Dysphagia 141study will be done to see if the swallow has improved due to spontaneous recovery of sensory and
motor functioning. Unfortunately, Frenchy also fails that test, and eventually a permanent gastric
tube leading directly to her stomach is required.
Case Study 7-3: Dysphagia and Tracheotomy in a 32-Year-Old Man
Robert, an accountant with a chain of nursing homes, died of complications related to asthma.
After his death, his parents set up a charitable fund in his name, and for several years, the
university speech and hearing clinic, where he had received dysarthria therapy, accepted donations
in his name. Although Robert had taken a power ful medi cation, it was only marginally successful
in controlling his asthma, particularly on dry, dusty days. Apparently, he had neglected to take it
for several days prior to a nearly fatal asthma attack in the mistaken belief that he had improved
and it was no longer needed. Robert also hated the side effects of the medi cation, especially
the anxiety. On the day of the attack, he was working in his office, managing the accounts of
hundreds of nursing home patients. An ambulance was summoned, and Robert was rushed to
the nearest hospital in respiratory arrest. He suffered anoxia, and his cerebellum took most of the
damage, leaving him severely ataxic. Clinically, he was stuporous when transferred to the regional
rehabilitation center. He was also on a respirator that pumped air into and out of his lungs through
a tracheal tube.
Robert’s levels of awareness and consciousness f luctuated. Sometimes he was alert and
responsive; at other times, he was semicomatose. Ordinarily, a patient on a respirator would not be
admitted to this rehabilitation center, but because of Robert’s f luctuating levels of awareness and
alertness, one goal was to wean him from the respirator. Another goal was to have him meet his
hydration and nutrition needs orally. Before coming to the rehabilitation center, he was fed orally
in the mistaken belief that with the cuff of the tracheotomy tube inf lated, he could not aspirate.
Robert had recurrent bouts of aspiration pneumonia in the acute care ward; the staff did not
understand how he could aspirate with the trachea blocked by the inf lated cuff.
After about 2 weeks in the rehabilitation center, Robert occasionally breathed on his own. He
was fed a puréed mixture by the nursing staff, and each time the cuff was inf lated to the proper
pressure. Nurses were perplexed at Robert’s recurrent aspiration pneumonia. They had been taught
that with the cuff inf lated, there is no way food or liquid can penetrate the lower air passageways.
Suspecting that remnant liquid and food particles were entering the lungs when the cuff was
def lated, they took special care that no liquid or food remained when def lating the cuff. Yet,
Robert continued to suffer from aspiration pneumonia. One nurse suspected that family members
were providing him with food when the cuff was def lated.
To test for aspiration when the cuff was inf lated, a dye was placed in the puréed food. Blue was
chosen because it is not the color of naturally occurring body f luids. The cuff was then inf lated
to the required pressure, and the blue puréed mix was placed in Robert’s mouth. He managed to
create a bolus and move it to the back of his throat. When it was in position, he swallowed. Then
a nurse slid a small suction tube through the tracheal opening and gently down toward his lungs.
Soon a bluish liquid could be seen going through the suction tube and into a container. Obviously,