Dysphagia 22:20–29 (2007)

DOI: 10.1007/s00455-006-9036-5

Dysphagic Patients with Tracheotomies: A Multidisciplinary Approach

to Treatment and Decannulation Management

Ulrike Frank, MSc,1 Mark Mäder, PhD,2 and Heike Sticher, FOTT2
1
Department of Linguistics, University of Potsdam, Potsdam, Germany; and 2REHAB Basel, Basel, Switzerland

Abstract. In 2000 a multidisciplinary protocol for The treatment of a patient with severe neuro-
weaning dysphagic patients from the tracheotomy genic dysphagia and a tracheotomy becomes more
tube and a decannulation decision chart created important in neurologic rehabilitation. However, to
according to principles of the F.O.T.T.Ò Concept our knowledge, only a few studies delineate criteria
(Face and Oral Tract Therapy) were introduced in and decision charts to follow for the safe and fast
the Swiss Neurological Rehabilitation Centre RE- decannulation of patients with severe dysphagia and
HAB in Basel. In the present study we introduce these describe treatment procedures for weaning dyspha-
guidelines and present an evaluation of the treatment gic patients from the tracheotomy tube in detail.
and decannulation procedure. We retrospectively Furthermore, there seems to be only little written on
compared data from patients before and after intro- and general consensus about these aspects of ther-
duction of the multidisciplinary procedure with apeutic intervention. In the present study, a multi-
regard to mean cannulation times and success of disciplinary swallowing and weaning protocol and a
decannulation. Furthermore, we analyzed the reha- decannulation decision chart that uses the principles
bilitation progress of the group who underwent of the F.O.T.T.Ò (Face and Oral Tract Therapy)
multidisciplinary treatment as well as the participa- Concept [1,2] are introduced. One part of the
tion of the speech language therapist. The results F.O.T.T. concept is a swallowing intervention ap-
show that the treatment introduced to improve proach that integrates the modification of tonus,
swallowing functions and wean patients from the posture, movement, and function by application of
tracheotomy tube led to a fast and safe decannulation treatment principles developed via the empirical
of our patients. The mean length of cannulation time work of therapists, principally Berta Bobath. It is
was reduced significantly. After decannulation the based on current knowledge about neurophysiology
patients showed clear functional improvements. and learning theory. After a short summary of the
Interdisciplinary treatment using the approach dis- theoretical background and the details of our ap-
cussed in this study can be considered efficient and an proach, we present data from a preliminary study
important basis for further functional progress in the that evaluated the efficiency of the treatment. We
rehabilitation process. retrospectively analyzed two groups of tracheotom-
ized patients with severe dysphagia three years be-
Key words: Deglutition — Deglutition disorders —
fore and three years after introduction of the new
Tracheotomy — Decannulation management —
protocol in our hospital. In addition, data con-
Multidisciplinary approach — Face and Oral Tract
cerning the functional rehabilitation progress of the
Therapy.
group who underwent the multidisciplinary treat-
ment and the duration of swallowing and weaning
intervention are presented. The objective of this
study was to motivate further discussion and scien-
tific exchange about treatment procedures and dec-
Correspondence to: Ulrike Frank, Department of Linguistics,
University of Potsdam, P.O. Box 601553, 14415 Potsdam, annulation decision charts for tracheotomized
Germany, E-mail: [email protected] dysphagic patients.
U. Frank et al.: Treatment and Decannulation of Tracheotomized Dysphagic Patients 21

