©

 COPYRIGHT 2015 EDIZIONI MINERVA MEDICA

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O R I G I N A L A RT I C L E

Changes of swallowing function after

tracheostomy: a videofluoroscopy study
P. CERIANA 1, A. CARLUCCI 1, A. SCHREIBER 1, C. FRACCHIA 2, C. CAZZANI 3,
M. DICHIARANTE 4, B. CATTANI 4, C. FASSIO 4, D. SEGAGNI 5, S. NAVA 6

1Respiratory Rehabilitation Unit, IRCCS Fondazione Maugeri, Pavia, Italy; 2Respiratory Rehabilitation Unit,
IRCCS Fondazione Maugeri, Montescano, Pavia, Italy; 3Radiology Department, IRCCS Fondazione Maugeri, Pavia,
Italy; 4Neurological Rehabilitation Unit, IRCCS Fondazione Maugeri, Pavia, Italy; 5Statistic and Biometry Department,
IRCCS Fondazione Maugeri, Pavia, Italy; 6Respiratory Intensive Care Unit, Policlinico S.Orsola, Bologna, Italy

ABSTRACT
Background. Patients after tracheostomy often present swallowing dysfunctions but little is known about the mech-
anism underlying dysphagia and its reversibility. The aims of this study were: 1) to characterize swallowing dysfunc-
tions in patients with dysphagia and tracheostomy; 2) to evaluate the reversibility of these changes; 3) to evaluate the
possible influence of the underlying disease.
Methods. Prospective, observational, single-center study enrolling patients with tracheostomy admitted to a reha-
bilitation center over a period of 36 months. All patients who were found to be dysphagic underwent a swallowing
study with videofluoroscopy (VF) at the beginning of hospital stay and a second VF study was repeated after ap-
proximately 4 weeks.
Results. A total of 557 patients with tracheostomy were admitted to the rehabilitation center during the considered
period. 187 patients fulfilled the enrolling criteria and were studied with VF soon after admission. They had been
tracheostomized for respiratory failure secondary to cerebrovascular accident (N.=106) or to acute-on chronic res-
piratory failure (N.=81). Incomplete backward epiglottis folding, pharyngeal retention, penetration and aspiration
were the most frequent swallowing dysfunctions, observed with a frequency of 48%, 32%, 33% and 28%, respec-
tively. Eighty-one patients underwent a second VF study, where these four swallowing phases again turned out to
be the most compromised, with a frequency of 41%, 19%, 27% and 17%, respectively. The improvement was less
evident in patients with chronic respiratory disease.
Conclusion. The swallowing function is impaired in patients with dysphagia and tracheostomy, but most swallow-
ing abnormalities appear to be partially reversible. Patients with chronic respiratory disease exhibit a worse swallow-
ing function. (Minerva Anestesiol 2015;81:389-97)
Key words: Swallowing - Tracheostomy - Deglution disorders - Epiglottis - Rehabilitation.

T ranslaryngeal intubation is generally con-

verted to tracheostomy when prolonged
nated movements and any difficulty during each
phase can interfere with the overall function. Af-
or other proprietary information of the Publisher.

ventilation is required.1 One of the advantages
of tracheostomy is the possibility to feed the
patient orally,2 although this procedure is some-
times risky and complicated. Swallowing is an
orderly process involving a sequence of coordi-
Comment in p. 357.
ter tracheostomy patients may experience silent
aspiration during meals 3 and develop inhalation
pneumonia, even when they are fed with the
tracheal tube cuff inflated, since this maneuver
does not impede the downward dripping of pen-
etrated food, due to leakage around the cuff.
Hence, swallowing function must always be

