TRACHEOSTOMY & Modified Blue/green Dye Test

INTRODUCTION

 Endotracheal intubation and tracheostomy: common artificial airway procedures done for
ventilation and tracheobronchial toileting.
 Most commonly seen in :ICU, neurological and HNS cancers patients.
 It can disrupt the normal coordinated physiology of swallowing in many ways.
 Recent extubation or decannulation can have dysphagia for a variable amount of time.
 Factors like neurological disorders and preexisting swallowing difficulties contribute to
the development of dysphagia.
INCIDENCE

 Range of dysphagia: 3% to 62% in intubated patients

 Longer the duration greater the dysphagia.
 Type of the test used to evaluate dysphagia also influences the incidence.
 The pilot phase of EDISVAL study reported that 27/29 [3] patients showed aspiration in Modified
Evans blue dye test.
 In HNS patients with tracheostomy : incidents of aspiration is 58%
 In the acute care setting, the causal relationship of tracheostomy tube and aspiration was reported by
Leder and colleagues
 The patients who had aspiration post-tracheostomy were the patients who had pretreatment
aspiration.
 So They concluded that there was no causal relationship between aspiration and tracheostomy status.
 Dysphagia in intubated patients often persists post-extubation.
 Brodsky and colleagues reported that one-third of patients who had been intubated for
acute respiratory distress syndrome had persisting dysphagia after hospital discharge
 This is important to recognize as these patients may benefit from further rehabilitation with
the swallowing pathologist.
POSSIBLE MECHANISMS OF DYSPHAGIA DUE
TO THE ARTIFICIAL AIRWAY APPLIANCES

 Various factors postulated to contribute to dysphagia in these patients are:

1. Compression of the esophagus by the cuff and tube
2. Impaired hyomandibular elevation
3. Inhibition of the stretch opening of the cricopharyngeus
4. Impaired anterior rotation of the larynx
5. Disuse of the laryngeal muscles
 Most significant: impaired hyomandibular elevation and the anterior rotation of the larynx. This results
in impaired opening of cricopharyngeal sphincter.
 Animal studies by Sasaki [8] showed that there is a disuse atrophy of the laryngeal muscles due to the
bypass of air through the tube.
 In patients without a concomitant neurological deficit, the commonest deficit was delayed triggering of
the swallow and pharyngeal pooling.
 This process does not reverse readily on extubation and could be the result of weakness and poor
coordination of the swallow response.
CUFF RELATED PROLEMS

 The cuffs are designed to protect the lower airway and to maintain pressure during
ventilation.
 But cuffs does not completely prevent aspiration
 Some amount of pooled secretions will flow into larynx.
 It’s a common belief that: inflated cuff protects airway, but more the cuff inflated the
resistance in the upward movement of larynx.
 Analysis shows that when there is an inflated cuff, there is reduced laryngeal elevation and
more silent aspiration.
 because an inflated cuff reduces the expiratory flow, and there is desensitization of the
larynx. So no effective clearance of secretions.
 patients with a tracheotomy, including cuff inflated and cuff-deflated conditions, the
frequency of aspiration was 64.8%.
 The frequency of silent aspiration for all tracheostomy patients was 29.9%
EVALUATIONS OF TUBE RELATED
DYSPHAGIA
 Clinical examination and a combination of tests are the usual evaluations in intubations or
tracheostomy
 Mental and pulmonary status of patient should be satisfactory to start on oral feeds.
 Typically, the patient is awake and has been extubated for 24  h with a stable pulmonary
status.
 Special attention given to
 1.Voice : wet, indicates secretions and impaired swallow
 2.Oral cavity: for thick crusts
 3.Palatal and tongue movements
 4.Cough strength :
 Once patient fit for evaluation , step wise examination can begin :
 1. Laryngeal movement : on swallowing with cuff deflated
 2. Various diet consistencies and responses are observed
 3. Reflexive cough indicates: penetration / aspiration
 4. Green/Evans blue dye is recommended : and tracheal suction and examination for blue dye
PREPARATION FOR THE PROCEDURES

 Semi-sitting position,
 Secretions were aspirated from both the inside of the tracheostomy tube and the subglottic
channel, and, finally, the tracheostomy cuffs were deflated.
ADMINISTRATION OF FOOD MATERIALS

 Such as ice, liquid, or mash, impregnated with methylene blue.

