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This Scoping review aims to identify any hypopharyngeal or laryngeal changes which are known to have an impact on swallowing function. We are looking to map the heterogeneity of the language used to describe these structures, looking to identify which have been found to have a direct, proven impact on swallowing function and to determine if any other information had been published which systematically rated severity in relation to hypopharyngeal/ laryngeal changes.

Objective: The objective of this scoping review is to describe the types, nature, and effectiveness of service delivery models for assessment utilised in swallowing management in metropolitan and non-metropolitan locations across the globe. Introduction: An impairment to swallow function, termed dysphagia, can impact the safety and efficiency of eating and drinking. It is well established that dysphagia results in increased morbidity and mortality, impacting people across the globe. For the purposes of this review, dysphagia refers to oropharyngeal dysphagia, which focuses on the oral and pharyngeal phases of swallow. Challenges in the provision of healthcare in non-metropolitan locations have been identified across different population groups, specifically regarding the assessment and management of dysphagia. The current socio-political context has resulted in innovative change in service delivery models, further supporting the need for exploring barriers and enablers for access to assessment and management in non-metropolitan locations. A scoping review will be conducted to describe the types, nature, and effectiveness of service delivery models for assessments utilised in swallowing management in metropolitan and non-metropolitan locations across the globe. Inclusion criteria: We will include studies investigating the use of assessments for swallowing management in impaired and unimpaired populations, across adult and paediatric populations. Methods: A search strategy will be developed with key terms. Electronic data bases including MEDLINE (OvidSP), CINAHL, Web of Science and SPEECHBITE will be searched. The search will be limited to full text articles published in English. Two members of the research team will screen according to the inclusion criteria and a risk of bias analysis will be conducted. References will be exported in Endnote and Covidence.

Purpose: Transoral robotic surgery (TORS) is most commonly undertaken as a minimally invasive approach for early staged oropharyngeal cancers (OPC), with good expectations for a functional recovery. A small number of patients, however, require TORS for recurrent or advanced OPC tumours. Their prospects for longer term recovery of communication and swallowing are both unreported and hypothesised to be poorer than the majority of TORS cases. This case-series describes the recovery of swallowing and communication function post-TORS for this unique group of patients.Method: Consecutive recruitment was carried out prospectively at a quaternity oncology referral centre. Participants were aged 18 years and older, with reconstruction involving a free-flap and tracheostomy. Patients were assessed using Fibreoptic Endoscopic Evaluation of Swallowing, and clinician and patient-reported outcomes 12-months post-TORS. Their pre-operative baseline and three-month post-TORS FOIS scores were collated retrospectively.Result: Six participants were recruited over an 18-month period of which three patients underwent TORS for recurrent, and three for advanced OPC. Those with recurrent-OPC did not return to their baseline diet and demonstrated post-swallow silent aspiration of pharyngeal residue. Three of the six were rehabilitated back to their baseline intelligibility (100%).Conclusion: TORS in the recurrent OPC setting appears congruent with high rates of silent aspiration and prolonged reliance on a feeding tube due to oropharyngeal dysphagia, as well as compromised intelligibility. This is the first study that evaluates this instrumentally and provides clinically relevant evidence to inform practice.

A scoping review exploring normative data, user experience and user centred design principles for pharyngeal residue interpretation tools use in flexible endoscopic evaluation of swallowing (FEES).

For patients requiring an artificial airway (either an endotracheal or tracheostomy tube), establishing effective communication is particularly challenging. The inability to communicate is one of the key stressors for patients with an artificial airway. Core outcome sets aim to standardise outcome reporting by identifying outcomes perceived fundamental for measurement in trials of a specific interest area. Our aim is to establish a core outcome measurement set (COMS) for studies of interventions designed to enable both non-vocal and vocal communication in adults requiring an artificial airway with or without mechanical ventilator support in a critical care environment including intensive care units (ICU), specialised weaning centres and step-down units. The purpose of this scoping review is to identify the outcomes and measures tools used in treatments designed to enable communication in adults with breathing tubes.