Vol. 81 - No. 4 MINERVA ANESTESIOLOGICA 389

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CERIANA SWALLOWING FUNCTION AFTER TRACHEOSTOMY
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properly evaluated when feeding by mouth a pa-
tient with tracheostomy.
Swallowing function is not always easy to as-
sess since, despite the promising role of magnetic
resonance imaging,4 only endoscopy 5 and video-
fluoroscopy (VF) 6 represent the standard diag-
nostic tests. The former can be carried out at the
bedside, but is much operator-dependent, the
latter has the inconvenience of radiation expo-
sure but enables to study all stages of swallowing.
From a theoretical point of view, the trache-
ostomy cannula can impair the normal swallow-
ing process through the following mechanisms:
reduced laryngeal elevation, mainly if the cuff
is inflated,7 reduced laryngeal sensitivity and
cough reflex,8 lack of subglottic pressure 9 and
worse coordination between swallowing and
breathing, especially in patients suffering from
a neuromuscular disease 10 or chronic obstruc-
tive pulmonary disease (COPD).11 Prevalence
of swallowing dysfunctions after tracheostomy is
not exactly known and is reported in literature
in a wide range (between 50% and 83%) 12 due
to different methodology used in the studies.
Besides, few, if any, pieces of information exist
about the reversibility of the swallowing changes
after a rehabilitation program.
In this observational, prospective, single-cen-
ter study we wanted to analyze: 1) the cause and
severity of swallowing dysfunction in patients
with tracheostomy and dysphagia 2) the revers-
ibility of these changes after a period of rehabili-
tation 3) the possible influence of the underlying
disease.
Materials and methods
Over a 36-month period we have studied all
the patients with tracheostomy admitted to our
Rehabilitation Center. This observational study
was approved by the local Ethics Committee
or other proprietary information of the Publisher.
with protocol number 643 and all the patients
gave their informed consent.
Our hospital is a 320-bed rehabilitation cent-
er with a neurological rehabilitation unit and a
respiratory rehabilitation unit specialized in the
rehabilitation of patients with cerebrovascular
disease and chronic respiratory diseases, respec-
tively. Patients had been tracheostomized in the
390 MINERVA ANESTESIOLOGICA April 2015
intensive care unit (ICU) of an acute care hospi-
tal, then transferred to our center for rehabilita-
tion and admitted to one of these units according
to the baseline disease responsible for disability.
The observational nature of the study implied
that all patients received usual care and were
treated according to the standard rehabilitation
procedures of each ward, hence without receiv-
ing any treatment considered experimental or far
from good clinical practice. Patients were clas-
sified, according to the ward of admittance, as
neurological patients (N group) and pulmonary
patients (P group). Data collection included age,
gender, underlying disease that required ICU
admission, tracheostomy technique and days
elapsed between tracheostomy and rehabilitation
ward admission. Upon ward admission, each
patient received an evaluation of his/her muscle
strength, using a score from 0 (no muscle con-
traction visible or felt) to 5 (normal power) using
a scale widely adopted in physical medicine.13
Within the first few days of hospital stay all
patients underwent a clinical bedside evaluation
of swallowing function if the following criteria
were fulfilled: alertness, capability to receive
food through the mouth and absence of gas-
trointestinal side effects due to oral feeding. The
assessment was based on the integrity of lips,
face, mouth, tongue and jaw movements, on the
presence of oral reflexes and the degree of up-
ward laryngeal elevation during dry swallowing.
To complete this bedside evaluation, the modi-
fied Evan’s blue dye test 14 was carried out deflat-
ing the cuff and feeding the patient with small
aliquots of dyed foodstuff. If any of the clinical
items were not consistent with safe swallowing
and if blue-tinged material was suctioned from
the trachea, the patient was scheduled for VF
study, provided that he/her was able to: 1) main-
tain the sitting position and 2) breathe sponta-
neously with the tracheostomy cuff deflated.
The VF test was performed on all patients al-
ways by a dedicated radiologist with more than
five-year experience in this technique, according
to the standard procedure 6 and the report in-
cluded the analysis of these swallowing phases:
glottis adduction/elevation (AE), oral phase of
transport (OP), onset of pharyngeal reflex (OR),
backward epiglottis folding (EF), pharyngeal
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means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
SWALLOWING FUNCTION AFTER TRACHEOSTOMY CERIANA
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contrast retention (PR), penetration (P) and
aspiration (A). Every patient received a 10-ml
bolus of barium contrast-impregnated water
with or without thickener, in order to evaluate
all consistencies (liquid, pudding and solid).
The effect of different postures (e.g., chin down)
was also evaluated, when indicated. The exam
was analyzed by the radiologist who performed
the exam together with another colleague who
viewed it independently. Each of the swallow-
ing phases was graded by both radiologists with
a numerical score from 1 (normal) to 2 (slightly
abnormal) and 3 (frankly abnormal) and a rate
of agreement between them greater than 95%
was searched as a target.
Rehabilitation procedures
Each patient underwent a tailor-made reha-
bilitation program according to his/her clinical
conditions and baseline disease, and targeted
to reverse the main causes of disability and to
wean him/her from tracheostomy, following an
already validated flowchart.15
When, after clinical and VF evaluation, dys-
phagia was diagnosed, it was approached through
a program set by physician, dietician and speech
therapist. The basic program adopted by N and
P wards included an oral feeding strategy based
on choosing the proper dietary consistency, ap-
plying supervision during meals with head po-
sitioning, cuff deflation and tracheal occlusion
with speaking valve; subsequently, oral and pha-
ryngeal thermal stimulation with ice chips were
prescribed, when indicated.
Furthermore, some patients from the N group
underwent a supplementary rehab program with
the performance of the Mendelsohn’s maneu-
ver 16 during meals and head raising exercises,17
when clinically indicated according to the speech
therapist indications.
or other proprietary information of the Publisher.
A second VF exam (T1VF) was performed
approximately four weeks after the first VF test
(T0VF), in order to assess the degree of revers-
ibility of the swallowing difficulties, so that each
patient acted as a control of him/herself. This
time lag was considered sufficient to observe a
significant rehabilitation outcome and change of
swallowing function.
Vol. 81 - No. 4 MINERVA ANESTESIOLOGICA 391
Statistical analysis
Data were reported as mean + standard devia-
tion when normally distributed or as median if
not normally distributed. According to this, we
performed the Shapiro-Wilk normality test on
the “age” variable. SPSS Statistical Software re-
lease 17.0.0 has been used for statistical analysis.
Data analysis was organized into three se-
quential steps: first, all VF exams taken at base-
line (T0VF) were pooled into a whole group
in order to see which of the different phases of
swallowing were more frequently recorded as
frankly abnormal; this was achieved through the
percentages of patients who scored 3 for every
single item from the VF report. At the end of
this step we expected to see which phases of the
swallowing process were most compromised in
patients with tracheostomy.
During the second step, patients were sepa-
rated into the two groups (N and P), according
to the baseline disease and the data of T0 exam
were compared between the two groups; differ-
ences in terms of categorical scores distribution
between the two groups were tested with the
Mann–Whitney test, a non-parametric statisti-
cal test for assessing whether one of two samples
of independent observations are statistically dif-
ferent between the N and P groups. At the end
of this step we expected to see the add-on effect
of the baseline disease on swallowing difficulties.
The third step included only the patients who
performed two tests (T0 and T1); in this case,
first, we compared pooled data of T0 with those
of T1 in order to seek for a possible improve-
ment at the end of the rehab period; then, we
repeated the same analysis but separately into
the two groups; T0 and T1 scores were com-
pared separately for each group (P and N) by
Wilcoxon rank-sum test for related samples to
search for a change. This analysis, according to
our expectations, should give us data about the
reversibility of the swallowing abnormalities, as-
sumed from the number of patients that, from
T0 to T1, passed from a higher to a lower score
for the same phase of swallowing. A P value
<0.05 was considered as threshold for statistical
significance.
The non-parametric Mann-Whitney test for
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CERIANA SWALLOWING FUNCTION AFTER TRACHEOSTOMY

