J. Wisener1,2, J. Ward2, C. Boardingham2, P. P. Yonclas1,2, D. Livingston1,2, S. Bonne1,2, N. E. Glass1,2 1Rutgers New Jersey Medical School,Trauma Surgery,Newark, NJ, USA 2University Hospital,Trauma Surgery,Newark, NJ, USA
Introduction:
The insertion of a tracheostomy is thought to compromise protective swallowing mechanisms leading to aspiration and dysphagia. Consequently, clinicians are reluctant to allow oral nutrition for patients with tracheostomies and continue nasoenteric tube feeds. To maximize the number of patients receiving oral nutrition and to minimize aspiration, we began an aggressive swallowing program by dedicated speech and language pathologists (SLP) using fiberoptic endoscopic evaluation of swallowing (FEES). We hypothesized that despite the presence of a tracheostomy, most patients would be able to be safely fed orally and this approach is optimal for this patient population.
Methods:
Retrospective chart review of all trauma patients who underwent a tracheostomy between 7/1/2016-6/30/2018. Data collected included, demographics, injury severity, time to tracheostomy, ICU and hospital lengths of stay. The time to SLP evaluation and FEES as well as outcomes of those assessments were also captured.
Results:
115 patients underwent a tracheostomy during this period with 90 (78%) evaluated by SLP. 72 (80%) underwent FEES and 53 (76%) of those passed and were allowed oral nutrition. 11 (61%) of the 18 patients seen by SLP and not evaluated by FEES had swallowing evaluated by another method and 5 of those were allowed to eat. 40 patients (55%) passed their first FEES. Among those who failed, 21 (66%) underwent a second FEES approximately a week later, and 10 (48%) passed. Total success rate for patients undergoing SLP ± FEES was 70% (58/83). Days between tracheostomy and time of first FEES was not significant between groups (11 vs 15, p=0.486). The median time to passing FEES was 13 days [IQR 7, 20.5]. Patients who passed FEES were younger (42 vs 55 years, p=0.005) and had more severe injuries (ISS 20 vs 14, p=0.03) compared to those who did not pass FEES. Both groups had similar ICU and hospital lengths of stay (32 vs 31, p=0.95 and 43 vs 36, p=0.14). 12 patients underwent PEG placement prior to SLP evaluation; 7 of which passed their FEES and were fed orally. There were few incidences of documented aspiration in all patients who were orally fed (3/55).
Conclusion:
Over two-thirds of trauma patients who have undergone a tracheostomy can safely take oral nutrition. Aggressive use of SLP and FEES allows oral nutrition, less use of nasoenteric tubes and gastrostomies which likely improves patient satisfaction. Failure to pass a FEES within the first 2 attempts allows objective indications for a gastrostomy tube. As patients who failed FEES were older, age may be a factor in the decision for earlier gastrostomy tube placement. In conclusion, oral nutrition is not only possible, but preferable in trauma patients undergoing tracheostomy and all eligible patients should be evaluated by FEES.