Logopedics Phoniatrics Vocology

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Tracheostomy management by speech-language

pathologists in Sweden

Sara Wiberg, Susanna Whitling & Liza Bergström

To cite this article: Sara Wiberg, Susanna Whitling & Liza Bergström (2022) Tracheostomy
management by speech-language pathologists in Sweden, Logopedics Phoniatrics Vocology,
47:3, 146-156, DOI: 10.1080/14015439.2020.1847320

To link to this article: https://doi.org/10.1080/14015439.2020.1847320

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LOGOPEDICS PHONIATRICS VOCOLOGY
2022, VOL. 47, NO. 3, 146–156
https://doi.org/10.1080/14015439.2020.1847320

RESEARCH ARTICLE

Tracheostomy management by speech-language pathologists in Sweden

Sara Wiberga,b , Susanna Whitlingb €mc,d
and Liza Bergstro
a
Department of Speech and Language Therapy, Helsingborg Hospital, Helsingborg, Sweden; bDepartment of Logopedics, Phoniatrics and
Audiology, Faculty of Medicine, Lund University, Lund, Sweden; cDivision of Speech and Language Pathology, Department of Clinical
Neuroscience and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden;
d
REMEO Stockholm, Sk€ondal, Sweden

ABSTRACT ARTICLE HISTORY

Purpose: Speech-language pathologists’ (SLPs) role in tracheostomy management is well described Received 15 April 2020
internationally. Surveys from Australia and the United Kingdom show high clinical consistency in SLP Revised 22 October 2020
tracheostomy management, and that practice follows guidelines, research evidence and protocols. Accepted 2 November 2020
Swedish SLPs work with tracheostomised patients, however, the content and extent of this practice,
KEYWORDS
and how it compares to international research is unknown. This study reports how SLPs in Sweden Speech-language therapy;
work with tracheostomised patients, investigating (a) the differences and similarities in SLPs tracheos­ speaking valve;
tomy management and (b) the facilitators and barriers to tracheostomy management, as reported questionnaire; tracheotomy;
by SLPs. practice; critical care;
Methods: A study-specific, online questionnaire was completed by 28 SLPs who had managed trache­ tracheostomy team
ostomised patients during the previous year. This study was conducted in 2018, pre Covid-19 pan­
demic. The answers were analysed for exploratory descriptive comparison of data. Content analyses
were made on answers from open-ended questions.
Results: Swedish SLPs manage tracheostomised patients, both for dysphagia and communication.
During this study, the use of protocols and guidelines were limited and SLPs were often not part of a
tracheostomy team. Speech-language pathologists reported that the biggest challenges in tracheos­
tomy management were in (a) collaboration with other professionals, (b) unclear roles and (c) self-per­
ceived inexperience. Improved collaboration with other professionals and clearer roles was suggested
to facilitate team tracheostomy management.
Conclusions: This study provides insight into SLP tracheostomy management in Sweden, previously
uncharted. Results suggest improved collaboration, further education and clinical training as beneficial
for a clearer and more involved SLP role in tracheostomy management.

Introduction lacking due to methodological issues [5]. Studies have also

Tracheostomy tube placement is one of the most common
procedures in the Intensive Care Unit (ICU) and is per­
formed to facilitate breathing [1]. The most common indica­
tions for tracheostomy are (1) acute respiratory failure and
need for prolonged mechanical ventilation, (2) neurological
insults requiring airway, or mechanical ventilation, or both,
and less common (3) upper airway obstruction [2].
The complexity of tracheostomised patients and tracheos­
tomy care requires a range of professional expertise and
emerging evidence suggests that optimal tracheostomy man­
agement requires a multidisciplinary approach [3–5]. Care
by multidisciplinary teams which include speech-language
pathologists (SLPs), have been shown to be beneficial for
patients. Benefits include decreased total tracheostomy time
and increased use of speaking valves, reduced ICU/hospital
length of stay and reduced tracheostomy-related complica­
tions; however, high-level evidence in some studies is
shown that a multidisciplinary approach and the use of pro­
tocols, reduce morbidity and mortality and that dedicated
tracheostomy teams enhance the consistency of care, which
allows more efficient and effective communication between
caregivers [6]. The SLP role in the multidisciplinary team
involves communication and dysphagia management
(assessment and intervention). Further, SLPs competence of
laryngeal function and secretion management is reported to
be beneficial in the weaning and decannulation pro­
cess [3,7,8].
A tracheostomy tube in situ is often associated with dys­
phagia and impaired airway protection. Whether the trache­
ostomy tube itself causes impaired swallowing function has
been debated. Some studies show that the tracheostomy
tube leads to reduced ability to build subglottic air pressure
when swallowing with an open tracheostomy tube, reduced
glottic closure, desensitization of the larynx, discoordination
of swallowing with respiration and reduction of laryngeal

CONTACT Sara Wiberg sara.wiberg@med.lu.se Department of Speech and Language Therapy, Helsingborg Hospital, Charlotte Yhlens gata 5, Helsingborg
S-251 87, Sweden
� 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),
which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.

