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Article

Speech Pathology Services Are Integral, but Underutilized in Tracheostomy Rehabilitation

by
Stephanie Davis
1,
Ashleigh M. Weyh
2,
Salam O. Salman
2,
Firas Madbak
3 and
John T. Fraker
4,5,*
1
Rehabilitation Services, University of Florida Health-Jacksonville, Jacksonville, FL, USA
2
Department of Oral and Maxillofacial Surgery, University of Florida Health-Jacksonville, Jacksonville, FL, USA
3
Division of Acute Critical Care Surgery, Department of Surgery, University of Florida-Jacksonville, Faculty Clinic, Jacksonville, FL, USA
4
Department of Otolaryngology, University of Florida-Jacksonville, Faculty Clinic, 653 8th St W 2nd floor, Jacksonville, FL 32209, USA
5
BayCare Health Systems Inc, 2995 Drew Street, Clearwater, FL 33759, USA
*
Author to whom correspondence should be addressed.
Craniomaxillofac. Trauma Reconstr. 2021, 14(2), 110-118; https://doi.org/10.1177/1943387520948381
Submission received: 1 December 2019 / Revised: 31 December 2019 / Accepted: 1 February 2020 / Published: 18 August 2020
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Abstract

:
Study Design: Retrospective case series. Objective: Speech language pathology (SLP) is an underutilized but important component in rehabilitation after tracheostomy. The purpose of this study was to determine rates of SLP utilization and to streamline tracheostomy decannulation to be more efficient and safer through increased utilization of SLP. Methods: Adult patients who underwent tracheostomy from April 2016 to December 2018 were evaluated. The primary outcome was completion of any SLP evaluation after tracheostomy, and secondary outcomes were duration from surgery to evaluation, speaking valve and swallow study utilization, downsize and decannulation rates, mean duration of cannulation, and complications. Results: A total of 255 subjects were included, where 197 (77.3%) underwent SLP evaluation. A minority received a speaking valve (33.7%), while approximately half underwent a swallow study (52.9%). There was a delay in SLP evaluation, with mean duration from surgery to SLP evaluation of 5.9 ± 8.0 days. There was consistent improvement in downsize and decannulation rates in all cohorts that utilized SLP services. Tracheostomy indication of head and neck cancer, trauma, completing a successful swallow study conferred increased odds of eventual decannulation, while obesity and tracheostomy history conferred lower odds. An interdisciplinary decannulation pathway was created, based on literature review and results, to assist in decision-making while progressing toward decannulation. Conclusion: Speech language pathologists are underutilized for rehabilitation of tracheostomy patients, where they are able to offer many skills to diagnose, treat, manage, and troubleshoot, as patients advance through the decannulation process.

