Fraser is an 8-year-old boy well known to everyone in A&E and the hospital. He has severe dystonic cerebral palsy as a result of his premature birth at 26 weeks’ gestation. Although he was ventilated for 5 weeks he did not develop chronic lung disease. He is gastrostomy fed and had a Nissen’s fundoplication 5 years ago. He has copious secretions and a poor cough reflex. These are made worse by nitrazepam which he requires for his dystonia. Evidence from previous barium studies and swallow assessments show that he chronically aspirates his secretions. He has no symptoms of upper airway obstruction.

Over the last year, he has had increasingly frequent lower respiratory tract infections, requiring admission and intra-venous antibiotics. His weight and height have fallen from the 10th to the 3rd percentile. A chest x ray shows chronic changes suggestive of underlying bronchiectasis and he is now colonised with Pseudomonas aeruginosa. Immune function and a sweat test are normal. He has not had a recent pH study or barium swallow. He awaits a CT scan of his chest.

He has daily physiotherapy and regular suction and usually produces copious muco-purulent secretions. He is on maximal anti-reflux medication already. Would …