elevation [9]. However, other studies have found no signifi­
cant changes in swallowing or aspiration due to tracheos­
tomy tube [10–12]. Leder et al. [11] reported that the
tracheostomy tube may affect swallowing function, but that
it is the underlying cause for needing tracheostomy that
causes dysphagia and not the tracheostomy in itself. SLPs
dysphagia management including bedside FEES can be used
to identify risk of aspiration, readiness for cuff deflation and
weaning [8,13–15].
A tracheostomy may also negatively impact a person’s
ability to communicate. A tracheostomy tube with an
inflated cuff causes total loss of voice and is debilitating for
oral communication. Communication difficulties have been
documented as one of the most negative hospital experien­
ces for patients [16,17]. A study by Laakso et al. [18]
showed that ventilated patients struggle in their attempt to
achieve effective communication and that health care profes­
sionals need to improve their understanding of communica­
tion for ventilated patients. The same study also suggested
continuous follow-up by SLPs tailoring individual commu­
nication solutions.
Research indicates that early, targeted SLP-lead interven­
tion using speaking valves leads to earlier return of voice
compared with standard care, i.e. without early speaking
valve intervention [5,16,19,20]. This return of voice leads to
an improvement in patient-reported cheerfulness and the
ability to be understood by others and are also associated
with a positive change in quality of life [21]. Aside from
restoring voice function, speaking valves have also been
reported to decrease tracheal secretions and to improve
sense of smell, ability to cough, and weaning trial tolerance
[22]. Speaking valves have shown to improve positive end-
expiratory pressure (PEEP), subglottic pressure and restore
protective expiration towards the upper airway after swal­
lowing [9,23,24]. For those patients who are unable to toler­
ate cuff deflation, Above Cuff Vocalisation (ACV) is
another possible communication technique. A retrograde
flow of gas is directed via the suction port (on those trache­
ostomy tubes that have an above-cuff suction port), allowing
airflow through larynx and thereby enabling voice [25].
The role of SLPs in tracheostomy management is well
established and described in several international health care
systems, including in both ICU and non-ICU wards
[16,26–28]. Surveys reporting on SLPs tracheostomy man­
agement in Australia [28] and the United Kingdom [27]
show high clinical consistency in tracheostomy management
by SLPs and that practice follows guidelines, research evi­
dence and protocols [8,29,30].
In Sweden, approximately 2000 patients undergo a
tracheotomy every year [31]. National recommendations for
tracheotomy and tracheostomy care in adults were published
in 2017, where referral to SLPs is recommended when a
swallowing impairment with aspiration is suspected [31],
otherwise there is no recommendations or role description
in SLP involvement in tracheostomy management. National
guidelines for tracheostomy management in children were
published in 2018, in which the SLP role and assessments
regarding swallowing and communication were described
LOGOPEDICS PHONIATRICS VOCOLOGY 147
[32]. Currently, there are no specific national guidelines for
SLP management of adult tracheostomised patients and no
available statistics on number of SLPs working with trache­
ostomised (paediatric or adult) patients in Sweden [33].
Anecdotal evidence suggests that Swedish SLPs work
with tracheostomised patients, however the content and
extent of this practice and how it compares to international
research is unknown. This study aims to report how
Swedish SLPs work with tracheostomised patients, investi­
gating (a) the differences and similarities in SLPs tracheos­
tomy management in Sweden, and (b) the facilitators and
barriers to tracheostomy management, as reported by SLPs.
Furthermore, this study specifically investigates the follow­
ing questions; (1) Are there dedicated teams to manage tra­
cheostomised patients? If so, are SLPs a part of these teams?
(2) Is there a correlation between the SLPs experience and
use of guidelines or protocols?
Methods
Study design
This is an observational, cross-sectional, survey-study using
a mixed method design, including quantitative and qualita­
tive outcomes. Non-probability sampling was used for par­
ticipant selection. Data was collected through a study-
specific, online questionnaire, May–June 2018.
Ethics
The study was conducted according to the Declaration of
Helsinki [34]. Ethical approval was obtained by the ethical
board at Lund University (VEN, ref nr 27-18). All partici­
pants received written information about the study, includ­
ing that participation was voluntary and answers were
confidential. By submitting the questionnaire participants
consented to study inclusion. Answers were not traceable
back to participants after questionnaire submission.
Data collection and participants
Inclusion criteria were SLPs working in Sweden who, during
the past year, had managed tracheostomised patients, chil­
dren and/or adults. The number of SLPs working with
tracheostomy patients in Sweden are believed to be few,
though actual figures are unknown. As part of this research
a follow-up email survey to the six university hospitals in
Sweden identified that although SLPs manage tracheostom­
ised patients, no dedicated SLP positions currently exist in