Introduction

Tracheostomy is a commonly performed procedure worldwide, often for critically ill patients with long-term dependence on mechanical ventilation. Over 100 000 patients receive a tracheostomy each year in the United States, with the tracheostomy tube remaining in place for days to weeks,[1] while some become tracheostomy dependent for life. The most common reasons for a tracheostomy are prolonged mechanical ventilation, trauma, and upper airway obstruction.[2]
Speech language pathologists (SLPs) work to assess, diagnose, and treat multiple speech, communication, cognitive linguistic, and swallowing disorders.[3] In addition to diagnostic and rehabilitative services, SLPs provide education, training, and counseling to patients, improving compliance, outcomes, and quality of life, while potentially reducing length of stay, costs to patients and health care systems, and readmissions.[4,5] For tracheostomy patients, SLPs are trained to diagnose and treat dysphagia and aspiration sequelae via a variety of swallow evaluations. They assist in determining upper airway patency, implementation of ventilator in-line placement or general speaking valves, and collaborate regarding appropriate tracheostomy device selection. Finally, they provide inspiratory/expiratory muscle strength training, improving pulmonary rehabilitation by increasing overall strength and ability to clear the airway.[6,7]
Speaking valves are important for both speech and swallow function, and SLPs provide and train patients on their use. Valves redirect airflow through the vocal cords and upper airway, allowing for improved vocalization and restoration of normal upper airway flow. Speaking valve use is validated by numerous studies to aid in weaning, decannulation, olfaction, infection control, restoring positive airway pressure, oxygenation, secretion management, swallowing, speech production, and improved overall quality of life.[8,9,10] Thus, it is prudent that most tracheostomy patient should be evaluated for a speaking valve, as they are not suitable for everyone. Cuff status, secretions, and upper airway patency can complicate use.
Swallow evaluations are performed as a clinical bedside swallow evaluation, fiber optic endoscopic evaluation of swallowing, or videofluoroscopy, also known as modified barium swallow. Bedside clinical swallow evaluation is an elaborate screen that assesses feeding position, consumption amount, need for supervision or adaptive equipment, and overall pleasure from eating and drinking.[11] Suspicion for aspiration and need for further investigation is determined through synthesis of case history and clinical assessment. By evaluating all of these parameters, SLPs can make a statistically significant judgment regarding aspiration. Thus, a recommendation for a videofluoroscopy after a bedside clinical swallow evaluation should be heeded.[11,12] Swallow studies are not pass/fail, but instead provide information about ability to swallow as a dynamic process. A fiber optic swallow study can be performed bedside by SLPs to evaluate secretion management and swallow physiology. Videofluoroscopy is the gold standard of swallow studies[13] and is performed in the radiology suite. The oral, pharyngeal, and esophageal phases of swallow are screened in real time to identify anatomical deficits, penetration and aspiration, and need for further management.[14] One or all three studies may be performed, depending on the complexity of the patient.
The purpose of this study was to determine the rate of speech language pathology (SLP) utilization and devise a protocol to streamline the tracheostomy weaning process to make it safer and more efficient. The specific aims are to (1) measure the rate of SLP evaluation for patients after tracheostomy, (2) measure the rate of speaking valve and swallow study utilization, and (3) synthesize the results of our literature review and this study to develop a workflow for tracheostomy decannulation.

Methods

