Catherine Shaker Fall Seminars to Inform Your Practice

Join your colleagues in Austin or Houston for advanced clinical learning opportunities! Choose your focus: advanced pediatric swallowing/feeding or pediatric/neonatal swallow studies or state-of-the-art NICU assessment.

October 22-23 (Austin) or November 10-11 (Houston): The Early Feeding Skills Assessment Tool: A Guide to Cue-Based Feeding in the NICU

October 24 (Austin) or November 12 (Houston): Neonatal/Pediatric Videofluoroscopic Swallow Studies.

October 25-26 (Austin) or November 13-14 (Houston): Advanced Infant/Pediatric Dysphagia: Problem-Solving Complex Patients and Practice Challenges 

Each state-of-the-art seminar infused with the latest research and problem-solving, enhanced by my 45 years of progressive clinical experience. I’ll be teaching the NICU-focused seminar with Dr. Suzanne Thoyre, PhD RN, a gifted, acclaimed NICU researcher and neonatal nurse, who beings insights that support evidence-based feeding practice, partnership with neonatal nurses, and strategies to guide your NICU team to better feeding outcomes.

A welcoming environment that fosters interaction and learning along with each other. Will change your practice.

Click here to download Shaker 2022 On-Site Seminars Brochure

Click here to Register 

Click here for On-Site Information for Austin

Click here for On-Site Information for Houston

Research Corner: Congenital Heart Disease and Vocal Fold Immotility

Congratulations to our pediatric colleague, Christine Rappazzo, for this wonderful addition to our evidence base related to the potential impact of the need for heart surgery on airway protection in our infant population. This, combined with the documented increased risk for R vocal fold motion impairment post ECMO in this population, helps us to advocate for our involvement in safe progression to PO for these vulnerable infants.

Citation: Narawane, A., Rappazzo, C., Hawney, J., Clason, H., Roddy, D. J., & Ongkasuwan, J. (2021). Vocal Fold Movement and Silent Aspiration After Congenital Heart Surgery. The Laryngoscope.

Abstract

Infants who undergo congenital heart surgery are at risk of developing vocal fold motion impairment (VFMI) and swallowing difficulties. This study aims to describe the dysphagia in this population and explore the associations between surgical complexity and vocal fold mobility with dysphagia and airway protection.

Methods

This is a retrospective chart review of infants (age <12 months) who underwent congenital heart surgery between 7/2008 and 1/2018 and received a subsequent videofluoroscopic swallow study (VFSS). Demographic information, Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery (STAT) category of each surgery, vocal fold mobility status, and VFSS findings were collected and analyzed.

Results

Three hundred and seventy-four patients were included in the study. Fifty-four percent of patients were male, 24% were premature, and the average age at the time of VFSS was 59 days. Sixty percent of patients had oral dysphagia and 64% of patients had pharyngeal dysphagia. Fifty-one percent of patients had laryngeal penetration and 45% had tracheal aspiration. Seventy-three percent of these aspirations were silent. There was no association between surgical complexity, as defined by the STAT category, and dysphagia or airway protection findings. Patients with VFMI after surgery were more likely to have silent aspiration (odds ratio = 1.94, P < .01), even when adjusting for other risk factors.

Conclusion

Infants who undergo congenital heart surgery are at high risk for VFMI and aspiration across all five STAT categories. This study demonstrates the high prevalence of silent aspiration in this population and the need for thorough postoperative swallow evaluation.

This will inform your pediatric practice whether in the inpatient or community pediatric setting.

 

 

 

 

Learning about Feeding/Swallowing: An International Pediatric Perspective

I was thrilled to welcome new SLP friends from Europe who traveled to Chicago to learn along with me! Florentine (left) from The Netherlands, and Heida (right) from Iceland.  Between them, they traveled over 7000 miles to be with me for 5 days. Despite our geographic distance, our infant and pediatric patents are so similar, as are the challenges we face each day. Their approaches and physician/institutional influences really are not all that different but their wisdom in thriving with different and less abundant resources were an eye opener for all of us. International perspectives on feeding and swallowing always round out conversations at my courses. It has been my pleasure over the years to welcome an ENT from Saudi Arabia, a pediatric dentist from Japan and in-the-trenches therapists from other far way places including Spain, Greece, the UK, South Africa, Australia, India, The United Arab Emirates, Ireland and Israel. Needless to say, my brain is on fire after the chance to share our passion for helping infants and children with feeding and swallowing problems. And it is great to have contacts for future problem-solving that literally span the globe! Safe travels to my new friends, Florentine and Heida!