any of the ICUs. To reach as many SLPs as able who work
with tracheostomised patients, snowball sampling was used,
in which participants were requested to forward the ques­
tionnaire link to colleagues and as many suitable candidates
as possible. A link to the questionnaire was sent to potential
participants through various SLP networks including, but
not limited to, regional dysphagia network groups, national
SLP tracheostomy working party and SLP-specific commun­
ities in social media.
148 S. WIBERG ET AL.
Online questionnaire
A study-specific questionnaire was developed through
Survey & Report version 4.3.3.5 [35]. A pilot questionnaire
was tested on two SLPs who manage tracheostomised
patients, and minor adjustments were made to clarify and
improve the questions. The questionnaire consisted of
n ¼ 30 questions (see Appendix A). Part I collected demo­
graphic data about the participants. Part II consisted of mul­
tiple choice and open-ended questions about tracheostomy
management. Part III included open-ended questions for the
participants to provide further insights into the topic, that
is, by describing in their own words how they work with
tracheostomised patients. The online questionnaire was dis­
tributed via email and online media and was open
for 30 days.
Data analysis
Data from the questionnaire were analysed using IBM SPSS
version 24 [36]. Descriptive statistics were used for partici­
pant demographic data. Non-parametric two-sided tests
were used due to sample size and data type. Comparison
between participants’ demographic data and research ques­
tion responses (such as participant tracheostomy experience
and use of assessment protocols or use of guidelines) were
calculated using Kruskal–Wallis test for ordinal data.
Significance level was set to p < .05 for all tests, at 95% con­
fidence level.
For qualitative analyses, Systematic Text Condensation
was used to analyse answers from open-ended questions
[37]. Answers from questions 25–28 were summarised and
presented for each topic. Answers from question 29 and 30
were more comprehensive. Data were analysed initially by
the first author who works as a SLP and manages tracheos­
tomised patients predominantly on a neurological ward.
Meaning units were identified, coded and sorted into sub­
groups. Subgroups were thereafter summarised into catego­
ries. Bias was minimised for systematic text condensation by
using the second author, who does not work with tracheos­
tomised patients and independently analysed this data
Table 1. Comparison and output content analysis.
Barriers
1st author 2nd author
1. Collaboration/team/roles 1. Lack of knowledge in other
professionals
2. Lack of knowledge in other 2. Lack of guidelines and role
professionals description in care
3. Complex patients 3. Uncertainty in
assessments/equipment
4. Lack of guidelines 4. SLP lack of experience
5. SLP own experience
and knowledge
Final
1. Collaboration with other professionals
2. Unclear roles and lack of guidelines
3. SLP experience and knowledge
separately. Comparison between these two analyses were
made and led to some adjustments regarding categories. See
Table 1 for comparative analysis process and final themes.
Results
Participant demographics
A total of 28 participants from six health care regions (in 10
different Swedish counties, of a total of 21 counties) com­
pleted the questionnaire and were included in the analysis.
No questions were left unanswered. Demographic data are
presented in Table 2. The estimated number of tracheos­
tomised patients seen per year ranged widely, from one
patient per year up to 80 patients per year, a median of 3,5,
(IQR ¼ 8) (range 2–10). Tracheostomised patients were
seen in different settings, most commonly in the ICU, in
acute settings, rehabilitation and/or within SLP departments.
The majority of SLPs worked with adult tracheostomised
patients only (79%) and managed both communication and
dysphagia (82%). Most participants reported that they had
little self-perceived experience with tracheostomy manage­
ment. Only two reported great experience. These two have
also reported that they see 20 respectively 80 patients per
year. Analysis using Kruskal–Wallis test showed there was a
statistically significant correlation between number of
patients seen per year and level of reported experience, H
(2) ¼ 7,138, p ¼ .028.
Communication management
Speech and language pathologists management for commu­
nication in ventilated and non-ventilated patients is sum­
marised in Figure 1. Half of the participants (n ¼ 14)
reported assessing communication in ventilated tracheos­
tomised patients. Assessments were made under varying
conditions as per Table 3. Comments show that assessment
was adapted according to patients’ status and whether a
speaking valve or cap was preferred by the treating medical
team. In this study, use of above cuff vocalisation (ACV)
was not used by any of the participants. The most common
Faciliators
1st author 2nd author
1. Teamwork/collaboration 1. Improved collaboration with other
professionals
2. Education/information to other 2. In-house education
professionals about SLP role
3. Increased education and 3. Collaboration with other SLP
experience, support from
other SLP
4. Access to adequate methods/ 4. Enough time
prerequisites
5. Better equipment
Final
1. Improved collaboration with other professionals
2. In-service training and education to other professionals
3. Support from more experienced colleagues
4. Adequate prerequisites
 LOGOPEDICS PHONIATRICS VOCOLOGY 149

