Babies with Tracheostomies:
Considerations for Speech & Language
Development
Presented by Nicole Heavilin
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
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Common Indications for
Tracheostomy in Babies
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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:
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Glottal stenosis
Vocal fold paralysis
Congenital centro hypoventricular syndrome
Tracheoesophageal fistula
Clinical Management
Considerations
RLN damage due to surgical procedure
 Infection or inflammation of trachea
 Chronic congestion, upper respiratory
infections, pneumonia
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– Tracheostomy bypasses normal warming,
filtering, & humidifying functions of upper
airway!
Therefore…
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Speech-language pathologists must have
knowledge of:
– babies’ medical condition, respiratory
involvement & reason for tracheostomy
– severity of underlying disease
– status of upper airway & respiration
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How will the status and severity change
over the time of cannulation?
Current Knowledge:
Associated risks on Communication
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Prematurity linked to respiratory difficulties
– Decreased lung support for speaking valve!
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Tracheostomy may be accompanied by
mechanical ventilator
– Possible periods of oxygen deprivation
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Long-term or recurrent hospitalizations can
disrupt socioemotional & environmental supports
for speech-language development
Current Knowledge:
Associated risks on Communication
(cont’d)
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Tracheostomy severely restricts opportunities for normal
vocalizations
– Manual occlusion of stoma or use of speaking valve help to make
this more “normal”
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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)
Other Associated Developmental
Risks
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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
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Greater effort in coordinating breathing, speaking, sucking,
swallowing, etc.
Role of the SLP
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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
History of Investigations on
Tracheostomy-Speech Development
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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
History of Investigations on
Tracheostomy-Speech Development
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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 6month old
– By age 4;4 speech & language was ageappropriate as measured by types of sounds,
syllable shapes, # spontaneous utterances &
syllables per utterance
History of Investigations on
Tracheostomy-Speech Development
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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/agematched 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…)
Kertoy et.al. on Speech &
Phonological Characteristics
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Kertoy et.al. (1999): 6 children ages 2;8-6;8
tracheostomized at or before 8 months of
age
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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
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
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Kertoy Study (cont’d)
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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
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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
Kertoy Study (cont’d)
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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
Implications of Kertoy Study
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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
Types of Speaking Valves
Olympic Trach Talk
 Montgomery Speaking Valve
 Hood Speaking Valve
 Kistner 1-way Valve
 Passy-Muir Speaking Valve
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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
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Purpose of the Passy-Muir
Speaking Valve (PMSV)
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Permits inspiration via stoma and expiration
via glottis to produce phonation
– Adult ability to speak without compromising
respiration
– How about in infants?
Eligibility of the PMSV
Audible air leak around tracheostomy tube
 7 days post-operative of tracheostomy
 Sustained awake, alert state
 Medical stability
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Tolerance of the Passy-Muir
Speaking Valve (PMSV)
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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
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
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Study on Children Under 2 Years of
Age
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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)
References:
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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