Our guest chat host tonight, March 5, 2001, is Roxan Diez Gross, 
Speech-Language Pathologist. Mrs. Diez Gross is a PhD candidate at the
University of Pittsburgh, researching air pressure/air flow and the
interaction between respiration and deglutition. She has written book
chapters and published papers dealing with the theme of troubleshooting
trachs to reach speech and swallowing objectives. Tonight Mrs. Diez Gross will
address "The Effects of Tracheotomy on Speech and Swallowing Physiology".

<Robin2> Tonight's chat has to do with the effects of trachs on speech and
    swallowing....has anyone worked with a patient with a trach?
<Laura> No, I'm a new student
<Adrienne> I have observed one
<Adrienne> she used a passy muir valve
<Laura> I don't even know what that is
<Adrienne> Roxann could you explain what a trach is?
<Adrienne> I'm also interested in the different reasons people get traceotomies
Roxann> A trach is short for a tracheostomy tube.  The surgery itself is called a
<Roxann> A tracheostomy is created as an artificial airway.  People get trachs for 3
    primary reasons:
<Roxann> 1.  To secure an airway in the event of severe swelling or obstruction.
<Roxann> 2.  For pulmonary "toilet" which means to clean the airways, administer
    meds, etc.
<Roxann> 3. To bypass the larynx and hook people up to ventilators.
<Laura> ok, thanks for the info
<Adrienne> why would the airwys need cleaning?
<Roxann> When there is excess mucous.
<Adrienne> ok
<Roxann> The mucous, etc. prevents the exchange of oxygen and must be removed.
<Adrienne> does everyone understand why a trach makes speech and swallowing an
<Robin2> Roxann, tell us about the use of vents/valves with a trached patient
<Roxann> How about valves?  Doe everyone know how speaking valves work?
<Ariela> no
<Adrienne> I think so
Laura> no
<Roxann> People with trachs can't talk because the trach lets the air escape below the
    level of the true vocal cords.
<Roxann> Without air for vibration, there is no phonation.
Roxann> When the trach tube is capped (closed with a cap), if the tube does not take
    up the entire trachea, air can go around the tube and through the larynx and people
    can talk....
<Ariela> can it be capped anytime?
<Roxann> However, not everyone can be capped.  Speaking valves are not all alike, but
    they are "one-way" valves that allow  the patient to breathe in through the trach tube...
<Adrienne> is that strenuous for them?
<Roxann> but the valves don't let air out, so the air has to go up around the tube and
    through the larynx...no it should not be strenuous.
<Roxann> The Passy-Muir valve is different from the rest because it closes by itself
    and does not leak.
<Adrienne> what is the advantage of that?
<Adrienne> do leaks mess up speech?
<Roxann> With the other valves, like Montgomery and Shiley, the patient must exhale
    to close off the valve and keep the pressure on to keep the valve closed.
<Roxann> Leaks in the valves?
<Adrienne> is it better to have auto-close or exhale-close?
<Roxann> The current thinking is that it is more natural to have the valve auto-close
    because we do not leak when we speak or swallow.  We cannot continue to exhale
    while swallowing.
<Adrienne> are these same valves used for swallowing?
<Anonymous87> Hello, I am a student in the undergraduate program at Eastern
    Kentucky, looking for a little extra information about tracheotomy
<Roxann> Some people will aspirate when they get a trach even though they have not
    had a stroke or anything.  The thinking is that the disruption to the airway affects
    swallowing.  The Passy-Muir valve is the only one that has been studied for swallowing. 
    Most researchers (myself included) want experimenter control and the PMV does not leak.
<Adrienne> that's cool
<Roxann> I hope you guys are getting this!  This is tough!
<Laura> I'm just following along
<Adrienne> 87, have you had clients with trachs?
<Anonymous87> no, our clients are mainly young children with basic speech and
    language problems, nothing as complicated as a trach
<Robin2> Isnt there a blom-singer valve?
<Roxann> That is a voice prothesis.
Adrienne> whoa, what is a voice prothesis?
<Ariela> I think we need to see them to understand better the different kinds
<Roxann> The blom-singer is a one way valve that is placed between the trach and
    esophagus after total laryngectomy.
Roxann> By trach, I mean trachea
<Anonymous87> In our Speech Science course we are doing a presentation on Long
    term impact on Tracheotomy on Speech Production
<Roxann> What are you learning about the long term impact?
<Roxann> Peds or adults?
<Anonymous87> We are still researching, but trying to focus on impacts on an early
<Roxann> Great-  good luck!
<Anonymous87> Our book states that an early trach does not have a negative impact,
    do you agree?
<Ariela> how severe can the impacts be?
<Adrienne> what do you mean by early? like young?
<Roxann> There is some discussion in the maxillo-facial and orthodontia literature
    that airflow is required for facial growth.
<Roxann> A trach can prevent speech development.
<Roxann> There is a possibility that a trach can disrupt swallowing too.
<Ariela> you mean permanent damage?
