We are pleased to welcome Roxann Diez Gross, Ph.D., CCC/SLP, 
as our guest host for the SLP chat tonight, Monday, February 3, 2003. 
Dr. Gross will lead us in a chat about "The Effects of Tracheotomy
on Speech and Swallowing Physiology".  Dr. Gross is an adjunct
Assistant Professor at the University of Pittsburgh where she does
clinical teaching of graduate students at the acute care Veteran's
Hospital.  She also works at the VA conducting research in the
area of swallowing: studying breathing and swallowing in people
with tracheostomy tubes, after strokes, with Parkinson's disease
and with those with chronic obstructive lung disease (COPD).
Dr. Gross has written book chapters and published papers dealing
with the theme of troubleshooting trachs to reach speech and
swallowing objectives.

<Robin> Welcome! I am glad everyone could be here tonight.
<Robin> Tonight we are chatting with Dr. Roxann Gross about The Effects of Tracheotomy on
          Speech and Swallowing Physiology. 
<Robin> Dr. Gross, could you start with an overview of tracheotomy? 
<RoxannGross> Well, tracheostomy tubes are placed in the trachea below the larynx to secure
          an airway. 
<Erin> Good evening. I was wondering if there are benefits and/or disadvantages to capping
          a trach vs long term use of a PMV (Passy-Muir Valve) ?  
<RoxannGross> If a person can tolerate capping, they should be capped. The PMV is for
          people that can't tolerate capping. 
<RoxannGross> Both will restore pressure and flow to the larynx. 
<AdrienneFSU> Can you talk a little bit about the sizes of PMVs? 
<RoxannGross> They are all the same size in that they fit a standard mm hub.
<Erin> I was told by and MD that use of a PMV reduces the patient's risk of aspiration
          compared to capping. Is this true? Could you please explain. 
<RoxannGross> A cap should be as good as a PMV for swallowing unless the patient can't get
          enough air in with the cap on.
<paw> When you are ready to address swallowing, I have a few questions re cuff
          inflation/deflation and swallowing/feeding. 
<RoxannGross> The thinking now is that the cuff should be DEFLATED for eating.
<RoxannGross> The cuff does not prevent aspiration. Anything that reaches the cuff has
          been aspirated.  
<KAS> I'm curious about your opinion of the blue dye test in regards to reliability.
<RoxannGross> I do not think that we should use blue dye testing unless we are trying to
          demonstrate gross aspiration. I do not use it. 
<RoxannGross> Blue dye has been shown to be unreliable especially for thin liquids and
          smaller amounts of aspiration. 
<paw> Do you do anything bedside to assess swallowing before doing a modified Barium
          Swallow test? 
<RoxannGross> We do a bedside first including a good oral motor eval. 
<paw> Do you present anything orally bedside? 
<RoxannGross> Yes. If they seem really risky, we use lollipops to increase saliva and see
          how that is managed. 
<paw> Oh. 
<RoxannGross> Lollipops can also be used to assess oral motor control for bolus manipulation.
          I use them in place of tongue blades too. We use the "dum dums" 
<paw> So, if they show poor ability to handle these secretions, you proceed with an MBS? 
<RoxannGross> Maybe not. We may try to improve their swallowing first. We like to use the
          MBS to the patient's benefit. 
<KAS> Under what conditions do you assess swallowing in ventilator patients? 
<RoxannGross> Any vent patient that is awake, alert and ready to eat....with a doctor's
          order- they're in the program. 
<Robin> Where do you start with a vent patient...you said you do a bedside eval?
<RoxannGross> Yes, bedside to understand oral motor function, secretion management,
          candidacy for PMV and cognitive level. 
<RoxannGross> We usually try to get vent patients on the PMVs for speech and swallowing
<KAS> I mean specifically, do you test vent patients with cuff inflated, deflated, or PMV
          on? If a patient does not tolerate PMV, do you hold on swallow eval? 
<RoxannGross> We will test with the cuff up if we have to and that is how they will eat.
          If things change and the cuff is going to be deflated, we retest. 
<Robin> Does everyone know what a cuff is? 
<RoxannGross> A cuff is a balloon that can be filled with air (inflated) or have the air
          drawn out (deflated). When the air is in, all breathing is through the tube only. 
<RoxannGross> The balloon or cuff is around the outside of the lower portion of the trach
          tube where we can't see. 
<RoxannGross> A pilot line and pilot balloon shows us cuff status. 