 Mixed 3 mL of water + 2 mL of methylene blue, obtaining 5 mL of liquid (instead of four
drops of the original Evans test), which corresponds to the smallest volume used in
procedures testing different volumes and consistencies.
 The 5 mL was administered in a syringe in the middle-posterior third of the tongue, and
then the patient was asked to swallow
SIGNS AND SYMPTOMS :

 early/late cough, changes in voice,

 asphyxia,
 a decrease of 3 or more points in pulse oximetry saturation, and
 the presence of blue stains (alone or mixed with secretions or saliva) through the
tracheostomy tube.
 If no cough or spontaneous secretions were present, suctioning into the tracheostomy
tube was repeated in 15-minute intervals for an hour, and the sample obtained was
examined for blue discoloration against a white background under full-room lighting.
 MBDT was considered positive if evidence of blue-stained material was obtained through
the tracheostomy cannula
 From research paper

 (1) Background:
 Diagnosis of dysphagia in critically ill patients with a tracheostomy is important to avoid aspiration pneumonia. The
objective of this study was to analyze the validity of the modified blue-dye test (MBDT) on the diagnosis of dysphagia in
these patients;
 (2) Methods:
 Comparative diagnostic test accuracy study. Tracheostomized patients admitted to the Intensive Care Unit (ICU) were
studied with two tests for dysphagia diagnosis: MBDT and fiberoptic endoscopic evaluation of swallowing (FEES) as the
reference standard. Comparing the results of both methods, all diagnostic measures were calculated, including the area
under the receiver-operating-characteristic curve (AUC);
 (3) Results:
 41 patients, 30 males and 11 females, mean age 61 ± 13.9 years. The prevalence of dysphagia was 70.7% (29 patients)
using FEES as the reference test. Using MBDT, 24 patients were diagnosed with dysphagia (80.7%). The sensitivity and
specificity of the MBDT were 0.79 (CI95%: 0.60–0.92) and 0.91 (CI95%: 0.61–0.99), respectively. Positive and negative
predictive values were 0.95 (CI95%: 0.77–0.99) and 0.64 (CI95%: 0.46–0.79). AUC was 0.85 (CI95%: 0.72–0.98);
 (4) Conclusions:
 MBDT should be considered for the diagnosis of dysphagia in critically ill tracheostomized patients. Caution should be
taken when using it as a screening test, but its use could avoid the need for an invasive procedure.
 5.Limitations:
 There is great controversy about the medical use of methylene blue.
 In 2003, the FDA banned its use because of some reports on the occurrence of adverse
effects with its administration in enteral formulations in patients with alterations in
intestinal permeability (septic), as it could be absorbed into the bloodstream [32].
 In Europe, such a prohibition has not taken place as the results are not considered
conclusive. A recent systematic review is also in the same direction when considering it
safe at the doses used for swallowing studies [33].
 Alternative substances, such as food dyes or contrast agents, have been suggested, but
there is little published experience to date.
 5. Gastroesophageal reflux assessed by using dye in RT feeds and examining
tracheal/secondary seceretion
 Common investigations are :
 1.FEES: structure can be visualized
 2.VFSS : gold standard method , can assess for aspiration , different stages of swallowing
will be tested
TECHNIQUES TO REDUCE DYSPHAGIA

 One method is tube occlusion.

 the presence of the tube prevents the building up of subglottic pressure resulting in an
impaired cough reflex. Occlusion of the tube can be possible with a finger, cap, or
speaking valves.
 When the tube was kept open, there was an increase in the pharyngeal activity duration
(PAD) and Bolus transit time (BTT).  The pharyngeal constrictors and suprahyoid muscles
were in contraction for a longer time.
 Leder and colleagues found that occluding the tracheostomy tube had no influence on the
prevalence of aspiration.
 Kang did a kinematic analysis and found no difference in the laryngeal elevation both pre-
and post-decannulation.
 Also, there was no change in the upper esophageal sphincteric mechanism or the
pharyngeal pressures between patients who had tracheostomy blocked or open.
WEANING OF PATIENTS FROM
TRACHEOSTOMY
 Mah and colleagues reported the efficacy of the “post-tracheostomy bundle”.
 The protocol consisted of a multidisciplinary collaboration between the surgeon, the
respiratory therapist, the registered nurse, and the swallowing pathologist.
 periodic reviews by the specialists and special tracheostomy rounds.
 The mechanism of decannulation is downsizing and closing of the tube which is to be done
under the supervision of the surgeon.
 the recommendations need to be individualized to patients.
 Patients who are recently extubated after prolonged intubation may need a period of 24 h
prior to dysphagia testing
 In patients who need a prolonged tracheostomy, the testing can be done with the tube in situ after the
patient is weaned from the ventilator.
 A blue dye test is performed, and the tracheal secretions are examined for the dye.
 If there is aspiration, the following can be done:
 1. Use of a smaller tracheostomy tube—downsizing the tracheostomy and using a speaking valve.
Alternatively, a cuffless tube can be used if the patient tolerates. These will promote sensitization of the
larynx
 2.The patient is reevaluated after 2 days and a repeat bedside assessment with a blue dye test
 3.If the patient on reassessment is showing signs of aspiration and has a wet voice and poor motor
function, then a VFS and FEES are done, and a referral is made for the swallowing pathologist.
 4. If the patient is showing no signs of aspiration and has good muscle motor movements and a strong
cough, then a diet of thick fluids is started.
CONCLUSION

 Literature is divided with regard to the extent of dysphagia in patients who have been
intubated or have a tracheostomy.
 Patients who have artificial airway appliances need to be assessed with bedside tests prior
to initialization of feeds.
 Multidisciplinary care is essential to ensure dysphagia management in this subset of
patients.
Inspiration & Generous knowledge
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