Noninvasive ventilation is preferred over invasive ventilation, especially for polio survivors who require noncontinuous ventilation, because of ease of administration, preservation of upper airway, lower cost, and quality of life. However, in the case of chronic respiratory insufficiency that cannot be corrected by noninvasive means, a tracheostomy may be the last resort (Make et al., 1998). A tracheotomy is an invasive surgical procedure that creates an opening into the trachea (windpipe) that allows air direct access to the lungs.
A tracheostomy may be necessary when there is pharyngeal or bulbar dysfunction that could cause aspiration, an ineffective cough, or when safe life support ventilation is needed for more than 20 hours per day (Bach, 1996). The tracheostomy tube should be chosen carefully so that it can be managed at home to assure optimal speech and swallowing. An uncuffed tube may be preferable, or one may deflate the cuff of the tube when not sleeping since it allows the individual to phonate; air loss is usually compensated for by increasing the tidal volume.
Complications of tracheostomies may include stomal infections, formulation of granulation tissue that may bleed, tracheal stenosis, and loss of effective cough, necessitating suctioning, or use of a cough machine such as the J.H. Emerson Company’s In-Exsufflator (see Cough Production) or the CoughAssist device manufactured by Philips. Speech and swallowing may also be hampered (Make et al., 1998). Speech and swallowing therapy by trained speech therapists may be very helpful in seeing if this function can be improved or to learn strategies to avoid aspiration.
More normal, uninterrupted speech and communication can be gained through the use of a tracheostomy speaking valve, such as the Passy Muir Tracheostomy Speaking Valve, connected to an uncuffed or deflated tracheostomy tube. This device allows air to enter the lungs during inhalation and exhalation through the mouth when the valve closes, directing the air up through the vocal cords to allow speech (Goodenberger 1993).
References
Bach, J.R. (1996). Pulmonary rehabilitation: The obstructive and paralytic conditions. Philadelphia, PA: Hanley & Belfus, Inc.
Goodenberger, D.M. (1993). Communication for the ventilator user with a tracheostomy. IVUN News, 7(2), 1-3.
Make, B.J., Hill, N.S., Goldberg, A.I., Bach, J.R., Criner, G.J., Dunne, P.E., Gilmartin, M.E., Heffner, J.E., Kacmarek, R., Keens, T.G., McInturff, S., O'Donohue, W.J., Oppenheimer, E.A., & Robert, D. (1998). Mechanical ventilation beyond the intensive care unit: Report of a consensus conference of the American College of Chest Physicians. Chest, 113, 289S-344S.