Children with

Tracheostomy, Voice
or Resonance
Disorders in the
Schools
Scott Dailey, PhD, CCC-SLP
Shannon Theis, PhD, CCC-SLP
Lynn Marty Grames, MA, CCC-SLP
 Objectives
• Basics of tracheostomy
– Anatomy, Trach tubes, Reasons for
trachs
• Complications with Tracheostomy
– Communication Development
– Feeding/Swallowing
• What to do
– Communication
– Feeding/Swallowing
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Anatomy
• Upper airway
– Nose
– Mouth
– Pharynx
• Larynx
• Lower airway
– Trachea
– Bronchi
– Bronchioles
– Alveoli

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 Tracheotomy
• Surgical procedure

• Incision into the trachea to form an

opening or stoma

• Placement of a tracheostomy tube

into the stoma

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 Tracheostomy Tubes
Pediatric
• A curved tube through the
tracheostoma
• Usually plastic or silicone
• Usually single-cannula for pediatrics
• Generally not cuffed for pediatrics
• Size and length determined by Dr
– Depends on child’s age, size, medical
need
– Proper diameter, length and curve to
minimize complications/damage to
tracheal wall
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Tracheostomy

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Tracheostomy Tubes
Pediatric

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Reasons for Tracheostomy
• Airway anomalies
– Subglottic stenosis
– Vocal cord paralysis
– Laryngo/tracheomalacia
– Laryngeal or subglottic web
– Glossoptosis—Pierre Robin Sequence
– Tumors (e.g. cystic hygroma, teratoma)
– Obstruction

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 Reasons for Tracheostomy

• Lung Conditions
– Bronchopulmonary
dysplasia
– Chronic lung
disease
– Congenital
diaphragmatic
hernia

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Reasons for Tracheostomy
• Airway injury
– Burn/inhalation injury
– Laryngeal trauma
– Chest trauma
– Obstruction from choking
– Caustic ingestion
Neurologic Conditions
– Congenital central hypoventilation
syndrome
– Spinal cord injury
– Brain injury
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 Reasons for Tracheostomy
• Muscular
conditions
– Muscular
dystrophies
– Cerebral palsy
– Diaphragmatic
paralysis
– Congenital
myasthenia
gravis

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 Risks Associated with
Tracheosomties in Kids
• Developmental delay
– Influences of chronic illness and frequent
hospitalizations

• Communication Deficits
– Also impacted by underlying diagnoses

• Feeding and swallowing problems

– Also impacted by underlying diagnoses

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 Communication
• Lack of vocalization
– Tracheostomy frequently reduces that
ability to move air through larynx to
upper airway

– Lack of opportunity for vocal play and

development

– Age of trach placement and removal is a

factor in communication difficulties

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 Communication
• Speech-Language deficits
– Expressive language delays may persist
after decannulation
– Slow development of sound acquisition,
vowel production
– Excessive use of phonological
processes (Kertoy et al. 1999)

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 Feeding & Swallowing
• Up to 80% of infants and
children with trachestomies have
been identified with dysphagia
(Norman et al. 2007)

• Difficulties with feeding &

swallowing are also impacted by
underlying diagnoses

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 Feeding & Swallowing
• Infants and children with
trachestomies are at increased
risk of:
– Oral motor/oral phase difficulties
– Aspiration
– Oral aversion

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 Feeding & Swallowing
• Physiologic changes in
Swallowing
– Delayed swallow initiation
– Slowing of laryngeal movement
– Delayed laryngeal closure during
swallowing
(Abraham & Wolf, 2000)

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 What do we do?
We work within a team including:
• Child
• Parents
• Trach home (the medical home where trach
is managed)
• Pediatrician
• Speech-Language Pathologists
• Respiratory Therapists
• OT/PT
• Teachers
• Nurses
• Para-educators

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 What do we do?
• Hospital/Clinic
– Evaluation and therapy
– Communicate with local service providers
• Home
– Evaluation and therapy
– Listen to and Involve parents and home nurses
• School
– Evaluation and therapy
– Seek information & assistance from
medical/trach home when needed
– Utilize the social situations in schools

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 What do we do?
• Communication
– Receptive language development
• Evaluation and therapy
• May need to start with basics for
communication
– Expressive language development
• Evaluation and therapy
• Multimodal communication methods
– Speech sound development
• Evaluation and therapy
• Phonological errors, but may need placement
cues and lots of practice

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 Receptive Language
Development
• Speech-language stimulation and
therapy
– Parent education and involvement
– Improving child’s use of signals(facial,
gestures)
– Turn taking
– Following directions
– Pointing
• Developmentally appropriate
activities
– Choice of toys and books
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 Expressive Language
Development
• Early gestures
– Target in therapy
– Parents should be participating also
• Sign language
– For early wants and needs then expand
• Augmentative communication
– Devices
– Electrolarynx
• Esophageal speech

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 Vocal & Speech Sound
Development
• Oral movement imitation activities
– May include smacking sounds, tongue
clicking, “kissing” sounds
– Making /p/ with air trapped in mouth
– Lip rounding
– Tongue movements (tongue tip up)

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 Vocal & Speech Sound
Development
• Leak vocalization/speech
– Vocalization with air that leaks around
trach either from active exhalation or air
pressure provided by ventilator
– May involve finger occlusion of
tracheostomy
– Reinforce vocalizations, humming etc
– Encourage imitation of vocalizations,
speech sounds, words

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 Speaking Valves
• Child must be medically ready
• Have enough space around trach to
pass air trach to upper airway and
maintain saturations
• Allows air into trach for inspiration,
then closes so exhalation goes
around trach to upper airway
• Need to be evaluated for tolerance of
valve with trained healthcare provider

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 Speaking Valves

Shikani Valves Passy-Muir Valves

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Speaking Valves

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Speaking Valves

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 Speaking Valves
• Goals may include
– Tolerate brief periods with valve in place
then gradually increase duration
– Vocalize with valve in place
– Imitate vocalizations, vowels,
consonants
– Speak certain number of syllables per
breath
– Imitate respiratory pattern with
vocalization on exhalation

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 Speaking Valves
• Activities with preschool children may
include
– Note type and contexts when child
makes sounds with valve in place
– Imitate the child’s sounds
– Encourage blowing bubbles, raspberries
– Make sounds associated with playing
with a toy—take turns with the toy.