The authors designed and implemented a retrospective case series, which was approved by the University of Florida Jacksonville’s Institutional Review Board. Included subjects had undergone open or percutaneous tracheostomy at our institution, an urban level 1 trauma center, performed by either the Oral and Maxillofacial Surgery, Otolaryngology, or Acute Critical Care Surgery teams, from April 2016 to December 2018, with 6 months of documented follow-up. Subjects were excluded if they were converted to a laryngectomy, expired within the immediate postoperative period, were never weaned from the ventilator, or had missing/incomplete records.
Variables collected describing the sample included demographics, history and physical findings, tracheostomy history, and comorbidities as a continuous variable using the Charlson comorbidity index (CCI), without age, to standardize and emphasize preexisting conditions.[15] Alcohol history was positive for moderate or greater drinking,[16] and smoking if there was a self-reported history. Indication for tracheostomy was a categorical variable: upper airway obstruction (infection, trauma, tumor, foreign body, obstructive sleep apnea (OSA), and stenosis), prolonged mechanical ventilation (respiratory failure, management of secretions, or to promote weaning), or neurological or neuromuscular disease (diaphragm weakness, aspiration due to disease, coma, ineffective cough, or neurological injury).
The primary outcome was to measure the rate of SLP evaluation after tracheostomy. A general SLP evaluation addresses many components, however for this study we counted only those evaluating swallow, cognition, and speech production. In our center, the process of ordering a SLP evaluation requires final approval by the managing physician, but can be suggested to the surgical team by SLPs or nursing. SLP utilization was further evaluated by measuring speaking valve use, performance of any type of swallow study, and duration from surgery until the SLP evaluation was ordered by the surgical team. The goal was for every patient to have a general SLP evaluation at minimum, as evidence suggests that many tracheostomy patients can benefit from early evaluation by SLPs, as well as from using a speaking valve.[17,18,19,20] Three swallow studies were available: clinical bedside swallow evaluation, fiber optic endoscopic evaluation of swallowing, and videofluoroscopy. For the purpose of this study, we defined a “successful swallow study” as any subject recommended to initiate a diet because they were able to manage their secretions, masticate and move the bolus, and effectively and efficiently manage food consistencies with no signs or symptoms of aspiration. A failure was defined as a subject not being recommended a diet, or to stay nil per os/pleasure feeding.[14] The primary predictor variable was etiology for the tracheostomy, and secondarily we evaluated subject demographics, comorbidities, and type of tracheostomy.
Secondarily we measured decannulation rates, mean duration the tracheostomies were present, and complications occurring within 30 days of decannulation. Complications included were respiratory failure, pneumonia, tracheostomy site infection, poor wound healing, granulation tissue needing intervention, and hemorrhage. Lastly, an interdisciplinary decannulation workflow was created, based on a review of the literature and our results to assist in decision-making and to optimize utilization of SLP rehabilitation services.
Study data were collected and managed using Research Electronic Data Capture tools hosted at the University of Florida.[21] All data were gathered from the electronic medical record (EMR), based on available notes, and accessed through Epic (Epic Systems, Verona, WI). Data were analyzed as frequencies for categorical variables and as means with standard deviations for continuous variables. χ2 test, ANOVA, t-test, and binary logistic regression with odds ratio were used to further analyze data. P values <0.05 were considered statistically significant. All analysis was completed utilizing MedCalc version 19 (MedCalc Software, Ostend, Belgium).