The main indications for tracheotomy and is ready for decannulation when he/she is weaned
application of a tracheotomy tube are respiratory from mechanical ventilation, protective reflexes are
dysfunctions or severe dysphagia with high incidence intact, coughing is effective, and 24 h of cuff deflation
of saliva aspiration [3]. While patients with trache- is tolerated even during mealtimes. Decannulation
otomies because of respiratory problems can often be criteria for neurologic and neurosurgical patients were
supplied with uncuffed, fenestrated tubes and speak- defined by Ladyshewsky and Gousseau [27] as fol-
ing valves, this is usually no option for dysphagic lows: a fenestrated tracheotomy tube is in situ, intact
patients. In this group, unfenestrated tubes with in- gag reflex and strong spontaneous cough, the ability
flated cuffs are applied to prevent aspirated material to swallow saliva as assessed by a speech pathologist,
from entering the deeper respiratory tract and caus- oxygen saturation above 90%, and arterial blood ga-
ing severe pulmonal complications. ses within normal limits within 24 h. Ross et al. [28]
Although cuffed tracheotomy tubes have a described criteria for the decannulation of patients
life-preserving function, there are several studies with spinal cord injuries, including an assessment of
showing their negative effects on swallowing and patency of the upper airway, cough effectiveness, and
communication. The question whether the tracheot- the ability to protect the airway from saliva. The au-
omy tube itself is a factor for increased aspiration has thors showed that with a multidisciplinary and closely
been discussed controversially in the research litera- monitored decannulation protocol, decannulations of
ture. It was argued, for example, that the inflated cuff four aspirating patients with long-term tracheotomies
might have an anchoring effect on the trachea by were successful after risks of premature decannulation
decreasing the elevation and anterior rotation of the were carefully compared against those of prolonged
larynx [4–6], or that the lack of respiratory airflow tracheotomy. Lipp and Schlaegel [29] introduced a
through the upper airway causes a gradual decrease weaning and decannulation protocol adapted from
in abductor vocal fold activity [7]. In contrast, other the F.O.T.T. concept, used in the Burgau Neurologi-
studies found no direct effect of the inflated cuff on cal Treatment Centre, Germany. In the weaning
the aspiration risk for dysphagic patients [8]. Some phase, the tracheal tube is deflated in increasing
authors suggested the addition of a one-way valve to intervals. In a second step, the patient is supplied with
the deflated tracheotomy tube [9–11] or digital a cuffless fenestrated tube that is capped in therapy
occlusion of the tube to reduce the incidence of sessions for stimulation of physiologic respiration
aspiration [12,13]. Again, other studies could not through the upper airway and swallowing and
confirm that these interventions had a significant ef- coughing functions. After successful completion of
fect on the incidence of aspiration in tracheotomized the weaning phase, patients are decannulated tempo-
individuals [14,15]. Undoubtedly, the occlusion of the rarily, and after rhinolaryngoscopic examination,
deflated tube has positive effects. The expiratory permanent decannulation follows.
airflow can find its physiologic way through the up-
per airway and improvement may be achieved in the
reinstatement of laryngeal adductor and abductor
reflexes [16], regulation and better clearing of upper Tracheotomy: Management in the REHAB Basel
airway secretions [17–19], olfactory sensation [17],
and improved ability for efficient coughing and verbal The REHAB Basel, Switzerland, is a private rehabil-
communication [15,20]. Considering that long-term itation center specializing in the treatment of para-
tracheotomies and especially inflated tracheotomy plegic and severely brain-damaged patients. In 2000,
tubes can lead to severe complications such as ste- binding written guidelines for weaning from a tra-
noses and tracheomalacias [21–23], it is obvious that cheotomy tube, a decannulation decision chart, and a
the main focus of the multidisciplinary team should protocol for decannulation were established. The
be a fast and secure weaning from the tracheot- bases for these guidelines were principles suggested by
omy tube and subsequent decannulation as soon as the F.O.T.T. Concept (Face and Oral Tract Therapy)
possible. [2] based on the Bobath Therapy Concept [30].
In the research literature descriptions about Tracheotomized dysphagic patients in our hospital
weaning procedures, decision charts, and decannula- usually have a dilatational tracheotomy and a tra-
tion protocols focus mainly on patients with trache- cheotomy tube with an inflated cuff because of severe
otomies due to respiratory indications [24,25]. Only a deglutition disorders. Speech-language pathologists
few studies report details about these procedures for have the main responsibility for the treatment of these
dysphagic patients with tracheotomy tubes. In an patients and dysphagia intervention begins on the day
early study, Greenbaum [26] suggested that a patient of admission. A main component of the swallowing
22 U. Frank et al.: Treatment and Decannulation of Tracheotomized Dysphagic Patients

Table 1. Protocol for cuff deflation and stimulation of upper airway respiration, swallowing, coughing, voicing, and communication in the
REHAB Basel

Nurse and speech pathologist:

1. Positioning of the patient (sitting up or lying on the side)
2. Cleaning of the oral tract
3. Pulse oximetry during the cuff-deflation interval
4. If necessary, suctioning of the mouth, nasopharyngeal tract, and within the tracheal tube
5. Introduction of the suctioning catheter into the tube without suction so that the end of the catheter remains just below the end of
the tube (nurse)
6. Cuff deflation during an expiration phase of the patient (speech pathologist)
7. Suctioning of secretions that are in danger of running from the cuff into the trachea after cuff-deflation. Avoidance of irritation for the
patient (nurse)
8. Occlusion of the tube either digitally or with a tube cap or one-way valve, first only in expiration phases then in inspiration phases.
Duration: a few breaths up to 20 min or more (speech pathologist)
9. Stimulation of swallowing, voicing, coughing, and throat clearing to improve management of secretions. Application of olfactory and
gustatory stimulations (speech pathologist)
10. Stimulation and support of verbal communication between patient, therapist, and the patientÕs family (speech pathologist/nurse)
11. Documentation of the cuff-deflation interval (speech pathologist/nurse)

