and subsequent aspiration has been previously established. (10-12) In 2003, our group published the results of a study of 28 patients; in that same article, we introduced our classification scheme for oropharyngeal secretions, which is based on a 5-point scale (the Marianjoy scale; figure). (12) We found that patients with higher secretion-scale values were more likely to aspirate than were patients with lower secretion values. We also found that patients with a tracheotomy tube had higher secretion levels than did patients without a tube.

Reports in the literature on the effects of tracheotomy tube occlusion on a person's ability to swallow safely have varied. Some investigators (7-9) have found that occlusion and the use of a one-way speaking valve reduce or eliminate aspiration, while others (13-15) have reported no effect; still others (5,6) have reported that some patients benefit and some do not.

Until now, no published research has involved the use of a standardized secretion scale to quantify the relationship between tracheotomized patients' accumulated oropharyngeal secretion levels as evaluated by endoscopy and their occlusion status. In this article, we describe the results of our prospective, descriptive study of the relationships between (1) secretion level and laryngeal penetration/aspiration status, (2) secretion level and occlusion status, and (3) occlusion status and aspiration status.

Patients and methods

Our study population was made up of 40 consecutive patients--24 men and 16 women, aged 30 to 85 years (mean: 62.8 [+ or -] 12.04)--who had been admitted over a 23-month period to Marianjoy Rehabilitation Hospital, a freestanding institution in Wheaton, Ill. These patients had been admitted for a variety of medical diagnoses, including stroke, traumatic brain injury, spinal cord injury, heart failure, and respiratory failure. The duration of intubation ranged from 14 to 192 days (mean: 74 [+ or -] 46).

All patients underwent a standard fiberoptic endoscopic evaluation of swallowing (FEES) in accordance with established protocols. (12,16-18) For 28 patients, orders had included nil per os (NPO) prior to FEES. Occlusion status indicated the type of occlusion that a patient had been able to tolerate prior to FEES. Tubes were occluded in one of three ways: by a cap, by a one-way speaking valve, or by a finger.

Prior to the presentation of any food or liquid, secretion levels were graded according to the 5-point Marianjoy secretion scale (figure). 12 Each swallow was evaluated for the degree of laryngeal penetration or aspiration. Laryngeal penetration was defined as the entry of material into the laryngeal vestibule down to the level of the vocal folds. Aspiration was defined as the entry of material below the level of the vocal folds. Aspiration was considered "silent" when no cough response occurred. The patient's diet levels were classified into four categories: NPO, therapeutic feedings, modified diet, and regular diet.

Olympus ENF flexible endoscopes and Pentax sensory flexible endoscopes were used for this study. Light was provided by an Olympus CLK-4 light source and a Kay Elemetrics RLS 9100B light source. The studies were recorded on digital videodisc. The institutional review board at Marianjoy Rehabilitation Hospital approved this study, and all patients signed an informed-consent statement.

Spearman's 9 (rank correlation coefficient) was calculated to evaluate the relationship between secretion-scale level and laryngeal penetration, aspiration, silent aspiration, initial diet level, and duration of tracheotomy tube placement. Cross-tabulations and chi-square ([chi square]) analyses were completed to test for an association between secretion level and aspiration status. Paired t tests and a one-way analysis of variance (ANOVA) were completed on the continuous variables.

Results

Secretion level and laryngeal penetration/aspiration status. Secretion levels were normal in 6 patients (15.0%), mild in 6 (15.0%), moderate in 4 (10.0%), severe in 9 (22.5%), and profound in 15 (37.5%). The mean secretion level in all 40 patients was 3.53.

Overall, 19 of 40 patients (47.5%) demonstrated aspiration; 15 of these 19 cases (78.9%) were silent. The mean secretion level was 4.3 for patients who aspirated and 2.8 for those who did not aspirate--the difference was statistically significant (p = 0.001).

The relationships between secretion level and laryngeal penetration, aspiration, silent aspiration, and initial diet level were all statistically significant; secretion level was not correlated with the duration of tracheotomy tube placement (table 1). Higher secretion levels were associated with a greater incidence of laryngeal penetration and aspiration. The significant relationship between secretion level and initial diet level indicates that patients with higher secretion levels were more likely to be on a restrictive diet or on NPO orders.

