British Journal of Anaesthesia 109 (4): 578–83 (2012)

Advance Access publication 26 June 2012 . doi:10.1093/bja/aes210

CRITICAL CARE

Influence of the cuff pressure on the swallowing reflex

in tracheostomized intensive care unit patients
R. Amathieu 1,2, S. Sauvat1,2, P. Reynaud 1,2, V. Slavov 1,2, D. Luis 1,2, A. Dinca1,2, L. Tual1,2, S. Bloc1,2
and G. Dhonneur 1,2*
1
Anaesthesia and Intensive Care Unit Department, Jean Verdier University Hospital of Paris, Av du 14 Juillet, 93143 Bondy, France
2
Paris 13 University School of Medicine, Bobigny, France
* Corresponding author. E-mail: gilles.dhonneur@jvr.aphp.fr

Background. Because recovery of an efficient swallowing reflex is a determining factor for

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Editor’s key points
† The recovery of the
swallowing reflex is key to
weaning from
tracheostomy.
† A cuffed tracheostomy tube
anchors the tracheal to the
anterior neck tissues and
interferes with swallowing.
† This study in intensive care
patients demonstrated that
the presence of a cuffed
tube interferes with both
the latency and magnitude
of the swallowing reflex.
† The effect increased with
greater cuff pressures,
especially above 25 cm H2O.
the recovery of airway protective reflexes, we have studied the influence of the
tracheostomy tube cuff pressure (CP) on the swallowing reflex in tracheotomized patients.
Methods. Twelve conscious adult intensive care unit (ICU) patients who had been weaned
from mechanical ventilation were studied. Simultaneous EMG of the submental muscles
with measurement of peak activity (EMGp) and amplitude of laryngeal acceleration (ALA)
were performed during reflex swallows elicited by pharyngeal injection of distilled water
boluses during end expiration. After cuff deflation, characteristics of the swallowing reflex
(latency time: LaT, EMGp, and ALA) were measured at CPs of 5, 10, 15, 20, 25, 30, 40, 50,
and 60 cm H2O.
Results. LaT and CP were linearly related (P,0.01). CP was inversely correlated (P,0.01) to
both ALA and EMGp.
Conclusions. We demonstrated that LaT, EMGp, and ALA of the swallowing reflex were
influenced by tracheostomy tube CP. The swallowing reflex was progressively more
difficult to elicit with increasing CP and when activated, the resulting motor swallowing
activity and efficiency at elevating the larynx were depressed.
Keywords: acceleromyography; airway protection; cuff pressure; electromyography;
swallowing reflex; tracheostomy
Accepted for publication: 21 February 2012

The presence of a cuffed tracheostomy tube alters the pha- Methods

ryngeal stage of swallowing. This is believed to be the
result of the anchoring of the trachea to the anterior neck
tissues, resulting in a reduction in elevation and anterior
movement of the larynx, uncoordinated laryngeal closure,
and oesophageal obstruction by the cuff in the proximal oe-
sophagus and hypopharynx.1 – 3 Other reasons including oro-
motor dysfunction and impaired sensation may contribute to
disordered deglutition in tracheostomized patients.4 During
the weaning process from the tracheostomy tube, continu-
ous scoring of swallowing performance is recommended.5
When the patient appears to be able to tolerate secretions
without difficulties, the cuff is deflated and a swallowing as-
sessment of food and fluid of varying consistencies is under-
taken. If any sign of frank aspiration is observed, the cuff is
immediately re-inflated. We hypothesized that cuff pressure
(CP) in the tracheostomy tube may influence recovery of
swallowing. We studied the influence of the CP on the swal-
lowing reflex elicited in tracheostomized patients.
After the local ethics committee approved the protocol and
informed consent had been obtained from the patient or
relatives, 12 consecutive tracheostomized adult patients
who had been weaned from mechanical ventilation were en-
rolled in the present study.
We studied patients who required intensive care after
severe blunt chest trauma. After resolution of the initial path-
ology, sedation (sufentanil and midazolam titrated on the
Ramsay sedation scale) was discontinued and the patients
were allowed to recover consciousness. After awaking
(Glasgow coma scale of 13–15), dysphagia assessment was
undertaken in the intensive care unit (ICU). This included
an assessment of the level of consciousness; cranial nerve
function; cough capability, oromusculature efficiency; and
volitional swallows. A multidisciplinary team including phy-
siotherapists and medical staff decided that patients were
fit for inclusion in the study when the patients tolerated