Table 2. Participant demographics.

Number of Percent of
Demographic Category participants participants (%)
Number of patients/year 1–5 16 57
6–10 7 25
15–80 5 18
Self-perceived experience Little 16 57
Moderate 10 36
Great 2 7
Patient population Adult 22 79
& management
Children 3 11
Children & Adult 3 11
Dysphagia & Communication 23 82
Dysphagia only 5 18
Communication only 0 0
Work setting ICU 13 46
Other inpatient care 9 32
Rehabilitation 8 29
SLT department 8 29
Acute setting 7 25
Specialist unit/team 7 25
Habilitation 3 11
Neonatal ward and NICU 2 7
Other outpatient care 2 7
Paediatric setting 1 4

Figure 1. Dysphagia and communication assessment on ventilated versus non-ventilated patients.

communication intervention was Augmentative and
Alternative Communication (AAC), and participants also
reported management such as information to caregivers and
therapy for speech, language and voice impairments.
Dysphagia management
Regarding dysphagia management, Speech and language
pathologists’ management for ventilated and non-ventilated
patients is summarised in Figure 1. Half of the participants
(n ¼ 14) conducted dysphagia assessments on non-ventilated
patients only, see Table 4. A few participants commented
that conditions for dysphagia assessments depended on
whether patients tolerated speaking valve and or cuff
deflation and types of tracheostomy tubes used. A range of
evaluation methods were used to assess dysphagia, see Table
5; however, the most commonly used methods were Flexible
Endoscopic Evaluation of Swallowing (FEES) and Clinical
Swallowing Examination (CSE).
Seven out of n ¼ 24 participants responded yes to the
question if they were using protocols in their dysphagia
assessment. However, examples given were mostly outcome
measures such as Functional Oral Intake Scale (FOIS) [38],
Penetration Aspiration Scale (PENASP) [39], Secretion
Severity Scale [40], EAT-10 [41] as well as several local pro­
tocols and one regional protocol. Statistical analysis using
Kruskal-Wallis test identified no statistically significant cor­
relation between number of patients seen per year and the
150 S. WIBERG ET AL.

Table 3. Assessment and management of communication.

Number of
Category responses
Communication Both ventilated and non-ventilated patients 13
assessments n ¼ 28
Non-ventilated patients 11
Ventilated patients 1
None 3
Communication assessment Inflated, deflated or deflated cuff with speaking valve 9
on ventilated patients n ¼ 14
Inflated cuff 1
Deflated cuff 1
Deflated cuff and speaking valve 0
Other 3
Communication assessment Deflated or inflated cuff 17
on non-ventilated patients n ¼ 24
Deflated cuff only 0
Uncuffed tube only 0
Speaking valve 19
Communication intervention n ¼ 25 AAC 24
Speaking valve trial 4
Other 6

Table 4. Assessment and management of dysphagia.

Number of
Category responses
Dysphagia Ventilated patients 1
assessment n ¼ 28
Non-ventilated patients 14
Both ventilated and non-ventilated patients 9
None 4
Dysphagia assessment Inflated or deflated cuff 2
on ventilated patients n ¼ 10
Deflated cuff only 1
Deflated cuff and speaking valve 1
Inflated, deflated or deflated cuff with speaking valve 4
Other 2
Dysphagia assessment Deflated or inflated cuff 9
on non-ventilated patients n ¼ 23
Deflated cuff only 5
Uncuffed tube only 2
Speaking valve 14
Cap 7

Table 5. Access to dysphagia evaluation methods. Table 6. Reported professions in tracheostomy team.
Assessment Number of participants Profession Number of reports
Clinical Swallowing Examination (CSE) 21 Registred nurse 8
Flexible Endoscopic Evaluation of Swallowing (FEES) 18 Physician 7
Cervical Auscultation (CA) 14 Enrolled nurse 6
Video Fluoroscopic Swallowing Study (VFSS) 11 Physiotherapist 4
Modified Evans Blue Dye test (MEBDT) 8 Speech Language Pathologist 4
Pulse oximetry 7 Social worker 2
Neither FEES nor VFSS 4 Occupational therapist 1
Dietician 1
Engineer 1
use of protocols in dysphagia assessment, H (1) ¼ 0, Dental technician 1
Municipal nurse 1
592, p ¼ .442.

Tracheostomy management
Results showed that it is most commonly a physician who
orders cuff deflation and speaking valve trials on ventilated
patients. In two cases, SLPs reported that they lead cuff
deflation and speaking valve trials and in one case it was
reported that this is nurse-lead. Four participants reported
that they did not know who prescribes cuff deflation and
speaking valve trials. Results showed that a majority of the
participants were not involved in weaning or decannulation
and eight (n ¼ 8) respectively nine (n ¼ 9) did not know if
the SLP were involved in weaning and decannulation. Only
five (n ¼ 5) SLPs reported involvement in the decanullation
process. Nine (n ¼ 9) participants reported that there is a

