The Effect of a Speaking Valve on Laryngeal Aspiration and Penetration in Children With Tracheotomies

Transcription

1 The Laryngoscope VC 2013 The American Laryngological, Rhinological and Otological Society, Inc. The Effect of a Speaking Valve on Laryngeal Aspiration and Penetration in Children With Tracheotomies Julina Ongkasuwan, MD; Catherine L. Turk, PhD, CCC-SLP; Christina A. Rappazzo, MA, CCC-SLP; Katherine A. Lavergne, MA, CCC-SLP; E. O Brian Smith, PhD; Ellen M. Friedman, MD Objectives/Hypothesis: Alterations in swallowing can occur after tracheotomy and can result in varying degrees of aspiration. In tracheotomized adult patients, use of a Passy Muir Speaking Valve (PMV) has been shown to decrease laryngeal penetration and aspiration of foods and liquids. The objective of this study was to determine if the PMV has a similar effect on laryngeal penetration and aspiration in tracheotomized children. Study Design: This is a prospective case-control study. Methods: Pediatric patients with tracheotomies who were able to tolerate the PMV were identified. Modified barium swallow (MBS) was performed with and without the PMV. Two consistencies, thin liquids and purees, were used. Two speech language pathologists (SLPs), who were blinded to the PMV status, reviewed the recorded MBSs. Three swallows of each consistency were graded on an 8 point Penetration-Aspiration Scale. in the vallecula, piriform sinuses, and posterior pharyngeal wall was graded. Results: Twelve patients were included for analysis. Laryngeal penetration and aspiration was decreased with purees over liquids (P and P , respectively) with either the sham valve or the PMV. The presence of the PMV decreased piriform sinus residue (P ); however, it did not demonstrate a decrease in laryngeal aspiration or penetration. Conclusion: Unlike in adults, the presence of PMV did not decrease laryngeal aspiration or penetration in children with tracheotomies. It did, however, improve piriform sinus residue. Key Words: Tracheostomy, larynx, aspiration, penetration, Passy Muir Speaking Valve. Level of Evidence: 3b. Laryngoscope, 124: , 2014 INTRODUCTION Swallowing requires the coordination of multiple muscles in order to propel food and liquids from the mouth to the stomach without entering the trachea or lungs. When the system malfunctions, aspiration can result, putting the patient at risk for infection, lung disease, and repeated hospitalizations. Difficulty with aspiration of food and/or liquids during swallowing often occurs after tracheotomy. Previous studies have shown that 50% to 87% of adult patients with tracheotomies aspirate. 1 4 Given the complexity of these patients, the mechanism of this dysphagia can be difficult to determine. Several theories have been proposed for aspiration in tracheotomized patients, including tethering of laryngeal elevation by From the Department of Pediatric Otolaryngology (J.O., E.M.F.), Texas Children s Hospital/Baylor College of Medicine; and Department of Pediatric Otolaryngology, Speech Language and Learning (C.L.T., C.A.R., K.A.L.); and Department of Pediatrics (E.O B.S.), Texas Children s Hospital, Houston, Texas, U.S.A. Editor s Note: This Manuscript was accepted for publication September 25, Podium Presentation at the American Laryngological Association meeting at the Combined Spring Meeting in Orlando, Florida, U.S.A., April 10 11, The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Julina Ongkasuwan, MD, 6701 Fannin, Suite 640, Houston, TX julinao@bcm.edu DOI: /lary the tube, 1,5,6 reduced anterior rotation, 5,7 esophageal compression by an inflated cuff, 8 loss of subglottic air pressure, 9 desensitization of the larynx, 6,9 11 disuse atrophy of laryngeal muscles, 12 reduced effectiveness of cough to clear secretions from the upper airway, 10,13 and uncoordinated laryngeal closure due to chronic air diversion In tracheotomized adult patients, the complete occlusion of the tracheotomy has been shown to improve swallowing function. In a similar fashion, a Passy Muir Speaking Valve (PMV) has also been shown to decrease laryngeal penetration and aspiration. 10,13,17 20 The PMV is a one-way valve, fitted to the end of the tracheostomy tube, which opens during inspiration and closes during expiration. It can allow for vocalization and phonation. In addition, closure of the valve increases subglottic pressure, which is considered critical to the mechanism of swallowing. 18 The data is somewhat mixed, while several authors have seen a decrease in laryngeal penetration and aspiration with the PMV, 10,13,17 19 Leder et al. found that tracheostomy tube occlusion status had no effect on the incidence of aspiration. 21 Improvement in swallowing in tracheotomized patients is associated with improved outcomes, such as fewer hospitalizations and fewer episodes of pneumonia with the associated morbidity and costs. The purpose of this study is to determine the effect of a PMV on swallowing in children with tracheotomies. 1469