Background Heterogeneity within studies examining transoral robotic surgery (TORS) for oropharyngeal cancer (OPC) has made it challenging to make clear conclusions on functional outcomes. Infrequent use of instrumental swallow examinations compounds uncertainty surrounding the proposed functional advantage to TORS. Methods A prospective cohort of 49 patients underwent speech and swallowing assessment 12 months following treatment for OPC. Patients were assessed using fibreoptic endoscopic evaluation of swallowing (FEES), clinician- and patient-reported outcomes. Participants were matched according to tumor site, T category, and age. Speech and swallowing outcomes were compared for those receiving TORS versus chemoradiation. Results When adjuvant radiotherapy to the primary site could be avoided, TORS demonstrated an advantage for feeding tube duration, secretion severity, penetration/aspiration, M. D. Anderson Dysphagia Inventory (MDADI), and airway protection. Conclusion This explorative study suggests that a treatment philosophy of selecting patients for TORS where adjuvant therapy can be omitted or confined to the neck warrants further evaluation.

OBJECTIVE: To investigate perspectives of patients, family members, caregivers (PFC), and healthcare professionals (HCP) on tracheostomy care during the COVID-19 pandemic. METHODS: The cross-sectional survey investigating barriers and facilitators to tracheostomy care was collaboratively developed by patients, family members, nurses, speech-language pathologists, respiratory care practitioners, physicians, and surgeons. The survey was distributed to the Global Tracheostomy Collaborative's learning community, and responses were analyzed. RESULTS: Survey respondents (n = 191) from 17 countries included individuals with a tracheostomy (85 [45 %]), families/caregivers (43 [22 %]), and diverse HCP (63 [33.0 %]). Overall, 94 % of respondents reported concern that patients with tracheostomy were at increased risk of critical illness from SARS-CoV-2 infection and COVID-19; 93 % reported fear or anxiety. With respect to prioritization of care, 38 % of PFC versus 16 % of HCP reported concern that patients with tracheostomies might not be valued or prioritized (p = 0.002). Respondents also differed in fear of contracting COVID-19 (69 % PFC vs. 49 % HCP group, p = 0.009); concern for hospitalization (55.5 % PFC vs. 27 % HCP, p

© 2020, © 2020 Informa UK Limited, trading as Taylor & Francis Group. This paper describes a novel model of learning, designed to enhance interprofessional education (IPE) and interprofessional collaboration (IPC). Lessons learned, plans for sustainability and future directions for policy, practice, implementation, and curriculum training are also discussed. The RIPE-N model (Reflective Interprofessional Education–Network model) was developed for an interprofessional simulation environment involving five health professions–pharmacy, nursing, orthoptics, physiotherapy, and speech pathology with the potential to increase the number of health professions involved. The RIPE-N model was adapted from the original RIPE Model (Reflective Interprofessional Education Model), utilising unfolding multidisciplinary case from admission through to discharge. Key adaptations of RIPE to include a greater focus on professional practice and the opportunity for collaboration by all disciplines. Reflection is critical to the RIPE-N model to develop the reflective practitioner, hence the inclusion of collaborative reflective (‘pause and reflect’) stations aimed at improving collaborative clinical decision-making skills among diverse healthcare professionals.

Background Admission to the intensive care unit (ICU) with mechanical ventilation can lead to patients experiencing impaired swallowing and communication function. This can negatively affect patient experiences and outcomes. There is increasing research supporting early intervention for swallowing and communication; however, there are no published ICU workforce data to determine patient access. Purpose The purpose of this study was to describe national ICU access to speech pathology (SP) services and to describe the nature of this workforce. Methods Prospective audit of Australian ICUs with a focussed workforce survey of SP service including workforce demographics, clinical practices, team environments, and training was conducted. Data are described as percentage (%, n) and as median (interquartile range). Qualitative data were analysed using thematic frameworks. Results SP services were available at 99% (n = 165) of the sites; 62 sites provided workforce data (45% response rate). Seventy-one percent of respondents serviced the ICU ≤10 h per week, with 23% reporting dedicated funding. Almost a third (32%) reported not participating in ICU team activities, and more than half of the sites (56%) did not provide ICU-specific training with resulting varied clinical confidence ratings. Facilitator and barriers both highlighted team working relationships. Facilitator themes were building working relationships, understanding the SP role in the multidisciplinary team, physical presence in the unit, and access to resources. Barrier themes were the multidisciplinary team's understanding of SP roles and lack of presence of SP services in the ICU. Conclusions SP services are not standard across Australian ICUs, with variations in confidence, funding, training, and team environments. Further research into the impact of these variations on patient outcomes is needed.