Pediatric Swallowing/Feeding: “We are all in this together!”

I just returned from teaching in Chicago for 5 days at Advocate Aurora Healthcare.  What an amazing pediatric team they have…engaged, thoughtful and embracing both the evidence base and the value of problem-solving. We were joined by therapists from across the US and Europe for conversations about our shared challenges …complex infants and children who land on our doorsteps, navigating swallow studies with physician colleagues, implementing IDDSI, fostering cue-based feeding in a volume-driven culture, GI co-morbidities from FTT through  ARFID in kids, the latest information on aspiration in the pediatric population, risks for feeding on CPAP/HFNC, enduring impacts of neurologic sequalae, and integrating motor learning as the foundation for rehabilitating and habilitating the swallow from infants through adolescents, and so much more. We all came away with new ideas, new data, new perspectives and a resounding sense that we are all in this together as pediatric swallowing and feeding specialists! We can do this!

Practicing at the Top of Your Profession in Feeding/Swallowing

An SLP asked recently, “What resources, articles, courses, etc. did you find helpful when you were first learning infant feeding? I’m looking for something to give me what I really need.”

“My seminars” I told her, “are designed to do just that. When I created them, and as I update them, I always think ‘What do I wish I had known, both research and clinical information, to practice in peds dysphagia when I started out? What is essential to work toward practicing at the top of our professions?’  My NICU and Pediatric as well as Advanced seminars, my Peds/ Neonatal Video Swallow Studies and Cue Based seminars are filled with everything I want to pass along. As I learn from colleagues and attendees at my courses, I weave that in as well. Sometimes I almost run out of time!

I will always offer you a welcoming environment that fosters interaction and learning along with each other.

Click here to download Shaker 2022 On-Site Seminars Brochure

Click here to Register

 

Problem-Solvers Join Catherine Shaker for Advanced Learning Opportunities

Such a wonderful group joined me in Atlanta last week! Here are some of the amazing problem-solvers from Childrens Heathcare of Atlanta and from across the US who came together for my Cue-based Feeding and Advanced Infant/Pediatric Dysphagia seminars. It was a great opportunity to apply critical thinking to neonates and children through school-age/adolescence with feeding and swallowing challenges. Everyone’s brains were “on fire” as I like to say, with conversations about complex co-morbidities, navigating swallow studies and case discussions.

I hope to see you at one of my next offerings in Chicago, Austin or Houston!

Click here to download Shaker 2022 On-Site Seminars Brochure

Click here to Register

Celebrating the Promise of Cue Based Feeding for our Infants

Dr. Suzanne Thoyre,  a gifted, acclaimed NICU researcher and neonatal nurse, joined me this weekend at Childrens Healthcare of Atlanta for our Cue-based Feeding seminar. We shared our insights and evidence-based feeding practice from a combined nearly-100-years of practice in the NICU. Therapists from across the US and Canada learned along with us to explore infant-guided assessment and intervention and develop a common language in the NICU to support neuroprotection and better feeding outcomes for infants who require intensive care. One of the attendees noted: “As out NICU team continues to transition to cue-based feeding, we will be better able to establish treatment plans for our little ones and have the team on the same page.”

We hope to see you in Austin (October) or Houston (November) for this exceptional learning opportunity.

