Assessment of Patients with Tracheostomy: Dispelling the Myths

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Assessment of Patients with Tracheostomy
Dispelling the Myths

• Stacey A. Skoretz, M.Sc., CCC-SLP
• University of Toronto
• James L. Coyle, M.A., CCC-SLP, BRS-S
• University of Pittsburgh

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Clinician Questions

• Why do patient require tracheostomies?
• Why do we have to worry about patients with
  tracheostomies?
• What patient characteristics need to be
  considered beyond the tracheostomy?
• What am I supposed to do with these patients?
• Why are they dysphagic?

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Some Answers

• High incidence of disordered swallowing following
  intubation, tracheostomies, prolonged
  mechanical ventilation (Smith et al., 1999,
  DeVita, 1990, Elpern, 1994, Tolep, 1996)
• Lack of dysphagia diagnosis and management can
  increase length of hospital stay and hospital
  costs (Harrington et. al., 1998)
• Mean length of cannulation time reduced when
  interdisciplinary approach utilised (Frank et
  al., 2007).
• Of 469 patients assessed for dysphagia in acute
  care, 276 aspirated silently (59) (Smith et al.,
  1999)
• 82 of tracheostomized patients who aspirated did
  so silently (Leder, 2002)

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Tracheostomy and Health
Disease, Condition
Disease, Condition

• Prolonged mechanical ventilation
• Neurologic
• Traumatic
• Neoplastic
• Structural
• Iatrogenic
• Progressive medical decompensation
• Pulmonary
• Upper airway obstruction (acute or chronic)
• Laryngeal/upper airway surgery
• Pulmonary toilet
• Obstructive sleep apnea

Pulmonary Nutritional Community
-Acquired Social Psychological Others
Tracheostomy
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Endotracheal Intubation

• Risk Factors for Compromised Airway Protection
• Translaryngeal placement
• Cuff position
• Duration of intubation
• Self-extubation

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Tracheostomy Placement (Durbin, 2005)

• Percutaneous tracheostomy
• Utilisation of guide-wires, dilators,
  bronchoscope
• Guide-wire placement between 1st 2nd tracheal
  ring
• Diameter of hole increased by using dilators
• Trach placed
• Surgical tracheostomy
• Patient under general anaesthesia
• Incision from 2nd tracheal ring
• Hole made between 3rd 4th tracheal rings with
  anterior portion removed
• Trach placed

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Tracheostomy Terminology

• Neckplate/flange
• Cannula
• Cuffed/cuffless

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Tracheostomy Terminology

• Fenestration
• Obturator

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Respiratory System Functions

• Ventilation
• Transfer of oxygen rich air into lungs
• Transfer of oxygen depleted/waste air out of
  lungs
• Respiration
• Transfer of oxygen to circulatory system, then to
  working organs
• Removal of some waste from working organs, via
  circulatory system

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Pulmonary Disease and Dysphagia

• The Respiratory System
• Mechanics of Ventilation
• Respiratory Physiology
• Restrictive and Obstructive Pulmonary Disease
• Aspiration Pneumonia and Pneumonitis

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Ventilation The Respiratory Pump
Mechanics of Ventilation

• Ventilation air is pulled into and pushed out of
  the lungs
• 1. Muscles and frame
• 2. Elasticity and Surface Tension

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Mechanics of Ventilation
Inspiration (expansion) Always Active
? REL?
Expiration (collapse) Passive at Rest
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Ventilation Mechanics

• Ventilation Impeded By Alveolar tendency to
  collapse
• Surface tension, elasticity

Alveoli are NON- COMPLIANT, elastic Structures. Li
ke balloons, they are less compliant When they
are Collapsed.
Surface Tension
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Ventilation Mechanics
Like balloons, Alveoli are More compliant When
they are Expanded.

• Ventilation is Facilitated by
• Alveoli held partially open at rest by pleural
  linkage, AND...
• Alveoli bathed in surfactant

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Respiration and Deglutition

• In Normals...
• Exhale ? Swallow ? Exhale Young and Old1
• Respiratory rate (young) is about 16/min.2
• (elderly)
  20/min.
• Total Swallow Duration, Swallow Apnea Duration3
• Increase with age
• Decrease with lower lung volumes

• Perlman et al., 2005 Hiss et al., 2002 Leslie
  et al., 2002
• Leslie et al., 2002
• Gross et al., 2003 Hiss et al., 2002 Leslie et
  al., 2005. Kim, McCullough, Asp, 2005

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Aspiration Pneumonia Prandial Aspiration
Source of Colonization Poor Host Resistance

• Oral/Pharyngeal Colonization
• Medications, Oral disease
• Host Risk Factors
• Underlying disease
• Mental Status (up to 70)
• Obesity, neck malignancy
• Medications, dementia
• Iatrogenic Factors
• Recent Extubation
• Tracheostomy