Secretion level and occlusion status. Of the 40 patients, 19 (47.5%) tolerated a tube cap, 9 (22.5%) tolerated a one-way speaking valve, and 12 (30.0%) tolerated only light finger occlusion (table 2). Patients who tolerated placement of a tube cap had the lowest mean secretion level (2.95), and those who tolerated only finger occlusion had the highest (4.34); the differences between secretion levels and occlusion status were statistically significant (F = 3.61, p = 0.037). Likewise, most patients with normal secretion levels tolerated a capped tube, while a plurality of patients with profound secretion levels tolerated only finger occlusion (table 3).

Occlusion status and aspiration status. Aspiration was seen in 7 of the 19 patients (36.8%) in the cap group, 4 of 9 (44.4%) in the speaking-valve group, and 8 of 12 (66.7%) in the finger group. The differences among aspiration rates in the three occlusion groups were not statistically significant ([chi square] = 2.667, p = 0.264). The aspiration rates in patients with profound secretions were fairly evenly distributed according to the type of occlusion--75.0% (3/4) in the cap group, 75.0% (3/4) in the speaking-valve group, and 85.7% (6/7) in the finger group.

Discussion

The results of this study are consistent with those of our earlier study. (12) Both studies showed that patients with higher secretion levels were more likely to demonstrate laryngeal penetration and aspiration. Moreover, the mean secretion levels in the two studies were similar--3.53 in the current study and 3.96 in the previous study.

The current study describes for the first time the relationship between secretion levels and occlusion status based on the use of a standardized secretion scale to describe accumulated oropharyngeal secretions. Previous studies of the relationship between secretion levels and occlusion status relied on anecdotal reports and subjective interpretations. (1-4)

Even though the digital-occlusion group had the highest aspiration rate (66.7%), no significant relationship between type of occlusion and aspiration rate was observed. The fact that the aspiration rates in those with profound secretions were fairly evenly distributed among the three types of occlusions suggests that occlusion status does not predict aspiration. In fact, we found that it is secretion level that predicts aspiration. The findings of our study support previous research that showed that occlusion status did not affect swallowing ability. (13-15)

One limitation of our study is that it was only a descriptive study. Another is that we did not establish a causal relationship between occlusion status and secretion level; the design of our study did not allow us to determine if a change in occlusion status was related to a change in secretion level or vice versa. At this time, we are able to state only that we observed an association between occlusion status and accumulated oropharyngeal secretions. Furthermore, we should also take into account the fact that accumulated oropharyngeal secretions can be affected by additional factors, such as pulmonary secretions, infection, medical instability, vocal fold immobility, swallowing frequency, laryngeal sensations, etc.

Current studies are focusing on the development of objective evaluations of the cause-and-effect relationship between occlusion status and secretion levels. These studies involve the use of a standardized secretion scale and direct endoscopic visualization of both the upper and lower airway at specified times.

Acknowledgment

Funding for this study was provided by the Dr. Ralph and Marian Falk Foundation Medical Research Trust.

From Otolaryngology-Head & Neck Surgery, Ltd., Naperville, Ill. (Dr. Donzelli), and the Department of Speech-Language Pathology, Marianjoy Rehabilitation Hospital, Wheaton, Ill. (Ms. Brady, Ms. Wesling, and Ms. Theisen).

Reprint requests: Susan Brady, Research Coordinator, Swallowing and Voice Center, Department of Speech-Language Pathology, Marianjoy

Rehabilitation Hospital, 26 W. 171 Roosevelt Rd., Wheaton, IL 60187. Phone: [phone]; fax: [phone]; e-mail: sbrady @ marianjoy.org

Originally presented at the 13th annual meeting of the Dysphagia Research Society; Oct. 14-16, 2004; Montreal.

References

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(2.) Passy V, Baydur A, Prentice W, Darnell-Neal R. Passy-Muir tracheostomy speaking valve on ventilator-dependent patients. Laryngoscope 1993;103:653-8.

(3.) Manzano JL, Lubillo S, Henriquez D, et al. Verbal communication of ventilator-dependent patients. Crit Care Med 1993;21:512-17.

(4.) Lichtman SW, Birnbaum IL, Sanfilippo MR, et al. Effect of a tracheostomy speaking valve on secretions, arterial oxygenation, and olfaction: A quantitative evaluation. J Speech Hear Res 1995;38:549-55.

(5.) Suiter DM, McCullough GH, Powell PW. Effects of cuff deflation and one-way tracheostomy speaking valve placement on swallow physiology. Dysphagia 2003;18:284-92.