Click here to download Shaker 2022 On-Site Seminars Brochure

Click here to Register

Problem-Solving: RR and PO Feeding in the NICU

QUESTION: I have a 33wker with a VSD that nursing is PO feeding every feeding. Are there studies regarding respiratory rate while feeding? The infant looked comfortable at 65 and below but I told nursing to stop feeding with rate above 80 (or allow major rest break for her to slow it down because she’s often cueing).  I’d love hard data to support those numbers

ANSWER:

I don’t know of any randomized controlled trials that yielded this data. Clinically we know that spontaneous RR is typically different than monitored RR, due to an artifact created by the monitor not consistently sensing rapid shallow breaths. We gather he best data by counting the spontaneous breaths, as it’s more reliable. Anytime the RR is above 60 we know there is greater risk, as it takes a second to complete the pharyngeal swallow. RR over 60 increases risk that the swallow and breathing will co-occur or “collide” as I like to say to parents. Work of breathing often goes hand in hand with the RR but can often be a more worrisome indicator of risk for airway invasion. As the effort goes up, breaths are more shallow, there is then less tidal volume, and the infant is more likely to need an urgent breath. In those moments, the need to breathe will override the swallow. Often this means opening the airway too early or not fully closing it at the moment of the swallow. Because NICU infants are at higher risk to silently aspirate, the infant described may show no outward signs. We know he is a 33 weeker – which means to me that he was born at 33 weeks. What is his PMA? Or are you meaning he is now 33 weeks PMA; if so, what was his GA? Helps me make sense of his risk. The VSD will drive up WOB and RR at baseline, and with the aerobic demands of feeding. Does he have an otherwise unremarkable history except for VSD? Currently requiring respiratory support? What are saturations like with PO? What physiologic and behavioral stress signs do you see even with interventions? What interventions are the nurses using to protect him? Perhaps having you offer guided participation while a nurse feeds and you think along with her, might build a conversation about airway protection and neuroprotection, both of which are likely at risk given what we know.

Problem-Solving: 2 -year-old with Pierre Robin Syndrome

Question: I have a complex case I have been following since her time at our NICU. She is 2 years old, and I just completed a repeat VFSS (outpatient, her seventh to date) which continues to show significant dysphagia with high aspiration and airway obstruction risk.

History is significant for Pierre Robin sequence (chromosome deletions at 10q11 and 20p12) and cleft palate. She was born full term but required intubation after birth for critical airway. She required mandibular distraction hardware placement for about 2 months, has required supplemental nutrition by means of a feeding tube since birth (has had a PEG for over a year), and had a bilateral palatoplasty around 18 months of age. She’s been followed by feeding therapy, but despite recommendations for NPO because of her significant risks, she really wants to eat and drink. She pulls food off of the table from her siblings’ plates and has been eating/drinking regular/thin without specific correlation to any respiratory compromise.

I wish I could insert a fluoro clip here as I think it will be hard to spell this out… her swallow is significantly uncoordinated. With all consistencies the bolus reaches the pyriforms and at the onset of her “swallow” she presents with immediate regurgitation to the oral cavity and nasopharynx. No barium enters the esophagus with the initial swallow, it almost appears that the timing of UES relaxation follows tongue base retraction after the majority of contents have been redirected from the hypopharynx. This sequence is repeated 18 times prior to what appears to be a complete swallow, during which the contents that weren’t incidentally passed through the UES are cleared through the pharynx. Laryngeal penetration and aspiration at the height of the swallow occur during most of the uncoordinated “swallows” (which is silent). The pattern is the same with all consistencies and is paired with an open mouth posture. When provided with tactile cueing to keep her lips closed, she appears to have the coordination/pressures needed to clear small boluses with single swallows, but her adaptations seem to drive the motor planning train at this point. I ethically could not proceed with solid foods even though mom called two months ago to ask if we could ‘try solids no matter what’ during the study… they had hot dogs for dinner last night and brought pieces of hot dog to the study today. I have no explanation for how a choking event did not happen.

My heart really goes out to this family; they need a lot of guidance, and it has been a journey for them. Our oral maxillofacial surgeon and gastroenterologist have agreed to have a sit-down care conference with the family which I am extremely grateful for… my question is in regard to where to go from here. I think she needs intensive feeding therapy at this point and the clinics that I am most familiar with in our area are behaviorally driven to help kids wean from tube feedings… but she is a special case in which she really wants to eat and drink but is not safe to do so… does anyone have any specific cleft palate clinics that they have worked with? Mom is very open to this and was very open to me posting the patient’s case here to get some ideas for them.

