Dysphagia is highly prevalent among individuals with tracheostomy, yet its causes are rarely attributable to a single factor. For medical speech‑language pathologists (SLPs), understanding the complex relationship among underlying disease processes, critical care factors, airway alterations, and sensory‑motor changes is essential to accurate assessment and clinical decision‑making. This article focuses on potential contributors to dysphagia and key assessment considerations in patients with tracheostomy across care settings. Early involvement of the SLP plays a critical role in identifying dysphagia, determining readiness for oral intake, developing a treatment plan, and informing interdisciplinary care.
Potential Causes of Dysphagia in Patients with Tracheostomy
Dysphagia is common in patients who require a tracheostomy, though its etiology is often multifactorial. While the presence of a tracheostomy tube has been associated with alterations in swallowing physiology, it is rarely the sole driver of impairment. More often, swallowing dysfunction reflects the broader clinical context in which a tracheotomy is necessary.
Research has described a range of sensorimotor changes associated with tracheostomy, including reduced hyolaryngeal excursion, altered subglottic pressure, impaired coordination of breathing and swallowing, diminished cough effectiveness, and changes in smell and taste (Amatheiu et al., 2012; Gross et al., 2003; Tsikoudas et al., 2011; Prigent et al., 2011; Park et al., 2018). These factors may influence airway protection and bolus clearance, although the degree to which the tracheostomy itself contributes varies considerably across individuals.
Instrumental studies highlight this variability. In patients with new tracheostomies, aspiration rates are high but not universal, with 59% demonstrating aspiration during instrumental assessment (Marvin and Thibeault, 2021). Using flexible endoscopic evaluation of swallowing, Leder (2002) reported aspiration in 33% of patients requiring tracheostomy and mechanical ventilation, indicating that the majority did not aspirate during assessment. Together, these findings underscore an important clinical principle: the presence of a tracheostomy alone does not predict swallowing function.
Equally important are the underlying conditions that necessitate tracheostomy placement. Neurologic injury, head and neck cancer, respiratory failure, systemic illness, and complications of critical illness such as neuromuscular weakness, sensory impairment, and delirium all independently increase dysphagia risk. These factors frequently coexist, reinforcing the need for careful, individualized assessment across care settings.
Does Airflow, Cuff Status, or Tracheostomy Occlusion Matter?
Restoration of airflow to the upper airway has received considerable attention in the dysphagia literature. Studies suggest that cuff deflation and tracheostomy occlusion with a speaking valve, may support swallowing by improving sensory awareness, secretion management, cough effectiveness, and airway protection (O’Connor et al., 2019). Similarly, externally delivered airflow above the cuff, commonly referred to as Above Cuff Vocalization (ACV), has been associated with improvements in secretion ratings and penetration‑aspiration outcomes in some patients with tracheostomy (Tang et al. 2025).
Despite these findings, the literature remains inconsistent. Systematic and scoping reviews have identified substantial variability in study design, patient populations, and outcome measures, limiting the ability to draw definitive conclusions regarding cuff status, occlusion, or airflow as isolated determinants of swallow safety (Goff and Patterson, 2018; Skoretz et al., 2020). At present, there is no universally accepted standard of care linking specific tracheostomy management strategies to predictable swallowing outcomes.
What is clear, however, is that swallowing assessment should not be deferred solely on the basis of cuff inflation or ventilator dependence. Patients with tracheostomy benefit from individualized evaluation, with clinical decisions guided by the full medical and respiratory context rather than assumptions about the tracheostomy tube itself.
Assessment Considerations
Comprehensive dysphagia assessment begins with a detailed review of the medical record and close collaboration with the interdisciplinary team. Key considerations include the patient’s hospital course, underlying diagnoses, neurologic and pulmonary status, history and duration of intubation, tracheostomy characteristics, ventilator settings when applicable, mental status, and secretion management (Brodsky et al., 2019).
A clinical swallowing evaluation remains a valuable component of assessment, even in patients at elevated risk for aspiration. Through patient and family interview, observation of cognitive and respiratory status, and oral mechanism examination, the SLP can assess readiness for instrumental testing and identify factors that may influence testing conditions. In some cases, oral intake during the clinical evaluation is limited or deferred. When trials are appropriate, small volumes such as ice chips may provide clinically meaningful information while minimizing pulmonary risk. (Pisegna & Langmore, 2018).
Meaningful interpretation of the clinical swallowing evaluation depends on adequate airflow to the upper airway. Upper airway airflow supports voicing, cough generation, and sensory awareness, all of which contribute to clinical judgments regarding airway protection and secretion management. When safely achievable, airflow may be restored through cuff deflation and tracheostomy occlusion using a speaking valve such as the Phon Assist Speaking Valve. In the absence of upper airway airflow, interpretation of voice quality and cough effectiveness is limited, reducing the reliability of the clinical exam. When airflow cannot be safely established, instrumental assessment should be strongly considered before conclusions are drawn regarding swallowing function or oral intake readiness.