Results

A total of 255 subjects were included in this study, and demographics are detailed in Table 1, as they relate to SLP evaluation. Only 197 (77.3%) had a SLP evaluation. The distribution of gender, age, BMI, and comorbidity score was consistent among those with and without SLP evaluation (P > 0.05). Regarding indication for tracheostomy, subjects with upper airway obstruction were less likely to receive SLP evaluations (P = 0.001). The majority this cohort received elective tracheostomy for head and neck cancer ablation and reconstruction, where decannulation usually occurs around 1 week postoperatively. Most tracheostomies were for upper airway obstruction (47%), followed by neuromuscular dysfunction (27%), and prolonged mechanical ventilation (25%). SLP evaluations were also generally ordered later into recovery, with a mean duration from surgery to SLP evaluation of 6 ± 8 days (median 4 days).
The minority of subjects in this study were evaluated and received a speaking valve (33.7%). Demographics regarding speaking valves are detailed in Table 2. Those receiving percutaneous tracheostomies or requiring tracheostomies secondary to trauma were more likely to be cleared for a speaking valve. Results of speaking valve use related to tracheostomy outcomes are detailed in Table 3 and Table 4. Subjects cleared for a speaking valve, compared to those who were not, had a longer mean duration of tracheostomy, 63.0 versus 19.9 days, but overall had higher rates of being downsized and decannulated within the 6 months of follow-up. No subjects that were tracheostomy dependent for <7 days received a speaking valve, and conversely patients who had a tracheostomy for over 2 weeks had the highest incidence of valve utilization (31%).
Table 1. Summary of subject demographic data stratified by SLP evaluation.
Table 1. Summary of subject demographic data stratified by SLP evaluation.
AllGeneral SLP evaluationNo SLP evaluationP value
Sample size, n255197 (77.3%)58 (22.7%)
Gender 0.996
Male167129 (77%)38 (23%)
Female8868 (77%)20 (23%)
Age (years)Range15-8815-8817-860.08b
Mean ± SD52.1 ± 17.650.9 ± 18.155.5 ± 15.5
CCI comorbidity scoreRange0-180-180-100.383b
Mean ± SD2.1 ± 2.32.0 ± 2.42.3 ± 1.9
BMIMean ± SD28.1 ± 9.428.0 ± 9.428.2 ± 9.40.887b
Tobacco, %141108 (77%)33 (23%)0.781
Alcohol, %4635 (76%)11 (24%)0.835
H&N cancer10070 (70%)30 (30%)<0.05
OSA2820 (71%)8 (29%)0.437
History of trach2214 (64%)8 (36%)0.112
Emergent procedure1918 (95%)1 (5%)0.06
Percutaneous tracheostomy8871 (81%)17 (19%)0.789
Trauma induced9887 (89%)11 (11%)<0.0010.001c
Reason for trach
Upper airway obstruction12187 (72%)34 (28%)
Mechanical Ventilation6452 (81%)12 (19%)
Neuromuscular Dysfunction7058 (83%)12 (17%)
Postoperative days until SLP evaluation (mean days) 5.9 ± 8.0N/A
Abbreviations: CCI, Charlson comorbidity score; H&N, head and neck; OSA, obstructive sleep apnea; SLP, speech language pathology; trach, tracheostomy. aGeneral evaluation refers to SLP evaluation of either swallow, cognition, or speech. Percentages reflect proportion of the total study population (all). P values are calculated with bχ2, then calculated with t-test, and cwith ANOVA.
Table 2. Preoperative variables stratified by SLP specialty services.
Table 2. Preoperative variables stratified by SLP specialty services.
Cmtr 14 00018 i001
Abbreviations: OSA, obstructive sleep apnea; H&N, head and neck; SLP, Speech language pathology; trach, tracheostomy. P values are calculated with aX2, then calculated with ANOVA. Bold is for p-values that are statistically significant <0.05.
Table 3. SLP procedures stratified by duration of tracheostomy dependence.a
Table 3. SLP procedures stratified by duration of tracheostomy dependence.a
Tracheostomy dependentTracheostomy dependentTracheostomy dependentTracheostomy dependentNot decannulated
All<7 Days7-13 days14-30 Days>30 Daysby 6 months
All subjects24434 (14%)44 (18%)40 (16%)39 (16%)87 (36%)
With or without
SLP intervention
SLP service performed
General evaluation18624 (13%)36 (19%)34 (18%)35 (19%)57 (31%)
Speaking valve8106 (7%)25 (31%)25 (31%)25 (31%)
Swallow study12611 (9%)26 (21%)25 (20%)29 (23%)35 (28%)
Abbreviation: SLP, speech language pathology. aEleven records excluded as they were confirmed to be decannulated, but could not confirm the exact date. General evaluation refers to SLP evaluation of either swallow, cognition, or speech.
Table 4. SLP procedures stratified by tracheostomy outcomes.
Table 4. SLP procedures stratified by tracheostomy outcomes.
AllDownsizedDecannulatedMean duration of tracheostomy dependence (days)Post decannulation complications
All subjects255203 (80%)159 (62%)34.7 ± 84.213 (5%)