treatment with tracheotomized patients is the process readiness for decannulation used by the speech
of cuff deflation and stimulation of swallowing and pathologist, nurse, and physician responsible for the
coughing functions while the cuff is deflated (Table 1). tracheotomized individual are shown in Table 2. If
By applying swallowing and coughing stimulation necessary the patientÕs swallowing ability is evaluated
techniques to the dysphagic individual during a cuff- by fiberoptic endoscopic evaluation of swallowing
deflation interval, an anchoring effect of the inflated (FEES) [31].
cuff on the larynx can be avoided and the expiratory If the patient meets the criteria, decannulation
airflow through the upper airway can be used to is conducted on the following day, early in the
improve the ability to cough and swallow [15–20]. morning, without intermediate steps like downsizing
During intervention the speech therapist supports or using fenestrated tubes. After decannulation, the
physiologic respiration via the upper airway, stimu- patient is placed on continuous pulse oximetry and
lates the respiratory muscles and thorax movements if checked in short intervals for a minimum of 12 h. If
necessary, and trains the patient the techniques of safe necessary, the speech pathologist and physiotherapist
swallowing and effective coughing [2]. Multimodal support the patientÕs saliva management by frequent
olfactory and gustatory stimulation is often used stimulation of the swallowing and breathing activity
during the deflation intervals as well. If the patient and positioning the patient so that the pooled saliva
tolerates the deflation and intervention procedures, can drool.
the cuff-deflation intervals are extended day by day The multidisciplinary weaning and treatment
until a minimum of 20 min of cuff deflation, capping protocol described above offered us the opportunity
(digitally or with a one-way valve), and swallowing to define the duties and responsibilities of every team
and coughing intervention are possible. By combining member working with a tracheotomized individual
cuff-deflation phases and swallowing therapy, it is and to use synergy effects of the activities of the
possible to wean the patient from the tracheotomy therapeutic and nursing team members. Before the
tube and intervene to reinstate swallowing functions introduction of this approach, cuff-deflation intervals
and protective reflexes simultaneously. We observed and swallowing interventions were coordinated ra-
that most patients benefit very much from the sensa- ther unsystematically; the new weaning protocol
tion of the expiratory airflow through the larynx and makes use of the synergy effects of these procedures
upper airways during cuff deflation. Most individuals as described above and assigns clear responsibilities
begin with swallowing and throat-clearing immedi- to every team member. Thus, the procedures and
ately after cuff deflation takes place. If improvements their effects became much more transparent to every
are seen during the continuous weaning and swal- team member and, thus, better efficiency in inter-
lowing therapy, the multidisciplinary team (nurse, vention time and costs were observed. After using the
speech therapist, and physician) discusses the indica- new protocol for three years, we aimed to evaluate
tions for decannulation. The specific criteria for this efficiency by a systematic analysis.
U. Frank et al.: Treatment and Decannulation of Tracheotomized Dysphagic Patients 23

Table 2. Multidisciplinary decision chart for evaluating readiness for decannulation used in the REHAB Basel

Speech Pathologist:
1. Patient can be positioned upright, on the side, or in prone position so that saliva can be swallowed or let drool
2. Cleaning of oral tract and teeth is possible
3. During cuff deflation intervals, only minimal secretions from above the cuff have to be suctioned
4. During cuff-deflation and tube-occlusion intervals, the patient can breathe spontaneously and sufficiently through the upper airway for a
minimum of 20 min with sufficient and stable oxygen saturation (minimum 95% ± 5%)
5. Patient can swallow his secretions spontaneously or with light stimulation
6. Efficient spontaneous coughing with subsequent swallowing
7. Improved vigilance
8. Exclusion of reflux and frequent vomiting
9. If necessary, fiberoptic endoscopic evaluation of swallowing (FEES)
Nurse (in addition to speech pathologistÕs criteria):
1. Decreasing need for tracheal suctioning
2. Secretions are liquid and whitish
3. Patient tolerates a mask for respiratory assistance if necessary
4. Positioning to support respiration and secretion management is possible
5. No anesthesia/operations planned for the following week
Physician (in addition to speech pathologistÕs and nurseÕs criteria):
1. No acute pulmonary complications, no atelectasis
2. If necessary, evaluation of patency of the upper airway
3. Evaluation of further specific medical contraindications

