Evaluation/Management of the Tracheostomized Patient

I've been assigned to evaluate the swallowing function of a tracheostomized pt. A colleague told me about the blue dye test. I've never performed this test. At the hospital, they do not have the blue dye for the evaluation. Do you use food coloring? What would be the process? How would you perform a swallowing trial to a tracheostomized pt? I know that you need the cuff to be deflated prior the assessment and it is important to verify changes in oxygen saturation during swallowing and cuff deflation. Thank you for your advise!
There's so much to comment on here. The blue dye test has a high incidence of false negative; meaning that if you see blue dye, they obviously aspirated. It also doesn't tell you WHY they aspirated (poor strength? poor timeliness? etc) HOWEVER, if you DON'T see blue dye, it doesn't mean that they didn't, you just didn't see it. I had a patient probably 7 years ago that I did the blue dye test on, negative on blue dye return. I let him eat, he kept getting sick, we did an MBS, and turns out he was a big time aspirator. I still remember his name, he was one of THOSE patients that taught me volumes. I never rely on the blue dye test as a primary determiner. If you decide to use it, you can use grape juice to color your foods or find foods that don't look like bodily fluids. You can use food coloring as well. We use phaegin blue vegetable dye (you would have to order it) but before that we used the aforementioned grape juice and kids apple sauce that was blue. We used these items for FEES exams and not for blue dye test but it would work.
Can this patient tolerate a passy muir valve? If so, then the exam should be done with the PMV in place. If they cannot tolerate a PMV (or cuff deflation) then I would proceed with caution and probably stick with ice chips and sips of water. If they are not managing their own secretions, then now is probably not the time to offer anything by mouth. An inflated cuff anchors the larynx and inhibits hyolaryngeal elevation and excursion, and could lead to a friction injury like granulation or worse, a tracheo-esophageal fistula. If they can tolerate cuff deflation, then I would consider a PMV eval first. If your bedside eval makes you wonder if the patient is aspirating, you are never wrong to ask for an instrumental eval such as a FEES or MBS.
Hope this helps.
Thank you! I understand what you are saying. Great advice!
This pt can tolerate the PMV, but presented marked difficulty with phonation. Pt is NPO with G -tube, A&O x4. The pt managed oral secretions adequately, but laryngeal elevation is limited (2/p trach). Cough reflex & throat clearing are weak. Pt is ventilator dependent, but tolerates periods of 45-60 mins without it. Pt presented respirations with audible secretions and the trach is permanent. The MD wants to know if the pt is able to manage foods & liquids intake safely.

If a pt does not tolerate a deflated cuff, but is able to manage sips of water, what would be your recommendation?
....if it is not ready to have a deflated cuff, maybe this respiratory issues should be solved prior to consider oral intake. At least, it needs a partially deflated cuff for the assessment.
Anacodia brings up a lot of great points. Does your facility have guidelines written for the blue dye test? Also, I would keep in mind that the FDA put out a warning on using blue dye with certain patients. Its helpful to keep in mind http://www.asha.org/Publications/leader/2003/031104/031104c/

The patient should be able to tolerate having the trach decuffed. If they tolerate the PMV, you want to have that in place. You want to allow the patient a few swallows of one consistency that's a color that will provide you a nice visual contrast. We usually use grape juice. After they drink, you want to check the trach site for any evidence of color. You then want to suction the trach to look for any evidence of color. If its colored then they aspirated. If not, they may have aspirated and may not. There is 50% or more false negatives with this test. This test takes 24 hours so you want nursing to document the color of the secretions with endotracheal suctioning. If the patient does well and no color is noted after 24 hours, an MBSS is usually performed at that point.

A couple readings I found helpful were "Use of Blue Dye and Glucose Oxidase Reagent Strips for Detection of Pulmonary Aspiration: Efficacy and Safety Update" by Susan Brady and "Tracheostomy and Dysphagia: A complex Association" by Rita L. Bailey. They can be found in the December 2005 issue of the ASHA leader.

No, it doesn't have guidelines for it. Thank you for the info.
I will certainly look for those articles.
Just keep in mind that the articles linked relate to tinted enteral feedings, which were large volumes fed through a tube. The amount you will be giving, if you decide to use this technique, is minuscule compared to an entire tube feeding. It is important to know about it however, because it always seems to come up. You likely wouldn't be using any more dye than it would take to frost a cake or two.
Right.
The blue dye test, after all, seems to be a screening tool to compliment the bedside assessment. It is not reliable and contraindicated for some pt's. It cannot be taken as a sole measure to determine a pt's capability for oral intake. But, what other procedures can be performed bedside?
You could use cervical auscultation, although it's about as reliable as the blue dye test. If this were my patient, I would use a standard bedside assessment, assessing strength and ROM, ability to follow directions, do a little teeth brushing (you can get a lot of info out of a patient by brushing their teeth- do they understand what you are doing? Do they protest? DO they allow it? Do they move the tongue out of the way, and open when they need to? Can they spit or do you have to use suction?) and then I'd start with ice chips and sips of water. After that, I'd do blue (or some other color) tinged foods and see whats in the tubing while they are being suctioned. If all of this is going well, I'd see them daily for feeding, get comfortable with that, and then loosen things up and allow nursing to assist. That's kind of my mental protocol that is subject to change at any moment with any patient. Sometimes, just a 'gut feeling' will stop me from allowing a patient to PO until an instrumental eval can take place.
Great tips, thank you! I did the teeth brushing, and found out so many important details about cognition, attention and oral-motor skills. At the hospital, the radiologist refused to perform the MBS. Do you know of any FEES certification in Florida?
Why did the radiologist refuse the MBS? Anyway, most states don't have a FEES certification per se, your hospital may need to come up with some kind of competency for it. There are multi day seminars offered pretty often from one place or another. You will get lots of passes of the scope and learn how to interpret what you see. If you have a good relationship with your ENTs, they can help streamline the process.
Have you heard about the Langmore FEES courses? Are they good? Any other recommendation regarding FEES courses?
I too would be worried about things related to eating with the cuff inflated. If your patient cannot tolerate cuff deflation (but Im assuming he can as he's using a PMV--unless it's inline), I personally wouldn't be going down the p.o. route, but that's me.

Are there any plans to vent wean?

Trach/vent patients make me nervous about silent aspiration as they have a high incidence (something like 50% of aspirators) of silent aspiration given laryngeal sensation changes inherent to long term trachestomies. I'd be even more nervous if this patient has a concurrent neuro diagnosis (e.g. CVA, TBI, ALS).

I'd push for an instrumental if the patient is accepting of p.o. and the initial return on the blue dye screen is negative. If there is no way to get an instrumental, I'd proceed, with caution, the way anacodia mentioned.
Thank you. The pt has COPD, BT & ESRD. After all, no instrumental evaluation was available. After the bedside, the analysis and my gut feeling told me to maintain this pt NPO. Pt presented reduced laryngeal excursion, poor secretions management, hypoactive, decreased strenght , coordination & ROM in the facial, intraoral, respiratory & laryngeal musculature. Presented cough episodes with sips of water and positive blue dye test .
The poor secretion management (and I guess the + blue dye--yikes) would've had me out. Has this person been trach/vent for a while?