dedicated tracheostomy team in their hospital, eight (n ¼ 8)
reported no team and n ¼ 11 did not know if there was a
team. For reported professions in these teams, see Table 6.
Only three (n ¼ 3) participants out of n ¼ 28 reported use
of guidelines. One respondent referred to the national
guidelines regarding tracheostomy management for children.
Another participant reported use of guidelines from other
countries and one participant used local guidelines.
Statistical analysis using Kruskal–Wallis test identifies a stat­
istically significant correlation between number of patients
seen per year and the use of tracheostomy specific guide­
lines, H (1) ¼ 4,41, p ¼ ,036.
Systematic text condensation
All participants answered the open-ended questions.
Answers to the open-ended questions, numbers 25–28 (see
Appendix A) “Is there anything else you would like to add
regarding assessment, intervention, collaboration and patient
follow-up?” were generally concise. Responses were sorted
into themes, see Table 1.
Regarding the theme of Assessment, comments provided
thoughts on the need to improve collaboration, to increase
SLP involvement in tracheostomy management, and that in-
service education was one way to achieve this (n ¼ 2). There
were also comments regarding the fact that SLPs were not
in charge of decisions regarding speaking valve trials
(n ¼ 1). Others commented on available evaluation methods
(n ¼ 3) or other tests and protocols (n ¼ 5) used in assess­
ment. Sixteen participants had nothing further to add.
In terms of the Collaboration theme, most comments
held examples on partners or carers (n ¼ 10), such as nurses,
physicians, physiotherapist but also SLP colleagues in other
clinics (n ¼ 3). Joint practice with Ear, Nose and Throat
(ENT) specialists for FEES (n ¼ 4) and change of tracheos­
tomy tubes were mentioned. Collaborative interventions
such as information to other caregivers regarding communi­
cation and swallowing were also stated (n ¼ 5). Ten (n ¼ 10)
participants had no comments.
Under the theme of Intervention, areas such as AAC tri­
als and training (n ¼ 8), and also swallowing intervention
(n ¼ 6), including diet modifications, were identified as
regular SLP management. Voice therapy (n ¼ 3), oral motor
stimulation (n ¼ 3), resistance breathing (n ¼ 1) and speak­
ing valve training (n ¼ 1) were reported by individual partic­
ipants. Eleven (n ¼ 11) participants had nothing to add.
Under the final theme of follow-up, different routines
and practices were mentioned. Most reported that follow-up
was based on patients’ needs (n ¼ 9), though systematic fol­
low-up was routinely performed mostly in the in-patient
setting (n ¼ 10). Several participants stated that a new
assessment should be conducted after decannulation. Others
reported that follow-up only occurred when other caregivers
or patients themselves indicated the need of a new assess­
ment (n ¼ 5). Some reported specific routines regarding
time, place and content for follow-up (n ¼ 5).
Answers to the open-ended questions number 29 and 30
(see Appendix A) consisted mainly of one or a couple of
LOGOPEDICS PHONIATRICS VOCOLOGY 151
phrases per participant. After qualitative analysis, the follow­
ing barriers and facilitators were identified, see Table 1.
Barrier 1: Collaboration with other professionals (n ¼ 20)
A majority of participants (n ¼ 20) commented on different
difficulties in collaborating with other professionals, regard­
ing communication and joint decisions. A few participants
(n ¼ 4) specified that collaboration with other professionals
was difficult due to the fact that SLPs were not a part of
teams nor present on wards where tracheostomised patients
were cared for. Together with a lack of knowledge regarding
tracheostomy and influence on swallowing and communica­
tion within other professions (n ¼ 5), this lead to a lack of,
or late, referrals for SLP assessment (n ¼ 3). Other profes­
sions, it was reported, lack an understanding for SLPs pre­
requisites for assessments. Common ground appeared to be
missing for collaboration regarding cuff-deflation, speaking
valves and decannulation (n ¼ 5).
Barrier 2: Unclear roles and lack of guidelines (n ¼ 14)
Unclear roles and confusing terminology were reported by
several participants (n ¼ 11). Questions regarding who was
responsible for what (n ¼ 4) and the lack of guidelines
(n ¼ 3) were pointed out. Team collaboration was not
clearly organised. Several participants noted that this is a
complex patient group (n ¼ 5), often very ill and in need of
highly specialised care.
Barrier 3: SLP experience and knowledge (n ¼ 16)
Lack of experience and knowledge regarding this patient
group were reported by half of the participants (n ¼ 14).
Tracheostomised patients were considered a rare patient
group for many SLPs (n ¼ 7) and therefore risk of not
maintaining competency was mentioned. Lack of formal
training regarding tracheostomy during basic SLP training
was also pointed out (n ¼ 1). Some reported an uncertainty
in assessments caused by lack of instrumental evaluation
methods available (n ¼ 2). Difficulties upholding knowledge
regarding different tubes, speaking valves and other materi­
als was also identified as a problematic factor.
Facilitator 1: Improved collaboration with other professio­
nals (n ¼ 14)
Half of the participants suggested improved collaboration as
a facilitator for better tracheostomy management (n ¼ 14).
Dialogue and close collaboration with physicians and nurses
were stated as examples (n ¼ 11). When SLPs were fully
involved as part of the team (n ¼ 3), the possibility for the
right intervention at the right time increased as one (n ¼ 1)
participant stated. Collaboration with the family as an
important factor for facilitating tracheostomy management
was also mentioned (n ¼ 2).
152 S. WIBERG ET AL.
Facilitator 2: In-service training and education to other