CDC/MMWR 46, RR-1, (1997) Langmore et
al, (1998) Eibling and Gross, 1996 Gross et
al, (2003).
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Aspiration Related Infiltrates
(R) Upper lobe infiltrates
(R) Basilar infiltrates
Aspiration produces pneumonitis or pneumonia in
gravity dependent portions of lung(s). Dependence
depends on posture when aspiration occurs,
density volume aspirated.
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Ventilation Terminology
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Ventilation Terminology

• Positive pressure ventilators
• Compliance
• Resistance
• Peak inspiratory pressure
• Pressure support ventilation (PSV)
• Continuous positive airway pressure (CPAP)

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• Trigger event
• Offset event
• PEEP

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Other stuff

• FiO2 (room air 21)
• Arterial blood gas (ABGs)
• PaCO2 (N 45mm Hg)
• PA O2 (N 95-104mm Hg)
• T-piece trials
• Plugging trials
• Button placement

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Possible Complications during Mechanical
Ventilation

• Cardiovascular (e.g., hypotension, cardiac
  dysrhythmias)
• Respiratory (e.g., barotrauma, infections)
• GI (e.g., GIB, poor nutrition, decreased
  peristalsis)
• Neurovascular (e.g., increased ICP)
• Renal/Electrolytic complications
• Metabolic disturbances
• Psychosocial (e.g., depression)

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Biomechanical Alterations of Upper Aerodigestive
Tract (UAT) following Tracheostomy

• Structural alterations
• Mechanical alterations
• Valving alterations

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Structural Alterations

• Epithelial damage
• Fistula formation
• Tracheal stenosis
• Granulation tissue
• Tracheobronchomalacia

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Mechanical Alterations

• Mechanical tethering of larynx
• disuse atrophy
• Airflow diversion
• Hypopharyngeal and laryngeal desensitization
• Decreased glottic closure and/or vocal fold
  paralysis
• Esophageal compression secondary to cuff
  inflation

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Myth 1 Laryngeal Tethering?

• Ding Logemann (2005)
• Significantly increased laryngeal elevation with
  cuff deflated (p lt 0.001)
• Terk, et al., (2007)
• Less hyoid elevation after decannulation
• A large effect size favoring tracheostomy tube to
  increase hyoid elevation (d0.73) ???

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Laryngeal Tethering
Data in this study are difficult to understand
Terk, Leder Burrell, (2007)
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Valving Alterations

• Impaired laryngeal reflexes
• Altered timing duration of glottic closure
• Decreased subglottic air pressure generation
• Impaired cough and secretion clearance
• Overall swallow discoordination (open vs. closed
  system)

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Myth 2.Pressure Generation

• Pharyngeal musculature functions optimally with
  closed system
• Does occlusion truly benefit swallow function?

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One Way Speaking Valves
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One Way Speaking Valves

• Benefits (Hiss et al., 2002)
• Respiratory
• Good segue to plugging
• Assists with weaning
• Improved cough secretion management
• Swallowing
• Utilising UAT
• Subglottic air pressure
• Speech/Voicing

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Physiologic Effects of Open and Closed
Tracheostomy Tubes on the Pharyngeal Swallow

• Gross et al., 2003
• Within subject study, 4 participants
• Dependent measures
• Penetration/aspiration
• Bolus transit time (BTT)
• Pharyngeal activity duration (PAD)
• Results (with PMV removed)
• Increased PAD, slower BTT, more severe
  aspiration/penetration

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Occlusion Status-Valve On-Off

• Further benefits
• Suiter, et al., 2003 (valve)-VFG
• Reduced PAS scores with valve ON
• Logemann, et al., 1998 (occlusion)-VFG
• Reduced aspiration from 4/4 to 2/4
• Both warn of individual variability
• Does not benefit
• Leder, et al., 2001 (occlusion)-FEES
• Occlusion did not affect pharyngeal or UES
  pressures
• Leder, 1999-FEES
• Did not affect aspiration

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Occlusion Status
Effect Size for Occlusion in Aspirating Patients
0.73
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Occlusion Status

• Other studies
• Muz et al. (1989) yes, 6/7 asp more without
  obturator
• Eibling and Gross (1996), Stachler et al.,
  (1996), others reduced aspiration

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Occlusion Status/Valve On-Off

• Conclusions?
• Patient variability is high
• There is sufficient evidence of a potential
  swallow benefit caused by the closure of the
  upper airway circuit, in patients with
  tracheostomy, to justify its investigation with
  appropriate patients.

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Myth 3

• Does the tracheostomy truly cause dysphagia?

