Abstract
We read with interest the article on Oral Feeding for patients with Tracheostomy: Balancing Risks and Benefits by JL Mullender et al., Oct 2014 edition. We are responding on behalf of the Royal College of Speech and Language Therapy (RCSLT) Tracheostomy Clinical Excellence Network (CEN), both to highlight the contribution this piece made to this challenging area and to inform about current speech and language therapy (SLT) and multi-disciplinary best practice in this area.
The article described the practice of one ICU in managing oral intake in this population and debated the significance of aspiration, patient experience and the benefits of a liberal approach to oral feeding.
This paper stimulated national debate amongst the Tracheostomy CEN. The salient points raised were:
Agreement that the presence of a tracheostomy tube does not necessarily in isolation cause a dysphagia. SLTs appreciate that aspiration events are not always clinically significant; however, predictors for developing aspiration pneumonia should be weighed carefully in every case, particularly in critical care patients.
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The use of Fibreoptic Endoscopic Examination of Swallowing (FEES) and a lack of evidence around meaningful clinical outcomes are raised in the paper. However, the use of FEES is quite widespread and has been shown to identify dysphagia, expedite feeding decisions, improve patient outcomes and influence decannulation decisions by highlighting laryngeal intubation trauma and secretion management issues.2,3 The authors highlight the controversy in the literature concerning the impact of cuff status on swallowing safety. While the CEN acknowledge this debate, in the clinical setting deflating the cuff is considered preferable as it yields more diagnostic information, provokes laryngeal airflow and sensory awareness for the patient. This guides a more accurate, thorough assessment and safer management of swallowing. The authors rightly acknowledge the limitations of the Modified Evans Blue Dye Test. Its poor reliability in detecting aspiration renders it a non-essential adjunct in the swallow assessment tool-kit. Recent national publications have instead consistently recommended locally agreed evidence-based screening criteria based on the needs of different tracheostomy clinical groups (e.g. neurological versus general ICU) in conjunction with true multi-disciplinary collaboration in the management of swallowing difficulties.4–6 We agree that oral feeding can make a huge psychological difference to patients in ICU. Teamwork is essential to the early identification of patients who are unsafe, to commencement of dysphagia rehabilitation and to managing swallowing problems appropriately.
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In conclusion, this article was welcomed as it stimulated discussion and raises awareness of an increasingly recognised issue. However, we felt it did not reflect the nuances of recent research, nor how the SLT profession has adopted this to inform and up-date clinical practice. The recommendation of NBM is always a last resort. Instead the focus within SLT is on swallow rehabilitation and regular reassessment of risk factors. As a profession, we recognise the need for more research into dysphagia incidence, outcomes and reliable indicators of dysphagia risk and prognosis in the tracheostomy and critical care population. Collaborative research is greatly encouraged by the CEN and is the way forward to addressing these gaps and advancing care for tracheostomy patients.