Instrumental evaluation using videofluoroscopic swallowing study or flexible endoscopic evaluation of swallowing is therefore often an essential component of assessment in this population. Both modalities are considered gold standards and provide complementary information. Flexible endoscopic evaluation of swallowing offers particular advantages in medically complex patients due to its portability, allowing assessment at the bedside across care settings. FEES also permits prolonged evaluation of secretion management, direct visualization of laryngeal and pharyngeal mucosa, and assessment of vocal fold structure and movement under varying airway conditions, including changes in cuff status or tracheostomy occlusion. These features support a more comprehensive understanding of airway protection over time, rather than during brief bolus trials alone.
Videofluoroscopic swallowing study remains valuable when visualization of the oral phase, assessment of bolus flow through the esophagus, or evaluation of submucosal structures is required. Selection of instrumental modality should be guided by the clinical questions being asked, patient tolerance, and available resources.
Summary
Dysphagia in patients with tracheostomy reflects the interaction of medical complexity, critical illness, airway alterations, and sensory‑motor impairment rather than the presence of a tracheostomy tube alone. Aspiration risk is common but not universal, reinforcing the importance of individualized, evidence‑informed assessment. Early involvement of the speech‑language pathologist across care settings is essential for identifying swallowing impairment, determining readiness for oral intake, and supporting interdisciplinary decision‑making. While this article has focused on potential causes of dysphagia and key assessment considerations, early treatment strategies, including approaches to airflow restoration in patients with tracheostomy, will be explored in a future newsletter article.
References
1. Amathieu R, Sauvat S, Reynaud P, Slavov V, Luis D, Dinca A, et al. Influence of the cuff pressure on the swallowing reflex in tracheostomized intensive care unit patients. Br J Anaesth. 2012;109(4):578–83. doi:10.1093/bja/aes210.
2. Brodsky MB, Mayfield EB, Gross RD. Clinical decision making in the ICU: dysphagia screening, assessment, and treatment. Semin Speech Lang. 2019;40(3):170–87. doi:10.1055/s-0039-1688980.
3. Goff D, Patterson J. Eating and drinking with an inflated tracheostomy cuff: a systematic review of the aspiration risk. Int J Lang Commun Disord. 2019;54(1):30–40. doi:10.1111/1460-6984.12430.
4. Gross RD, Mahlmann J, Grayhack JP. Physiologic effects of open and closed tracheostomy tubes on the pharyngeal swallow. Ann Otol Rhinol Laryngol. 2003;112(2):143–52. doi:10.1177/000348940311200207.
5. Leder SB. Incidence and type of aspiration in acute care patients requiring mechanical ventilation via a new tracheotomy. Chest. 2002;122(5):1721–6. doi:10.1378/chest.122.5.1721.
6. Marvin S, Thibeault SL. Predictors of aspiration and silent aspiration in patients with new tracheostomy. Am J Speech Lang Pathol. 2021;30(6):2554–60. doi:10.1044/2021_AJSLP-20-00377.
7. Park M, Lee S. Changes in swallowing and cough functions among stroke patients before and after tracheostomy decannulation. Dysphagia. 2018;33:857–65. doi:10.1007/s00455-018-9920-9.
8. Pisegna JM, Langmore SE. The ice chip protocol: a description of the protocol and case reports. Perspect ASHA Spec Interest Groups. 2018;3(13).
9. Prigent H, Lejaille M, Terzi N, Annane D, Figere M, Orlikowski D, et al. Effect of a tracheostomy speaking valve on breathing–swallowing interaction. Intensive Care Med. 2012;38(1):85–90. doi:10.1007/s00134-011-2417-8.
10. Skoretz SA, Riopelle SJ, Wellman L, Dawson C. Investigating swallowing and tracheostomy following critical illness: a scoping review. Crit Care Med. 2020;48(2):141–51. doi:10.1097/CCM.0000000000004098.
11. Tang ZM, Peng ZY, Shi ZH, Wu HW, Chen LS, Yang ZL, et al. Enhancing swallowing function in tracheotomy patients with subglottic oxygen flow: a randomized self-controlled crossover trial. Dysphagia. 2026;41(1):60–67. doi:10.1007/s00455-025-10852-0.
12. Tsikoudas A, Barnes M, White P. The impact of tracheostomy on the nose. Eur Arch Otorhinolaryngol. 2011;268(7):1005–8. doi:10.1007/s00405-011-1522-1.