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2 independent samples was applied in order to
evaluate if age differed between patients belong-
ing to N and P groups.
Results
During the 36-month period 557 patients
with tracheostomy were admitted in our reha-
bilitation hospital and 187 patient who satis-
fied the inclusion criteria were enrolled in the
study (Figure 1); they were 129 males and 58
females with a mean age of 65.8+9.5 years,
106 belonged to the N group and 81 to the P
group. The age variable resulted not normally
distributed (P=0.003), with a median of 67. The
causes of disability were, for Group N patients,
an ischemic cerebrovascular accident, a head
trauma or a cerebral haemorrhage (75%, 15%
and 10%, respectively) while for Group P pa-
tients they were an exacerbated chronic obstruc-
tive pulmonary disease or a restrictive thoracic
disease (65% and 35%, respectively). Patients
belonging to group P were older (P=0.001)
than those of group N (70.4+9.6 and 63.8+5.2
years for groups P and N, respectively). Trache-
otomy had been performed with percutaneous
technique 26.4+18.6 days before admission in
the rehab center, without significant difference
between groups P and N and all patients were
fed via enteral route through a nasogastric tube
that was in place since the first day of admission
in the ICU. Muscle strength score was grade 1
(flicker of muscle contraction but no movement
of joint) in 40% of patients, grade 2 (muscle
moves joint with gravity eliminated) in 45% of
patients and grade 3 (muscle moves joint against
gravity, but not against resistance) for 15% of pa-
tients. During T0VF exam all the patients were
breathing through a standard 8 mm (internal
diameter) cuffed tracheotomy single-lumen can-
nula with the cuff deflated and without speaking
valve. During the analysis of VF tests the score
given to the swallowing phases by both radiolo-
gists independently reached a rate of agreement
of 96% at first analysis; in the remaining 4% of
cases the agreement was reached during a second