Evaluation of the Multidisciplinary Tracheotomy for three years and it was considered to be established and well-
Management known by all team members. Because we wanted to compare our
findings with data from a patient group who had not undergone
this systematic treatment, we chose to analyze data from patients
In a retrospective study, we evaluated the efficiency of tracheotomized in 1997, when our systematic multidisciplinary
the multidisciplinary protocol with regard to saving approach had not yet been established. Thus, patient populations
time, complication rate, and functional improvement three years before and three years after introduction of the multi-
disciplinary approach were included. Inclusion criteria were tra-
of the tracheotomized individuals. We defined the cheotomy due to severe dysphagia and high incidence of saliva
following research questions: aspiration, a cuffed tracheotomy tube in place, and dysphagia as
assessed by a speech therapist. The dysphagia assessment included
1. Has the introduction of the multidisciplinary ap-
an evaluation of basic oral sensory and motor functions, type and
proach led to a reduction in the mean duration of appropriateness of the tracheotomy tube, spontaneous and assisted
cannulation? swallowing, protective reflexes and an aspiration rating related to
2. Have decannulations been successful? the amount of secretions suctioned from above the cuff.
3. How has the development of functional rehabili- Group 1 comprised all 35 tracheotomized patients admitted
to the REHAB Basel in 2003, seven of whom were in a persistent
tation of the individuals treated with the multi-
vegetative state and one was in a minimally conscious state. In
disciplinary approach progressed? 1997, 13 tracheotomized patients were admitted to the REHAB
4. If a decreased duration of cannulation time is Basel. One patient was excluded from the study because he was
shown, can this effect be attributed to the multi- admitted to our hospital two years after tracheotomy and con-
disciplinary approach or rather to mechanisms of founding influences from other kinds of intervention could not be
excluded. Group 2 therefore comprised 12 patients with 4 patients
general functional improvement in the rehabilita- in a persistent vegetative state. None of the patients in our study
tion process? received oral nutrition until decannulation and all patients were fed
5. How much time does it take to wean a patient via a percutaneous gastrostomy tube or a jejunostomy tube.
from the tracheotomy tube in relation to the total
duration of speech therapy? Measures

To evaluate the functional rehabilitation progress of our patients,

Materials and Methods we used the FIM assessment (Functional Independence Measure)
[32]. The FIM is a 7-level assessment tool containing 18 items de-
signed to assess the amount of assistance a person needs to perform
Participants basic life activities related to self-care, sphincter control, transfers,
locomotion, communication, and social cognition. By adding the
To evaluate the effects of our new treatment protocol, we chose points for each item, a score that can range from 18 (lowest) to
to analyze data from tracheotomized patients admitted to the 126 (highest) shows the level of functional independence of the
REHAB Basel in 2003. At this time we had been using our protocol individual. According to Streppel et al. [33,34], a difference of 13
24 U. Frank et al.: Treatment and Decannulation of Tracheotomized Dysphagic Patients

Table 3. Comparison of the data samples of two groups of tracheotomized patients in the REHAB Basel

Parameter Group 1 (2003) (n = 35) Group 2 (1997) (n = 12) Comparison

Medical classification FischerÕs exact (two-tailed)

traumatic n = 17 n=8 p > 0.05
vascular n = 18 n=4 p > 0.05
Age (mean/SD) 47.29 (17.53) 35.53 (14.81) T = )2.08, df = 45 p < 0.05*
FIMa scores(mean/SD/median)
(1) admission 20.54 (5.43; 18) 18.17 (0.58; 18) U = 146.0, p > 0.05
(2) decannulation 21.64 (5.64; 19) 22.0 (12.94; 18) U = 116.5, p > 0.05
(3) discharge 59.91 (42.84; 42) 42.08 (33.42; 25) U = 153.5, p > 0.05

SD = standard deviation.
a
FIM scale = Functional Independence Measure; range = 18 (lowest) – 126 (highest).

FIM points between two measurements indicates functional pro- Results

gress. Because the FIM evaluation parameters require marked
improvements to assign a higher score to a patient, severely im-
paired individuals often show floor effects in FIM assessment Comparability of the Two Groups
scores. This means that the FIM assessment does not appropriately
indicate if an individual in a persistent vegetative state or a mini- A comparison of biographical and medical data of
mally conscious state shows improvements in basic abilities. To the two groups is given in Table 3. Both groups show
account for these floor effects, we also used the EFA (Early
no significant difference in the prevalence of medical
Functional Abilities) [35,36], an assessment tool for patients in a
persistent vegetative state or a minimally conscious state. The EFA classification and functional independence status
scale contains 20 items on five levels and assesses early basic abil- (FIM scores) at the time of admission, decannulation,
ities related to vegetative functions, face and oral activities, sen- and discharge. Comparing the means of the subjectsÕ
sory-motor activities, and sensory-cognitive abilities. FIM and ages, we found a marginal significant difference
EFA scores were calculated every week by the therapists, nurses,
(*p = 0.043).
and physicians responsible for the patient.