Background The relationship between swallowing outcomes and radiotherapy dose to dysphagia and aspiration-related structures (DARS) may be different following definitive versus postoperative radiotherapy (PORT) for mucosal head and neck cancer (HNC) and has not been well-studied. Method Patient- and clinician-reported swallowing measures were prospectively collected at six time points from baseline to 24 months postradiotherapy HNC. Radiotherapy plans were retrospectively analyzed to assess dose delivered to DARS. The association between swallowing outcomes and participant demographics, tumor characteristics, and radiotherapy dose in definitive and postoperative treatment cohorts was assessed. Results Ninety-three participants who received radiotherapy for HNC were included in the analysis (n = 49 definitive radiotherapy for laryngeal/pharyngeal primary tumors and n = 44 postoperative PORT for predominantly oral cavity/salivary gland tumors). Participants undergoing PORT had lower doses to DARS than those undergoing definitive RT. High dose to the pharyngeal constrictors and base of tongue for definitive RT and the esophageal inlet, supraglottic larynx and cervical esophagus for the PORT group were associated with worse swallowing function. Conclusion Radiation dose to DARS is associated with post-treatment swallowing outcomes. These dose/outcome relationships may vary between the definitive and postoperative settings.

BACKGROUND: The impact of COVID-19 on swallowing function is not well understood. Despite low hospital admission rates in Australia, the virus and subsequent treatment affects swallow function in those requiring intensive care unit (ICU) treatment. As such, the current pandemic provides a unique opportunity to describe swallowing function and outline dysphagia characteristics and trajectory of recovery for a series of cases across NSW. AIM: The aims of this study were to describe (i) physiological characteristics of swallowing dysfunction and (ii) pattern of swallowing recovery and outcomes, in ICU patients with COVID-19. METHODS: All patients admitted to 17 participating NSW Health ICU sites over a 12-month period (March 2020-March 2021), diagnosed with COVID-19, treated with the aim for survival, and seen by a speech pathologist for clinical swallowing examination during hospital admission were considered for inclusion. Demographic, critical care airway management, speech pathology treatment, and swallowing outcome data were collected. RESULTS: Twenty-seven patients (22 male; 5 female) with a median age of 65 years (interquartile range [IQR] = 15.5) were recruited. All required mechanical ventilation. Almost 90% of the total cohort had pre-existing comorbidities, with the two most frequently observed being diabetes (63%, 95% confidence interval = 44%-78%) and cardiac disease (59%, 95% confidence interval = 40%-75%) in origin. Prevalence of dysphagia was 93%, with the majority (44%) exhibiting profound dysphagia at the initial assessment. Median duration to initiate oral feeding was 38.5 days (IQR = 31.25) from ICU admission, and 33% received dysphagia rehabilitation. Dysphagia recovery was observed in 81% with a median duration of 44 days (IQR = 29). Positive linear associations were identified between duration of intubation, mechanical ventilation, hospital and ICU length of stay, and the duration to speech pathology assessment (p

Purpose To summarise the patient communication status in an intensive care unit (ICU), including methods of communication used and the frequency, degree and nature of communication breakdown. Materials and methods A multidisciplinary daily ward audit was conducted on ten consecutive weekdays in a 30-bed general ICU of a tertiary Australian hospital. Data included patient demographics, patients' mode of communication and the level of difficulty in communicating. Descriptive statistics and means (standard deviation)/medians (interquartile range) were used to summarise the data. Results Over the audit period, data were collected from 87 patients (median age 58 years, interquartile range 43 to 67; 60% males), equivalent to 232 occupied bed days. Patients from non–English-speaking backgrounds accounted for 14% of the cohort, with Mandarin the most common non-English language. Altered cognition occurred on 11% of bed days. Staff reported difficulty in communicating with patients on 35% of bed days, with an inability to communicate with patients in 49% of these cases. Alternate modes of communication were reported, with gesture the most common, but they were not used with all suitable patients. Conclusions About one-third of the caseload in the ICU experienced difficulty in communicating. While alternate communication methods were reported, they were not used with all patients. A multidisciplinary approach to enhance communication ability may be beneficial.

