Swallowing Management of Individuals with Tracheostomy

Since there is no airflow through the upper airway with an inflated cuff, there is a lack of sensation of secretions which tend to pool above the level of the cuff.  Since there is not an airtight seal, aspirated secretions may pass around the cuff and into the lower airways and lungs.  Secretions are also unable to be coughed through the upper airway due to impaired subglottic pressures with an open tracheostomy tube. Subglottic and tracheal suctioning can aid to lessen the amount of secretions that enter the lungs. .  

Patients with tracheostomy tubes have been found to have a higher secretion levels compared to those without tracheostomy tubes.  Secretion levels have been associated with aspiration for patients, with higher secretion levels more likely to aspirate than patients with lower secretion levels (Donzelli et al, 2003, 2006).  

A reduction of secretions has been demonstrated when a speaking valve is placed (Manzano, 1993; Litchman,1995; Donzelli et al, 2006). The Manzano study reported a reduction in the frequency of suctioning following speaking valve use, but did not provide objective data or direct visualization of secretions.  Litchman study measured the amount of secretions suctioned both orally and tracheally over a 24 hour period and found a 40% reduction in secretions when using the Passy-Muir Valve.  The sample size was small (7 individuals) and suctioning occurred based on individual need rather than at standardized times comparing speaking valve to non-occluded conditions.  In the Donzelli study, tubes were occluded by light finger occlusion, speaking valve or capping and those who were able to tolerate capping had the lowest secretion ratings, followed by speaking valves and those who tolerated finger occlusion only were the highest secretion ratings (Donzelli et al, 2006).  Causation could not be determined due to the prospective nature of the study. 

The Evans Blue Dye test was introduced by Cameron et al in 1973 and is usually performed by placing 4 drops of methylene blue dye on the patient’s tongue every four hours and then performing tracheal suctioning regularly for 48 hours.  Secretions are monitored for traces of blue.  If blue tinged tracheal secretions are observed, this indicates that the patient is aspirating.  The Evan’s Blue Dye test differs from a Modified Evan’s Blue Dye (MEBD) assessment in that the latter is performed using food and/or liquids that is to be swallowed. The cuff should ideally be deflated prior to performing the Modified Evan’s Blue Dye assessment to provide for increased sensitivity. Then assessment of secretions or one consistency of food or liquid is provided.  The patient is then tracheally suctioned immediately following trials and throughout the 24 hour period the individual should be monitored for blue dye.  

If blue tinged tracheally secretions are found, this indicates that the individual is aspirating.  However, it will not indicate why, when or how the material was aspirated.  It is often best to perform one consistency per day.  This is because if delayed aspiration occurs, there is no way of determining which consistency was aspirated. 

If blue dye is not found in tracheal secretions this does not indicate that the individual did not aspirate.  It could potentially be a false negative.  

It is important to look for blue dyed secretions: during tracheal suctioning, in the tracheostomy tube during coughing, at the stoma site, on stoma dressings, on the inner cannula.  Blue tingued secretions found at any of these locations all indicate aspiration. 

It is recommended to use the Blue Dye test as a screening tool only and not to rely completely on it. The Modified Evan’s Blue Dye test has been shown to have poor sensitivity of 10- 50% accurate in assessing if aspiration exists (Brady et al, 1999; Donzelli, J et al, 2001; Thomspon, H Filho, L et al, 2019).  In other words, if blue dye is found, it can be assumed that the patient is aspirating.  However, if blue dye is not suctioned the patient may still be aspirating, but it can be missed.  The screen typically can assess gross aspiration, but can easily miss smaller amounts.  

When the assessment is repeated, sensitivity has been shown to increase.  Balasky et al and Fiorelli et al (2011) repeated the Modified Evan’s Blue Dye test three times and had a sensitivity of 87% and 85%. 

Note: In 2003, the Food and Drug Administration issued a public health advisory based on toxicity and mortality reports regarding the use of blue dye in enteral feeding.  The adverse effects reported were patients who were all critically ill and larger amounts for enteral feedings.  However, the Modified Blue Dye test uses much smaller quantities (typically 1 millimeter) and there has not been adverse effects reported in these small quantities (ASHA, 2015).  The FDA has not issued a specific warning at this time for use of blue dye during swallowing evaluations. 

Another potential concern with the use of blue dye is the possibility of cross contamination with bacterial colonization from multiuse non-sterile bottles.  Clinicians utilizing blue dye should consider single use vials.  

 Due to the high rates of aspiration and silent aspiration in those with tracheostomy and the reduced sensitivity of the MEBD, instrumental assessments are recommended.  An instrumental swallow assessment should be used for a more comprehensive diagnosis of dysphagia and treatment plan in individuals with tracheostomy.