<Adrienne> how different does speech sound with trachs?
<Roxann> I don't think permanent damage, other then disruption of facial growth if that
    is true (I don't know).  Speech is achieved a few different ways with a trach....
<Ariela> and in terms of swallowing?
<Roxann> With the cuff up, there is no speech.  When the cuff is down, but nothing is
    on the end of the tube, speech is sometimes possible...
<Roxann> but it will be weak with very short duration because of air loss.  Capping,
    finger occluding and speaking valves result in normal speech.
<Roxann> Swallowing is sometimes disrupted by a trach and sometimes not.  No one
    knows who will be and who won't.
<Adrienne> how does it disrupt it?
<Anonymous87> With children, is articulatory functioning disrupted?
<Roxann> There are a few theories.  Most think that subglottic air pressure, or a
    pressure build up during the swallow under the vocal cords is needed for efficient
<Roxann> What I've seen is that kids do not develop articulation without phonation.
    They are usually taught sign.
<Adrienne> even though they could speak?
<Adrienne> is that controversial?
<Roxann> Not when they can speak with the trach.  Lots of babies and kids use PMV's.
<Roxann> Some kids get enough air around the tubes to talk because ped tubes are
    usually not cuffed.
<Adrienne> do valves ever fall out or anything?
<Roxann> Yes.
<Roxann> When people cough, the pressure is much greater and they can fly across
    the room
<Adrienne> um, that's not good... what happens then??
<Adrienne> you can't choke on them or anything can you?
<Roxann> Find it, clean it and slap it back on!  Passy-Muir now offers a little secure-it
    that attaches to the PMV and trach collar so it doesn't fly.
<Ariela> can they not even talk by moving their lips kind of like a  whisper, is there
    absolutely no air comming up?
<Roxann> Anything is possible, but they are big, plus with an open trach, you can't
    really choke!
<Roxann> I have not seen kids articulate without phonation.  Where I work, we
    establish phonation first.  I have had a kid learn speech using an electrolarynx.
<Adrienne> what is an electrolarynx?
<Roxann> They are used in head and neck cancer.  They vibrate.
<Anonymous87> Could you tell me some causes for children to have a trach?
<Roxann> Usually because of the need for a ventilator, pulmonary toliet, stenosis or
    narrowing of the upper airway.
<Anonymous87> We just watched a video in class and there were two brothers both
    with a Passy-Muir valve
<Roxann> I think I've seen their pictures.
<Adrienne> Roxann, how prevalent are trachs?
<Roxann> I do not really know that one. There seems to be a lot though.
<jillspeech> Roxann, we've been studying swallowing exams with trachs...
Anonymous87> Have you found that children have reduced vowel space?
<jillspeech> some of us are trying to figure out if the trach is affecting the swallow or if
    it's dysphagia..how to tell the difference..
<Roxann> I have not studied or completed acoustic measurements on kids with
<Roxann> The medical history would be the most helpful.  Typically, if there is no
    neurologic insult and no alteration of the anatomy, the trach is blamed.
<jillspeech> would that be something you'd be considering in a child ?
<jillspeech> yes that makes sense
<Roxann> thanks!
<Roxann> A lot of people are afraid of trachs, including the patients and their
    families...I tell then to think of it as just another nostril...it's snotty and you breathe
    through it!  Sorry I'm so gross!
<Anonymous87> How do you feel about a one-way valve with children learning to
<Roxann> I think that it is a worthy goal.
<Roxann> The first thing I do when I get a kid with a trach is start to find a way to get a valve on them.
<Adrienne> what obstacles do you face?
<Roxann> The trach is usually too fat and takes up too much of the airway.
<Anonymous87> Does that entail using articulatory movements without voicing?
<Adrienne> are there different sizes?
<jillspeech> maybe someone has asked this..are children going to school with
<Roxann> There are different diameters and lengths.  Kids are going to school with
<Roxann> I imagine that you can begin some type of artic training using visual
    feedback, but it's not been my experience.
<jillspeech> I haven't had any students with trachs yet..and I work with special ed
    students..but I've heard we may be seeing more...
<Adrienne> are elderly populations to have more trachs or kids?
<Roxann> If you need some training, maybe the hospital based SLP's can visit you or
    you can visit them.  We do a lot of that here in Pittsburgh.  I've gone to a school before.
<Adrienne> elderly or kids, not trachs or kids
Ariela> In kids, do their oral muscles become weak from not using them?
<jillspeech> that's a great idea Roxann..thank you
<Adrienne> good question Ariela
<Roxann> I don't really know which has more.  Ariela, I think that a lot of those kids
    have oral motor problems to begin with.  Normal kids don't get trachs really.
<Roxann> They usually have saliva control issues, feeding problems, etc.
<Anonymous87> Why is there oral motor to begin with?
<Anonymous87> I understand now
<Roxann> Most of the kids that are sick enough for trachs have more going on.  Those that just have airway problems like some that Passy-Muir features in their literature,
    have normal speech and oral motor function