professionals (n ¼ 4)
The importance of educating other professionals for deeper
understanding for SLP work and recommendations, for
example, regarding diet modifications, was suggested by
four participants (n ¼ 4). Education or information was also
highlighted as important in order to ensure more appropri­
ate and earlier referrals (n ¼ 1).
Facilitator 3: Support from more experienced col­
leagues (n ¼ 9)
Several participants reported that discussions with more
experienced SLP colleagues was of great importance for
facilitating tracheostomy management (n ¼ 8). One (n ¼ 1)
also suggested that assessment together with other SLP col­
leagues and access to network groups was beneficial.
Facilitator 4: Adequate prerequisites (n ¼ 8)
Further education for SLPs (n ¼ 3) and more experience is
needed (n ¼ 1) for optimising tracheostomy management
according to several participants. Some also report the
importance of access to adequate evaluation methods (for
example FEES/VFSS) (n ¼ 2) and the importance of
adequate preparation time before seeing a patient (n ¼ 2).
Discussion
This is the first study to provide insight into tracheostomy
management by Swedish SLPs. The similarities and differen­
ces in tracheostomy management, as per the first aim of
this study, are reported. Results suggest wide variations in
terms of number of patients seen per year and work set­
tings, however this study presents valuable information
regarding SLPs workload, management and, most import­
antly, SLPs’ thoughts on facilitators and barriers for optimal
tracheostomy management, as per the second aim of
this study.
SLP tracheostomy management in Sweden
In the current study, most participants manage both com­
munication and dysphagia in tracheostomised patients,
including assessments and interventions, similar to SLP
tracheostomy management in the United States, United
Kingdom and Australia [26–28]. However, most participat­
ing SLPs are not involved in decannulation and none
reported to be involved in weaning the patient from the
ventilator. This is a clear difference in SLP work practice
compared to international studies [26–28]. Baumgartner
et al. [26] describe SLP management among tracheostom­
ised patients in the United States and point out that SLPs
are often consulted to determine if a patient is suitable for
speaking valve trialling. This is in contrast to the current
study where AAC-trials were the most common communi­
cation intervention. Initial speaking valve trials by SLPs
were reported by only a few participants in this study, since
it is most often other team members who prescribe and lead
speaking valve use. Results from this study also suggest that
Swedish SLPs do not use ACV as a communication option
as is the case in other countries [25]. These findings high­
light that Swedish SLPs are not integrally involved in trache­
ostomy teams or tracheostomy management to trial
different phonation/communication options, nor are they
integrally involved in introducing and trialling speaking
valves for early communication, swallowing and respiratory
rehabilitation, as per multidisciplinary tracheostomy practice
elsewhere [3,16,19]. Thirteen participants (n ¼ 13, 46%)
reported that they see tracheostomised patients in the ICU
likely in a consultancy capacity since current information
indicates that SLP positions do not exist within
Swedish ICUs.
In the current study, Swedish SLPs are seldom part of a
tracheostomy team. This is contrary to evolving literature
which establishes that multidisciplinary tracheostomy teams
have been shown to optimise tracheostomy care [5,6]. Most
remarkable is the fact that a major part of this study’s par­
ticipants do not know whether or not there is a dedicated
tracheostomy team in their workplace. This may reflect a
suboptimal structure for tracheostomy care which also was
noted in SLP responses. The impact that this may have on
patient outcomes has not been investigated in this study.
However, as per international practice, it could be antici­
pated that SLP management would be beneficial for trache­
ostomy teams to identify risk of aspiration, enhance
communicative ability and contribute to determining readi­
ness for decannulation [3]. The current study further sug­
gests suboptimal tracheostomy teamwork, a finding also
found in the United Kingdom by McGowan et al. [27].
However, the McGowan study showed high clinical consist­
ency among SLPs and, furthermore, that SLPs have a
defined role within the multidisciplinary team, which
according to the current study, is lacking in Sweden. This
could be influenced by the lack of guidelines and protocols
available or used by Swedish SLPs. Unclear roles and/or the
lack of national SLP-specific protocols was noted by n ¼ 19
of n ¼ 28 participants. In other countries where SLPs are
more involved in tracheostomy management, there are both
guidelines and protocols to support this clarified
role [27,42,43].
The current study showed strong correlation with self-
perceived experience, number of patients seen (H (2) ¼
7,138, p ¼ .028) and use of guidelines (H (1) ¼ 0, 592,
p ¼ .442.). However, only two participants reported self-per­
ceived experience as great and three participants use of
guidelines. Statistically, there was no correlation between
number of patients seen per year and use of protocols. This
is an interesting finding since one would assume that partic­
ipants with greater experience (e.g. more patients seen per
year) would more likely work in a setting with optimised
organisational structure for team management and also be
using or have better access to established guidelines.
Contrary, SLPs with lesser experience would benefit more
from protocols to support their clinical practice since the
tracheostomised patient group is both complex and rare in
their otherwise daily workload. Regardless of SLP level of

