Feeding patients with tracheostomies.

Abstract

The recent article on feeding patients with tracheostomies was of great interest to our team, as we manage acute cervical spinal cord injury (CSCI) patients requiring respiratory support via tracheostomy. We appreciate that the paper acknowledges multi-disciplinary team (MDT) decision-making and expert assessment to include flexible endoscopic evaluation of swallowing (FEES), which is a therapeutic approach to dysphagia management. There are several issues to pick up from your article: We agree that the evidence on the impact of tracheostomies on swallowing is poor, but consider the primary diagnosis to be the over-riding factor with regard to the effect on laryngeal function. This should be carefully assessed using objective, instrumental assessment. The limitations of the blue dye test were acknowledged in your paper. We do not use this test within our unit. The sensitivity of this test is poor and tells us no information as to why or when the patient aspirated. We have seen a number of patients transferred to our hospital who have been eating and drinking orally but who present with disordered swallow patterns and compensatory behaviours. Further assessment and discussions have revealed subtle food avoidances, prolonged mealtimes, choking and avoidance of social occasions, which result in longer term issues. The clinical aim should be not only to promote oral intake but also to ensure that swallow function is as close to normal swallow physiology as possible. For our team this includes normalising upper airflow through employing cuff deflation, which has the added advantage of allowing verbal communication. Critically ill patients are usually unable to maintain adequate oral intake to meet their metabolic demands. Current evidence suggests that enteral nutrition, initiated early, may serve therapeutic roles beyond providing calories and protein as discussed at the recent Intensive Care Society State of the Art meeting in the UK. The goal should always be for safe oral feeding with a nasogastric tube (NGT) being a short term solution. A recent study has highlighted the specific impact of NGTs and although a small sample, this has also been seen in clinical practice under fibreoptic nasendoscopy. For high cervical SCI patients who have evidence of dysphagia, we recommend transition to gastrostomy feeding, which provides additional support for fluid management and administration of medication until full return to oral intake supported by speech and language therapy intervention. The acute tetraplegic population are known to be silent aspirators and often have poor sensation within the pharynx and larynx. The high risk of aspiration and consequent respiratory compromise makes this a vulnerable patient group. We are currently undertaking a study that looks at the clinical decisions that are made in intensive care around managing nutrition, swallowing and respiratory function in CSCI, called the DAISY project (www.daisyproject.info). Feedback from patients reflecting on their critical care management, report confusion and frustration when transferred to different units with varied clinical approaches to feeding. Consistency is very important and it would be valuable to establish nationwide agreement and guidelines for practice.