Procedures Cannulation Time and Rate of Decannulation

On the basis of medical charts and speech pathology documenta- Table 4 shows the results of our analysis with respect
tion, we retrospectively analyzed data of the two groups of tra- to duration of cannulation and rate of successful dec-
cheotomized patients. Parameters extracted from the database were
biographical data; date of admission and discharge; etiology and
annulations (questions 1 and 2). In Group 1 (2003) we
onset of the brain lesion; date of tracheotomy and decannulation; could wean from the tube and decannulate 33 of the 35
FIM and EFA scores at admission, in the week before decannula- tracheotomized patients (94.3%) without complica-
tion, and at discharge; complications such as aspiration pneumonias tions. Two patients had to be recannulated (6%) within
up to one week after decannulation; and the duration of the speech two weeks of decannulation because of failure to
therapistÕs intervention. To identify pneumonic complications re-
lated to decannulation, we provided the following operational
manage secretions. In Group 1 (2003) the mean length
definition: We assumed that dysphagic aspiration pneumonia was of time the tracheotomy tube remained in place was
related to the decannulation when we observed typical pneumonic 28.3 days from admission to decannulation and 48.24
symptoms that were confirmed by specific bacteriologic findings and days from tracheotomy to decannulation. In Group 2
a radiologic assessment within one week after decannulation, (1997), successful weaning from the tube and decann-
and when we could exclude other causes for these symptoms. We
assumed a successful weaning and decannulation process when after
ulation was possible for 10 of the 12 tracheotomized
decannulation we found no aspiration-related pneumonia and when individuals (83.3%) without complications and with-
there was no indication for recannulation because of insufficient out any recannulations. In this group the mean dura-
secretion management or respiratory failure. tion of cannulation was 94.7 days from tracheotomy to
As an objective method to distinguish the effects of general decannulation and the mean duration from admission
functional improvement from the effects of therapeutic intervention
(question 4), we predefined the following criterion: If we find a
to decannulation was 75.4 days. Comparing the
significant correlation between the amount of general functional duration of cannulation in both groups, we found
improvement (as shown by an increase in FIM and EFA scores) a highly significant reduction in the mean length of
and the duration of cannulation, a rapid weaning and decannula- cannulation time (Mann-Whitney **p = 0.004, U =
tion process can be attributed to the effects of general functional 65.0) in the period between admission and decannu-
recovery. If we find no significant correlation between the increase
in FIM and EFA scores and the duration of cannulation, we can
lation and a significant reduction in the period between
assume a positive influence of the multidisciplinary intervention tracheotomy and decannulation (Mann-Whitney
protocol on the weaning and decannulation process. *p = 0.016, U = 81.0).
U. Frank et al.: Treatment and Decannulation of Tracheotomized Dysphagic Patients 25

Table 4. Comparison of cannulation time data in both analyzed groups of tracheotomized patients in the REHAB Basel

Parameter Group 1 (2003) (n = 35) Group 2 (1997) (n = 12)

Decannulations 33 10
Cannulation time (days) tracheotomy to decannulation (mean/SD/median) 48.2 (51.58; 31) 94.7 (60.01; 90)
Cannulation time (days) admission to decannulation (mean/SD/median) 28.3 (43.7; 11) 75.4 (59.87; 72.5)
Complications/pneumonias (1 week None None
after decannulation)
Recannulations 2 None

120

110

100

90

80

70

60

50

40

30

20

10

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Patients
FIM Admission FIM Decannulation FIM Discharge

Fig. 1. Development of FIM (Functional Independence Measure) scores in tracheotomized dysphagic patients of Group 1 (2003) in the REHAB
Basel. Data sorted by FIM scores at the day of discharge. Range = 18 (lowest) – 126 (highest).

Development in the Rehabilitation Process of Group 1 patients was only 0.93 points (SD = 1.78, Md = 0)
(2003) from admission to decannulation. In contrast to these
results, we found a clear increase in FIM scores after
Results concerning the general functional develop- decannulation. In the period between decannulation
ment of Group 1 (question 3) are given in Figure 1. and discharge, 19 of the 33 individuals improved their
We found that the 35 subjects of Group 1 (2003) FIM scores by more than 13 points and the mean
improved their FIM scores from admission to dis- score of the decannulated group (n = 33) increased
charge by an average of 40.23 [SD = 44.03, median by 41.79 points (SD = 44.43, Md = 24). Four
(Md)= 20] points. An analysis of the scores of the 33 patients showed an increase in their scores after dec-
decannulated individuals shows that none of the annulation but failed to meet the 13-point-difference
patients could improve their FIM scores up to a criterion of Streppel et al. [33]. In general, a relevant
minimum of 13 points until decannulation. This improvement of functional abilities was evident only
would have indicated a clear functional improvement after decannulation. In two of our patients we ob-
according to Streppel et al. [33]. The mean increase of served a slight increase in FIM scores until decann-
FIM scores in the whole group of decannulated ulation and then a decrease in FIM scores. These were
26 U. Frank et al.: Treatment and Decannulation of Tracheotomized Dysphagic Patients

75
70
65
60
55
50
45
40
35
30
25
20
15
10
5
0
1 2 3 4 5 6 7 8
Patients

EFA Admission EFA Decannulation EFA Discharge

Fig. 2. Development of EFA (Early Functional Abilities) scores in severely impaired tracheotomized patients (persistent vegetative state or
minimally conscious state) of Group 1 (2003) in the REHAB Basel. Range = 20 (lowest) – 100 (highest).