Dysphagia occurs commonly in the intensive care unit (ICU). Despite the clinical relevance, there is little worldwide research on prevention, assessment, evaluation, and/or treatment of dysphagia for ICU patients. We aimed to gain insight into this international knowledge gap. We conducted a multi-center, international online cross-sectional survey of adult ICUs. Local survey distribution champions were recruited through professional and personal networks. The survey was administered from November 2017 to June 2019 with three emails and a final telephone reminder. Responses were received from 746 ICUs (26 countries). In patients intubated > 48 h, 17% expected a > 50% chance that dysphagia would develop. This proportion increased to 43% in patients intubated > 7 days, and to 52% in tracheotomized patients. Speech-language pathologist (SLP) consultation was available in 66% of ICUs, only 4% reported a dedicated SLP. Although 66% considered a routine post-extubation dysphagia protocol important, most (67%) did not have a protocol. Few ICUs routinely assessed for dysphagia after 48 h of intubation (30%) or tracheostomy (41%). A large proportion (46%) used water swallow screening tests to determine aspiration, few (8%) used instrumental assessments (i.e., flexible endoscopic evaluation of swallowing). Swallowing exercises were used for dysphagia management by 30% of ICUs. There seems to be limited awareness among ICU practitioners that patients are at risk of dysphagia, particularly as ventilation persists, protocols, routine assessment, and instrumental assessments are generally not used. We recommend the development of a research agenda to increase the quality of evidence and ameliorate the implementation of evidence-based dysphagia protocols by dedicated SLPs.

BackgroundTransoral robotic surgery (TORS) is a minimally invasive approach for the treatment of oropharyngeal cancer. The effects on swallowing and speech need to be comprehensively evaluated to understand the associated morbidity.MethodsA prospective cohort of 21 patients was recruited to undergo pre-TORS and post-TORS swallowing and communication assessment. Fiberoptic endoscopic evaluation of swallowing (FEES) was used in the first postoperative week.ResultsSixteen participants (76.2%) had penetration-aspiration scores ≥3 or higher, seven (33.3%) aspirated on thin liquids, three (14.3%) did so silently. Prolonged recovery trajectory occurred for the majority of the cohort, particularly if TORS was followed by adjuvant radiotherapy. Swallowing and communication scores were significantly worse in base of tongue primary tumors and with advanced age.ConclusionEarly FEES demonstrates a significant decline in swallowing function, including increased secretion load, pharyngeal residue, laryngeal penetration, and aspiration. Silent aspiration occurred in 14% and thus highlights the necessity for instrumental assessment to ascertain aspiration risk.

Objectives A tracheostomy tube can profoundly impact ability to communicate. The impact of this on patients’ self-esteem and quality of life in the care continuum from the intensive care unit to after decannulation has not been reported. Therefore, the aim was to investigate the patient-reported experience regarding change in communication function, communication-related self-esteem and quality of life. Research design A mixed methods approach was utilised. Quantitative data were obtained using validated measures of self-esteem related to communication-related quality of life and general health. Data were measured before return of voice, within 48 hours of voice return and six months after tracheostomy decannulation. Qualitative data were collected through structured interviews six months after tracheostomy. Results Seventeen participants completed the study. Four themes emerged from the interviews: It’s hard communicating without a voice; What is happening to me?; A storm of dark emotions and More than a response…it’s participating and recovering. Significant positive change occurred in six items of self-esteem related to communication from baseline to return of voice. Overall, positive changes in quality of life scores were observed. Conclusions Voice loss with tracheostomy significantly affected participants’ abilities to effectively communicate their care and comfort needs. Restoration of voice occurred in conjunction with patient-reported improved mood, outlook and sense of recovery.

© 2018 Elsevier Ltd Objectives: A tracheostomy tube can profoundly impact ability to communicate. The impact of this on patients’ self-esteem and quality of life in the care continuum from the intensive care unit to after decannulation has not been reported. Therefore, the aim was to investigate the patient-reported experience regarding change in communication function, communication-related self-esteem and quality of life. Research design: A mixed methods approach was utilised. Quantitative data were obtained using validated measures of self-esteem related to communication-related quality of life and general health. Data were measured before return of voice, within 48 hours of voice return and six months after tracheostomy decannulation. Qualitative data were collected through structured interviews six months after tracheostomy. Results: Seventeen participants completed the study. Four themes emerged from the interviews: It's hard communicating without a voice; What is happening to me?; A storm of dark emotions and More than a response…it's participating and recovering. Significant positive change occurred in six items of self-esteem related to communication from baseline to return of voice. Overall, positive changes in quality of life scores were observed. Conclusions: Voice loss with tracheostomy significantly affected participants’ abilities to effectively communicate their care and comfort needs. Restoration of voice occurred in conjunction with patient-reported improved mood, outlook and sense of recovery.