Figure 1.—Flow-chart of patients screened and enrolled in the study during the considered period.
or other proprietary information of the Publisher.

Table I.—Results of T0 VF of the overall population (N.=187 patients).

AE EF OP PR OR P A
TOT T0VF 187 187 187 187 187 187 187
% score 3 17.5 48.8 14.8 32.6 16.6 33.7 28.9
The percentage with which each phase of swallowing has been scored 3 (frankly abnormal) is reported in the bottom line. AE: glottis adduction/
elevation; EF: epiglottis folding; OP: oral phase of transport; PR: pharyngeal contrast retention; OR: onset of pharyngeal reflex; P: glottis penetra-
tion; A: tracheal aspiration.

392 MINERVA ANESTESIOLOGICA April 2015

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SWALLOWING FUNCTION AFTER TRACHEOSTOMY CERIANA

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view. The results of T0VF exam are shown in Ta-
ble I, where we have listed, in percentages, the
swallowing phases which scored 3 (frankly ab-
normal). As can be observed, the most compro-
mised swallowing phases are epiglottis folding,
pharyngeal retention, penetration and aspira-
tion. Eighty-one patients underwent a second VF
exam (T1VF) 27+8 days after T0VF; they were
27 females and 54 males, 50 belonged to group
N, 31 to group P, and the mean age was 61.3 and
70.5 years for group N and P, respectively. Dur-
ing this test they were spontaneously breathing
through a 7 mm (internal diameter) cuffless can-
nula with speaking valve. Table II illustrates the
percentage distribution of the different phases of
swallowing, according to the score assigned, after
the separation of patients in P or N group dur-
ing both T0 and T1 VF, while Table III shows the
percentage distribution of the different phase of
swallowing in the overall population who per-
formed both VF tests (81 patients). As it can be
observed, during T0VF group P patients showed
worse scores than group N patients, with respect
to pharyngeal retention (P<0.012), penetration
and aspiration (P<0.001). At T1VF, all phases
of swallowing except epiglottis folding showed
a significant improvement compared to T0VF,
as demonstrated by the increase of phases scored
1 and 2 and the decrease of phases scored 3, as
a general trend of the whole population (Table
III). However, when comparing the results of
the two VF tests (T0 with T1) within each group
separately (Table II), we observed that, while
group N patients had a significant improvement
(P<0.03) in all phases of swallowing except epi-
glottis folding and onset of reflex, group P pa-
tients had an improvement only in the aspiration
phase (P<0.03).
Discussion
With the present study we demonstrated that
swallowing function is impaired in patients with
dysphagia and tracheostomy after ICU stay and
that the most common dysfunctions are the in-
complete backward epiglottis folding, pharyn-
geal retention, penetration and aspiration. Most
of these swallowing disorders are to some extent
reversible with time and appear to be facilitat-
ed by rehabilitation. The degree of reversibility
seems to be less evident in patients with chronic
respiratory disease.

Table II.—The percentages of each VF score (1=normal, 2=slightly abnormal, 3=frankly abnormal) grouped for disease (P and
N) and for swallowing phase.
AE EF OP PR OR P A
Disease group VF Score
T0 T1 T0 T1 T0 T1 T0 T1 T0 T1 T0 T1 T0 T1
P 1 38 67 20 26 25 44 21 26 33 31 19 33 40 53
2 46 24 42 37 66 48 39 48 40 55 41 23 34 27
3 17  9 38 37  9  8 40 26 27 14 40 44 26 20
N 1 51 73 21 29 16 23 37 47 29 50 41 54 63 87
2 31 23 22 27 66 66 34 37 58 45 37 33 26 10
3 18  4 57 44 18 11 29 16 13  5 22 13 11  3
* * * * *
T0 and T1 indicate the first and second execution of the VF test. AE: glottis adduction/elevation; EF: epiglottis folding; OP: oral phase of transport;
PR: pharyngeal retention; OR: onset of reflex; P: glottis penetration; A: airway aspiration. *= P<0.03.

Table III.—The frequencies of each VF score (1=normal, 2=slightly abnormal, 3=frankly abnormal) in the overall population
or other proprietary information of the Publisher.

(P and N) who performed both VF tests (81 patients).

AE EF OP PR OR P A
T0 T1 T0 T1 T0 T1 T0 T1 T0 T1 T0 T1 T0 T1
Score 1 40 69 16 28 12 31 26 39 16 24 21 42 34 62
Score 2 43 24 36 31 71 59 39 42 64 65 34 31 29 21
Score 3 17  7 48 41 17 10 35 19 18 11 45 27 37 17
T0 and T1 indicate the first and second VF test. AE: glottis adduction/elevation; EF: epiglottis folding; OP: oral phase of transport; PR: pharyngeal
retention; OR: onset of reflex; P: glottis penetration; A: airway aspiration.

