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Babies with Tracheostomies:

Babies with Tracheostomies:. Considerations for Speech & Language Development Presented by Nicole Heavilin. Incidence/Prevalence. Within the 1 st year of life, we can expect 3,000 babies to undergo a tracheostomy 85% of children requiring tracheostomies are < 1 year old.

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Babies with Tracheostomies:

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  1. Babies with Tracheostomies: Considerations for Speech & Language Development Presented by Nicole Heavilin

  2. Incidence/Prevalence • Within the 1st year of life, we can expect 3,000 babies to undergo a tracheostomy • 85% of children requiring tracheostomies are < 1 year old

  3. Common Indications for Tracheostomy in Babies • Most frequently to provide artificial airway for mechanical ventilation • To bypass obstruction within upper airway • To protect airway due to reduced/absent protective responses e.g. coughing, swallowing • Poor pulmonary hygiene due to inability to clear secretions from trachea • Examples of such medical conditions include: • Glottal stenosis • Vocal fold paralysis • Congenital centro hypoventricular syndrome • Tracheoesophageal fistula

  4. Clinical Management Considerations • RLN damage due to surgical procedure • Infection or inflammation of trachea • Chronic congestion, upper respiratory infections, pneumonia • Tracheostomy bypasses normal warming, filtering, & humidifying functions of upper airway!

  5. Therefore… • Speech-language pathologists must have knowledge of: • babies’ medical condition, respiratory involvement & reason for tracheostomy • severity of underlying disease • status of upper airway & respiration • How will the status and severity change over the time of cannulation?

  6. Current Knowledge:Associated risks on Communication • Prematurity linked to respiratory difficulties • Decreased lung support for speaking valve! • Tracheostomy may be accompanied by mechanical ventilator • Possible periods of oxygen deprivation • Long-term or recurrent hospitalizations can disrupt socioemotional & environmental supports for speech-language development

  7. Current Knowledge:Associated risks on Communication (cont’d) • Tracheostomy severely restricts opportunities for normal vocalizations • Manual occlusion of stoma or use of speaking valve help to make this more “normal” • Cannula tube may limit tongue mobility/muscle strength for articulatory development specifically for infants because of closer approximation of glossal muscles to laryngeal framework. • Child misses out on critical periods of vocal play (1st 12 months) and building of 1 & 2 utterances (12-24 months)

  8. Other Associated Developmental Risks • Tracheostomy and related medical conditions my impede motor development due to the need for advanced life support systems • Ventilator machine, feeding tube, trach tube/valves • Communication barrier my lead to behavior issues • Less oral exploration e.g. tongue clicks, raspberries, lip smacking, and inhalation phonation • May affect prelinguistic development • Greater effort in coordinating breathing, speaking, sucking, swallowing, etc.

  9. Role of the SLP • Evaluate feeding/nutritional needs • Work with respiratory therapist on breath support for speech, • Provide speech-language intervention (& counsel caregivers) • 2 most efficient modes for communicating • Sing language • One way speaking valve (more about this to come!) • Advocate for an environment that facilitates communication development, • Especially in the hospital/NICU unit & home • Special therapy materials on the market • www.passy-muir.com/pediatrictoy.htm

  10. History of Investigations on Tracheostomy-Speech Development • Developmental risks incl. Speech delay • Hill & Singer (1990): 61% (19/31) of children ages 2;1-8;6 had articulation difficulties based on standardized tests • Bliele (1993): 13-17% of children under long-term tracheostomy have delayed speech in relation to other areas of development at age 5 • Singer et. al.(1989): tracheostomy lasting >3months produced low average language skills & high incidence articulation & phonological difficulties

  11. History of Investigations on Tracheostomy-Speech Development • Locke & Pearson (1990): case study of child from age 1;5-1;9 during final months of cannulation & 1 month post • Severely restricted speech typical to that of a 6-month old • By age 4;4 speech & language was age-appropriate as measured by types of sounds, syllable shapes, # spontaneous utterances & syllables per utterance

  12. History of Investigations on Tracheostomy-Speech Development • Kamen & Watson (1991) case study: 8 children (3;3-5;0 years old) with history of tracheostomy • Front stops or fricatives for velars • Glottal fricative /h/ for stops & fricatives • This generally occurs in children under age 3 • Significant vowel differences between gender/age-matched peers without history of tracheostomy • Lower F1 formants for /a/ • Lower F1 & F2 formants for /i/ • No differences in F1 or F2 values for /u/ (a back vowel…)