Background Technological advances in radiotherapy have allowed investigations into new methods to spare healthy tissue in those treated for head and neck cancer. This systematic review with meta-analysis demonstrates the effect that radiation has on swallowing. Methods Selection and analysis of studies examining the effect of radiation to swallowing structures. A fixed effects meta-analysis calculated the pooled proportions for select outcomes of dysphagia, common across many studies. Results The majority of the papers found a correlation between radiation dose to the swallowing structures and dysphagia, however a meta-analysis found the studies carried a significant degree of heterogeneity. The appraisal demonstrates the need for large-scale studies using a randomized design and instrumental dysphagia assessments. Conclusions Radiation dose to dysphagia and aspiration structures is correlated with incidence of dysphagia and aspiration. The variables in this population contribute to the heterogeneity within and cross studies and future studies should consider controlling for this.

A cuffed tracheostomy tube facilitates prolonged mechanical ventilation and weaning but usually leads to prolonged voicelessness, which can be one of the most negative experiences of hospitalization. No randomized trials have examined the effects of targeted early communication intervention for the restoration of voice in ventilated tracheostomy patients in the ICU.A prospective randomized clinical trial.The trial was conducted in the ICU of an urban tertiary level hospital.Thirty adult participants enrolled, with 15 randomly allocated to the intervention and control groups.The early intervention group received early cuff deflation and insertion of an in-line speaking valve during mechanical ventilation. The control group received standard cuff deflation and a speaking valve during self-ventilation. A speech-language pathologist provided all treatments.The primary outcome measure was time from tracheostomy insertion to phonation. Early intervention significantly hastened return to phonation (median difference = 11 d; hazard ratio = 3.66; 95% CI, 1.54-8.68) with no significant effect on duration of tracheostomy cannulation (hazard ratio = 1.40; 95% CI, 0.65-3.03), duration of mechanical ventilation in days from tracheostomy insertion (hazard ratio = 1.19; 95% CI, 0.58-2.51), length of stay in ICU (hazard ratio = 1.16; 95% CI, 0.54-2.52), or time to return to oral intake (hazard ratio = 2.35; 95% CI, 0.79-6.98). Adverse events were low and equal in both groups. There was no significant change in measures of quality of life.Focused early intervention for communication during mechanical ventilation allows the restoration of phonation significantly sooner than standard treatment, with no increase in complications in a small patient cohort. Although these results are favorable, further research is needed to determine whether the effects on any of the secondary outcomes are statistically significant and clinically important.