the two patients who had to be recannulated and their decannulation and the cannulation times in the
scores decreased shortly after recannulation. Our data patients of Group 1 (Spearman rank p = 0.428,
also reveal that for 8 of the 33 decannulated patients rs = )0.146).
the FIM scores did not change at all. All these pa- Likewise, there was no significant correlation
tients were in a persistent vegetative state or a mini- between the increase in EFA scores in this period and
mally conscious state and thus showed floor effects in the duration of cannulation in the eight severely im-
the FIM assessment. A secondary analysis of EFA paired patients (Spearman rank p = 0.227, rs =
scores of this subgroup (Fig. 2) in the period from )0.482). Therefore, we assume that the rapid dec-
admission to discharge showed a mean increase of annulation of our patients is not related to any
20.63 points (SD = 12.17, Md = 17). From admis- spontaneous recovery of the neurologic state and that
sion to decannulation, the mean increase was only there is a positive influence of the treatment protocol.
4.63 points (SD = 6.67, Md = 2), and, again, only
after decannulation was there a clear mean increase of Duration of the Weaning Phase in Proportion to Total
16 points (SD = 8.88, Md = 15.5). Thus, these data Duration of Speech and Language Therapy
confirm that a clear functional improvement becomes
evident after decannulation of the tracheotomized Evaluating the efficiency of the protocols, the factor
patients. of the duration of therapeutical intervention in the
weaning phase was considered important (question
Decreased Weaning Phases: Result of Treatment or 5). To exemplify this, we analyzed the duration of
General Functional Recovery? speech therapy in the tracheotomized individuals of
Group 1. In the swallowing intervention and weaning
After finding a significant reduction of the weaning phase from the day of admission up to the day of
phase and cannulation times, we wanted to verify if decannulation, the speech-language therapists spent
this effect could be attributed to the weaning and an average of 23.04 h (SD = 32.06, Md = 13)
decannulation protocol (question 4). Analyzing cor- treating the patients of Group 1. During the entire
relations between the duration of cannulation and the stay in our rehabilitation center, these patients
functional development of the neurologic state, we received an average of 137.7 h (SD = 88.25,
found no significant correlation between the increase Md = 123) of speech and language therapy. Thus,
in FIM scores in the period between admission and using the multidisciplinary approach, the period of
U. Frank et al.: Treatment and Decannulation of Tracheotomized Dysphagic Patients 27

weaning from the tracheotomy tube took only phase took only about 17% of the entire time of
16.73% of the total time spent on speech-language speech and language treatment.
therapy. Although we found a marginally significant
difference in the average age of the subjects, we
consider them to be comparable. The rehabilitation
Discussion status of the two groups at the time of admission,
decannulation, and discharge did not differ signifi-
There is a growing need for information about cantly. The fact that Group 2 (1997) was found to be
treatment of tracheotomized dysphagic individuals significantly younger than Group 1 can be considered
and treatment methods have to be evaluated objec- an advantage for this group. More problematic is the
tively. Only a few publications have given descrip- difference in sample size between the two groups.
tions of weaning from a tracheotomy tube and Because we compared retrospective data with clearly
decannulation criteria and protocols for this patient defined inclusion criteria for subjects, we had little
group. In our study, we aimed to introduce a method influence on sample sizes. Our choice of samples with
and protocol that we use in our rehabilitation center a six-year time span between patient groups may have
and describe some preliminary data we collected to contributed to this disadvantageous effect. In the
evaluate this approach. These data show that fast course of the last decade, we observed a general in-
and safe weaning from the tracheotomy tube and crease in admission of tracheotomized patients to our
decannulation of tracheotomized dysphagic patients rehabilitation unit. An explanation for this might be
is possible with a multidisciplinary approach that that because of progress in intensive care medicine,
combines cuff-deflation intervals and swallowing more severely injured patients survive and are
therapy systematically. The average cannulation time admitted to early rehabilitation and that there is more
for the patients treated with this protocol decreased awareness of the need for tracheotomization of se-
significantly compared with formerly treated patients. verely dysphagic patients. This has led to an increased
The mean cannulation time with the new approach need for scientific exchange in this field and has
was 28 days, which is in line with the findings of motivated our study. A followup study to verify our
Leung et al. [37], who found an average cannulation results should include prospective data of tracheo-
time of 33 days for their aspirating patients. In both tomized dysphagic patient groups of a defined period
groups of patients in our study, two patients could and contain systematic instrumental pre- and post-
not be decannulated. The difficulty in assessing the decannulation swallowing evaluations to be able to
readiness for decannulation is evident in the fact that quantify direct effects of our approach on dysphagia.
another two patients in Group 1 (2003) had to be Tracheotomy and the application of a cuffed
recannulated. Both were long-time tracheotomized tracheotomy tube is a life-supporting measure for
patients who clearly had difficulty in their manage- aspirating individuals with severe dysphagia. In the
ment of secretions, even after weaning and swallow- early phase after brain lesions, it ensures secretion
ing therapy. These difficulties could obviously not be management and protection against aspiration pneu-
influenced sufficiently by therapeutical intervention monias. On the other hand, the inflated cuff hinders
before and after decannulation. Regarding the reha- the tracheotomized patient from swallowing and
bilitation progress of Group 1 (2003), our data re- coughing efficiently, and the lack of expiratory airflow
vealed that clear functional improvements, as shown and subsequent deprivation of the pharyngolaryngeal
by an increase in FIM and EFA scores, were not and oral tract is likely to have an impact on the
evident before decannulation. After decannulation, aspiration risk. Decannulation alone certainly does
however, the functional improvements showed a not solve the problem and it does not resolve dys-
rapid and positive development in most patients. The phagia. In the light of conflicting findings about the
comparatively short cannulation times we found in effect of cuffed tracheotomy tubes on the incidence
Group 1 can presumably not be attributed to pro- and severity of aspiration, it remains unclear whether
cesses of general functional recovery, because we decannulation itself has a facilitating effect on the
found no significant correlations between cannula- swallowing process. However, our clinical observa-
tion times of the individuals and their FIM and EFA tions, confirmed by data we presented here, show that
scores. Therefore, a relationship between the short an intensive weaning phase combining cuff-deflation
cannulation periods and the multidisciplinary inter- intervals with swallowing and coughing stimulation
vention approach as described can be assumed. An- techniques can lead to fast and safe decannulation of
other positive result that shows the efficiency of the dysphagic tracheotomized patients. Furthermore, our
treatment is that the weaning and decannulation data show that decannulation can be considered the
28 U. Frank et al.: Treatment and Decannulation of Tracheotomized Dysphagic Patients

basis for further functional improvement, on which 12. Logemann JA, Pauloski BR, Colangelo L: Light digital
further therapeutic goals such as communication and occlusion of the tracheostomy tube: a pilot study of effects on
aspiration and biomechanics of the swallow. Head Neck
oral nutrition can be achieved. 20:52–57, 1998
13. Muz J, Hamlet SL, Mathog RH, Farris R: Scintigraphic
assessment for aspiration in head and neck cancer patients
Conclusion with tracheostomy. Head Neck 16:17–20, 1994
14. Leder SB, Ross DA, Burrell MI, Sasaki C: Tracheotomy
tube occlusion status and aspiration in early postsurgical
Weaning from the tracheotomy tube and decannu- head and neck cancer patients. Dysphagia 13:167–171, 1998
lation as fast and safely as possible should be the 15. Leder SB, Tarro JM, Burrell MI: The effect of occlusion of a
main focus of the medical and therapeutical staff in tracheotomy tube on aspiration. Dysphagia 11:254–258, 1996
neurologic rehabilitation to build the basis for func- 16. Buckwalter JA, Sasaki CT: Effect of tracheotomy on lar-
tional rehabilitation and independence. This study yngeal function. Otolaryngol Clin North Am 17:41–48, 1984
shows that this is possible with an adequate amount 17. Lichtman SW, Birnbaum IL, Sanfilipo MR, Pellicone JT,
Damon WJ, King ML: Effect of a tracheostomy speaking
of therapeutic intervention time when a multidisci-
valve on secretions, arterial oxygenation, and olfaction: a
plinary approach is followed consequently. Further quantitative evaluation. J Speech Hear Res 38:549–555, 1995
research and exchange is needed to modify the mul- 18. Muz J, Mathog RH, Nelson R, Jones LA: Aspiration in
tidisciplinary approach and evaluate it with larger patients with head and neck cancer and tracheostomy. Am J
and more homogeneous populations of tracheotom- Otolaryngol 10:282–286, 1989
ized dysphagic patients. 19. Siebens AA, Tippett DC, Kirby N, French J: Dysphagia and
expiratory airflow. Dysphagia 8:266–269, 1993
20. Leder SB: Perceptual rankings of speech quality produced
Acknowledgments. The authors thank the speech-language pathol- with one-way tracheotomy speaking valves. J Speech Hear
ogists of the REHAB Basel for supporting this study and for re- Res 37:1308–1312, 1994
search assistance. 21. Kirchner JA: Tracheotomy and its problems. Surg Clin
North Am 60:1093–1104, 1980
22. Heffner JE, Miller S, Sahn SA: Tracheostomy in the
References intensive care unit. Part 2: Complications. Chest 90:430–
1. Gratz C, Woite D: Die Therapie des Facio-oralen Traktes bei 436, 1986
neurologischen Patienten, Zwei Fallbeispiele. Idstein: Schulz- 23. Graumueller S, Dommerich S, Mach H, Eich HJA: Spa-
Kirchner-Verlag, 1999 etkomplikationen und Nachsorge nach Tracheotomie unter
2. Sticher H, Gratz C: Trachealkanuelenmanagement in der besonderer Beruecksichtigung der Punktionstracheotomie in
F.O.T.T.—Der Weg zurueck zur Physiologie In: Nusser- der neurologischen Fruehrehabilitation. Neurol Rehabil
Mueller-Busch R. (ed.) Die Therapie des Facio-oralen Trakts. 8:122–127, 2002
Berlin: Springer-Verlag, 2004, pp174–191 24. Heffner JE, Hess D: Tracheostomy management in the
3. Dikeman KJ, Kazandjian MS: Communication and swallow- chronically ventilated patient. Clin Chest Med 22:55–69,