experience, this study suggests limited use of tracheostomy
guidelines or protocols – a difference compared to inter­
national practice [27,28]. In places where guidelines are
lacking, establishing a tracheostomy team could provide a
platform for developing practice guidelines and further
implement interprofessional tracheostomy protocols ensur­
ing all patients have the same management and care irre­
spective ward or location [5,6].
SLP thoughts on facilitators and barriers for
tracheostomy management
As for the second aim of this study, participants identified
facilitators and barriers for tracheostomy management. The
most reported challenge for Swedish SLPs in tracheostomy
management is collaboration with other professionals and
unclear roles. Participants noted that referrals from wards
may be delayed or missed because of unawareness from
other professions, including lack of knowledge regarding
tracheostomies’ effect on communication and swallowing,
what the SLPs role is and how SLPs can contribute to
patient care. Similar challenges were found in Ward et al
[43] who report that the SLP role in the United Kingdom
varied between teams and wards. Critical care wards had a
greater awareness of the SLP role and was explained by a
higher exposure to tracheostomised patients and therefore a
more firmly established role for the SLP. Further, Ward
et al. [42,43] recommend that clinicians provide training
and education to staff on those wards with less experience
of tracheostomised patients, with the aim to improve SLP
role recognition.
In terms of facilitators, SLPs in Sweden identified that
improved collaboration with other professionals would
enable improved tracheostomy management for patients.
Similar to the recommendations by Ward et al. [42,43],
SLPs in Sweden suggest in-service training for increasing
the multidisciplinary team’s awareness of SLPs role and
expertise in tracheostomy management, and further to
improve collaboration and facilitate more appropriate and
earlier referrals. Welton et al. [44] found as a secondary
outcome measure that the implementing of a tracheostomy
team led to earlier SLP referrals for swallowing assessments.
Ward et al. [42,43] also suggest that SLPs not being part of
a tracheostomy team is a challenge for clinicians at the
international scale which findings from the current
study support.
Results from this study indicate that tracheostomised
patients are a rare patient group for SLPs in Sweden, which
causes difficulties in acquiring experience and maintaining
competency. Insufficient formal training and inadequate
prerequisites such as preparation time was reported. Similar
findings were reported by Ward et al. [42,43] who discussed
the complexity of the SLP role in tracheostomised patients
and the large variability in amount and type of tracheos­
tomy-specific training received by SLPs in Australia. The
need for continuing clinical training and education stated
by participants in the current study as a facilitator is similar
LOGOPEDICS PHONIATRICS VOCOLOGY 153
to issues identified by SLP colleagues in the United
Kingdom and Australia.
Another facilitator identified by Swedish SLPs was the
support from more experienced colleagues and access to
network groups. This seems to be of great importance in
facilitating improved tracheostomy management for Swedish
SLPs and is also reported by SLPs in Australia and the
United Kingdom [42,43]. It is recognised that this is a com­
plex patient group in need of highly specialised care.
Specialist knowledge is not expected to be seen in newly
examined SLP and according to Ward et al. [42,43] both
clinical mentoring and professional development activities
are recommended, especially for those who see few trache­
ostomised patients in their caseloads. This recommendation
would also be applicable to Swedish conditions.
Tracheostomy management by Swedish SLPs shows some
similarities with SLP practice internationally. However, dif­
ferences identified are that Swedish SLPs do not have con­
sistency of practice nor established clinical guidelines as per
the United Kingdom and Australia. Furthermore, Swedish
SLPs are not as involved in tracheostomy care as compared
to SLP colleagues internationally specifically in terms of
ACV, speaking valve trials, decannulation and weaning
input. Of note, however, is that many of the challenges and
perceived facilitators identified in the current study, reflect
findings from previous international studies, suggesting that
SLPs, irrespective of location, face quite similar challenges.
Study limitations
Despite the snowball sampling and SLP recruitment drive,
this study’s sample is small (n ¼ 28) and demonstrates a var­
iety in number of patients seen per year and within different
work settings. This small sample size may well be represen­
tative of current SLP tracheostomy management in Sweden
though true representation is not possible since there are no
available statistics on number of SLPs working with trache­
ostomised patients [33]. At the time of the survey, there
were no assigned SLPs in ICUs at any University Hospital
in Sweden, which differs from international practice [27,28].
Given these above study limitations, results may not be truly
representative of the entire population and caution with
interpretation and generalisability is warranted.
Also, this study was conducted in 2018, pre Covid-19
pandemic. Since this time, an increase in tracheostomy
teams and provision of SLP service into tracheostomy man­
agement has been identified in Sweden [45,46]. Further
research and study replication would be recommended given
this changed and changing environment.
Conclusions
This study shows that Swedish SLPs contribute to trache­
ostomy management; however, the number of patients
seen per year and experience varies widely. Swedish SLPs
are often not part of dedicated tracheostomy teams and
are not as involved in tracheostomy management as com­
pared to SLPs practicing in the US, Australia and the
154 S. WIBERG ET AL.
United Kingdom. SLPs report that the biggest challenges
in tracheostomy management are (a) limited collabor­
ation with other professionals, (b) the unclear role of
SLPs in tracheostomy management and (c) self-perceived
experience. To facilitate optimal tracheostomy manage­
ment, SLPs suggest better understanding for SLP roles
among other professionals, clinical support from col­
leagues that are more experienced, further education, and
improved collaboration with other professionals, prefer­
ably in dedicated teams. This study’s results provide an
insight into Swedish SLP tracheostomy management pre­
viously unchartered. Further research is needed, however
this initial report on perceived facilitators and barriers,
similar to international literature, suggests a need for fur­
ther education and clinical training for SLPs to take a
clearer and more involved role in tracheostomy manage­
ment. Moreover, interprofessional education to all team
members is further suggested to ensure a greater under­
standing for roles and responsibilities in the multidiscip­
linary collaboration for optimal tracheostomy
patient care.
Disclosure statement
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the paper.
Notes on contributors
Sara Wiberg, MSc, registered Speech and Language Pathologist
Helsingborg Hospital; clinical lecturer of Speech and Language
Pathology at the Department of Logopedics, Phoniatrics and
Audiology, Faculty of Medicine, Lund University, Lund, Sweden.
Susanna Whitling, PhD, registered Speech and Language Pathologist,
post doctoral researcher and lecturer of Speech and Language
Pathology, Department of Logopedics, Phoniatrics and Audiology,
Faculty of Medicine, Lund University, Lund, Sweden.
Liza Bergstr€om, PhD, registered Speech and Language Pathologist,
REMEO, Stockholm; researcher and lecturer, Unit of Speech and
Language Pathology, Institute of Neuroscience and Physiology,
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
ORCID
Sara Wiberg http://orcid.org/0000-0001-6161-8443
Susanna Whitling http://orcid.org/0000-0001-5977-8288
Liza Bergstr€
om http://orcid.org/0000-0002-6749-9390
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19–26. Part I
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b. No
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2007;15(1):7–26. b. No
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d. Neonatal ICU
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pdf. : Paediatric Allergy Section; 2018. i. Specialist unit, team or clinic
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j. Other in-patient clinic
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[34] Association WM. World Medical Association Declaration of l. Other, please specify:
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human subjects. JAMA. 2013;310(20):2191–2194. the last 12 months.
[35] Survey & Report. V€axj€ o, Sweden: Artisan Global Media. 2018. 6. What experience do you have with tracheostomised patients?
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Part II
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156 S. WIBERG ET AL.