Superior based pharyngeal flap surgery is in the discussion, but until her adaptive “swallows” are not the driving force of her function, I don’t see how she will safely manage as I think her ability to redirect boluses into her nasopharynx are her saving grace (as strange as that sounds).

Any and all help/insight is appreciated.

 

Answer: The infants and children we see never cease to amaze me with their adaptive behavior to accomplish a task in the face of such challenges. Bonnie Martin Harris always reinforces the dynamic nature of the swallow pathway, and how alterations in one point along that pathway can create compensatory behaviors along the pathway that may not always be beneficial but may indeed be maladaptive behaviors. What is the source of the alteration versus the compensatory behavior always needs to be sorted out, and you have done that so very well!

I have had three children with similar clinical and videofluoroscopic presentations. They each had mandibular hypoplasia, only one had the benefit of mandibular distraction. The impact of mandibular hypoplasia on motor learning in utero is not always fully appreciated. Early on, it creates muscular and structural restrictions to base of tongue integrity (decreased ROM, decreased posterior prolusion, decreased BOT retraction for the dynamic swallow). The fetus swallows amniotic fluid from 17 weeks on, and so by birth at term, has had 23 weeks of motor learning to help build the motor maps that underpin the swallow. Mandibular hypoplasia leads to reduced oral cavity space, this displaces the tongue body, leads to an altered tongue position, typically retracted back into the oral cavity and often with some form of glossoptosis; it also can create muscle shortening that will impede full ROM for the necessary base of tongue retraction. Even post MDO (Mandibular Distraction Osteogenesis), many infants continue to show reduced BOT retraction on VFSS for this reason. That’s why MDO is not a “fix all” for Pierre Robin sequence or mandibular hypoplasia, with its attendant alterations in muscular function, though MDO is unfortunately viewed as such by some medical professionals (i.e., “the infant was distracted, why doesn’t he eat?”). The co-occurring open mouth posture likely adversely affects an anterior seal on the bolus, which, along with reduced BOT retraction, acts as another impediment to generating the pressure required to relax and open the UES. The resistance to bolus flow causes the bolus to take the path of least resistance. The need to establish the more typical motor plan in order to habilitate (or maybe even rehabilitate at this point despite her young age) feeding skills is important.

Working on an anterior seal (lots of fun ways to do that at her age) and pressure generation with smaller boluses would be helpful. I wonder if a short repeat study to objectify optimal viscosity/viscosities for pressure generation might be informative, and like a short biofeedback for her, if she is cognitively appropriate, and perhaps to objectify the impact of optimal cueing strategies, utensils and neuromotor facilitation provided. Pharyngeal manometry to better objectify the role of pharyngeal pressure generation in bolus flow.

I so appreciate your critical thinking and living in the gray zone as I like to call it; where you are ok with pausing to think of possibilities, weighing them and asking more questions, instead of rushing to an answer. I’d be happy to work alongside each of you anytime.

Research Corner: Swallowing Biomechanics in Infants with Feeding Difficulties

Variability in Swallowing Biomechanics in Infants with Feeding Difficulties: A Videofluoroscopic Analysis by Laura Fuller, Anna Miles, Isuru Dharmarathn, Jacqui Allen1 (2022) Dysphagia – published online March 2022

This just published paper adds to our evidence and understanding about the dynamic infant swallow.

Abstract

Clinicians performing feeding evaluations in infants often report swallow variability or inconsistency as concerning. However, little is known about whether this represents pathological incoordination or normal physiologic variance in a developing child. Our retrospective study explored quantitative videofluoroscopic measures in 50 bottle-fed infants (0–9 months) referred
with feeding concerns. Our research questions were as follows: Is it possible to assess swallow to swallow variability in an infant with feeding concerns, is there variability in pharyngeal timing and displacement in infants referred for videofluoroscopy, and is variability associated with aspiration risk? Measures were taken from a mid-feed, 20-s loop recorded at 30 frames per second. Each swallow within the 20-s loop (n=349 swallows) was analysed using quantitative digital measures of timing, displacement and coordination (Swallowtail™). Two blinded raters measured all swallows with strong inter-rater reliability (ICC .78). Swallow frequency, suck-swallow ratio, residue and aspiration were also rated. Variability in timing and displacement was identified across all infants but did not correlate with aspiration (p>.05). Sixteen infants (32%) aspirated. Across the cohort, swallow frequency varied from 1 to 15 within the 20-s loops; suck-swallow ratios varied from 1:1
to 6:1. Within-infant variability in suck-swallow ratios was associated with higher penetration-aspiration scores (p<.001). In conclusion, pharyngeal timing and displacement variability is present in infants referred with feeding difficulties but does not correlate with aspiration. Suck-swallow ratio variability, however, is an important risk factor for aspiration that can be
observed at bedside without radiation. These objective measures provide insight into infant swallowing biomechanics and deserve further exploration for their clinical applicability.

