A tracheostomy is a medical procedure that creates an opening in the neck, through which a tube is placed into the trachea (windpipe) to help a person breathe. The tracheostomy tube bypasses the upper airway, which is necessary when the airway is blocked or when long-term mechanical ventilation is required. A person can eat with a tracheostomy tube, but this ability depends entirely on the individual’s underlying medical condition and requires a thorough medical assessment to ensure swallowing safety.
The Physiological Impact of a Tracheostomy on Swallowing
The presence of a tracheostomy tube, especially one with an inflated cuff, can complicate the natural process of swallowing. Swallowing requires the larynx to elevate and move forward to protect the airway from food or liquid entering the lungs. The tracheostomy tube can physically impede this necessary upward and forward movement, a phenomenon known as laryngeal tethering.
The ability to generate a strong, protective cough is also compromised, which impacts swallowing safety. A normal cough relies on the buildup of subglottic pressure (air pressure beneath the vocal cords). The open tracheostomy tube allows air to escape through the neck opening, preventing this pressure from building up and diminishing the effectiveness of the cough reflex.
Airflow through the tube, rather than through the nose and mouth, reduces sensory input to the larynx and pharynx. This decreased laryngeal sensation can delay the protective swallow reflex. This delay may allow food or liquid to enter the airway without the person noticing, known as silent aspiration. These physiological changes necessitate a cautious approach to reintroducing oral feeding.
Clinical Assessment and Determining Swallowing Safety
Before oral intake is permitted, a formal evaluation of swallowing function minimizes the risk of aspiration and subsequent lung infections. The Speech-Language Pathologist (SLP) conducts this assessment and develops a safe feeding plan. Evaluation often begins with a clinical bedside assessment, checking the patient’s alertness, ability to follow commands, and management of oral secretions.
Instrumental assessments provide objective data and are recommended before commencing a diet. The Modified Barium Swallow (MBS), also known as a Videofluoroscopic Swallowing Study (VFSS), uses X-ray technology to visualize the entire swallowing process in real-time. This helps the clinician determine the cause of difficulty and identify specific strategies or diet modifications.
The Fiberoptic Endoscopic Evaluation of Swallowing (FEES) is another common instrumental test. It involves passing a small, flexible camera through the nose to view the throat and vocal cords directly. FEES is often preferred for tracheostomy patients because it can be performed at the bedside and assesses secretion management and laryngeal function.
The Modified Blue Dye Test (MBDT) is a common bedside screening tool. A small amount of food or liquid mixed with blue dye is swallowed while the patient’s tracheal secretions are suctioned. The appearance of blue dye indicates aspiration, but the test has a high rate of false negatives and cannot definitively rule out risk.
Strategies for Safe Oral Intake
Once the SLP determines a person is safe to eat, specific strategies compensate for altered swallowing physiology. If the tracheostomy tube has an air-filled cuff, it must be completely deflated during meals and assessments. Deflating the cuff improves laryngeal elevation and prevents the cuff from mechanically restricting the passage of food in the esophagus.
Using a one-way speaking valve during oral intake is often recommended to normalize airflow. The valve closes on exhalation, redirecting air through the vocal cords and mouth. This restores the subglottic pressure needed for a forceful cough, improving laryngeal sensation and enhancing swallowing safety.
Optimal positioning is an effective strategy, requiring the patient to sit upright at a 90-degree angle with the head slightly forward during and immediately after the meal. The SLP may recommend modifications to food and liquid texture, such as thickened liquids or pureed foods, to make them easier to control. Specific swallowing techniques, like the chin tuck maneuver, can also help narrow the airway entrance and improve protection.
Practical Mealtime Adjustments
Other practical adjustments help ensure safe oral intake:
- Taking small bites and sips.
- Chewing thoroughly and eating slowly without distractions.
- Suctioning the tracheostomy tube before eating to clear built-up secretions.
- Continually practicing and adjusting techniques based on progress.
Alternative Feeding Methods
When swallowing remains unsafe or insufficient to meet nutritional needs, alternative feeding methods are required. These methods deliver nutrition directly into the digestive system, bypassing oral swallowing and minimizing the risk of aspiration pneumonia.
For short-term support, a Nasogastric (NG) tube is commonly used. This thin, flexible tube is inserted through the nose and guided into the stomach. NG tubes are typically used for a few weeks or up to a month, as they are not designed for long-term use.
For extended feeding assistance, a Gastrostomy (G) tube is the preferred option. A G-tube, often placed using a Percutaneous Endoscopic Gastrostomy (PEG) procedure, is surgically inserted through the abdominal wall directly into the stomach. This method ensures adequate calorie and fluid intake while the patient works on improving oral swallowing function.