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 Speaking Valves
• Activities with older children may
include
– Vowel imitation
• start with vowels child already produces and
varying length
• Introduce new vowels (only vowels because
consonants can affect vowel) then add
consonants VC, or CVC
• In words/syllables track vowel errors and then
work on vowel pairs for contrast

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 When Trach removed
• Possible Goals
– Increasing rate and complexity of child’s
vocalizations
– Continuing to improve consonant
productions
• Select classes of sound child already
produces
• Activities
– Songs and rhymes
– Activities with frequent target sounds
– Work on increasing number of syllables

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 What do we do?
• Feeding & Swallowing
– Aversion

– Oral motor difficulties

– Aspiration

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 Aversion
• Provide positive face and oral
experiences
• Facial/oral stimulation to decrease
any hypersensitivity
• Toothbrushing
• Start with empty utensils
• Tastes of food on child’s fingers

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 Oral Motor Deficits
• Work on aversion first because need
to be able to get near and into child’s
mouth
• Oral motor therapy for lip, tongue and
jaw movement and control
– Downward pressure on tongue with
finger, spoon, brush, other utensil to
promote tongue cupping
• For chewing, work on lateralization of
tongue, place therapy aides or foods
on molars when child ready
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 Aspiration
• Swallow study analysis to determine cause
and timing of aspiration
• Swallow study to determine if any
compensations reduce/eliminate aspiration
• Even is grossly aspirating, consider
continued offering of tastes of food/liquid to
prevent aversion
• Size of bolus is sometimes a factor
• Thickening of fluids sometimes helpful

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 Summary
• Infants and Children have trachs for
multiple reasons
• Tracheostomy can affect speech-
language development and
feeding/swallowing
• Therapy is needed to help develop
multiple modes of communication
• Therapy may be needed for
feeding/swallowing difficulty

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 Summary
• Communication between local services
providers and medical/trach home is
necessary

• Be cautious and respectful when dealing

with a child with a trach, but don’t panic
because basic communication and
feeding/swallowing evaluation and
treatment apply

• Look at overall development as well as

communication and feeding/swallowing

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 Questions & Answers

• For a copy of the

updated version of
this presentation
– Email:
scott-dailey@uiowa.edu

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 References
• Hill, B.P., Singer, L. T., (1990) Speech and language development after infant tracheostomy. Journal of
Speech & Hearing Disorders 55: 15-20.
• Hull, E.N., Dumas, H.M., Crowley, R. A. & Kharasch, V. S. (2005) Tracheostomy speaking valves for
children: tolerance and clinical benefit. Pediatric Rehabilitation 8(3) 214-219.
• Jiang, D. & Morrison, G.A, J. (2003) the influence of long-term tracheostomy on speech and language
development in children. International Journal of Pediatric Otorhinolaryngology 5751, 5217-5220.
• Kamen, R.S., Watson, B.C. (1991) Effects of long-term tracheostomy on spectral characteristics of vowel
production. Journal of Speech and Hearing Research 34, 1057-1065.
• Kertoy, M. (2002) Children with Tracheostomies Resource Guide, Albany: Singular Publishing Group.
• Kertoy, M., Guest C.M., Quart, E, Lieh-Lai, M. (1999) Speech and phonological characteristics of individual
children with a history of tracheostomy. Journal of Speech, Language and Hearing Research 42, 621-635.
• Kramer, R. Plante, E. & Green, G.E. (2005) Changes in speech and language development of a young child
after decannulation. Journal of Communication Disorders 38, 349-358.
• Morris, L. L., Afifi, M. S. (ed) (2010) Tracheostomies The Complete Guide, New York: The Springer
Publishing Group.
• Norman, V., Louw, B., Kriztzinger A. (2007) Incidence and description of dysphagia in infants and toddlers
with tracheostomies: A retrospective review. Internationl Journal of Pediatric Otorhinoaryngology 71, 1087-
1092.
• Patel, M. R., Zdanski, C. J., Abode, K. A., Relly, C. A., Malinzak, E. B., Stein, J. N., Harris, W. T., & Drake,
A. F. (2009) Experience of the school-age child with tracheostomy, International Journal of Pediatric
Otorhinolaryngology.73, 975-980.
• Singer, L. T., Hill, B. P., Orlowski, J. P., & Doershuk, C. F. (1991). Medical and social factors as predictors
of outcome in infant tracheostomy. Pediatric Pulmonology 11, 243-248.
• Sisk, E. A., Kim T. B., Schumacher, R., Dechert, R., Driver, L., Ramsey, A. M. & Lesperance, M. M. (2006)
Tracheotomy in very low birth weight neonates: Indications and outcomes, The Laryngoscope 116, 928-
933.
• Torres L. Y. (2004) Clinical Benefits of the Passy-Muir Tracheostomy and Ventilator Speaking Valves in the
NICU. Neonatal Intensive Care 17, 20-23.
• Woodnorth, G. H. (2004) Assessing and managing medically fragile children: tracheostomy and ventilatory
support. Language, Speech, and Hearing Services in Schools 35, 363-372.

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