  13. Kertoy et.al. on Speech & Phonological Characteristics • Kertoy et.al. (1999): 6 children ages 2;8-6;8 tracheostomized at or before 8 months of age • Hospitalization ranged from 1 month-1year • Cannulation ranged from 15-72 months • Normal hearing • 3 with tubes for otitis media with effusion • 2 receiving speech services at time of study

  14. Kertoy Study (cont’d) • 3/6 children had expressive/receptive language WNL based on PLS-3 • All had cognitive skills WNL based on Goodenough Draw a Person Test or informal Piagetian drawing task

  15. Kertoy Study (cont’d) • Phonological deviancy ranged from mild to profound compared to norms of children ages 2;2-2;5 • Processes reflected those common in children with phonological delays without tracheostomy: • Stridency deletion, Liquid deviation for /l/ and /r/, Cluster reduction • Inconsistent consonant use may reflect normal inconsistencies due to developing sound classes (fricatives, affricates, liquids) • Voiced-voiceless stop errors; not yet realized the distinction of such consonant cognates • Likelihood of maintaining high, retracted tongue position makes high,front vowels more difficult

  16. Kertoy Study (cont’d) • Adjustments in speech production after 3 months • Some children advanced whereas others regressed • Most likely reflects individual differences [vocal paralysis, ventilator dependency, (de)cannulation] and dynamic process of language learning

  17. Implications of Kertoy Study • Some children may continue to experience subtle expressive language difficulties after decannulation • Prevalence of phonological processes should be part of a standard assessment for children with history of tracheostomy • Need for further research on individual expectations of speech characteristics and resolution over time • Help families establish realistic expectations • Help professionals take appropriate steps to promote development

  18. Types of Speaking Valves • Olympic Trach Talk • Montgomery Speaking Valve • Hood Speaking Valve • Kistner 1-way Valve • Passy-Muir Speaking Valve

  19. Use of Speaking Valves: the Passy-Muir • Developed in early-1980’s by Patricia Passy and David Muir who at 5 was diagnosed with muscular dystrophy and at 23 went under respiratory arrest. • passy-muir airflow

  20. Purpose of the Passy-Muir Speaking Valve (PMSV) • Permits inspiration via stoma and expiration via glottis to produce phonation • Adult ability to speak without compromising respiration • How about in infants?

  21. Eligibility of the PMSV • Audible air leak around tracheostomy tube • 7 days post-operative of tracheostomy • Sustained awake, alert state • Medical stability

  22. Tolerance of the Passy-Muir Speaking Valve (PMSV) • Tolerance refers to • Oxygen saturation of 88% or more • No change in color, heart or respiratory rates, or in respiratory effort • Minimal to no agitation

  23. Study on Children Under 2 Years of Age • 64 children: 29 were eligible for PMSV • 24 of the 29 (83%) tolerated the PMSV • 75% of those 24 vocalized on the 1st trial • 21% vocalized on the 2nd trial • Tolerance ranged from 5-10 seconds to 35 minutes • Youngest participant was 13 days old • The PMSV may offer more normalized development of vocal play to actual speech

  24. Study on Children Under 2 Years of Age • Participants demonstrated increased voice clarity and intensity with the PMSV • Ventilator dependency may require close monitoring to remove valve after period of time (15 minutes in study) due to “breath stacking” & “positive end expiratory pressure” • Need for further research on benefits of PMSV on children’s overall speech development (unknown if benefits mirror those seen in adults)

  25. References: • Abraham, S.S. (2003, March 18). Babies with tracheostomies: The challenge of providing specialized clinical care. The ASHA Leader, 8 (5), 4 & 26. • Engleman, S.G. & Turnage-Carrier, C. (1997). Tolerance of the passy-muir speaking valve in infants and children less than 2 years of age. Pediatric Nursing, 23(6), 571-575. • Kertoy, M.K., Guest, C.M., Quart, E. & Lieh-Lai, M. (1999, June). Speech and phonological characteristics of individual children with a history of tracheostomy. Journal of Speech, Language, and Hearing Research, 42, 621-635. • Mason, M.F. (1993) Speech pathology for tracheostomized and ventilator dependent patients. Newport Beach, CA: Voicing, inc. • Passy-Muir, Inc. (N.D.) Retrieved on April 6, 2003 from, http://www.passy-muir.com

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