Dysphagia
The children with tracheostomy may be fed by oral route and/or by tube,
depending on underlying conditions and swallowing abilities. Mainly, the
severity and characteristics of neurological impairment are
determinative of feeding route. For instance, the lack or diminished gag
reflex, the disorders with bulbar involvement require tube feeding.
Factors that may affect feeding of the children with tracheostomy are
given in Table 8 33,52.
Swallowing is a complex process which is controlled by brain stem,
cortex and enteric nervous system that innervates esophagus smooth
muscles. There are three phases of swallowing. The oral phase begins
with opening of the mouth and continues with sucking, biting, chewing.
The tongue movements and addition of the saliva allow the food bolus to
pass into oropharynx. In pharyngeal phase, the velum elevates to close
the nasopharynx. The hyoid and larynx elevate with anterior moving,
epiglottis descends and vocal cords are closed. The laryngeal elevation
protects the airway and anterior movement of the larynx helps open the
upper esophageal sphincter. The contraction of the pharyngeal muscles
moves the bolus from the pharynx to the esophagus. In esophageal phase,
bolus passes into the stomach by esophagus peristaltism, gravity and LES
relaxation53. The effect of tracheostomy tube on
increasing the risk of aspiration and penetration is defined but there
is no strong evidence. Tracheostomy tube fixes the larynx and prevents
laryngeal elevation. Also it desensitizes larynx and leads an
ineffective cough mechanism, because a positive subglottic pressure
cannot be maintained during swallowing. The cuff of the tracheostomy
tube may impringe on the esophagus during
deglutition8,53. Streppel M et al54.
reported 70% of the children with tracheostomy had swallowing
disorders. The aspiration rate in the study group was 43% and half of
them had silent aspiration. The underlying diseases may also contribute
to the development of swallowing disorders54.
The aspiration, penetration and other swallowing problems can be
detected by various diagnostic approaches. Penetration is passage of
material into the laryngeal lumen, but remaining above the vocal cords,
not passing to the glottis. Aspiration is the passage of material below
the vocal cords. The Modified Blue Dye Test is a screening test for
aspiration. After the patient swallow a methylene blue mixed drink or
food, suctioning a colored secretion is considered as aspiration.
Flexible Endoscopic Evaluation of Swallowing (FEES) and Videofluoroscopy
(VFS) are the gold standart methods to evaluate swallowing
dysfunction33,53,54. Pharyngeal phase of swallowing,
penetration and aspiration can be detected by FEES. A speech and
language therapist (SLT) and a pediatric Ear-Nose-Throat (ENT)
specialist can perform FEES. A VFS demonstrate oral, pharyngeal and
esophageal phases of swallowing, penetration, aspiration, obstruction,
fistulas and motility problems can be observed. VFS is usually performed
by a SLT and a radiologist. In the suspicion of an abnormality in the
esophageal phase of swallowing, manometry may be considered. Swallowing
the different consistencies of foods such as liquids, thickened liquids,
purees and solids can be determined 33,53,54.
Aspiration is a major problem that complicates the clinical status and
respiratory condition of these children. Aspiration may lead hypoxemia,
cough, respiratory distress or it may be silent. Untreated aspiration
may result in bronchiectasis and decreased lung
function33. On contrary, in recent years many centers
change their feeding strategy to giving heavy-thickened liquids even if
there is aspiration and/or penetration on VFSS. Particularly in patients
with tracheostomy it is considered to be safer due to the chance of
removing aspirates through the tracheostomy tube. Furthermore,
improvement of the swallowing function depending on oral stimulation
over time is possible55,56.
In the first 2-4 months of life, swallowing and sucking are reflexive,
subsequently swallowing becomes more voluntary and it progressively
develops in the first years of life. The development of proper oral
feeding skills is negatively affected in premature infants who had long
term intubation in intensive care units. Oral-motor and sensory feeding
difficulties such as weak or incoordinate suck and swallow, oral
aversion, hypersensitivity to oral stimuli (may be due to repetitive
aspirations), refusal to taste food may occur32,53,54.
The early experience of oral feeding in tube fed children will be
beneficial as follows; facilitates the oral motor skills such as chewing
and swallowing, improves sensory skills such as taste and texture of the
foods, and reduces oral aversion. A team work should be required to
decide and carry out to transit oral feeding in tube-feeding children
with tracheostomy. The team should be consist of an occupational
therapist, speech language pathologist, physical therapist, respiratory
therapist, psychologist, dietitian and clinicians as pediatric
pulmonologist, pediatric ear-nose-throat specialist and pediatric
gastroenterologist32,53,54.
Following the instrumental tests, the patients who have a medical
stability, swallow their oral secretions, need infrequent tracheal
suctioning are seem to be ready to oral feeding. Oral feeding should be
attempted under the actual mode of ventilation with following oxygen
saturation. The aspiration and oral aversion risk may be reduced by
tasting small amounts of food in extreme caution. Coughing, chocking,
increased oxygen demand or worsening pulmonary functions, presence or
suctioning of food or liquid around the stoma or in the tracheostomy
tube, sudden changes in the amount, constituency or color of the
secretions are significant findings of unsuccessful
swallowing32,55.