Voicelessness, which is an absence of voice or sound, is a sequela of tracheostomy tube insertion and inflation of the tracheostomy cuff. Air is diverted from the larynx and prevents the generation of voice. Voicel Voicelessness, which is an absence of voice or sound, is a sequela of tracheostomy tube insertion and inflation of the tracheostomy cuff. Air is diverted from the larynx and prevents the generation of voice. Voicelessness in such circumstances is not identified within a patient’s medical record as a specific medical diagnostic code in Australia and therefore its incidence, and any episodes of treatment are not accurately measured, costed or reported. Patients admitted to the intensive care unit experience loss of voice from placement of a tracheostomy tube every day. Over 160,000 patient admissions per year are recorded in Australian and New Zealand Intensive care units (ICU) with 39.1% of these admissions requiring invasive mechanical ventilation (ANZICS, 2014). Approximately 24 % of ventilated patients will require mechanical ventilation via a tracheostomy (Esteban et al., 2000) and many patients are likely to experience a long period of voicelessness as a result. Absence of voice to communicate has been described by patients as stressful, frustrating, isolating and one of the worst parts of their hospital admission. Without a voice, patients can experience reduced level of participation, lack of choice and decision making in their own healthcare. Restoration of voice is one of the primary aims of speech pathologists treating tracheostomy patients. Speech Pathology intervention is aimed at assisting the patient to progress along the tracheostomy weaning pathway; a process that includes cuff deflation and facilitation of phonation through use of speaking valves. There is a paucity of evidence-based literature describing the timing of intervention for phonation, with the majority of papers consisting of case studies. There have been no randomised control trials published on the type or timing of speech pathology intervention. Currently, access to early speech pathology intervention for phonation during mechanical ventilation is not standard practice in Australia. Knowledge of the effectiveness of early versus standard timing of speech pathology intervention to restore phonation, improve clinical outcomes and improve patient reported health quality of life is unknown and not documented in the published literature. This thesis details the definition of standard care via a retrospective file audit of tracheostomy patients admitted to the intensive care unit of a tertiary Australian hospital over a 12 month period, which is presented as a published paper (Chapter 2). Results showed that the median period of time patients were without voice during tracheostomy placement was 12 days with a range of 1-103 days. This finding contributed to the development of the remaining studies in this thesis, which aimed to evaluate the effectiveness of early Speech Pathology intervention for restoration of phonation during mechanical ventilation. This was investigated within a randomised control trial of standard versus Early Speech Pathology Review and Intervention for Tracheostomy patients in intensive care early versus standard Speech Pathology Intervention (ESPRIT). The specific research questions investigated were: 1. Does targeted early communication intervention for the restoration of voice in ventilated tracheostomy patients in the ICU improve time to phonation and verbal communication compared with standard care? 2. Does this early intervention decrease the duration of tracheostomy cannulation, duration of mechanical ventilation, length of ICU or hospital stay, and time to oral intake? 3. Is this early intervention safe? 4. Does this early intervention change patient reported quality of life scores? Thirty participants were enrolled and completed the trial. The primary outcome – return to voice – was significantly hastened in the early intervention group. Secondary outcomes reported include patient safety (including adverse events), mechanical ventilation and tracheostomy cannulation time, length of stay, time to oral intake, patient reported self-esteem of communication and general quality of life. The results of this trial led to two submitted publications with report of the quantitative findings from the RCT reported in Chapter 4 and the report of self-esteem related to communication and general quality of life provided in Chapter 5. Finally, the lived experience of voicelessness was further investigated in a multiple methods study conducted 6-months after tracheostomy tube decannulation (Chapter 6). This was investigated by thematic analysis of semi-structured in-depth interviews and use of validated self-esteem and quality of life outcome measures. There were four major themes identified by patients during the experience of voicelessness, which centre on patient awareness of their clinical situation; communication without voice; emotions experienced with voice loss; and level of participation and recovery. These are presented in a publication intended for submission. The publications arising from this thesis inform standard care for tracheostomy patients, compare timing and type of intervention for return of voice and examine the impact on patients, their experiences and participation within the ICU setting when voiceless. This thesis reports on the initial randomised controlled trial for return of voice for tracheostomy patients, and advocates the role of early Speech Pathology intervention within the ICU. Restoration of voice and effective communication is important in facilitating timely care and allows increased patient participation within the healthcare system. Ongoing research and enhancement of communication function for tracheostomy patients would only further a positive patient experience and ensure ongoing monitoring of safety parameters.

There is variability in the practical prescription for CRRT and minimal evidence to inform basic settings such as blood flow rate (BFR). Blood flow is important for solute control andmay also have an association with circuit clotting and premature CRRT failure. The purpose of this pilot study was to collect data and assess the feasibility for a larger randomised controlled trial (RCT) investigating the impact of BFR on circuit life in patients treated with CRRT. A prospective RCT conducted over one year in a tertiary ICU in Melbourne. Adult patients with acute kidney injury requiring CRRT were randomised to a BFR of either 150mls/min or 250mls/min. Circuit and patient data were collected until the circuit was clotted according to a standardiseddefinition, or ceased electively for other reasons. Duration data are presented as median (inter-quartile range) and differences were examined using Mann–Whitney U, p

Speech-language pathologists manage communication and swallowing disorders, both of which can occur in patients after tracheostomy insertion. An audit on the incidence and timing of speech-language pathology intervention for adults with tracheostomies has not previously been published. Data were retrospectively extracted from the medical records of all patients who were tracheostomized at Royal Prince Alfred Hospital, NSW, Australia, from October 2007 for 1 year. Extracted data included diagnosis, date and type of tracheostomy, time to speech-language pathologist involvement, time to phonation, and time to oral intake. Among the 140 patients (mean age 58 years, range 16-85), diagnoses were neurological (32%), head and neck (25%), cardiothoracic (24%), respiratory (6%), and other (13%). Speech-language pathology was involved with 78% of patients, with initial assessment on average 14 days after tracheostomy insertion (14 days to 166 days). Median time from tracheostomy insertion to phonation was 12 days (range 1-103). Median time from tracheostomy insertion to oral intake was 15 days (range 1-142). Only 20% of patients returned to verbal communication within 1 week after tracheostomy insertion. Further research into access to and timing of speech-language pathology intervention in the critical care setting is warranted.