<AdrienneFSU> So the cuff blocks air from getting to the larynx any way other than through
          the tube? 
<RoxannGross> Yes- the cuff blocks any air from getting around the tube to the larynx. 
<RoxannGross> When patients breathe in and out of a trach with a cuff inflated no air
          reaches the larynx. All air goes in and out of the tube. When we deflate the cuff,
          and the trach is not too fat, air can move around the tube to the larynx. 
<Robin> Roxann, tell us about the valves used so the patient can speak. 
<RoxannGross> A speaking valve is a one-way air flow valve that allows patients to breathe
          in through the tube but out around the tube so they can talk. 
<RoxannGross> Hey everyone- great questions! 
<paw> Can you answer a few questions about swallowing/safely with a trach? 
<RoxannGross> What I am working on is that the larynx may well be an organ of swallowing
          and that anything that is unnatural for the larynx may be bad for swallowing. 
<paw> I know it's optimal for a trach patient to swallow with the cuff deflated. Is there
          any problem with swallowing with it inflated? 
<RoxannGross> When the cuff is inflated and no air or pressure can reach the larynx, the
          sensory-motor integration between the respiratory system and alimentary track
          (eating) is disrupted. People are more likely to aspirate silently. Some feel that
          the cuff disrupts laryngeal elevation. 
<AdrienneFSU> The final protection of the airway is coughing, which won't work with the
          cuff inflated right? 
<RoxannGross> Right- can't cough! A PMV or cap is great for coughing. Even with an open
          trach and cuff down, it is hard to build up enough pressure to cough well.
<Mary> Do you recommend doing laryngeal strengthening or vocal adduction exercises with a
          trach? I've heard conflicting thoughts about these exercises being damaging while
<RoxannGross> I do laryngeal exercises with trach patients and will do adduction exercises
          with a PMV, always after it is cleared by ENT. 
<paw> DPNS is very 'popular' in my area. I have serious qualms about this tx with a trach
          patient. Can you comment? 
<RoxannGross> I think that there are some patients that can benefit from that tx. I have
          gagged patients that had surgery on the posterior pharyngeal wall. 
<RoxannGross> Because that is the only thing that brought on movement (with the pt's
          permission). I would not use this tx with trach pts. 
<Robin> Can you explain DPNS? 
<RoxannGross> I'm not an expert, but it stands for deep pharyngeal neuromuscular
<paw> It's a controversial swallowing treatment. 
<RoxannGross> This is a controversial technique. Before someone named it and started to
          market and teach it, I used the gag out of desperation. 
<amygirl> What are some pathologies a person might have that would lead to them having
          this procedure done? 
<RoxannGross> Trachs are placed to secure an airway in the event of facial swelling after
          an accident or surgery, for pulmonary toliet or to give access to the lungs after
          someone has been orally intubated for too long (greater than 2 weeks usually) so
          that the larynx can be bypassed, but the patient can stay on the vent.  
<Mary> I don't know if I missed this, but do you do blue dye tests? What consistency do
          you start with, and how do you base that decision? 
<RoxannGross> I do not do blue dye tests. They miss too much aspiration and do not give
          any information about swallowing function. 
<RoxannGross> As a rule of thumb, if the swallow seems fast, but may be weak, I start
          with thinner or lower viscosities. If the swallow is very delayed, I'll start with
          thicker. It can detect GROSS (no pun intended) aspiration.
<paw> If a patient shows blue immediately though, it does indicate aspiration, right? 
<paw> Are you saying often, they aspirate and the blue dye does not show?   
<RoxannGross> Yes, they can aspirate and no blue dye will be suctioned or seen in the trach.
          Thin liquids can flow right to the lung bases--whether it's dyed blue or not. 
<Robin> I understand that there have been a couple of fatalities from blue dye....is that
<RoxannGross> I have heard of deaths associated with dying tube feedings blue for prolonged
<paw> So, rather than waste our time using blue coloring, just do the testing without it? 
<RoxannGross> We use FEES or MBS. 
<paw> We progress from a bedside assessment to an MBS. 
<paw> Depending on bedside results. 
<RoxannGross> Good. 
<Mary> What indicates at a bedside that a patient is appropriate for MBS? 
<Mary> Do you ever start feeding a patient without MBS or FEES? Or is a rule of thumb to
          complete a MBS always? 
<RoxannGross> I usually say that if you cannot answer all of your questions from the bedside
          eval or FEES, that you need to see the bolus move and the associated physiology,
          so do an MBS if you have questions. 