(6.) Logemann JA, Pauloski BR, Colangelo L. Light digital occlusion of the tracheostomy tube: A pilot study of effects on aspiration and biomechanics of the swallow. Head Neck 1998;20:52-7.

(7.) Dettelbach MA, Gross RD, Mahlmann J, Eibling DE. Effect of the Passy-Muir Valve on aspiration in patients with tracheostomy. Head Neck 1995; 17:297-302.

(8.) Elpern EH, Borkgren Okonek M, Bacon M, et al. Effect of the Passy-Muir tracheostomy speaking valve on pulmonary aspiration in adults. Heart Lung 2000;29:287-93.

(9.) Stachler RJ, Hamlet SL, Choi J, Fleming S. Scintigraphic quantification of aspiration reduction with the Passy-Muir valve. Laryngoscope 1996; 106:231-4.

(10.) Murray J, Langmore SE, Ginsberg S, Dostie A. The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia 1996; 11:99-103.

(11.) Link DT, Willging JP, Miller CK, et al. Pediatric laryngopharyngeal sensory testing during flexible endoscopic evaluation of swallowing: Feasible and correlative. Ann Otol Rhinol Laryngol 2000; 109: 899-905.

(12.) Donzelli J, Brady S, Wesling M, Craney M. Predictive value of accumulated oropharyngeal secretions for aspiration during video nasal endoscopic evaluation of the swallow. Ann Otol Rhinol Laryngol 2003; 112:469-75.

(13.) Leder SB. Effect of a one-way tracheotomy speaking valve on the incidence of aspiration in previously aspirating patients with tracheotomy. Dysphagia 1999;14:73-7.

(14.) Leder SB, Ross DA, Burrell MI, Sasaki CT. Tracheotomy tube occlusion status and aspiration in early postsurgical head and neck cancer patients. Dysphagia 1998;13:167-71.

(15.) Leder SB, Tarro JM, Burrell MI. Effect of occlusion of a tracheotomy tube on aspiration. Dysphagia 1996;11:254-8.

(16.) Langmore SE, Schatz K, Olsen N. Fiberoptic endoscopic examination of swallowing safety: A new procedure. Dysphagia 1988;2: 216-19.

(17.) Bastian RW. Videoendoscopic evaluation of patients with dysphagia: An adjunct to the modified barium swallow. Otolaryngol Head Neck Surg 1991;104:339-50.

(18.) Donzelli J, Brady S, Wesling M, Craney M. Simultaneous modified Evans blue dye procedure and video nasal endoscopic evaluation of the swallow. Laryngoscope 2001;111:1746-50.

Joseph Donzelli, MD; Susan Brady, MS, CCC-SLP; Michele Wesling, MA, CCC-SLP; Melissa Theisen, MS, CCC-SLP

Table 1. Spearman's rank correlation coefficient for
secretion level

                          Correlation   p Value

Laryngeal penetration        0.621      0.001
Aspiration                   0.507      0.001
Silent aspiration            0.471      0.004
Initial diet level          -0.613      0.0001
Duration of tracheotomy     -0.193      0.2

Table 2. Mean secretion levels according to the type of occlusion

Occlusion type             n (%)      Mean secretion level

Cap                      19 (47.5)            2.95
Speaking valve            9 (22.5)            3.67
Finger                   12 (30.0)            4.34

Table 3. Occlusion status according to secretion level

                                n (%)

Secretion level      Cap      One-way valve    Finger

1 (n = 6)         5 (83.3)          0         1 (16.7)
2 (n = 6)         3 (50.0)      3 (50.0)         0
3 (n = 4)         3 (75.0)      1 (25.0)         0
4 (n = 9)         4 (44.4)      1 (11.1)      4 (44.4)
5 (n = 15)        4 (26.7)      4 (26.7)      7 (46.7)

Figure. Marianjov 5-point secretion scale (adapted from reference 12).

Level        Secretion characteristics

1, normal    Thin, clear pharyngeal secretions;
             <10% pooling in the piriform sinuses
             and/or vallecular space

2, mild      10 to 25% pooling of secretions in the
             piriform sinuses and/or vallecular
             space

3, moderate  >25% pooling; no endolaryngeal
             secretions

4, severe    Laryngeal penetration of secretions
             above the level of the true vocal folds;
             intermittent laryngeal penetration of
             secretions with inhalation; no
             aspiration of secretions; endolaryngeal
             secretions present

5, profound  Presence of secretions on the vocal
             folds and/or presence of tracheal
             aspiration of secretions