Vol. 81 - No. 4 MINERVA ANESTESIOLOGICA 393

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CERIANA SWALLOWING FUNCTION AFTER TRACHEOSTOMY
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Reduced laryngeal elevation has been reported
as one of the main causes of swallowing impair-
ment after tracheostomy,18 especially with the
cuff inflated,7 although the concept of laryngeal
elevation has been questioned by Terk 19 and by
Kang.20
During T0VF, we observed an impaired glottis
elevation (score 3) only in a minority of our pa-
tients (17% and 18% of patients in group P and
N, respectively), and during T1VF this percent-
age further dropped to 9% and 4%, hence we
cannot support the concept that the tracheosto-
my cannula can hamper laryngeal elevation. Pos-
sible explanations to our data can be the mainte-
nance of the cuff always deflated and the process
of downsizing, since all patients passed from an
8 mm cuffed cannula to a 7 mm cuffless cannula.
Another possible mechanism of swallowing
dysfunction connected to tracheostomy has
been considered the loss of subglottic pressure 9
which provides airway protection and favors the
coordination between respiration and swallow-
ing.21, 22 When the tracheostomy cannula is
open, subglottic airway pressure is disrupted and
the risk of penetration and aspiration is increased
because of worse swallowing-breathing interac-
or other proprietary information of the Publisher.
Figure 2.—Incomplete backward epiglottis folding during
swallowing a bolus of contrast medium. The epiglottis is the
grey thin and curved structure indicated by the red arrow and
surrounded by the contrast medium. The incomplete backward
movement makes the glottis not protected against the penetra-
tion of barium in the airways.
394 MINERVA ANESTESIOLOGICA April 2015
tion and less efficiency in the airway protection
mechanism. In our patients, the improvement in
aspiration and penetration VF scores from T0 to
T1 can be partly explained by the application of
a speaking valve, that restores subglottic air pres-
sure, as confirmed by other authors.23, 24
The most common disorder of swallowing
function found in our patients was the incom-
plete backward epiglottis folding (Figure 2).
During normal swallowing, the elevation of the
hyoid bone exerts anterior traction to the base
of the epiglottis through the hyoepiglottic liga-
ment and this generates an horizontal downfold-
ing of the epiglottis; further contributions to this
downfolding movement is given by the elevation
of the laryngeal cartilage and by the pressure
generated by tongue base.
How this swallowing dysfunction can be ex-
plained and considered somehow linked to tra-
cheostomy is not straightforward. In absence of
clear VF data about hyoid bone movement, we
can only hypothesize that the impaired backward
epiglottis folding could be secondary to reduced
anterior hyoid displacement, although a possi-
ble role played by reduced strength of tongue
muscles cannot be excluded. Should this be the
case, the swallowing dysfunction would be more
linked to critical illness than to the tracheostomy
cannula per se. Critical illness polyneuropathy
can cause weakness and stiffness of all striated
muscles, including laryngeal and pharyngeal
ones, with consequent disuse muscle atrophy
and impaired swallowing mechanism.
The second significant swallowing difficulty
observed during VF study was the retention of
contrast media in the pharyngeal recesses and
vallecula (Figure 3), a problem already reported
by other authors.25, 26 We think that this can be
secondary to impaired tongue propulsion and
reduced pharyngeal and lingual contractile effi-
cacy, although a possible contribution to residue
in the vallecula can be explained by the reduced
mobility of the epiglottis itself.
Food retained in the pharynx can subsequent-
ly spill down slowly and penetrate into the glot-
tis and, in absence of an adequate cough reflex,
may also cause airway aspiration, and could be
the main reason of the high incidence of pen-
etration and aspiration observed in our patients.
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means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
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Figure 3.—Pharyngeal retention of contrast media in the epi-
glottis vallecula, indicated by the red arrow.
When patients were separately analyzed in
the two groups, we observed a worse swallow-
ing pattern in patients with chronic respiratory
disease for pharyngeal retention, penetration
and aspiration compared to neurologic patients.
Based on the lack of any difference between the
two groups with respect to the type of cannula
and to the time elapsed from tracheostomy to
admission to the rehab unit, we can assume that
an explanation may be found in the baseline res-
piratory disease. Actually, breathing-swallowing
interaction problems have already been reported
in COPD patients,27 as well as an increased ten-
dency to glottis penetration and airway aspira-
tion 28 and reduced laryngeal elevation 29 com-
pared to control subjects.
With respect to the significant improvements
in swallowing in the N group we must observe
that recovery of swallowing function after cer-
ebral ischemia/hemorrhage, follows a particular
pattern after the acute event. The incidence of
dysphagia after stroke ranges between 20% and