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Causation is debatable

• Leder Ross (2000) 20 subjects consecutively
  enrolled, variety of diagnoses
• Swallow Ax conducted before and after trach
  placement
• 12 subjects who aspirated before trach, also
  aspirated after
• 7/8 subjects who did not aspirate before trach,
  did not aspirate after trach placement

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Causation is debatable

• Donzelli et al. (2005) 37 consecutive patients
  w/ tracheostomy, variety of diagnoses, variety of
  trach types
• Instrumental Ax w/ FEES
• Pureed boluses
• Assessed with trach in situ and directly after
  decannulation
• 35/37 aspirated before and after decannulation
• 2/37 aspirated after decannulation
• Decannulation did not alter the incidence of
  aspiration/penetration
• Medical diagnoses had more bearing on swallow
  impairment rather than the tracheostomy itself

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The Clinical Assessment
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The Clinical Assessment Part I

• Attending referral
• Medical history
• Chart review
• Discussion with attending
• Discussion with RT, OT, PT, RN, family
• Patient observation

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Medical History

• Attend to medical diagnoses and complications,
  ?stability
• e.g., sepsis, LOC,
• Current and past respiratory details
• Trach details size, type, cuff deflation,
  plugging trials
• Anatomic abnormalties
• Weaning parameters, number and length of
  intubations,RR, O2 requirements, suctioning
  frequency
• Hx of po attempts? Results?
• Physical abilities
• e.g., ambulation, sitting tolerance, self care

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Patient Observation

• SECRETION TOLERANCE
• suctioning frequency, spontaneous phonations,
  spontaneous coughs, spontaneous swallows
• LOC
• General bed/chair mobility
• Respiratory measures RR, tracings, O2 sats

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The Clinical Ax Part II

• Oral Facial Sensory-Motor Exam
• Assess oral mucosa (hydrate if necessary)
• Assess oral hygeine, dentition
• Oral/tongue function/strength
• Cuff Deflation (if not already deflated)
• Attending approval necessary, done in conjuction
  with RT

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Why Cuff Deflation?

• Is decannulation the goal?
• Tracheotomy site is inferior to vocal folds
• NO Aspiration can be reliably detected while cuff
  inflated
• Only oral stage can be observed while cuff
  inflated
• If cuff deflation is NOT approved, patient may
  NOT be a good candidate for significant oral
  intake at this time.
• Again, what is the overall goal?

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Myth 4

• Does the tracheostomy cuff affect swallowing
  function?
• Does it eliminate aspiration?

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Cuff Inflation Status

• Prevention of Aspiration?
• No! The cuff lies below the vocal folds!!!
• Tracheostomy cuffs may not completely seal upper
  from lower airway
• Winklmaier, et al., (2006)
• Pig tracheas water and artificial saliva, vent
  and no-vent conditions

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Cuff Inflation Status

• Winklmaier, et al., (2006)
• 6mL methylene blue infused over cuff
• Inspection at 5, 10, 15 minutes
• Portex
• Water with vent 2.68, 13.46, 26.20 mL leakage
• Water no vent 5.53, 60.45, 75.0 mL leakage
• Saliva no vent 0, 0, 0.93 mL leakage
• Significantly more leakage with water/saliva

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Cuff Inflation Status

• Ding Logemann, 2005.
• 623 patients with tracheostomy
• Cuff inflated or deflated during the VFG study
• Significantly greater frequency of silent
  aspiration in cuff inflated condition (p lt
  0.001)
• Significantly less hyolaryngeal elevation during
  swallow (p lt 0.001)

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Cuff Inflation Status

• Excessive inflation pressure

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Cuff Deflation Process

• Medical clearance, pretrial suctioning
• Cuff is deflated, suction repeated
• Note additional matter suctioned (from above
  cuff)
• Note volume of air removed from cuff
• Note tolerance of deflation
• Patient remains stable
• Occlusion on expiration ONLY
• Airway back pressure, absent voicing or
  glottic voicing on cough ENT referral

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Cuff Deflation Process (cont)

• Saliva swallow during occlusion
• ?spontaneous
• Often the next step is the swallow trials!!

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The Clinical Ax Part III

• Feeding trials
• Observations to make
• Vocal (wet) quality change
• Cough/clear airway with or without cue
• Laryngeal elevation timing
• Changes in RR, anxiety, O2 sats
• Oral residue
• Variable responses according to consistency
• Referral for instrumental Assessment

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Myth 5

• To Dye or Not to Dye.

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Clinical Assessment Myths

• The Blue Dye Plague of 2003
• Cameron JL, Reynolds J, Zuidema GD., (1973).
  Aspiration in patients with tracheotomies. Surg
  Gynecol Obstet 13668-70.
• Evans Blue Dye Tracheostomy aspiration Test
• Thompson-Henry S, Braddock B (1995). The
  modified Evans blue dye procedure fails to
  detect aspiration in the tracheotomized patient
  five case reports. Dysphagia 10172-174.
• Stained boluses administered

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• The Blue Dye Plague of 2003
• FDC Blue 1 has resulted in a few publicized
  patient adverse events
• ...and has been pulled from the healthcare market

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SUMMARY OF REPORTS ... the FDA is aware of 20
cases ... associating the use of blue dye in tube
feedings with blue discoloration of body fluids
and skin, as well as more serious complications.
There have been 12 reported deaths... In more
than 75 of all reported cases, patients had a
reported history of sepsis (and therefore likely
altered gut permeability) before or during
systemic absorption of Blue 1...
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• ...patients at risk for increased intestinal
  permeability, which includes those with sepsis,
  burns, trauma, shock, surgical interventions,
  renal failure, celiac sprue, or inflammatory
  bowel disease, appear to be at increased risk of
  absorbing Blue 1 from tinted enteral feedings.

David W. K. Acheson, MDChief Medical
OfficerCenter for Food Safety and Applied
NutritionFood and Drug Administration
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The Blue Dye Plague of 2003

• Volumes used in enteral formula 5-100 cc per
  1000 cc.
• Safe human consumption
• Data from life-exposure animal studies supports
  an ADI (acceptable daily intake) of Blue 1 of
  12.0 milligrams/kilogram body weight/day.
  (HEALTHY individual)
• 110 lb. patient ? 50-600 mg/day.

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The Blue Dye Plague of 2003

• 0.5 solution is most common dilution (99.5
  water)
• 12.0 mg to 2388 mg water (2.4 liters) 0.5 sln.
• 50mg Blue (minimum safe) ? 12 liters water
• 600mg Blue (max safe) ? 144 liters water
• 25 to 293 lbs. FDC Blue 2 solution
• 75 adverse event cases included sepsis
  (septicemia) as a diagnosis

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The Blue Dye Plague

• Reported Contamination of Multiple Use Container
• File, et al., (1995)
• Gastric colonization with pseudomonas aeruginosa
  from common use blue food color bottle used for
  enteral feeding dye, caused ventilator associated
  respiratory infection outbreak in ICU
• Knoll, 1993
• Gram negative and gram positive rods found in
  opened and unopened bottles of blue dye in
  hospital nursing station.

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• Conclusion
• There is no credible evidence suggesting that the
  use of small amounts of FDC blue 1 is harmful
• Avoid use in patients with abnormal gut
  permeability

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Precision of Clue Dye Testing

• Overwhelmingly, the sensitivity is found to be
  moderate to poor.
• Sensitivity aspirators detected
• Specificity non-aspirators detected
• ONeil-Pirozzi et al, (2003)
• Simultaneous, masked VFG/MEBDT
• Donzelli, et al., 2001
• Visualization of subglottic larynx

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Precision of Clue Dye Testing
Moderate Sensitivity and Specificity
ONeil-Pirozzi et al. 2001,
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MEBDT

• Donzelli et al. (2001)
• Microaspiration not detected with MEBDT (0)
• Overall (50)
• 50 false-negative
• Larger volume aspiration detected (67)
• Spinadequate data

Poor Sensitivity and Specificity for
Microaspiration
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Case Review
63 y.o. male MVA, C7 - functioning as a
C4 PMHx sleep apnea, ?CHF, HTN Post-op course
POD 8 trach POD 12 PEG Patient already on
DAT at time of referral
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Case Review

• CSA
• Voicing with partial cuff deflation
• Trached vented
• RN report of suctioning food particles from trach
  post meal
• Typically eating with cuff inflated
• Weak volitional cough
• OME

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Case Review

• 49 year old male admitted for CABGx2
• PMHx MI, failed angioplasty/stent,
  hyperlipidemia, smoker
• OR uncomplicated
• Post-op course
• multiple intubations
• difficulty weaning from vent
• tracheostomy placement/decannulation

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Case Review

• VFSS 1, POD 28
• Frank silent aspiration across consistencies
  tested, airway penetrations during/after swallow,
  vallecular/pyriform sinus residue
• Swallow maneuvers, postural changes and
  consistency modifications ineffective
• Alternative to oral feeding, ice chips sparingly
  (1/4 c. bid with supervision)

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Case Review

• VFSS 2, POD 34
• Effortful swallow (ES) appeared to reduce residue
  and no aspiration/penetration events observed
  with same
• ½ cup level 3 or pureed tid w/ ES, alternative to
  oral feeding for nutrition/meds
• VFSS 3, POD 38
• Discharge imminent, patient refusing feeding tube
  (removed), MD ordered repeat VFSS, respiratory
  status stable (room air, chest clear, afebrile)
• sEMG VFSS

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Case Review

• sEMG training POD 34-40 with po (modified diet)
• Discharged POD 40
• Outpatient dysphagia follow-up and repeat VFSS