SLP evaluation197172 (87%)134 (68%)38.5 ± 92.111 (6%)
No SLP evaluation5831 (53%)25 (43%)17.2 ± 21.02 (3%)
P value <0.0001<0.0010.082a0.726
Speaking valve8679 (92%)58 (67%)63.0 ± 131.47 (8%)
No speaking valve169124 (73%)101 (60%)19.0 ± 29.56 (4%)
P value <0.0010.276<0.0001a0.18
Swallow study performed135122 (90%)95 (70%)46.0 ± 107.09 (7%)
No swallow study12081 (68%)64 (53%)19.2 ± 27.54 (3%)
P value <0.0001<0.01<0.01a0.149
Successful swallow study7971 (90%)59 (75%)50.7 ± 123.45 (6%)
Failed swallow study5651 (91%)36 (64%)36.7 ± 65.44 (7%)
P value 0.8460.1690.44a0.816
Abbreviation: SLP, Speech language pathology. P values are calculated with aχ2, then calculated with t-test. Bold is for p-values that are statistically significant <0.05.
Approximately half of subjects had a swallow study (52.9%), and most frequently via only a bedside evaluation (75%). Videofluoroscopy, either alone or combined with a bedside swallow study, were performed for a quarter of the subjects. Demographics for swallow study subjects are detailed in Table 2. Those receiving a swallow study were more likely to have had an emergent tracheostomy or trauma etiology (P < 0.05), while head and neck cancer subjects were less likely to undergo a swallow study (P < 0.001). Similar to speaking valves, swallow studies were performed more often on subjects who were tracheostomy dependent longer, 63.0 days versus 19.2, and again were overall more likely to be downsized and decannulated (Table 3 and Table 4).
Results summarizing tracheostomy decannulation, downsize, mean duration of tracheostomy dependence, and complications are summarized in Table 4. Overall, the majority of subjects were eventually decannulated (62%) during our follow-up period. SLP services were utilized more in subjects with a longer duration of tracheostomy dependence, and there was consistent improvement in downsize and decannulation rates in all cohorts utilizing SLP services. Head and neck cancer subjects overall had a shorter mean duration of tracheostomy dependence of 19.3 days, compared to 34.7 days overall. Acute complications after decannulation were evenly distributed among all SLP cohorts, with an overall complication rate of 5%, and no statistically significant difference between cohorts. A logistic regression with odds ratio (Figure 1) was performed to analyze which variables conferred higher odds of eventually being decannulated. Tracheostomy etiology of head and neck cancer and trauma, those completing a successful swallow study all conferred increased odds of decannulation, while obesity and prior tracheostomy history all conferred lower odds of decannulation.
We secondarily evaluated what additional variables lead to successful decannulation. When looking at subjects who had an acute complication after being decannulated, it was found that having pneumonia and unmanageable secretions were both predictive for decannulating too early. As one third of those decannulated with pneumonia, and one quarter of those with unmanageable secretions had a postdecannulation complication. Positive predictive value of the following to predict a successful decannulation (without acute post decannulation complications), where all >93%: tracheostomy tube had been downsized, adequate cough to clear secretions, toleration of occlusive cap for 24 hours, and maintenance of SpO2 >90% for 24 hours on room air. An alert and oriented subject, or a subject with a successful swallow study and receiving a speaking valve both had a positive predictive value of 87%. Additionally, increased body mass index was known in our population to negatively affect decannulation outcomes from a previous study and our regression analysis.[22] Figure 2 was created to highlight these findings, and can be utilized by nursing, SLPs, or a tracheostomy team simply as a guide when the surgical team can be alerted to patients’ readiness to be decannulated. After analyzing these results, with findings from our literature review[3,4,18,19,20,22] which was based on tracheostomy decannulation as well as commonly accepted criteria for endotracheal tube extubation a decannulation workflow process was created to assist in decision-making while progressing toward the goal of decannulation. We also used the same information to change our decannulation process to find which steps in the decannulation process could benefit from SLP intervention. We present this as a workflow pathway, which is presented in Figure 3. It outlines a reasonable progression from surgery to decannulation in an ideal environment as well as how and when rehabilitation services can be utilized to optimize patient progression.