New Shaker Publication: Aerodigestive changes for feeding and swallowing in the neonatal intensive care unit (NICU)

I am pleased to announce my new publication on aerodigestive challenges for preterm and sick newborns who require neonatal intensive care. Supporting safe and successful feeding and swallowing in the setting of aerodigestive co-morbidities requires thoughtful reflection from multiple perspectives, to help us navigate both therapeutic differentials and interventions. The article addresses:  considerations post-extubation, the potential impact of HFNC and CPAP, supporting feeding readiness in fragile infants, stridor, PMV trials, a protocol for NICU infants requiring long-term tracheostomy, and the contribution of instrumental assessment via videofluoroscopic swallow studies. Should be available on the Passy-Muir website soon.

Shaker, C.S. (2022) Aerodigestive changes for feeding and swallowing in the neonatal intensive care unit (NICU). Passy Muir’s Aerodigestive Health Volume 5 Issue 1; 35-42.

Click here to go to Passy Muir website education and download article

Research Corner: The Effect of Severe Intraventricular Hemorrhage on the Biorhythms of Feeding in Premature Infants

Gewolb, I. H., Sobowale, B. T., Vice, F. L., Patwardhan, A., Solomonia, N., & Reynolds, E. W. (2021). The Effect of Severe Intraventricular Hemorrhage on the Biorhythms of Feeding in Premature Infants. Frontiers in Pediatrics, 870.

Background: Suck-swallow rhythmicity and the integration of breathing into infant feeding are developmentally regulated. Neurological injury and breathing abnormalities can both impact feeding in preterm infants.

Objective: To determine the effects of neurologic injury independent of effects of
disordered breathing on feeding biorhythms in premature infants

Conclusions: We have previously shown that the suck-swallow-breathe rhythms and patterns in preterm infants with bronchopulmonary dysplasia (BPD) differ significantly from those in low-risk
preterm infants (14–18). This has raised the question as to whether the dysrhythmias and abnormal coordination patterns noted in infants with BPD are caused by difficulty breathing
or by the often-concomitant underlying neurological injury commonly seen as co-morbid conditions (such as IVH) in medically complex preterm infants. Neonates with BPD often have IVH or other markers of neurological injury; thus, it is important to differentiate the dysrhythmic effects of neurological injury from any direct respiratory effects of BPD on infant feeding, since a specific “signature” in feeding in infants with neurological issues pointing to a more
vulnerable population would allow resources to be targeted.

Severe IVH has a negative impact on the biorhythms of suck, suck and suck-swallow in preterm infants 35–42 weeks PMA. If a preterm infant with IVH but without BPD at 35–42 weeks PMA
lacks adequate feeding biorhythms, there could be a need for additional workup to identify possibly undetected neurological injury. The independent effect of severe IVH on feeding rhythms
suggests that quantitative analysis of feeding may both reflect and predict neurological sequelae, and perhaps points to a critical period where intervention may be most efficacious.

Research: Feeding outcomes in former preterms in the first 7 months of life

Click on this secure  link: Hill et la (2020) Bottle Feeding preterm Infant first 7 months of life

Those of you in Early Intervention and in the NICU will find this new paper just published a valuable addition to your research base for practice.

Hill, R. R., Park, J., & Pados, B. F. (2020). Bottle-Feeding Challenges in Preterm-Born Infants in the First 7 Months of Life. Global Pediatric Health7, 2333794X20952688

It reinforces some of the key factors that may lead to enduring feeding problems after the NICU. It may be helpful for your neonatology team, as its findings suggests that watchful vigilance both in the NICU by the SLP, and indeed after discharge by our colleagues in Early Intervention,  should be a part of the plan of care for our at risk infants and their families. Perhaps this early provision of infant-guided support may in the long run avoid the onset of feeding aversions that can arise from stressful feeding experiences.

