Problem Solving: Trached 6 y/o with PNA

Question: Currently have a 6 y/o pt on an inpatient rehabilitation unit.  She is trach and vent dependent following necrotizing pneumonia.  She is allowed to have cuff deflated 3x/day and can use a pmv while cuff is deflated although she is only tolerating for approximately 30 minutes a day. Getting ready to do an mbs, would you assess pt with cuff down and speaking valve on in addition to cuff inflated?  Do people generally wait until a pt is able to tolerate speaking valve for a certain amount time prior to taking pt to mbs.  Is it always safer for a trach patient to eat/drink with speaking valve inline?  We are having some disagreements on the treatment team.  Thanks for your advice/opinions.

Answer: We don’t know much about her history and other co-morbidities, which might affect next steps and treatment plan. But given what we know: it’s great that she is tolerating cuff deflation and is tolerating the PMV for 30 minutes at a time. While in radiology, I would also observe her with the cuff deflated and the PMV in place. That will give you some objective data about the effect of the PMV on swallowing physiology in comparison to physiology without the PMV in place. Typically in pediatric patients we do often observe better driving force on the bolus and better pharyngeal clearing, likely associated at least in part with restoration of subglottic pressure. Also, the restoration of taste and smell is critical for our pediatric patients to help either normalize or enhance the oral-sensory system, which is such a critical variable in both healthy and medically fragile pediatric patients.

The most recent study I am aware of in Laryngoscope 2013 (Ongkasuwan et al, “The effects of a speaking valve on laryngeal aspiration and penetration in children with tracheostomies”) concluded the PMV did not demonstrate a decrease in laryngeal penetration or aspiration. However, this was small sample with quite varied ages and indications for tracheostomy. Most unfortunately, the study only looked at occurrence of aspiration and penetration. As Bonnie Martin Harris has so wisely stated, aspiration and penetration are neither sufficient nor necessary for a swallowing impairment.

So for this discussion, it reminds us that in radiology with this child it will be important to look beyond the effect of the PMV on just “aspiration” and “penetration”. Consider its effect on her swallowing physiology, and its components, which underlie safe bolus transport.

Let us know what your impressions are, Stephanie, so we can further inform our clinical wisdom.


Catherine S. Shaker, MS/CCC-SLP, BCS-S
Board Certified Specialist – Swallowing and Swallowing Disorders

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