Speech therapy can help provide guidance in progressing a child’s speech with tracheostomy. Speech therapists are specialists in communication, communication disorders and also swallowing. Speech therapists provide a comprehensive assessment of the child’s strengths and weaknesses. They can work with the family on implementing speaking valves and potentially improving voice, speech and swallowing.
Do children with tracheostomy have difficulty with speech?
Children with tracheostomy have difficulty producing voice due to the changes in airflow that occur when a tracheostomy tube is placed. When a tracheostomy tube is placed, airflow typically flows in and out through the tracheostomy tube. There will be a lack of airflow around the tracheostomy tube and through the upper airway. Therefore, voicing is impaired.
Due to the lack of sufficient airflow and limited voicing, children with tracheostomy may present with speech delays, articulation disorders, phonological disorders, and difficulty with breathing and speech coordination. In one study, a group of non-neurological disorder children, 60.9% had normal speech and language development. Achieving earlier deacannulation improved the chances of normal speech and language development (Jiang, D &Morrison, GA, 2003).
Can a child with a tracheostomy speak?
Children with a tracheostomy may have the ability to speak. Speaking may happen by generating enough airflow around the tracheostomy tube in order to pass through the vocal folds. Occlusion of the tracheostomy tube is the most effective way to produce voicing with a tracheostomy tube. Occluding the tracheostomy tube can occur with digital occlusion, a speaking valve, or capping. If present, the cuff of the tracheostomy tube must be completed deflated. The cuff must be deflated in order to breathe through the upper airway. A speech-language pathologist with expertise in working with those with tracheostomy can help to decide which strategy is best.
Digital occlusion, or finger occlusion, is a technique where a clean finger (usually with a glove) is placed at the end of the tracheostomy tube. It may be easiest for the individual with tracheostomy to breathe if the tube is only occluded on exhalation.
A speaking valve such as the Passy-Muir Tracheostomy & Swallowing Valve may also be used to help with speech. A speaking valve can improve infection control when compared to digital occlusion. It is also a hands free approach to speech. The speaking valve is placed at the end (hub) of the tracheostomy tube. Speaking valves fit any size tracheostomy tube since the hub of the tracheostomy tube is a universal 15mm. Once the valve is placed, air flows in through the tracheostomy tube and exhaled air flows around the tracheostomy tube, through the vocal folds and out the upper airway for speech.
Benefits of a speaking valve besides voice include restoring positive airway pressure, improving secretion management, improved swallowing, may reduce the risk of aspiration, quicker decannulation, in-line ventilator use, improved olfaction, improved oxygenation.
Capping is another technique to occlude the tracheostomy tube for speech. It is more difficult to breathe with a cap in place compared to a speaking valve. It is recommended to first begin with a speaking valve prior to capping.
Speech Therapy Techniques for Tracheostomy
Kids with tracheostomy may need to ease into occlusion of the tracheostomy tube. First, digital occlusion may be best in order to determine if there is adequate airflow around the tracheostomy tube. A speaking valve may be trialed by a clinician who is competent in placement. Children with tracheostomy who are beginning to use a speaking valve often have difficulty adjusting to the change in airflow. Education is important. A wear schedule with increasing time with the valve on can help.
The first few times wearing a speaking valve can be a frightening time to learn how to breathe through the vocal folds and out the upper airway. Children may also have difficulty learning to use their upper airway for speech. If the child can follow instructions, techniques such as blowing may improve the ability to use the upper airway. There are activities in Songs for Kids with Trachs that are fun and distracting for help improving tolerance.
Music can be a fun distraction to using a speaking valve as many children love music. Research has shown that music can have a positive effect on speech development and may reduce anxiety for those on mechanical ventilation .
Songs for Kids with Trachs
Finding Your Voice– Songs for Kids with Trachs is a song set with a choice of either a USB or download of 15 songs that focus on helping children achieve vocalization through imitation and verbal turn-taking. Also included in the set are 3 instrumental tracks, printable illustrations and a manual of activities and instructions for each song!
The set provides a fun and less stressful approach to learning to speak with a tracheostomy. The songs allow for the child to explore using their upper airway in a fun and enjoyable way. Songs for Kids with Trachs was developed by a speech-language pathologist, with songs chosen to specifically address the needs of kids with trachs. Many of the songs target difficulty that is common for kids with tracheostomy including improving airflow, improving breath support, vowel production, stops, and nasals.
Each child is different and any speech deficits should be assessed and treated according to individual needs.
Increasing oral exhalation
Therapy can focus on oral exhalation such as blowing, whistles, bubbles, and horns to allow the child to understand how airflow is necessary through the upper airway to produce voicing. Imitation of mouth movements or sounds is also a technique to use. Songs for Kids with Trachs has some activities. The Animal Face Cut Outs are adorable laminated poster boards that are perfect for imitation. Place your face inside the animal face, say a sound or word and then pass the animal face to the child. It is then the child’s turn to repeat it. The Animal Face Cut outs are great to use with the Animal Songs with Songs for Kids with Trachs.
Trachie-O-Potamus's Big Race
Trachie-O-Potamus Big Race is an adorable book to help children with tracheostomy feel included. It is a book about a hippo named Trachie-O who happens to breathe through a tracheostomy tube. Trachie-O demonstrates that even though he has a tracheostomy tube, he is quite capable. Working together with his friend Ginger Giraffe, they set out for The Big Race. It’s a great addition for a speech-language pathologist for therapy.
Speech pathologists also work on swallowing and swallowing disorders. Children with tracheostomy tubes often have secretion management issues due to their medical condition as well as due to the tracheostomy tube itself. Since the tracheostomy tube redirects air through the upper airway, there is a lack of airflow through the upper airway. This can result in a loss of sensation and reduce spontaneous swallowing. Secretions can pool due to limited swallowing as well as due to the trach itself since it is a foreign object.
Speech pathologists can assess for swallowing disorders using instrumental exams such as a modified barium swallow study or flexible endoscopic evaluation of swallowing. These tests can determine the patient’s swallow physiology and assess for aspiration. An individualized plan can follow to potentially provide food by mouth. Some children can begin eating while on mechanical ventilation, while others may be best to wait until they are weaned and some may not be able to eat safely by mouth. It depends on the child’s medical status, cognitive status and other variables.
Speech therapy for children with tracheostomy will be similar to those with a natural airway once a speaking valve or cap is in place. Initially there is a focus on exhaling through the upper airway to learn how to use the upper airway for speech. The child may have specific speech sound disorders that are common for children with tracheostomy. An articulation assessment can determine which sounds require therapy. A speech-language pathologist can assess the child for which speech sounds are inaccurate in order to treat the child individually.