& The Author [2012]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
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Swallowing with a tracheostomy tube
cuff deflation with a stable respiratory rate, arterial oxygen
saturation, and expired carbon dioxide expiratory partial
pressure. In order to be included, the patients had to demon-
strate they were co-operative and able to respond on
command simple orders such as ‘swallow your saliva’ and
‘raise your right hand’.
Once recruited, the stomach content of the patient was
suctioned and the nasogastric feeding tube was removed.
The patients were then requested to fast for a minimum of
6 h. The studies were conducted with the patient sat up at
458. Before measurement of the swallowing reflex character-
istics, oropharyngeal secretions were suctioned. After trache-
ostomy tube cuff deflation (TRACOE VARIOTM , high-volume
and low-pressure cuff, POURET Medical, Clichy, France),
suction was performed through the tracheostomy tube to
remove secretions that had been sitting on the top of the
cuff. Figure 1 shows details of the electrophysiological mea-
surements. A 0.8 mm ID, polyvinyl catheter was placed
through the nostril into the oropharynx using water lubricant
gel without local anaesthetic. The tip of the catheter was
positioned at the inferior limit of the oropharynx. This was
checked visually and the catheter secured. Surface elec-
trodes, used to measure EMG activity of the submental swal-
lowing muscles, were placed 2 cm away from the mid-line
EMG
LA
DPS
CP Controller
PnT
Fig 1 Schematic illustration of the method used to evaluate the
influence of CP increase on the swallowing reflex in tracheosto-
mized patients. EMG and laryngeal acceleration (LA) were mea-
sured during reflexively elicited swallows at different values of
CP measured using a CP controller (CPC). A pneumotachograph
and a differential pressure transducer (PnT) were used to syn-
chronize hypopharyngeal stimulations with the end-expiratory
phase. A double-piston syringe (DPS) was used to simultaneously
inject the pharyngeal stimulus (predefined: 0.3 –5 ml volume,
cold 38C, distilled water bolus), and flush 1 ml of air within the
ventilatory circuit.
BJA
and 1.5 cm above the hyoid arch. The EMG was amplified
and band-pass filtered from 30 to 300 Hz, and then rectified
and integrated (100 ms time constant), and the peak electro-
myographic activity was measured (EMGp).
The quality of laryngeal elevation was measured by accel-
erometry with the use of a piezoelectric probe measuring
2×2×4 mm (Entran; Garston, Watford, UK), which was
fixed in the mid-line with an adhesive tape 0.5 cm above
the tip of the thyroid cartilage. This probe measured acceler-
ation values ranging from 5 to 25 G. The probe was orien-
tated to measure the amplitude of laryngeal acceleration
(ALA) generated by the contraction of the submental swal-
lowing muscles.
In order to synchronize pharyngeal stimuli with respir-
ation, ventilatory flows were monitored at the T-piece of
the tracheostomy tube with a pneumotachograph (Fleish 2)
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and a differential pressure transducer (Validyne MP 45,
Northridge, CA, USA). Reflex swallows were systematically eli-
cited with boluses of distilled cold water (38C) injected
through the pharyngeal catheter at the end of expiration.
The latency time of the swallowing reflex (LaT) was defined
as the time elapsing between the moment of bolus injection
of distilled water in the hypopharynx (a double-piston syringe
allowed simultaneous injection of distilled cold water into
the pharynx and 1 ml of air into the ventilatory circuit) and
the beginning of the evoked EMG signal (Fig. 2).
Patients were included in the study, if reflex swallows
could be elicited and if the characteristics of the swallowing
reflex could be measured accurately. In order to evaluate
pharyngeal sensory perception, we first determined in each
tracheostomized patient the pharyngeal sensory threshold
(PST). After cuff deflation (CP¼0 cmH2O), patients received
in a random order 0.3, 0.5, 0.8, 1, 3, 5, or 10 ml boluses of
cold (38C) distilled water through the pharyngeal catheter.
PST was arbitrary defined as the lowest (stimulation)
volume of distilled water systematically triggering three suc-
cessive end-expiratory reflexively activated swallows with an
LaT of below 10 s. The following variables, LaT, EMGp, and
ALA elicited with PST, were considered as the control
values for the swallowing reflex in that patient.
If a 10 ml cold water bolus did not systematically elicit a
reflex swallow or a PST of .5 ml was associated with frank
tracheal aspiration signs, or if only poor-quality recordings
of LaT, EMGp, or ALA could be obtained during elicited
reflex swallows, the patient was excluded from the study.
All signals were recorded simultaneously and stored on a
personal computer.
The control values of the swallowing reflex were com-
pared with those obtained with the tracheostomy cuff
inflated with air to different pressures: 5, 10, 15, 20, 25, 30,
40, 50, and 60 cm H2O (Endotest manometer, Pressure
Cuffs, Rusch, Betschdorf, France), applied in a random order
determined by a computer-generated randomization list. At
each CP and for each variable (LaT, EMGp, and ALA), a
mean value of a set of three consecutive measures per-
formed over 1 min was normalized to the control value. An
interval of at least 1 min was allowed between each
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LaT
EMG
LA
Flow Expiration
Inspiration
Pharyngeal
stimulation
Fig 2 Typical recording from one patient showing the characteristics of the swallowing reflex. EMG, electromyography; LA, laryngeal acceler-
ation. The peak EMG (EMGp) and ALA were measured. For each reflexively elicited swallow, EMGp and ALA were computed. Reflex swallows
were elicited during the end-expiratory phase using a continuous ventilatory flow monitoring. The latency time (LaT) of the swallowing
reflex was calculated as the time elapsing between the onset of the pharyngeal stimulation artifact (respiratory flow trace) and that of
the integrated EMG signal.
measurement and return to the basal respiratory rate was
required before the next measurement was performed.
After each set of three tests, CP was reset to 0 cm H2O.
When all the measurements were completed, patients
were asked to swallow 10 ml of water gel coloured with a
white dye given orally with the cuff deflated. A flexible bron-
choscope was passed through the tracheostomy to identify
pulmonary aspiration manifest as coloured liquid seen on
the tracheal wall.
The overall impact of CP increase upon the swallowing
reflex variables was evaluated using a Friedman test. Then,
a Wilcoxon non-parametric test for repeated measures was
performed to evaluate the impact of a specific level of CP
upon each variable.
Regression lines obtained by the method of least squares
and the Spearman correlation coefficients were calculated to
assess the relationship between CP and the three variables
LaT, EMGp, and ALA. Values are mean [standard deviation
(SD)] unless specified. A P-value of ,0.05 was considered
statistically significant.
Results
Eighteen patients were recruited and 12 completed the trial.
Among the recruited patients, four lacked capacity to give
580
Amathieu et al.
EMGp
ALA
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300 ms
consent at the time of the trial. For these patients, consent
to enter the study was given by family members. Retrospect-
ively, we obtained signed consent from all the patients.
Six patients were excluded. Reasons for exclusion were a
low amplitude of ALA measures (n¼2), poor pharyngeal sen-
sation as confirmed by the impossibility to trigger reflex
swallows (n¼2), and because of frank tracheal aspiration
signs (n¼2) during PST determination.
The mean age of patients studied was 37 (range: 19–54) yr.
Most of the patients were admitted in the ICU because of
severe thoracic and abdominal trauma. Percutaneous trache-
ostomy was performed 10 days after ICU admission (range;
7–18). All the patients were fully conscious at the time of
swallowing reflex evaluation performed 14 (range: 5–20)
days after cuffed tracheostomy tube placement.
The mean (SD) PST volume and control LaT were 1.5 (1.3)
ml and 1.5 (0.8) s, respectively. A significant linear relation-
ship (P,0.05) was observed between PST and control LaT
[LaT¼0.4 (PST)+0.8; r 2 ¼0.726, P,0.05].
We observed that CP and LaT were significantly correlated
(Fig. 3). An inverse correlation was identified between CP and
both ALA and EMGp (Figs 4 and 5, respectively). The charac-
teristics of the swallowing reflex deteriorated with increasing
CP. ALA and LaT were the most sensitive variables to CP in-
crease. ALA and LaT significantly deteriorated with a CP of
Swallowing with a tracheostomy tube BJA
25 and 30 cm H2O, respectively. When compared with the
Latency Time (% of Control) control value, the mean LaT was increased by 2.3-fold
350
Latency Time = 2.7(Cuff Pressure) + 70.3, when CP was 60 cm H2O.
300 *
r2 = 0.91, p <0.01 The mean changes in respiratory rate and SaO2 over the
250 * time period elapsing between the first and last CP tests
* were 1.5 (3.0) bpm and 21.9 (0.6)%, respectively. Four
200
* patients experienced pulmonary aspiration when attempting
150
to swallow 10 ml of coloured thin liquid.
100
50
0 10 20 30 40 50 60 Discussion
Cuff Pressure (cmH20) In this study, the sensory component of the swallowing
reflex was evaluated by LaT and the motor component was
Fig 3 Influence of CP (cm H2O) increase on the latency times of reflected by submental EMGp and resulting ALA. We demon-
the swallowing reflex expressed in the percentage of control strated that increasing tracheostomy tube CP influenced
measures. Values are means (blue diamonds) and SD (vertical both sensory and motor components of the swallowing

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bars), *P,0.05 when compared with control values. reflex. The swallowing reflex was progressively more difficult
to elicit with increasing CP and when activated, the resulting
motor swallowing activity was depressed. These findings
suggest that peripheral mechanical constraints and centrally
125 controlled inhibition may be involved in CP increase-induced
deterioration of instrumental characteristics of the swallow-
ALA (% of Control)

ing reflex.
100 * * We have used the method described by Nishino and col-
leagues6 7 using submental EMG to study the swallowing
75 * * * reflex. The method is easy to perform and to repeat in the
same patient and allows for evaluation of the pharyngeal
ALA= –0.8 (Cuff Pressure)
+102.1, r2 = 0.87, p < 0.01 reflex components of swallowing. We have improved the ac-
50 curacy of latency time calculation. Instead of visual observa-
0 10 20 30 40 50 60 tion of laryngeal movements, we identified precisely on
Cuff Pressure (cmH20) signal recordings both the time of pharyngeal stimulus and
the beginning of evoked EMG response. Moreover, we
Fig 4 Influence of CP (cm H2O) increase on swallowing-induced recorded the average values generated by repeated stimuli
laryngeal elevation accelerometry amplitude (ALA) expressed over 1 min. These methodological improvements prevented
as the percentage of control values. Values are means (blue dia- non-stimulated swallows interfering with our results. Al-
monds) and SD (vertical bars). *P,0.05 when compared with
though superficial submental EMG recording was shown to
control values.
be a valuable means of identifying swallowing activity, this
method does not allow precise quantification of pharyngeal
muscular activity.
In order to better quantify the motor component of the
125
swallowing reflex, we performed simultaneous measure-
EMGp (% of Control)

ments of submental EMG in combination with the resulting

* acceleration of laryngeal elevation. It has been demon-
100 *
* strated that the pattern of laryngeal elevation acceleration
characterizes pharyngeal subhyoid muscle function and the
75 resulting acceleration signal peak amplitude correlates with
the amount of laryngeal elevation.8 9
EMGp = –0.5 (Cuff Pressure) + 104.7,
r2 = 0.88, p < 0.01
When compared with healthy volunteers placed in the
50 same experimental conditions (personal unpublished data),
0 10 20 30 40 50 60 reflex swallows in tracheostomized conscious young patients
Cuff Pressure (cmH20) required a more intense afferent input to be elicited and
demonstrated a longer activation time. A number of factors
Fig 5 Influence of CP (cm H2O) increase on the integrated peak may explain this fact. Although we did not examine directly
electromyography (EMGp) of the submental swallowing muscles the mucosal lesions caused by prolonged contact of upper
expressed as the percentage of control measures. Values are airway tubes (nasogatric and orotracheal), the alteration of
means (blue diamonds) and SD (vertical bars). *P,0.05 when chemoreceptors or mechanoreceptors located in pharyngeal
compared with control values.
mucosa may have impaired sensation, resulting in an

581
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increased PST. It has been demonstrated that residual effects
of sedation influence the swallowing reflex and such cannot
be excluded as a cause for the prolonged swallowing reflex
latency time.10 The influence of other factors such as hypox-
aemia and hypercabia that have been demonstrated to
impair the swallowing reflex appear unlikely in the present
study.11 All of our patients were weaned from mechanical
ventilation assistance before entering the protocol and SpO2
did not vary during the tests. Since respiratory rate we have
measured remained stable during CP increase challenge, it
is unlikely that large arterial CO2 changes may have occurred.
Although tracheal cuff-induced dysphagia in tracheosto-
mized patients has been discussed in many publications,
only few have investigated the influence of CP on airway pro-
tection mechanisms.12 – 14 No study has evaluated the
impact of tracheostomy CP upon swallowing physiology.
The frequency of reduced laryngeal elevation and silent as-
piration has been shown to be greater when the cuff is
inflated.12 13 Deflation of the tracheostomy cuff was shown
to reduce the aspiration risk for liquid boluses and improve
the laryngeal excursion during swallows.12 We did not
study the efficiency of airway protective mechanisms, but
rather analysed the impact of tracheostomy CP on physio-
logical mechanisms controlling the swallowing reflex. Our
observations suggest that central inhibition of the swallow-
ing centre is probably involved in CP increase-induced deteri-
oration of the characteristics of the swallowing reflex. The
swallowing reflex was progressively more difficult to elicit
with increasing CP. This observation agrees with physiological
studies demonstrating that sensory inputs from peripheral
receptors affect the control of swallowing.15 EMG data and
recordings of vagal motor fibres show reversible inhibition
of swallowing during distension of the cervical oesophagus.16
Using an intra-oesophageal balloon, Jean17 demonstrated
that the neuronal swallowing activity was delayed and wea-
kened by slight distension of cervical oesophagus and sup-
pressed when the distension was increased. The authors
also demonstrated that after balloon deflation, neuronal
swallowing activity returned to normal. Increasing the
tracheostomy tube CP was shown to increase intraluminal
proximal oesophageal pressure.18 These observations
mimic our data in tracheostomized patients. Inflation of
the cuff induced-oesophageal anterior mucous membrane
distension may have stimulated oesophageal mecano/
stretch receptors, resulting in an inhibition of the central
control of swallowing causing both a delayed swallowing
reflex and impaired muscular activity of submental muscles.
The most marked effect of CP increase was lengthening of
the swallowing reflex latency time by 2.3-fold when com-
pared with the control. The magnitude of the decrease in la-
ryngeal acceleration was less marked with a maximum
reduction to 42% of control values at 60 cm H2O CP. Our
results do not contradict a recent pharyngeal swallow bio-
mechanics trial which concluded that tracheostomy tubes
do not affect laryngeal movement.19 The authors did not
measure tracheostomy CP, but rather inflated the cuff with
a standard volume for all patients.19 It is possible that the
582
Amathieu et al.
patients we studied had normal hyoid bone displacement,
but this displacement was performed with reduced accelera-
tion when tracheostomy CP increased.
The results we report on the effect of CP on the swallowing
have clinical implications for intensive care daily practice. Al-
though all patients we have included in the present trial were
capable of swallowing on command, most of them had ab-
normal airway protective mechanisms. The present results
emphasize for strict monitoring of CP in ICU tracheostomized
patients. Inflation of tracheostomy cuff is mandatory but po-
tentially a harmful procedure. Excessive CP may not only ser-
iously damage tracheal wall with the risk of tracheal
ulceration, dilatation, and perforation, but also impair spon-
taneous rehabilitation and efficiency of protective reflexes
such as the swallowing reflex. We demonstrated that when
CP exceeds 20–25 cm H2O, reflex swallows were elicited
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with difficulty and the efficiency of submental muscles was
depressed. Impeded laryngeal elevation during swallowing
was associated with imperfect closure of the larynx, resulting
in possible aspiration of pharyngeal content.20 With a
CP-induced reduction in spontaneous swallows and an
open larynx, pharyngeal secretions may flow into the
trachea and accumulate above the cuff with the risk of pul-
monary aspiration. Moreover, maintaining an efficient swal-
lowing reflex may favour high spontaneous swallowing
rates, which probably contribute to swallowing effectiveness.
In the case of dysphagia, swallowing function should be
evaluated and re-educated with a CP controlled at 20–25
cm H2O.
Our study has limitations. First, we tested the effect of CPs
exceeding 30 cm H2O, that is, higher than the commonly
recommended CP. Moreover, we showed that the greatest
impact of CP upon swallowing reflex occurred at the
highest CPs. However, we demonstrated that LaT and ALA,
both important determining factors for airway protective
swallowing reflex efficiency, were significantly altered for
CP situated in the upper limit of the normal range. Secondly,
we have excluded from the present study patients showing
poor pharyngeal perception and aspiration signs suggesting
severe dysphagia. Then, it is questionable whether our find-
ings could be applicable to patients with severe swallowing
difficulties. We believe that the more the airway protective
reflexes are altered, the more the impact of strict CP
control during ICU stay is crucial for patient’s recovery of ef-
ficient swallowing reflex. Finally, we demonstrated significant
correlations between CP and instrumental characteristics of
the swallowing reflex, but it does not mean that these rela-
tions are strictly linear. Indeed, a non-linear relationship
between CP and the measured parameters we have studied
may better explain our results. Moreover, non-linear relation-
ship analysis may permit identification of a critical pressure
range for each variable, resulting at the point of deviation
from linearity. Careful observation of Figures 3–5 suggests
such a critical CP in the range of 25– 40 cm H2O, above
which the impact of CP increase upon the swallowing reflex
seems to be marked. Above this critical CP range, the swal-
lowing reflex is more difficult to elicit, the activity of
Swallowing with a tracheostomy tube
swallowing muscles is depressed, resulting in severe impair-
ment of their efficiency at elevating the larynx as illustrated
by intense reduction of laryngeal elevation acceleration.
Interestingly, this critical CP range is situated within the
clinical range of pressure commonly measured in ICU
tracheostomized patients. Thus, although our results are
statistically relevant, possible non-linear relationship analysis
between tracheostomy tube CP and electrophysiological
parameters of the swallowing reflex may be more clinically
pertinent.
In conclusion, CP in the tracheostomy tube influences the
characteristics of the swallowing reflex in conscious tra-
cheostomized patients. Excessive CP alters electrophysio-
logical characteristics of the swallowing reflex.
Acknowledgements
The authors acknowledge Dr Archie I.J. Brain [FFARCSI, FRCA
(Hon), FANZCA (Hon)] and Patricia Jabre (MD PhD) for their
very helpful respective contribution to the editing process
and statistical assistance.
Declaration of interest
None declared.
Funding
Departmental funding only.
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