Dysphagia in Pediatric Patients with Tracheostomy

Abstract

Objective: Post-tracheotomy swallowing function has not been well described in the pediatric population. This study aims to (1) determine differences in swallowing functioning pre- and post-tracheotomy and (2) examine the association between postoperative dysphagia and indication for tracheotomy, age at the time of tracheotomy, and time between tracheotomy and modified barium swallow (MBS). Methods: A retrospective chart review was performed on 752 patients who underwent a tracheotomy from 2003 to 2018 and had adequate documentation for review. Patients were included if they received a post-operative MBS. Descriptive statistics, logistic regression, and Fisher’s exact test were used to analyze the data. Results: The cohort included 233 patients. The mean age at the time of tracheotomy was 25 months (±50.5). The indications for the tracheotomy were upper airway obstruction (110/233, 47.2%), chronic respiratory failure (104/233, 44.6%), and neurologic disease (19/233, 8.2%). The mean time from tracheotomy to post-operative MBS was 224 days (±297.7). Of the patients who had documented pre- and post-tracheotomy diets, nearly half of patients had improvement in their swallowing function after tracheotomy placement (82/195; 42.1%). Post-tracheotomy MBS recommended thickened liquids in 30.9% of the patients (72/233) and 42.5% (99/233) were recommended thin liquids. The remainder (62/233, 26.6%) remained nothing by mouth (NPO). Patients with neurological disease as the indication for the tracheotomy were more likely to remain NPO ( P = .039). Conclusion: A tracheotomy can functionally and anatomically affect swallowing in pediatric patients. The majority of our studied cohort was able to resume some form of an oral diet postoperatively based on MBS. This study highlights the need for objective measurements of swallowing in the postoperative tracheotomy patient to allow for safe and timely commencement of an oral diet. Level of Evidence Level 3.

Long-Term Feeding Outcomes after Infant Tracheostomy

“…On the contrary, Luu et al's study of 233 children with tracheostomy who had a modi ed barium swallow test performed after tracheostomy, found 42.1% who were previously fed nothing by mouth (NPO) were advanced to oral feeds, 36.4% continued with their current diet at the time of the swallow study, and 21.5% had either progressed to thickened diet or NPO [10]. The number of children who were NPO after the swallow study further decreased from 63-28% and the group of children who were able to advance their diet also were found to be more likely to require mechanical ventilation [10]. Infant tracheostomy represents a heterogenous group and there can be multiple factors which contribute to feeding outcomes.…”

“…This relationship was described in a study of 46 pediatric patients who relied on feeding tubes for nutrition after discharge on home mechanical ventilation and transitioned to full oral feeds when liberated from respiratory support [22]. On the contrary, Luu et al's study of 233 children with tracheostomy who had a modi ed barium swallow test performed after tracheostomy, found 42.1% who were previously fed nothing by mouth (NPO) were advanced to oral feeds, 36.4% continued with their current diet at the time of the swallow study, and 21.5% had either progressed to thickened diet or NPO [10]. The number of children who were NPO after the swallow study further decreased from 63-28% and the group of children who were able to advance their diet also were found to be more likely to require mechanical ventilation [10].…”

“…According to adult studies, there are several proposed mechanisms for dysphagia after tracheostomy placement such as impact on laryngeal elevation, compression of the esophagus with an in ated cuff, impaired use of laryngeal muscles, decreased sensation of the larynx and decreased ability to clear secretions [8]. Video uoroscopic studies performed on four toddlers with tracheostomies distinguished differences in arytenoid and epiglottis excursion and delayed swallow; however, the exact mechanism and impact on swallowing has not been fully understood [9][10].…”