Probably the most important thing to check is that the patient has a patent (clear) upper airway. Remember, the reason for the tracheostomy in the first place might well have been because of a problem with the upper airway (trauma, tumour or swelling for example).

Even if the patient did not have a primary airway problem, prolonged periods of time with a trans-laryngeal tracheal tube that can physically or functionally damage the larynx can mean unexpected problems have developed.

The safest option is to investigate the airway with a visual assessment. Fibreoptic Endoscopic Examination of Swallow (FEES) is usually carried out by a trained Speech & Language Therapist, and involves a dynamic evaluation of the airway and the laryngeal function for talking, coughing and swallowing. The assessment may detect problems that were unknown, often occult laryngeal injury (intubation trauma), significant swelling, or vocal cord dysfunction.

Fig 1 is a video showing FEES and airway assessment in a tracheostomised ICU patient. Notice how he is wide awake and can cooperate fully, even taking a drink so that the bedside team can watch how well his larynx copes with the challenges of food, liquid or secretions.

FEES is explored in more detail later in this session. If you don't have access to FEES, then clinical assessments can help establish the patency of the upper airway. We will review these on the next page.