g. Other, please specify: e. Don’t know

12. What dysphagia evaluations do you have access to? 20. Are SLPs involved in weaning from ventilator?
a. Fibreoptic Endoscopic Evaluation of Swallowing (FEES) a. Yes
b. Video Fluoroscopic Swallowing Study (VFSS) b. No
c. Clinical Swallowing Examination (CSE) c. Don’t know
d. CSE with Modified Evans Blue Dye Test (MEBDT) 21. Are SLPs involved in decannulation?
e. CSE with Cervical Auscultation (CA) a. Yes
f. CSE with pulse oximetry b. No
g. Other, please specify: c. Don’t know
13. Do you use any protocols in your dysphagia assessment? 22. Do you use any guidelines in SLP tracheostomy management?
a. Yes a. Yes
b. No b. No
14. If yes, specify what protocols you use c. If yes, please specify
15. Do you perform communication assessments on tracheostom­ 23. Is there a dedicated tracheostomy team in the hospital you
ised patients? work in?
a. Yes, ventilated patients a. Yes
b. Yes, non-ventilated patients b. No
c. No c. Don’t know
16. What kind of communication intervention do you provide? 24. If yes, what professions are part of this team?
a. Augmentative and Alternative Communication (AAC) a. Occupational therapist
b. Speaking valve trial b. Dietician
c. Other, please specify: c. Physiotherapist
17. For communication assessments on ventilated patients, do you d. Social worker
assess with e. Speech-language pathologist
a. Only inflated cuff f. Physician
b. Only deflated cuff g. Registered nurse
c. Deflated cuff with speaking valve h. Enrolled nurse
d. Other, please specify: i. Other, please specify:
18. For communication assessments on non-ventilated patients, do you 25. Excluding current answers – is there anything else you do regard­
assess with ing assessment?
a. Cuffed tube, only inflated 26. Excluding current answers – is there anything else you do regard­
b. Cuffed tube, only deflated ing intervention?
c. Cuffed tube, both inflated and deflated 27. Excluding current answers – is there anything else you do regard­
d. Speaking valve ing collaboration?
28. How do you manage tracheostomised patients regarding follow-up?
e. Cap
f. Other, please specify:
Part III
19. Who orders deflation and speaking valve on ventilated patients?
a. Physicians
29. What challenges do you experience with SLP tracheos­
b. SLPs
tomy management?
c. Nurse 30. What facilitators are there to SLP tracheostomy management?
d. Other, please specify: