Literature Review: April 2026

NTSP Literature Review Podcast: April 2026 (S7, Ep4)

This months papers cover:

• Clinical Position Statement of the Union of European Phoniatricians (UEP) Swallowing Committee: Management of Dysphagia in Patients with Tracheostomy:
• Impact of Tracheostomy on Dysphagia in Children

Brendan is joined by SLT legend Prof Sarah Wallace to discuss the UEP position statement and what this means for bedside clinical care.

Link to supporting PDF: https://tracheostomy.org.uk/Podcast-Resources

The UK National Tracheostomy Safety Project (NTSP) is committed to providing education, information and resources to improve patient safety and the patient experience for those with tracheostomies and laryngectomies. All of our resources are housed on our website www.tracheostomy.org.uk, accessed by over 30,000 visitors each month from around the world.

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Our goal is to improve the safety and quality of care for patients with tracheostomies and laryngectomies through education. We work closely with patients, families and healthcare professionals to develop new resources to improve care. We’ve collaborated with key stakeholders in tracheostomy care since 2009, and developed freely accessible resources, supported by online learning developed with the UK Department of Health. We’ve worked with the Global Tracheostomy Collaborative since 2012 to improve care for patients and their families everywhere.

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Transcript

SPEAKER_02 0:07

Hi, it's Brendan McGraw from the NTSP. Welcome to our in-depth look at the papers that have caught my eye in April 2026. A couple of papers on the theme of dysphagia this month, which I thought was worth taking a slightly deeper dive into. So dysphagia is variably defined, but it's essentially eating, drinking and swallowing difficulty. The first paper comes from the very grand-sounding Union of European Phoniatronics Swallowing Committee. Now, a phoniatrician is a medical doctor who specialises in voice, speech, language swallowing and communication disorders. And phoniatrix is a recognised medical specialty in many European countries, particularly Germany, Austria, Sweden, and it sort of sits at the intersection of ear, nose and throat medicine, speech and language therapy, neurology, rehabilitation medicine. So in the US and the UK and other parts of the world, this workload is typically undertaken by other specialties such as speech and language therapy, ENT or otolaryngology, neurology, and then the wider multisplinary tracheostomy team. So this committee have produced an important consensus paper looking at dysphagia management in tracheostomised adult patients. So dysphagia after tracheostomy is something we talk about all the time clinically, but the evidence base is actually surprisingly, I think, quite difficult to interpret. Reported prevalence of dysphagia range anywhere from about 11% all the way up to way over 90%, which immediately tells you there's a huge heterogeneity in both the patient populations and the assessment methods. One of the key themes running through this paper is that swallowing problems in patients with tracheostomies are rarely caused by just one thing. Sometimes the tracheostomy itself contributes through reduced subglottic pressure, altered airflow, impaired cough, and reduced laryngeal sensation, or sometimes effects related to the presence of the cuff. But often dysphagia is also heavily influenced by the underlying condition that led to tracheostomy in the first place. Things like stroke, critical illness, weakness, neurological disease, head and neck cancer, or prolonged ventilation. So disentangling what's causing the problems, whether it's the tube or whether it's the patient's wider physiology, is usually very challenging. So this paper is not a formal guideline, but it's a position statement developed through literature review and expert consensus, and they involved 11 experienced European phonetricians over a one-year process. Overall, the message comes out very favourably in strong support of a multidisciplinary approach. The authors repeatedly emphasized that safe swallowing management in patients with tracheostomies depends on coordinated teamwork between speech and language therapists, nurses, physicians, respiratory therapists, physiotherapists, and dietitians. One of the most important points in the paper relates to silent aspiration. Now many listeners will know that aspiration in patients with tracheostomies is often clinically very difficult to detect. Patients may not cough very effectively, sensation may be impaired, and bedside attestment alone can miss really important, clinically significant aspiration events. So because of that, the authors very strongly advocate for early and structured swallowing assessment. Interestingly, this paper is fairly critical of relying too heavily on blue dye testing. So the modified Evans blue dye test is acknowledged as a very simple, very accessible sort of test, but the authors point out its sensitivity is very poor. And that means it can miss aspiration quite frequently. So instead the paper reinforces that instrumental assessment remains a gold standard, and that means fees. So flexible or sometimes fibroptic, uh endoscopic evaluation of swallow. That's where someone who's trained sticks a camera up in your nose and looks down the back of your throat, and you can look at the way you handle secretions passively, you can look at the airway structures, and you can look at the way that the laryngopharynx deals with um oral intake, whether that's uh liquid, saliva, uh thickened fluids, or uh food itself. So fees allows this direct visualization of what's going on. It can give you uh uh an assessment of airway protection, it can look at what residues there, it can look at bolus flow, and it can do all that at the bedside. The other option is video fluoroscopy, and that provides a more dynamic assessment. It's a radiological assessment, meaning you need x-rays for it, but that inadvertently means that you need to go to an X-ray suite, so there's transport involved, and there's a little bit of radiation exposure, which does make it slightly less attractive than a fees. Another area that the paper spends a lot of time discussing is tracheostomy tube selection and the various adjuncts that are associated with tracheostomy tubes. Unsurprisingly, one-way valves or speaking valves as sometimes known as a feature very heavily. The authors highlight that speaking valves can restore more normal upper airway flow and subloctic pressure, they can improve secretion clearance, they can reduce aspiration risk and even improve the sense of smell and overall quality of life. That aligns very closely with a lot of the existing tracheostomy rehab literature out there. The paper discusses tracheostomy cuff management, the use of fenestrations, different tube sizes and various capping strategies, whilst acknowledging that evidence remains very heterogeneous and very patient-specific. Another strong theme here is uh individualization. So the authors repeatedly stressed that dysphagia rehab shouldn't follow a rigid protocol, which is something I really like. Instead, management should be tailored to the patient's individual neurological status, their respiratory function, their secretion burden, their cognition, and their overall recovery trajectory. And if anyone who works in this space will appreciate, all of that can change very dynamically over time. The sort of interventions that the paper discusses are sort of patient positioning, diet modifications, swallowing exercises, oral hygiene, respiratory muscle training, and then progressive cuff deflation and speaking valve use, and all of that will be familiar to listeners of this podcast, and they're all the sort of things that we know have a positive effect in our patients. Another important thing that occurs in this position statement is that the paper links dysphagia management directly with decannulation success. And we know if you scoop all those things together, you can have a real impact on the patient's journey. And the authors argue that safe decannulation practice requires very careful assessment of airway patency, cough effectiveness, accretion management, and swallowing safety, all of which are all tied in with this assessment and management of dysphagia. The paper takes a fairly balanced and realistic real-world approach, and I recognise a lot of what the uh suggestions and uh practice they were putting forward. Um a lot of those I recognise in our real-world practice. The authors importantly acknowledge that evidence in this field remains quite limited, and that's because tracheostomy populations are very heterogeneous. Patients differ enormously in their diagnosis, their ventilation duration, their neurological status, and their airway anatomy. And all that means that different patients have different rehab potential, which all links in with the different sort of dysphagia strategies and trajectories. So, overall, there's very few one size fits all answers. But despite all of those caveats, I think the paper provides a very useful synthesis of current thinking and it reinforces several key principles which lots of you listening to this will already recognise. So, early assessment is really important. That means as soon as somebody wakes up or is able to participate in a swallowing assessment, silent aspiration is common and should be actively sought out. Instrumental evaluation is essential, one-way valves are hugely valuable, and multidisciplinary rehab remains central to good tracheostomy care. Now, I wanted to discuss this page with an expert in the field because I think it's a really important topic, and there's always room for improvement in how we manage dysphagia. So let's jump out of this podcast for a minute and into the ICU, and I'll see if I can find a passing international dysphagia expert. So when I read that paper, there's obviously lots of information about dysphagia, and I thought, who better to ask about dysphagia than my friend and colleague, international dysphagia expert to do with tracheostomies, Professor Sarah Wallace. So thank you, Sarah, for making the time to do this. So you and I were both registered by that paper, and obviously dysphagia is something that you spend a lot of your time sort of looking at. We both felt that the paper sort of highlighted the sort of often overlooked problems with dysphagia. I mean, but perhaps you could shed just a little bit of light over the sort of things you see in your practice and why dysphagia is so important for this group of patients.

SPEAKER_00 9:04

Yeah, well we know it's common and we have got a small number of studies and a systematic review in 2020 which showed the prevalence is up to 93% of patients with tracheostomies can have a dysphagia. So, but it isn't often always detected and certainly not detected early. When patients are dysphagic, we know that they end up with the tracheostomy for longer. They might not even be able to decannulate at all, so it's a real barrier to progress, but alongside that we know it affects their mortality. And the patient experience of being unsafe to eat and drink is devastating, and so it is really, really important for patients' quality of life as well as their sort of medical recovery and ability to actually decannulate safely. So, yeah.

SPEAKER_02 9:58

Important stuff.

SPEAKER_00 9:59

Very important.

SPEAKER_02 10:00

Yeah. I mean one of the things that that we were talking about just before was that this is a consensus statement, and and that is because often that the literature out there that underpins some of these recommendations and statements is is a little bit thin, but it's thin for a reason, isn't it?

SPEAKER_00 10:18

It's it's thin in terms of number of studies, but also in terms of the studies themselves have small sample sizes, and also they often include a very um large amount of heterogeneity. And you know, if you think about it, lots of different types of patients get tracheostomies, and dysphagia exists for many, many reasons when patients have lots of underlying comorbidities. So separating all of that out and doing research which is on a single population is difficult. Um, plus a lot of this early work's been led by speech and language therapists, and that's you know, we're we're thin on the ground, and we're not always able to access funding for research and have dedicated time. So the studies that we have are good, but we need more research with larger populations and perhaps focusing on certain populations of tracheostomy patients where we've got head and neck cancer, patients with trachees, or um in the neurological population, those are the areas where there is the most robust research. But you know, as well as me, when I come into the general ICU, I don't tend to see those patients. I'm seeing patients with pneumonia, with post-gastric surgery, but you know, any number of things. So there's a lot of uh patients with lots of different conditions. Um, the thing they have in common is a tube in the neck, and they've all been intubated. We also know that dysphagia in tracheostomy patients is highly multifactorial. I never see a patient where it's just one reason. Um and one of the things we need to do with managing dysphagia is try and understand why the dysphagic, how much is the intubation, potential trauma contributing, how much is it to do with the sedation and underlying diseases and their illness severity and their weakness, and you know, all of these things we need to unpick when we're assessing dysphagia, um, and it's difficult. So finding uh or conducting a study where you eliminate all those variables is really, really hard.

SPEAKER_02 12:29

Yeah. It's clear when you read papers like this, you know, there isn't the evidence-based meta-analysis and make evidence-based recommendations, but I was still struck by the fact that these uh the descriptions that the the guys are making in the paper is it they're the patients that we see. And so even though these are sort of you know best practice statements, I mean that there's still a lot of mileage in that, and I think you and I both agree that it could still enable change and people find it helpful.

SPEAKER_00 12:56

I mean, I think the best that we've got up to date is uh the scarette systematic review in 2020, which really helped to identify um what we do have in terms of studies and um also like the factors that really matter in terms of dysphagia and tracheostomy around um you know the biomechanics of swallowing. And so that's really nice, but as you say, in the real world, what we're trying to do is start rehab early, identify the problems, use instrumental tools like fees in ICU, videophoscopy in other populations who are not so acutely or not, um, and work as a team and really do tailored tailored intervention because I think a lot of the focus in the past has been on just picking up the dysphagia uh but then not necessarily focusing on what do we do about it. And we know a watch and wait sort of scenario is not okay, it's not going to get patients better quickly, it means that patients end up with trackies for longer. Yeah. Um, and the sooner we can use accurate tools like FEES to really understand the structure and function of the upper railway, um, the faster we can wean patients and decannulate them safely. Um, yeah.

SPEAKER_02 14:14

I mean that was something that came out very clearly that that there's it should be a focus on very early assessment. And I know that's something that you're very proactive in doing, and and I mean, you know, just for the reasons you like you've uh highlighted there, you know, if you can find a problem early and do something about it early, you know, certainly in our practice and some of our data would suggest that that does make a difference.

SPEAKER_00 14:34

It does, and I think it doesn't just make a difference to the dysphagia management, does it? It makes a difference to the ween, uh it makes a difference to the physio who's trying to rehab the cough. Um, you know, for example, in a patient who's got a vocal cord immobility problem, that's going to be harder. Yeah. Um it influences how tube choice, you know, if we want to downsize or sort of pick up issues that might mean that we need ENT intervention early to help us decannulate safely. And and just if you think about the patient's perspective, giving them that understanding of what um is happening uh to them in terms of what are we going to do about the fact that they might not be safe to eat and drink yet. Yeah, it's not enough for them to just go, okay, I'm nailed by mouth, now what? You know, we we have to get a plan in place and we need to also monitor them regularly. And the number of patients that I do fees on in in the ICU setting is extremely high. It's like 90% of patients, if not more now, who need a fees. Um, but they also then need a repeat and a repeat and repeat because we know they change.

SPEAKER_01 15:45

Yeah.

SPEAKER_00 15:45

Um generally hopefully getting better. But you know, that that's an essential tool for the whole team to understand the upper airway. And if we're trying to get a patient breathing through the upper airway and talking and swallowing, then we need to look.

SPEAKER_02 16:02

Yeah, yeah, it's all clearly joined up, isn't it? Yeah, yeah. I mean, we're obviously lucky to have you here, Sarah, doing so many fees. I mean, the the the the value of fees that you've demonstrated through a lot of your work is that ability to see what's going on. But I mean for for for some of those centres perhaps that that haven't got uh the the access uh that perhaps we have here, what what sort of things do you think would would drive a centre towards that the greater use of fees?

SPEAKER_00 16:34

Yeah, I think it's it's a reality, isn't it? And we know um from this consensus statement, we know from talking to professionals in other countries. Um Aaron Miles and I did an international survey last year which um looked at 52 countries and what their practice was in terms of managing tracheostomies and swallowing. Um, and access to fees is a big problem, but the other thing that came out of that was its number one priority for the speech pathologists to get fees. So everyone understands the value of it, but um it is really tricky. I mean, we still need to do clinical bedside assessment, that's still my first assessment. Um and we still you know, if you don't have fees, then we tend to fall back on other things like blue dye testing. And what's nice in this consensus paper is that it talks about problems with that in terms of missing silent aspiration, and that's the reason, another reason why we need to instrumental. So I understand that if you've got nothing else, you might use that, but it's so unreliable that it can be a hindrance actually. And I feel like something like this paper could really support clinicians who are trying to you know ask for equipment or to just be able to go into ICU to see the patients earlier and do scopes together with intensivists, with ENT, whoever. It doesn't, you know, it is a team team approach. So hopefully this is a driver for change. I I I mean, you I think it would be, you know, it should be.

SPEAKER_02 18:17

Yeah, okay, fantastic. Well, I mean my my my takeaways from it were just as you summarise there, it's it's it's a team game, that's exactly what the consensus paper is is trying to highlight. Uh, that early assessment is is really important, and we have various tools to do that, but clearly a focus on the better ones, uh, which comes with its with its sort of implications. But that that sort of early integral role of of speech and language therapists in that um sort of very early assessment is is certainly what I saw echoed in that paper, which is nice when it echoes your own practice. Oh yeah, that's good, someone else thinks it's a good idea too.

SPEAKER_00 18:52

And I think the other thing about the early practices and and early interventions, you as we've seen in in our other work is the earlier cuff deflation on the back of that. And cuff deflation and is one of the key factors that changes swallowing and improves swallow function. Um, so airflow. So the earlier we start getting involved with these patients, the earlier we get their cuffs down and we get them using one-way valves, and their swallow improves quicker. So, yeah, it's it's everyone's a winner. It is.

SPEAKER_02 19:24

We haven't even talked about anxiety, communication, going to the toilet, all these wonderful things. So, right, we'll save that for another day. Okay. So, thank you, Sarah. I know uh I've just literally dragged you off the ward and we're sat in my C cubicles, so uh apologies for the background noise. This is a working ICU, uh, and thank you so much for your time.

SPEAKER_01 19:42

Thank you.

SPEAKER_02 19:49

So, thanks to Professor Sarah Wallace for her insights into the paper and on dysphagia management in general. There's lots more information on our website which is tracheostomy.org.uk. So, next up we're shifting over into the pediatric world, but sticking with dysphagia. This paper looks at dysphagia in children undergoing tracheostomy, and that's a question that many of us working in MTT care could probably wonder about uh for quite some time. So the question we ask is does the tracheostomy itself worsen swallow function? Or are the swallowing problems we see simply a reflection of the complex medical conditions that these children already have? So this study comes from a large pediatric cohort and examines swallow both before and after tracheostomy replacement using predominantly video fluoroscopy or VFS. Now, before we work we get into the result, it's probably worth reflecting on on why this is important. So swallowing difficulties, dysphagia, very common in children who require tracheostomy. The indications of tracheostomy are often different to those with adults. So lots of kids have neurological disorders, complex airway abnormalities, developmental conditions, uh chronic respiratory disease, or prolonged periods of mechanical ventilation. Any one of those factors can affect swallowing and add a tracheostomy into the mix, and things get potentially even more complicated. There's long been a concern that the tracheostomy itself may impair swallow by restricting laryngeal movement by sort of pinning the laryngeal apparatus in place. And altering normal airflow patterns through the upper airway can have an impact on reducing subloc pressure, all of which sort of messes with the complex mechanisms that we all use when we swallow without even thinking about it. Now, these mechanisms are all very biologic plausible, but surprisingly little evidence exists in children. So the authors set out to try and change that with a review of over 500 children who underwent tracheostomy and that examined swallowing symptoms alongside objective video fluoroscopy findings, both before and after the procedure. So the first thing that stood out was just how common dysphagia is. So before tracheostomy, around a third of children. Reported to have swallowing difficulties. So a total of 194 out of 525 children had symptom-based dysphagia before their tracheostomy. That's around 37%. 282 or 54% reported symptom-based dysphagia after tracheostomy placement, and that was a significant difference. So the tracheostomy on the face of it did seem to increase the symptoms of dysphagia. So at first glance that sounds bad, but as ever, we need to take a more careful look at what those numbers actually mean. So at baseline, these aren't healthy kids. Many of them had the significant co opidities that we've already outlined, and it's difficult to separate the impact of the tracheostomy itself from the underlying reasons why the child requires a tracheostomy in the first place. So when the authors looked at the video fluoroscopy findings, they found abnormalities throughout the swallowing process. So this starts to shed a little bit of light onto what was happening. So the oral phase is the first thing that happens when you put something in your mouth, and the impairment of the oral phase on the video fluoroscopy often increased after tracheostomy placement, and that affected nearly nine out of ten children. The pharyngeal phase abnormalities were also common, and delayed swallow and swallow triggering appeared quite frequently. And that's interesting because it probably gives you some clues about the physiological effects of the presence of the tracheostomy. So the author suggests that altered laryngeal mechanics, reducing sublotic airflow pressure or degree of laryngeal tethering, so pinning the larynx in place, could contribute to that delayed initiation of the swelling reflex. But you know, proving causation is quite difficult in this retrospective study. But the observation is definitely plausible and it aligns with the mechanisms that have been proposed in adult populations. But another important finding relates to the aspiration risk. So what the authors found was that thin liquids were considerably more problematic than thickened fluids, and rates of penetration or aspiration into the lungs that are beyond the tracheostomy were higher with thin liquids following tracheostomy, whereas aspiration of thickened fluids was less common. Again, this probably wouldn't surprise swallow experts listen to this pod, but you know, thin fluids require very rapid coordination of the airway protection mechanisms and swallowing timing, and any disruption to that system can increase the aspiration risk. So perhaps the most interesting part of this study is the paired analysis because that followed children who underwent video fluoroscopy before and after tracheostomy. Now there weren't many completely paired analyses. So it was performed in 65 children before tracheostomy, 225 children after tracheostomy. So there were 25 kids in this big cohort who had the paired before and after assessments. So although some swelling abnormalities worsened after trache, the overall story was actually a bit more nuanced. So penetration aspiration scores improved in most children and only worsened in a tiny amount. So even more strikingly, the oral intake improved significantly in the majority of patients following tracheostomy. So whilst some of those scores changed and whilst some of the self-reported metrics of swallowing difficulty seemed to change, the actual proof of the pudding being in the eating, literally, oral intake did increase in the majority of children following tracheostomy. So that raises a completely different angle on this paper. So tracheostomy for some children may provide that respiratory stability and clinical stability that allows feeding and rehab to progress more effectively, despite some evidence of ongoing swallowing impairment. So on one hand, there's some physical and physiological effects of the presence of the tracheostomy, but in other words, the presence of the tracheostomy tube actually improves the overall health of the children. And so the swallowing abnormalities seen on imaging don't necessarily translate into worse feeding outcomes. And I think that's a really important message from this paper. So swallowing function is complex. It's influenced not only by airway mechanics, but respiratory status, neurological function, the endurance, the developmental progression, rehab input, and the overall stability and wellness of the child. The study also identified several groups who were particularly at high risk of swallowing dysfunction, including infants, male children, and significant comorbidities. But you know that this was a complex, sort of messy study, but I think you know those sort of headlines do emerge from the data. This was a relatively small study when you look at the paired assessments and it's a retrospective single centre review. And I think therefore the strength of the conclusions are, you know, they're obviously causal and we've got to look at them with a pinch of salt. But I think you know the take-home message for me is that tracheostomy itself does not inevitably cause dysphagia. Rather, it reinforces the fact that children who require tracheostomy represent an exceptionally high risk group for swallowing impairment both before and after the procedure. Solling abnormalities remain. Delayed swallow is a particular problem, and you need to think about the consistency of the liquids that were given these children. But actually, a lot of parents and some children will tell you that when children have a tracheostomy, when they've been umming and houring about whether they should or shouldn't, often it's seen as a real transformative step in that child's life. And the presence of the tube itself generally causes a stabilizing effect and can actually encourage children to sort of develop better and to thrive and reduce some of those problems that have plagued children and their families with multiple trips to hospital sort of prior to the tracheostomy. So clearly, after tracheostomy, children require ongoing swallowing surveillance, they need close collaboration between the airway teams, the speech and language therapists, and a recognition that improvements in feeding can occur even if those physiological swallowing abnormalities persist, even on imaging. So dysphagia is highly prevalent in these children, and continued assessment and management is essential to minimise any respiratory complications while supporting nutrition, growth, rehab, and focusing on maximising oral intake if that's appropriate for those kids. I think a broader lesson is that swallowing outcomes are not influenced just by a single factor, and so understanding the interaction between the tube, the airway, underlying conditions, and the child itself remains one of the most important challenges in pediatric tracheostomy care. So that's it for this episode focused on dysphagia. We've spent a lot of time looking at it this month, and I hope you found that useful. There's lots more topics in our back catalogue that go all the way back now to 2021. Please follow us on our various platforms and social media and feel free to comment on the discussion. As ever, the views are my own and don't represent any of the organisations for which I work. That was Tracky Talk, edited by Simon Williams and produced by him as well. Thanks for listening and we look forward to seeing you next time. Bye for now.