2 TABLE I. Rosenbek 8 Point Penetration-Aspiration Scale. 1. Material does not enter the airway. 2. Material enters the airway, remains above the vocal folds, and is ejected from the airway. 3. Material enters the airway, remains above the vocal folds, and is not ejected from the airway. 4. Material enters the airway, contacts the vocal folds, and is ejected from the airway. 5. Material enters the airway, contacts the vocal folds, and is not ejected from the airway. 6. Material enters the airway, passes below the vocal folds, and is ejected into the larynx or out of the airway. 7. Material enters the airway, passes below the vocal folds, and is not ejected from the trachea despite effort. 8. Material enters the airway, passes below the vocal folds, and no effort is made to eject. TABLE II. Patient Characteristics. Patient B No. Gestational Age (weeks) at Birth Age (months) at Tracheotomy Age (months) at Swallow Study Primary Nutritional Route Diagnoses PO Prematurity (twin gestation), tracheomalacia, laryngomalacia, patent ductus arteriosis (s/p ligation), unilateral vocal fold paralysis PO Prematurity, Pierre Robin Sequence PO Prematurity, bronchomalacia, bronchopulmonary dysplasia, necrotizing enterocolitis GT Severe hypotonic quadriplegic cerebral palsy, respiratory failure PO Intrauterine growth retardation, tracheomalacia PO Laryngomalacia GT Prematurity, tracheomalacia, subglottic stenosis, bronchopulmonary dysplasia PO Chiari malformation, myelomeningocele, hydrocephalus, bilateral true vocal fold paralysis PO Chiari malformation, myelomeningocele, bilateral true vocal fold paralysis PO/(GT at night) Prematurity, hemorrhagic hydrocephalus, bronchopulmonary dysplasia, pulmonary hypertension GT Congenital high airway obstruction syndrome s/p ex utero intrapartum treatment procedure, prematurity, necrotizing enterocolitis PO/(GT at night) Bilateral true vocal fold paralysis, subglottic stenosis GT 5 gastrostomy tube; PO 5 per os. MATERIALS AND METHODS This was a pilot study wherein 12 consecutive pediatric patients were identified who had a tracheotomy and could tolerate a PMV for the purposes of phonation and for whom a Modified Barium Swallow (MBS) was clinically indicated. The clinical indication for MBS was to make recommendations regarding readiness to start oral feeds or change in diet. Consent was obtained from the patients families to participate in the study. The MBS was performed by a licensed speechlanguage pathologist (SLP) under fluoroscopy. Two consistencies of liquids and solids with a small amount of barium were offered to the patient. The oral, oropharyngeal, and pharyngeal phases of swallow were evaluated. Entry of food material into the airway was also assessed. Thin liquids and purees were used in this study. Trials were performed on each patient with both a PMV as well with a sham valve, which appears the same on fluoroscopy, as the control. The patients served as their own control. The order in which the PMV versus the sham valve were used was randomly assigned to minimize the effect of learned improvement. Two SLPs, who were blinded to the PMV status, reviewed the recorded MBSs. Three swallows of each consistency were evaluated on a modified Rosenbek 8 point Penetration- Aspiration Scale (PAS) (Table I, categories 7 and 8 were collapsed into one as audio was not available). 22 in the valleculae, piriform sinus, and posterior pharyngeal wall was analyzed and scaled (0 5 none, 1 5 mild, 2 5 moderate, 3 5 severe). Statistical analysis was performed using a generalized linear model estimating equation in SPSS. Institutional Review Board approval was obtained for this study. RESULTS Of the 12 patients who were identified to meet inclusion criteria, there were seven males and five 1470

3 TABLE III. Individual Rosenbek and Scores. Reviewer 1 Reviewer 2 PMV on Sham PMV on Sham liquids puree liquids puree liquids puree liquids puree Patient 1 PAS* Vallecula Piriform sinus Patient 2 PAS Vallecula Piriform sinus Patient 3 PAS Vallecula Patient 4 PAS Vallecula Piriform sinus Posterior pharyngeal wall Patient 5 PAS Vallecula Piriform sinus Posterior pharyngeal wall Patient 6 PAS Vallecula Piriform sinus Posterior pharyngeal wall Patient 7 PAS Vallecula Patient 8 PAS Vallecula

4 TABLE III. (Continued) Reviewer 1 Reviewer 2 PMV on Sham PMV on Sham liquids puree liquids puree liquids puree liquids puree Patient 9 PAS Vallecula Piriform sinus Posterior pharyngeal wall Patient 10 PAS Vallecula Patient 11 PAS Vallecula Patient 12 PAS Vallecula *PAS 5 Rosenbek 8 point Penetration-Aspiration Scale; see Table I; PMV 5 Passy Muir Speaking Valve. scored as: 0 5 none; 1 5 mild; 2 5 moderate; 3 5 severe. females. Average gestational age at birth was 32 weeks (range weeks). Median age at the time of tracheotomy was 2 months (range 1 day 9 years). The median age at time of MBS was 16 months (range 3 months 9 years). The indications for tracheotomy included upper airway obstruction (7 patients), respiratory insufficiency (4 patients), and neurologic disorder (1 patient). Seven of the patients received nutrition primarily by mouth (PO), three were primarily gastrostomy tube fed (GT), and two received PO feeds during the day and GT feeds at night (Table II). The average scores over the three trials for each patient are shown in (Table III). The individual PAS scores ranged from 0 to 7. Regarding thin liquids, five patients ( 2, 3, 4, 5, and 10) had evidence of penetration or aspiration (average PAS >1, as judged by both reviewers) with the sham valve, which improved with the PMV. However, four patients ( 1, 7, 8, and 11) had a worse PAS with the PMV versus the sham valve. Patients 6, 9, and 12 had no difference between the sham and PMV with thin liquids. With purees, one patient ( 5) had improvement in PAS with the PMV. On the other hand, one patient ( 4), had a worse PAS. Overall, laryngeal penetration and aspiration was decreased with purees over liquids (P and P , respectively) in all patients with and without the PMV. The presence of the PMV decreased piriform sinus residue (P ); however, it did not demonstrate a decrease in laryngeal aspiration or penetration (Table IV). DISCUSSION Aspiration is a challenging problem in hospitalized patients, especially those with tracheotomies. Swallowing function in tracheostomized children poses additional challenges because they may have multiple other comorbidities that can also contribute to swallowing dysfunction. Many of these patients are former premature infants with neurologic deficits and global developmental delay. While the ability to feed by mouth can be a source of bonding and joy for the patient and family, the 1472