ing management of tracheostomized and ventilator-dependent 2001
adults. San Diego, CA: Singular Publishing Group, 1995 25. Reibel JF: Decannulation: How and Where. Respir Care
4. Bonanno PC: Swallowing dysfunction after tracheostomy. 44:856–859, 1999
Ann Surg 174:29–33, 1971 26. Greenbaum DM: Decannulation of the tracheostomized
5. Pinkus NB: The dangers of oral feeding in the presence of patient. Heart Lung 5:119–123, 1976
cuffed tracheostomy tubes. Med J Aust 1:1238, 1973 27. Ladyshewsky A, Gousseau A: Successful tracheal weaning.
6. Elpern EH, Scott MG, Petro L, Ries MH: Pulmonary aspi- Can Nurse 92:35–38, 1996
ration in mechanically ventilated patients with tracheosto- 28. Ross J, White M: Removal of the tracheostomy tube in the
mies. Chest 105:563–566, 1994 aspirating spinal cord-injured patient. Spinal Cord 41:636–
7. Sasaki C, Suzuki M, Horiuchi M, Kirchner J: The effect of 642, 2003
tracheostomy on the laryngeal closure reflex. Laryngoscope 29. Lipp B, Schlaegel W: Das Tracheostoma in der neurologis-
87:1428–1432, 1977 chen Fruehrehabilitation. Forum Logop 2:1–4, 1997
8. Leder SB, Ross DA: Investigation of the causal relationship 30. Bobath B: Adult hemiplegia: Evaluation and treatment.
between tracheotomy and aspiration in the acute care setting. London: Heinemann, 1970
Laryngoscope 110:641–644, 2000 31. Langmore SE, Schatz K, Olsen N: Fiberoptic endoscopic
9. Dettelbach MA, Gross RD, Mahlmann J, Eibling DE: The examination of swallowing safety: A new procedure. Dys-
effect of the Passy-Muir valve on aspiration in patients with phagia 2:216–219, 1988
tracheostomy. Head Neck 17:297–302, 1995 32. Granger CV, Hamilton BB, Keith RA, Zielezny M, Sherwin
10. Stachler RJ, Hamlet SL, Choi J, Fleming S: Scintigraphic FS: Advances in functional assessment for medical rehabili-
quantification of aspiration reduction with the Passy-Muir tation. Top Geriatr Rehabil 1:59–74, 1986
valve. Laryngoscope 106:231–234, 1996 33. Streppel KRM, Van Harten WH: The Functional Indepen-
11. Suiter DM, McCullough GH, Powell PW: Effects of cuff dence Measure used in a Dutch rehabilitating stroke popu-
deflation and one-way tracheostomy speaking valve place- lation; a pilot study to assess progress. Int J Rehabil Res
ment on swallow physiology. Dysphagia 18:284–292, 2003 25:87–91, 2002
U. Frank et al.: Treatment and Decannulation of Tracheotomized Dysphagic Patients 29

34. Ottenbacher KJ, Yungwen H, Granger CV, Fiedler RC: The 36. Heck G, Steiger-Baechler G, Schmidt T: Early Functional
reliability of the Functional Independence Measure: A Abilities (EFA)—eine Skala zur Evaluation von Behand-
quantitative review. Arch Phys Med Rehabil 77:1226–1231, lungsverlaeufen in der neurologischen Fruehrehabilitation.
1996 Neurol Rehabil 6:125–133, 2000
35. Heck G, Schoenberger JL: Early Functional Abilities 37. Leung R, Campbell D, MacGregor L, Berkowitz RG: Dec-
(EFA)—eine Skala fuer die Evaluierung von klinischem annulation and survival following tracheostomy in an
Zustandsbild und Verlauf bei Patienten mit schweren cere- intensive care unit. Ann Otol Rhinol Laryngol 112:853–858,
bralen Schaedigungen. Neurol Rehabil Suppl 4:10, 1996 2003
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.