Discussion

Speech language pathology services were found to be underutilized and often requested later than recommended in this study. In our center, SLPs is trained to evaluate and begin rehabilitation of patients when they are still ventilator dependent, however most consultations did not occur until several days postoperatively, and for many patients after several weeks. The results show many missed opportunities for rehabilitation, as almost of a quarter of all tracheostomy subjects in this study were never evaluated by SLP. Although not every subject may need a SLP evaluation, the vast majority of our tracheostomy patients are quite complex secondary to traumatic brain injuries, morbid obesity, or undergoing extensive reconstruction of the oral cavity/pharynx due to cancer. Although the majority of the head and neck cancer subjects were evaluated by SLP (70%), they were one of the lowest utilizers of SLP. This is likely because the tracheostomy performed was elective to prevent temporary airway obstruction after surgery, and these subjects are often promptly decannulated on postoperative day 4 or 5 without SLP intervention. Still, not involving SLP in their care could be disadvantageous, as the majority underwent ablation and reconstruction of the oral cavity, causing significant alteration to their anatomy and speech/swallow. Furthermore, we did find that decannulation was met more often in patients under the care of SLP; however, it was difficult to evaluate a correlation between specialized SLP services (swallow evaluations and speaking valves) and other decannulation outcomes, as SLPs tended to treat subjects with more complex clinical courses and those with long-term tracheostomies unable to be weaned. While the benefits of these specialized services to result in decannulation may not be completely clear, the negative consequences of not utilizing speaking valves for rehabilitation is well documented to result in pulmonary deconditioning, decreased ability to communicate and swallow, and increased risk of aspiration which in turn can increased length of tracheostomy.[8,9,10]
We found a lack of standardization and communication after tracheostomy which was the impetus for the creation of our hospital’s tracheostomy team. These frequent late, or often missed, consults to SLP were causing frequent delays in the rehabilitation and decannulation process. Additionally, there were regular urgent consults placed to SLP and the surgical airway teams on the day of discharge to give evaluation and guidance about decannulation, where rehabilitation potential is limited due to time constraints. Patients were frequently keeping their tracheostomies longer than needed from a lack of recognition and specified benchmarks indicating when to proceed with a safe downsize or decannulation. Poor follow-up after discharge also compounded the patient’s course. Having three surgical teams performing tracheostomies made it difficult for primary care services to coordinate proper follow-up after discharge, as a medicine team was often left managing the patients’ other hospital problems once the patient was surgically stable after tracheostomy. This caused many patients to remain tracheostomy dependent for unclear underlying medical or surgical conditions that were never followed up with the surgical team. SLP also functioned as the consistent provider throughout many of these patients’ care, thus it was recognized that an initial evaluation with SLP could lead to better continuity of care, as they remained on caseload while navigating through the decannulation process. SLP was consistent in providing multiple assessments, skilled intervention and treatment, and if appropriate, immediate referral back to the surgical team.
Tracheostomy teams are still quite rare in the United States, so our framework was based on guidance from literature review, as well as the requirement to meet our own unique needs following a preliminary meeting of the multidisciplinary team. Extensive evidence-based research supports the recruitment of tracheostomy teams, as they improve outcomes and reduce costs through reducing time of ventilator and tracheostomy dependence, deescalating need for intensive care, and reducing length of stay.[4,5,23,24,25,26] Goals were focused on ways to improve outcomes, safety, and overall standardization of care to reduce costs, length of patient stay, and unnecessary cannulation time. The team at large included surgical services performing tracheostomies, SLPs, respiratory therapy, nursing, case management, and information technology. A smaller team meets to round on all tracheostomy patients in the hospital once a week, where ongoing evaluation and recommendations are developed and then discussed with the responsible surgical teams.
Objectives were delineated for three phases of tracheostomy. First, preoperative decisions address selection of the proper tracheostomy tube, plans for future weaning, barriers to weaning, and potential adjunctive therapies that can be utilized to optimize the patient for decannulation. Proper tube selection is important, as many are incompatible with speaking valves and this can delay rehabilitation efforts. Second, the tracheostomy phase addresses issues of organization to wean the patient with use of speaking valves, swallow studies, when to downsize, occlusive capping, and ancillary rehabilitation services. We utilize Figure 2 and Figure 3 to track patients’ progression toward decannulation. Attention is focused on team troubleshooting for identification of upper airway problems such as stenosis or granulation tissue and quickly routing referrals to the surgical airway team for management. Finally, post-tracheostomy phase focuses on enriched training and education for staff, patients, caregivers, and coordination of care upon discharge. Potential innovations include home health care visits, specifically aimed clinics for post discharge care, referrals to outpatient SLP, and creation of a documentation flow sheet in the EMR to facilitate improved record keeping and communication between all team members for inpatients.
This study is inherently limited as it is a retrospective chart review, and inaccuracies in the EMR can cause overor underestimation of the variables. To decrease misinterpretation and bias, most variables were recorded as binary data regardless of the magnitude. Additionally, the majority of SLP evaluations were placed for patients deemed to be more medically complex, and for those who were not progressing as expected through the decannulation process. Consequently, the results will sometimes falsely reflect inferior results in the SLP cohorts. Ideally SLP would have been consulted on every tracheostomy case, so we could infer a better association between SLP utilization and decannulation outcomes.
The external validity is based on only a few studies investigating the role of SLP and tracheostomy outcomes. Those published find superior results when SLP is utilized supporting early intervention for communication with speaking valves,[27] and that SLP services result in faster rates of decannulation, higher safety for subjects tolerating diets,[28] and reduced length of hospital stay.[29] The rate of SLP evaluation will likely vary hospital to hospital based on structure, patient population, and airway teams’ experiences. However, with the new trend of establishing tracheostomy teams, we believe there will be an increase of studies on this topic as well as more focus on how tracheostomy teams can utilize all the available resources to best optimize patients for decannulation.