5 TABLE IV. Average Rosenbek and Scores. Reviewer 1 Reviewer 2 PMV on Sham PMV on Sham liquids (SD*) puree liquids puree liquids puree liquids puree PAS 1.89 (1.75) 1.03 (0.10) 1.78 (1.13) 1.06 (0.19) 1.97 (1.80) 1.03 (0.10) 1.94 (1.37) 1.03 (0.10) Vallecula 0.36 (0.36) 0.17 (0.22) 0.44 (0.41) 0.33 (0.40) 0.36 (0.39) 0.28 (0.34) 0.47 (0.44) 0.53 (0.48) Piriform sinus 0.06 (0.13) 0.06 (0.19) 0.14 (0.30) 0.08 (0.21) 0.11 (0.22) 0.03 (0.10) 0.19 (0.30) 0.17 (0.33) Posterior pharyngeal wall 0.03 (0.10) 0.03 (0.10) 0.03 (0.10) 0.06 (0.13) 0.03 (0.10) (0.30) *SD 5 standard deviation. PAS 5 Rosenbek 8 point Penetration-Aspiration Scale, see Table I. scored as: 0 5 none; 1 5 mild; 2 5 moderate; 3 5 severe. associated chronic aspiration may increase the number of hospitalizations and can lead to chronic lung disease and respiratory failure. In this series, use of the PMV did not have a statistically significant effect on laryngeal aspiration or penetration. Shortcomings of this study include the small sample size and the fact that it is a mixed group of patients with various indications for tracheotomy. We were limited by those tracheotomized patients who tolerate the PMV for voicing and for whom the MBS was clinically indicated. This is, however, a realistic representation of the tracheotomized pediatric population in our practice. Patients with upper air airway obstruction appeared to do no better (patients 6, 9, 12), or even worse (patients 7, 8, 9, 11), with the PMV versus sham; however, this did not meet statistical significance. This may be related to the degree of subglottic pressure generated, or the more marginal tolerance of the valve interfering with the timing of the swallow. On the other hand, patients who underwent tracheostomy for prematurity or respiratory failure ( 2, 3, 4, 5, and 10) had improvement in their swallow with the PMV. Overall, there was no clear association with underlying diagnosis or primary feeding route (PO vs. GT) with the PAS or residue. A larger sample size will be needed to assess if different subgroups of patients truly have varying response to PMV placement. We acknowledge that our n is small; however, it is comparable to the adult literature (n ,13,17 21,23 ). Modified barium swallow is used to evaluate for aspiration and penetration; however, it has limitations related to patient cooperation. In addition, if the patient only aspirates intermittently, this can be missed on MBS. In this study, multiple swallow trials were used to try to minimize this issue. Further, larger studies, on the mechanisms of aspiration in the patient population will have to be undertaken to further evaluate this question. Evaluation could include the examination of pressure gradients throughout the pharynx and cervical esophagus, as well as manometry quantification of the pharyngoesophageal segment. CONCLUSION The adult literature on this topic is somewhat mixed, with data both supporting and refuting the use of the PMV to decrease the incidence of aspiration. In this limited study, the presence of PMV did not reduce laryngeal aspiration or penetration in children with tracheotomies. It did, however, decrease the amount of piriform sinus residue, which may have some as yet undetermined clinical significance. Acknowledgement Institution where the work was done: Pediatric Otolaryngology Texas Children s Hospital. BIBLIOGRAPHY 1. Elpern EH, Jacobs ER, Bone RC. Incidence of aspiration in tracheally intubated adults. Heart Lung 1987;16: Bone DK, Davis JL, Zuidema GD, Cameron JL. Aspiration pneumonia. Prevention of aspiration in patients with tracheostomies. Ann Thorac Surg 1974;18: Pannunzio TG. Aspiration of oral feedings in patients with tracheostomies. AACN Clin Issues 1996;7: Cameron JL, Reynolds J, Zuidema GD. Aspiration in patients with tracheostomies. 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