or other proprietary information of the Publisher.
50% 30 and recovery is rather common and takes
part generally within weeks.31 Studies conducted
with transcranial magnetic stimulation (TMS) 32
have shown that swallowing muscles are repre-
sented bilaterally in the cerebral cortex, but in
an asymmetric manner, so that patients may
have a sort of dominant swallowing hemisphere
that, if affected by stroke, makes the occurrence
Vol. 81 - No. 4 MINERVA ANESTESIOLOGICA 395
of dysphagia more likely.33 The study of cortical
connections over time with TMS showed that
patients recovering from dysphagia after stroke
increased their cortical maps in the unaffected
hemisphere, suggesting the hypothesis of a reor-
ganization of swallowing function in the unaf-
fected hemisphere.34
Limitations of the study
Our study presents some limitations: first, the
low number of patients who performed the sec-
ond VF test compared to the original population
(81 vs. 187) finds its explanation in the observa-
tional nature of the study. In fact, the decision to
perform the second VF study after approximate-
ly four weeks was stated a priori since it is part of
our routine practice, and so the second VF exam
was performed to all patients (who had previ-
ously performed the first VF study) that were
still in hospital when the second VF study was
scheduled (Figure 1). Second, we are aware that
more data about comorbidities and time elapsed
between intubation and tracheostomy could
have been helpful in order to better understand
possible additional causes of dysphagia, but since
data were gathered from documents enclosed in
the patient charts, in many cases were lacking, so
we decided to collect only data that were always
reported. Third, we have used a non-validated
scale for the evaluation of dysphagia, but we
must consider that only a limited number of
large-scale studies on dysphagia have been con-
ducted so far, with only two validated scores.35, 36
Yet, we found these scales not suitable for the
evaluation of our patients since the former 35
takes into account only two phases of swallow-
ing (aspiration and penetration) and the latter 36
was especially designed for stroke patients and
took into account some items that we could not
analyze, like lip closure, nasal penetration, oral
and pharyngeal transit time. Moreover, the in-
ter-rater reliability of this latter scale turned out
to be only moderate,37 with many parameters
showing even a low rate of agreement, implying
that even the use of a validated scale does not
represent a warranty for the reliability and the
validity of the data. Fourth, we have not includ-
ed as a control group patients with tracheostomy
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not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
CERIANA SWALLOWING FUNCTION AFTER TRACHEOSTOMY
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
but without dysphagia because this was a “real
life” observational study and the indication to
perform videofluoroscopy was given only when
dysphagia was suspected at the end of a clinical
evaluation. On the other hand, the performance
of an X-ray exam only for scientific purpose (i.e.,
in all patients with tracheostomy), would have
required a different study design.
Conclusions
In conclusion, we found that patients with
dysphagia and tracheotomy exhibit an impaired
swallowing function and that these changes are
to a significant extent reversible. This swallow-
ing dysfunction seems to be partly due to the
cannula itself but also the muscle weakness sec-
ondary to the post-critical phase seems to play
an important role. So the observed improvement
could be partly attributable to the tracheostomy
weaning process as well as to the recovery of ad-
equate muscular function as a result of physical
rehabilitation. Patients with chronic respiratory
disease exhibit the worse swallowing pattern and
show a reduced margin of reversibility compared
to neurologic patients.
Key messages
—— A significant percentage of patients
with tracheotomy have swallowing dysfunc-
tions, but it must be clear that tracheostomy
per se does not necessarily imply dysphagia.
Therefore, the resumption of oral feeding af-
ter tracheostomy requires a proper evaluation
for dysphagia.
—— The most common swallowing dys-
functions observed in patients discharged
from ICU with tracheostomy are the incom-
plete backward epiglottis folding and pha-
ryngeal retention.
or other proprietary information of the Publisher.
—— Besides the role played by tracheos-
tomy, this post-ICU epiglottis dysfunction
could also be linked to the after-effect of
critical illness myopathy and neuropathy.
—— Swallowing dysfunctions observed in
patients with tracheostomy and dysphagia
are potentially reversible to a variable extent.
396 MINERVA ANESTESIOLOGICA April 2015
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SWALLOWING FUNCTION AFTER TRACHEOSTOMY CERIANA
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Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material discussed
in the manuscript.
Received on January 23, 2014. - Accepted for publication on September 1, 2014. - Epub ahead of print on September 15, 2014.
Corresponding author: P. Ceriana, Pulmonary Rehabilitation Unit. Fondazione Maugeri, via Maugeri 4, 27100 Pavia, Italy.
E-mail; piero.ceriana@fsm.it
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