Quoting their conclusions:

Very preterm infants (i.e., those born <32 weeks GA at birth) had significantly more symptoms of problematic bottle-feeding than infants born full-term, moderately preterm or late preterm. Factors such as BPD (Chronic Lung Disease), GER, and congenital anomalies of the face, mouth and gastrointestinal tract were significant contributors. Early difficulty with breastfeeding was also a risk factor for later difficulties with bottle-feeding. There was improvement in symptoms with increasing age, which is likely reflection of improvement of medical factors and infant maturation. These findings support the need for frequent assessment of feeding in preterm-born infants after NICU discharge and provides clinicians with information regarding particular medical factors that place infant at risk for feeding difficulty beyond the NICU. The identification of infants who are struggling with bottle-feeding may facilitate interventions within the primary care setting or referral to feeding experts to improve longer outcomes and decrease the likelihood of negative sequelae that could persist into late childhood.

 

 

Problem-Solving: Intervention with NICU Infants Who Are Vent Dependent

QUESTION

Can you share feeding protocols when asked to work with infants on a ventilator in the NICU. Specifically, patients that are expected to go home on a home ventilator.

CATHERINE’S ANSWER

These indeed are often our most fragile NICU infants. Each one is typically unique, so I always start with understanding that infant’s unique co-morbidities that led to the need for long-term ventilation. For example,   PPHN, CLD, CHD, congenital malformations, neuromuscular disorders, and structural airway alterations, or multiple complex co-occurring co-morbidities, which then create an even higher risk for the infant to, at some point, safely tolerate oral feeding. This then is the foundation for determining timing and nature of intervention, as we consider relevant factors for feeding readiness/oral-sensory-motor treatment to support the prerequisite skills for future PO feeding.

Multiple factors need to be considered such as: level and mode of respiratory support in the setting of that infant’s respiratory history, the prerequisite  oral-motor integrity, ability to swallow saliva, oral-sensory processing, non-nutritive sucking, as well as physiologic stability during  interventions utilized to support these prerequisites, if they are emerging. Once these prerequisites are established, I would likely be considering appropriateness of, and tolerance for,  an in line valve like the PMV to establish flow into the upper airway  that promotes restoration of taste, smell and subglottic pressure, which most optimally underpins swallowing; at this juncture, working closely with ENT/Pulmonology and the respiratory therapist is essential.

For those infants with readiness skills for whom a PMV is contraindicated (per diagnosis and/or airway status and/or clinical status), I would perhaps offer a cautious pacifier dips for purposeful swallows — because, without a PMV in line, there won’t be the taste or smell or subglottic pressure so critical for an infant who has no previous motor learning with suck-swallow-breathe and bolus control; I would offer this motor learning experience via very limited pacifier dips with SLP to allow some interval sensory-motor learning in preparation a swallow study very early on in the therapeutic process to objectify swallowing physiology.

For those infants with readiness skills, and who are appropriate for and tolerate a PMV (with MD approval), considerations may include: pacifier dips with PMV in line, limited trace PO via ultra preemie nipple (for interval sensory-motor learning in preparation a swallow study very early on in the therapeutic process to objectify swallowing physiology). I prefer an NICU infant’s first PO feeding not be in radiology if possible, recognizing safety concerns; but some interval motor learning is likely important to reduce artifacts. This must be carefully and cautiously balanced with that infant’s risk for, and ability tolerate airway invasion, especially from a pulmonary perspective.

In my 35 years in the NICU, I have never seen one of our trach/vent infants go home as a full safe PO feeder. Often in some NICUs, the challenge may be having the entire team on board about risk, prerequisites, silent aspiration, that it isn’t just about “aspiration” (but rather the dynamic impact of altered or impaired swallowing physiology),  in the setting of the complex co-morbidities these fragile infants have.