Conclusion

Speech language pathology is an underutilized resource after tracheostomy, which is unfortunate as it could be a benefit to these complex patients. Speech pathologists possess many skills to diagnosis, treat, manage, and troubleshoot to aid patients through the decannulation progression. Without these skilled services, one may incur increased length of time to decannulation and overall cost. By having a system in place to recognize a need for SLP services, such as a tracheostomy team, tracheostomy patients’ progress can be better managed, reducing delays in decannulation and possible improvement in functional outcomes.

Authors’ Note

The study was performed at University of Florida-Jacksonville, Jacksonville, Florida, USA. Results of this manuscript have not been previously presented elsewhere.

Funding

This research received no external funding.

Acknowledgments

The authors would like to acknowledge Maribel Ciampitti, speech language pathologist at the University of Florida-Jacksonville, for her work in helping to build the tracheostomy team and assistance with this study.

Conflicts of Interest

The authors declare no conflict of interest.

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Figure 1. Odds ratio of perioperative variables versus decannulation. Dots indicate odds ratio and bars indicate 95% confidence interval. Only head and neck cancer (P < 0.001), successful swallow study (P < 0.001), obesity (P = 0.022) were statistically significant. Odds ratio >1 has increased odds of event occurring (decannulation), and <1 is decreased odds. OSA indicates obstructive sleep apnea; SS, swallow study; trach, tracheostomy.
Figure 1. Odds ratio of perioperative variables versus decannulation. Dots indicate odds ratio and bars indicate 95% confidence interval. Only head and neck cancer (P < 0.001), successful swallow study (P < 0.001), obesity (P = 0.022) were statistically significant. Odds ratio >1 has increased odds of event occurring (decannulation), and <1 is decreased odds. OSA indicates obstructive sleep apnea; SS, swallow study; trach, tracheostomy.
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Figure 2. Readiness to be decannulated predictors. Note that successful swallow study correlates with no signs or symptoms of aspiration and recommendation to begin a diet from SLP. Variables in this figure are supported by findings of our study as well as review of the literature.[3,4,18,19,20,22]
Figure 2. Readiness to be decannulated predictors. Note that successful swallow study correlates with no signs or symptoms of aspiration and recommendation to begin a diet from SLP. Variables in this figure are supported by findings of our study as well as review of the literature.[3,4,18,19,20,22]
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Figure 3. Ideal workflow process from tracheostomy to decannulation. Ideal workflow from surgery to decannulation, with suggested points of intervention for rehabilitation services. This workflow represents our current clinical practice where we found all points to optimize care with rehabilitation services, however this workflow may not be appropriate for all patients.
Figure 3. Ideal workflow process from tracheostomy to decannulation. Ideal workflow from surgery to decannulation, with suggested points of intervention for rehabilitation services. This workflow represents our current clinical practice where we found all points to optimize care with rehabilitation services, however this workflow may not be appropriate for all patients.
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MDPI and ACS Style

Davis, S.; Weyh, A.M.; Salman, S.O.; Madbak, F.; Fraker, J.T. Speech Pathology Services Are Integral, but Underutilized in Tracheostomy Rehabilitation. Craniomaxillofac. Trauma Reconstr. 2021, 14, 110-118. https://doi.org/10.1177/1943387520948381

AMA Style

Davis S, Weyh AM, Salman SO, Madbak F, Fraker JT. Speech Pathology Services Are Integral, but Underutilized in Tracheostomy Rehabilitation. Craniomaxillofacial Trauma & Reconstruction. 2021; 14(2):110-118. https://doi.org/10.1177/1943387520948381

Chicago/Turabian Style

Davis, Stephanie, Ashleigh M. Weyh, Salam O. Salman, Firas Madbak, and John T. Fraker. 2021. "Speech Pathology Services Are Integral, but Underutilized in Tracheostomy Rehabilitation" Craniomaxillofacial Trauma & Reconstruction 14, no. 2: 110-118. https://doi.org/10.1177/1943387520948381

APA Style

Davis, S., Weyh, A. M., Salman, S. O., Madbak, F., & Fraker, J. T. (2021). Speech Pathology Services Are Integral, but Underutilized in Tracheostomy Rehabilitation. Craniomaxillofacial Trauma & Reconstruction, 14(2), 110-118. https://doi.org/10.1177/1943387520948381

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