Tracheostomies and COPD

Patients with advanced COPD are likely to have tracheostomy tubes as it stabilises their airway and assists with their breathing (Health Communities, 2007; Wheeler, 1995). However, tracheostomy tubes affect swallowing mechanisms due to their position in the larynx (Goldsmith, 2000). The tracheosto
esophageus_and_tracheostomy.gif
Figure 1: A schematic representation of the location of a tracheostomy tube.
my tube is placed in the larynx below the vocal folds and can affect the passage of air through the trachea. It is thought that dysphagia and COPD are related by the breakdown of the respiration cycle while eating (Good-Fratturelli, 2000). Using a tracheostomy tube may help to regulate the respiration cycle but as seen below this can cause other complications.


Currently, one method to allow greater air flow for eating and speaking is to reduce the diameter of the tube. Theoretically this would increase the space that air could flow through, easing the swallowing and respiratory cycle. However, this could increase the risk of aspiration as there is greater space around the tube. As there have currently been no empirical studies on the validity of downsizing in regards to speech and swallowing further study is required to determine the validity of this theory (Grohler, 2010).

Tracheostomy tubes can also increase the risk of getting an infection (Grohler, 2010). Infections occur because a foreign object is located in one’s body. A severe infection can cause tissue breakdown which creates a space between the oesophagus and trachea. This breakdown creates an opening which once again can increase the risk of aspiration as it allows food to enter the lungs (Grohler, 2010).

Some believe that one possible method to decrease aspiration is to use a cuff with the tracheostomy tube. The theory behind the cuff is that it blocks the entrance to the lungs which in turn stops aspiration. It works by pressing against the wall of the trachea and sealing off the flow of any secretions from entering the lungs (Ding, 2005).
Trach_Tube_PICT.png
Figure 2: The correct placement of a trach tube in the trachea.(National Heart Lung and Blood Institute Diseases and Condition Index, 2010).
However, as air is not flowing through the larynx there is a decrease in sensitivity. This decrease in sensitivity can mask the appearance of a foreign body which does not alert the cough reflex. Ding (2005) found that silent aspiration was significantly increased when the cuff was inflated rather than deflated.


Care must be taken when attributing all aspiration to the tracheostomy. Leder (2005; 2000) has found there to be no causal link between tracheostomys and aspiration. Rather, it is the comorbidity of the disease and dysphagia before the tracheostomy that causes aspiration. This is important to be mindful of because current literature supports the findings that eventual removal of the tracheostomy tube will decrease aspiration. Instead Leder (2000) has reported that swallowing functions may not return once the tracheostomy tube has been removed and also that swallowing functions have improved even while the tube remains.

When planning treatment for a patient with COPD suffering from dysphagia who has a tracheostomy tube it is important to have a thorough case history. From this case history we can determine the occurrence before the tracheostomy. This determination will help us to see if aspiration and the tracheostomy are linked and if so what course of treatment to follow.














Reference:
Ding, R., & Logemann, J. (2005). Swallow physiology in patients with trach cuff inflated or deflated: A retrospective study. Head and Neck, 27(9), 809-813.
Goldsmith, T. (2000). Evaluation and treatment of swallowing disorders following endotracheal intubation and tracheostomy. International Anesthesiology Clinics,D 38(3), 219-242.
Good-Fratturelli, M., Curlee, R., & Holle, J. (2000). Prevalence and nature of dysphagia in VA patients with COPD referred for videofluoroscopic swallow examination. Journal of Communication Disorders, 33, 93-110.
Grohler, M., & Crary, M. (2010). Dysphagia: Clinical Management in Adults and Children. Maryland Heights, MO: Mosby, Inc.
Health Communities. (2007). Therapy for Chronic Obstructive Pulmonary Disease Acute Exacerbations. Retrieved from http://www.pulmonologychannel.com/copd/acuteexacerbation.shtml

Leder, S., Joe, J., Ross, D., Coehlo, D., & Mendes, J. (2005). Presence of a tracheotomy tube and aspiration status in early, postsurgical head and neck cancer patients. Head and Neck, 27(9), 757-761.
Leder, S., & Ross, D. (2000). Investigation of the causal relationship between tracheotomy and aspiration in the acute care setting. The Laryngoscope, 110(4), 641-644.National Heart Lung and Blood Institute Diseases and Condition Index. (2010). What to expect during a tracheostomy. Retrieved from http://www.nhlbi.nih.gov/health/dci/Diseases/trach/trach_during.html.
Wheeler, D. (1995). Communication and swallowing problems in the frail older person. Topics in Geriatric Rehabilitation, 11(2), 11-25.