You will notice as you read my thoughts above, they aren’t a protocol as much as a scaffolding I use, when I unpeel the layers as I go along, learn from the infant, combine that with his history and ask more questions. I hope this is helpful.

COMMENTARY FROM KRISTIN KING at PASSY MUIR

First, thank you, Catherine Shaker for such a well-thought out response as always. I learn something new each time I read a response from you.

I am only responding to the question about cuff deflation and cuff deflation with use of a PMV. All that I provide here is somewhat contingent on following the information that  Catherine Shaker’s response provides. I realize much of this will be known if you work with patients on a vent, but I do not want to miss an important aspect.

Typically, I do not recommend a cuff deflation trial prior to PMV use or swallowing assessment. If with cuff deflation and airway assessment, it is determined that the airway is patent, and all other factors being appropriate, then I would trial a PMV shortly after cuff deflation. Ideally, for swallowing/feeding, a child could use a PMV to restore various physiologic functions (such as subglottic pressure), but it may not be necessary in some cases. In considering cuff deflation and a trial of cuff deflation, an inflated cuff is used to “seal” the airway allowing all airflow to be to and from the ventilator. PEEP (positive end-expiratory pressure) is provided via the vent because with an open tracheostomy there can be a loss of PEEP/decreased pressure in the lungs. PEEP assists with keeping the alveoli open for good gas exchange and oxygenation. If the ventilator is not properly adjusted, having an open tracheostomy tube with deflated cuff may cause loss of PEEP and de-recruitment of the lungs. Now, this is all in relation to infants/children who have a cuffed trach tube with ventilation. Infants/children are frequently ventilated with cuffless trach tubes and that is a different situation.

The loss of PEEP and de-recruitment with cuff deflation has been shown in research on adults (Sutt et al, 2016, 2017, Critical Care); unfortunately, we do not have much research on infants and children. Having a cuff deflation trial may actually cause a person (no matter the age) to have difficulty maintaining good lung recruitment and PEEP, if the trach tube is left open.

Trialing a PMV assists with maintaining lung recruitment and PEEP. The potential impacts and need for a closed system are illustrated in a case presentation in the 2018 pediatric issue of Aerodigestive Health presented by an RT and the issues they had transitioning a 10-year old child from the vent and use of a PMV to trach collar without a PMV (for the cuff deflation/trach collar trial). While this case presentation is with an older child, the concepts with cuff deflation still apply. Restoring more physiological PEEP with use of the PMV sooner will assist with overall respiratory function (the Sutt research even showed improved diaphragmatic use).

As to the swallowing/MBS assessment, ideally, the cuff would be deflated and a PMV available for trial. I recommend testing with and without the Valve and with and without cuff deflation, if at all possible and with considerations for exposure. Lastly, this is all contingent on the cuff being properly managed/inflated.

Hope this helps some. It is a little bit different slant than the initial question.

FOLLOWUP RESONSE FROM CATHERINE

Thank you, Kristin, for sharing this wonderful issue that informs everyone’s practice with this population, and for the helpful response. Laura Brooks wrote an article in a previous edition of Passy-Muir’s Aerodigestive Health that was also specific to trach and vent dependent infants and children in intensive care which is very helpful. All issues can be found at www.passymuir.com/resources .

I agree that if an in-line PMV trial is indicated, partnering with RT and trialing cuff deflation immediately prior to attempting the in line PMV,  is best for these little ones, who also can readily experience physiologic stress and anxiety when a cuff is deflated even extremely slowly. They, like the ten year old in the article, require so much patience and thoughtful progression of interventions. It is worrisome to me that the complexity of the swallow-breathe interface for neonates in the setting of a trach is not always appreciated by all members of the team. In those situations, these infants can readily decompensate,  and then both neuroprotection and airway protection are often adversely affected.

On a side note, in radiology I have typically seen improved swallowing physiology with the PMV in place for these complex neonates. I suspect part of that is that most were not PO feeding prior to their trach (due to complex co-morbidities), and so they often have no previous “motor learning” with PO feeding to “fall back on” to “guide them” when and if they start to PO feed. When a tolerated PMV restores the fundamental underpinnings for swallowing,  it seems to make all the difference for these fragile neonates.

Thanks again for your insights too , Kristin. So appreciated.