<Erin> Has research ever showed any difference in amount/incidence of aspiration using a
          PMV vs capped? 
<RoxannGross> No. Aspiration is less with a PMV vs open trach. Jeri Logemann did a study
          where they covered the tube with their finger and they aspirated less.  
<paw> Can you comment on swallow assessments on trach patients who are still on a vent,
<RoxannGross> We evaluate swallowing on vent patients using whatever status the cuff must
          be. The best thing to do is a videofluoroscopic eval. If they have to have the
          cuff up, I'd study them that way. 
<paw> Would it be necessary to repeat the MBS after they get off the vent and the cuff can
          be deflated? 
<RoxannGross> If they can't swallow well with the cuff up, we work toward getting the cuff
          down and a PMV on and try to repeat the study.  
<paw> I'm thinking of those who we start p.o. intake while on a vent. I'd expect the
          swallow to improve with the advance off the vent. 
<RoxannGross> Usually it does. 
<paw> Thanks 
<Mary> Do you always complete an MBS or FEES prior to starting p.o.? 
<RoxannGross> Not if the bedside is sufficient. 
<RoxannGross> We do use cervical ausculation. Do you know what that is? 
<AdrienneFSU> Julie Stierwalt at FSU is doing a study to find some norms for cervical
<Robin> Tell us about how you incorporate the cervical auscultation into your bedside eval. 
<Mary> I saw a product for sale that included a stethoscope to be used to listen to the
          swallow. I have tried this, but do not know what I am listening for. What does a
          normal vs impaired swallow sound like? 
<RoxannGross> We listen to the airway at the level of the larynx before and after the
          swallow. If we detect fluid or wheezing after a presentation that wasn't there
          before, it can suggest that material entered the larynx. We don't listen to the
          swallow itself... 
<RoxannGross> Also, you can determine if wet sounds are coming from the posterior
          oropharynx or larynx. 
<RoxannGross> Making this distinction can guide you to oral motor dysfunction rather than
          aspiration- possibly. 
<Robin> interesting 
<Mary> So what does fluid sound like? Just a wheezing soud?  
<RoxannGross> I hope to see it used more. You can hear a popping or fluid noise that is
          different from the dry air sound of usual breathing. I've heard kids and patients
          with COPD wheeze and found that they were aspirating when I x-rayed them. 
<Robin> Interesting....there is a CEU course posted on that subject on the course page of
          this website. 
<ALMT> Having trach/vent doesn't necessarily mean there will be a swallowing problem.
          I think the patient's diagnoses are important to look at. Would it be someone at
          high risk for dysphagia even without the trach/vent? 
<RoxannGross> You are right. Some people swallow just fine with a trach or on a vent.
          If we could figure out how they do it, if or how they compensate, then we could
          help the others that have difficulties. 
<ALMT> Does anyone have ideas on how to get respiratory therapists excited about
          collaborating on trying Passy Muir valve with vent patients?? 
<RoxannGross> I gave our respiratory therapists an inservice on swallowing. 
<RoxannGross> I told them about the theories of subglottic air pressure and swallowing
<Robin> ALMT, I just went to a great CEU course presented by a respiratory therapist and
          an SLP who work together all the time.
<RoxannGross> Through education, we work together all of the time now too. 
<Robin> Its very important to work with each other on these cases.
<RoxannGross> More fun too. 
<ALMT> We're getting there with patients off the vent, but not with patients on the vent. 
<RoxannGross> That was our problem. Teach them about PMV vent valves.
<Robin> It is getting late...are there any more questions for Dr. Gross?  
<Mary> Do you think it is necessary to pass an MBS before decannulation? I often argue
          with one doctor who feels this is necessary. I think the patients will do better
          on MBS after decannulation. Most doc's agree that if decannulation is near,
          hold on MBS. 
<RoxannGross> I do not think that you have to pass an MBS to be decannulated. I agree
          with you. Waiting until the swallow adjusts to the trach delays recovery and
          probably prolongs the hospital stay. 
<RoxannGross> Might that be the doctor's goal?  
<Mary> I just think he is being extra cautious. 
<RoxannGross> Well, there is still a need for research and information. 
<ALMT> Thanks. Bye.
<Robin> Thank you very much for joining us again, Dr. Gross, and sharing your expertise!  
<RoxannGross> Thank you for asking me Robin. It was really fun and I'll be here any time
          that you ask. 
<RoxannGross> Good night! 
<Robin> Goodnight all and thanks for joining us!