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TRANSCRIPT
3/29/2015
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Tracheostomy Tubes and Speaking Valves
Mississippi Speech-Language-Hearing Association
April 1, 2015
Presenter
• Leigh Anne Baker, M.S., CCC-SLP, BCS-S
• Passy-Muir Inc. Clinical Consultant
• Director of Clinical Education at Southern
University in Baton Rouge, LA
Financial Disclosure: Passy-Muir, Inc. has provided financial support for my travel to Jackson and a speaking fee for this presentation. Non-Financial Disclosure: I receive a salary from Southern University as the Director of Clinical Education for the Department of Speech-Language Pathology
Disclosure Statement
• Passy-Muir, Inc. has developed and patented
a licensed technology trademarked as the Passy-Muir® Tracheostomy and Ventilator
Swallowing and Speaking Valve. This presentation will focus primarily on the biased-closed position Passy-Muir® Valve and will
include little to no information on other speaking valves.
Learning Objectives:
• Tracheotomy and Tracheostomy Tubes
• Passy-Muir® Valves
• Interprofessional
Education and Practice
Tracheostomy and mechanical ventilation can have devastating effects on communication and swallowing.
Indications for Tracheostomy Tube
• Prolonged intubation
• Long-term mechanical ventilation
• Permanent tracheostomy tube
• Inability to intubate due to trauma
• Airway protection/
secretion removal
• Airway anomaly
• Patient comfort
• Facilitate weaning
• Oral feeding and communication options
• A tracheostomy tube does not prevent aspiration
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There are many choices of tubes!!!! Parts of a tracheostomy tube
15 mm connector
Pilot port with one way valve
Tube shaft
Cuff Inflation line
Neck flange
Tracheostomy Tubes
• Single Lumen/Cannula • Double Lumen/Cannula
Types of Tubes
• MATERIALS – PVC, Silicone, Metal
– Metal Reinforced
• SHAPE – Curved, Angular, Non-
pre formed
• LENGTH – Standard
– Extra length
• Proximal
• Distal
• Adjustable Flan
• SINGLE LUMEN • DOUBLE LUMEN
• FENESTRATED • MRI COMPATIBLE
– Conditional
• Subglottic Suction • TRACH TALK
• CUFFS – Air, water, or foam
– Double cuffed – Un-cuffed
• Custom Made
Calculating Tube Size
• ATS Consensus: The tracheostomy tube should take up no more than 2/3 the inner diameter of the trachea.
(for pediatrics, no adult standard)
• Anterior/Posterior Diameter of trachea
– Male: 18 +/- 5mm
– Female: 12 +/- 3 mm
Kamel, et al 2009
tube
I.D.
trachea
Jackson Metal Tracheostomy Tubes
• Original Style
• Improved
• Permanent 15mm
Adapter
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Cuff Choices
• AIR FILLED – minimal
leak
• TTS™ : WATER FILLED – minimal occlusion (can
be air filled)
• FOME-Cuff® – self sealing
– Contraindicated for
Passy-Muir® Valve use
Not all Trach Sizes are Equal
Size 6.0 Tracheostomy Tube
ID OD L
Portex 6.0 8.3 55.0
Bivona 6.0 8.8 70.0
Shiley 6.4 10.8 74.0
SCT 6.0 8.3 67.0
Early Tracheostomy (7-10 days) May: • Reduce incidence of
Hospital-Acquired Pneumonia
• Reduce injury to larynx
• Improve patient comfort
• Allow for oral communication and oral diet and requirement for less sedation
• Improve oral hygiene
• Improve secretion management
Complications of the Tracheostomy Tube
Clinical Complications of the Tracheostomy
• Lack of vocal production-communication
• Decreased sense of smell/taste
• Limited airflow through upper airway
• Reduced cough effectiveness
• Complications of long term cuff inflation
• Psychological complications-agony, fear, panic, frustration
Airflow
Clinical Complications (Continued)
• Removal of natural filtration and
humidification system
• Cycle of irritation and
secretion production
• Decreased Sensation in
the oropharynx
• Poor secretion
management
(Siebens, Tippet, Kirby, & French, 1993)
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Clinical Complications (Continued)
• Lack of subglottic pressure (0cmH20)
• Decreased physiologic PEEP (positive end
expiratory pressure)
Eibling & Gross,1996; Gross, Atwood, Grayhack, & Shaiman ,2003
Airflow
Tracheostomy Tube Effect on Swallowing:
• Scar tissue formation from the tracheotomy
procedure may affix the
trachea to overlying tissues and the larynx may not
move freely
• If the tube is too large for the patient’s trachea,
patient may feel
discomfort and may compensate with reduced
laryngeal excursion
Tracheostomy Tube Effect on Swallowing
• Impaired oral-pharyngeal pressure
• Impaired hyolaryngeal elevation/excursion
• Impaired glottic closure
• Reduced subglottic
pressures and reduced sensation
• Muscle disuse atrophy
Tracheostomy and Aspiration
• Does a cuff prevent aspiration?
• Definition
• Incidence of aspiration
– 50% - 87% rate for trach and vent patients1
– 75% silent aspiration2
– Aspiration around the
cuff3
1.Elpern et al., 1987, 1994, 2000; Tolep et al., 1996 2.Davis & Stanton, 2004; Elpern et aI., 1994 3.Bone, Davis, Zuidema, & Cameron, 1974; Elpem et al.,1987; Nash, 1988; Pavlin, VanNimwegan, & Hombein, 1975; Ross & White, 2003
Complications of Cuff
• Inflated cuffs can tether larynx – Larynx does not elevate
• Epiglottis does project down to protect airway
– Larynx does not move anteriorly • Esophagus does not
increase its diameter, creating the vacuum environment for food bolus transition
• Esophageal impingement • Reflux • Necrosis and Trauma
Amathieu, R. et al. (2012). British Journal of Anaesthesia. 109(4):578-83.
Cuff mismanagement associated with:
• Tracheal stenosis
• Granulation tissue
formation
• Tracheal erosion
• Tracheoesophageal
fistula
• Tracheal dilation
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Cuff Deflation Benefits
• Reduces aspiration1, 2
• Improves laryngeal elevation2,3
• Weaning time was shorter -average of 3 days versus 8 days4
• Fewer respiratory infections including ventilator associated pneumonia (20% vs. 36%) 4
• Swallowing better and improved more from baseline4
1. Davis, et al. (2002). Journal of Intensive Care Medicine. 17(3): 132-135. 2. Ding, R. & Logeman, J. (2005). Head & Neck. 27(9):809-13 3. Amathieu, R., et al. British journal of anaesthesia109.4 (2012): 578-583.
4. Hernendez, et al. (2013). Intensive Care Medicine. 39(6):1063-70
Cuff deflation
• Adequate ventilation can still be achieved with
the tracheostomy tube cuff deflated.1
• Cuff deflation during continuous positive airway
pressure (CPAP) has been associated with stable respiratory parameters and allowed patients to vocalize and swallow. 2
1. Bach, J. & Alba, J. (1990). Tracheostomy Ventilation: A study of efficacy with deflated cuffs and cuffless tubes. Chest, 97: 679-83. 2. Conway, D. & Mackie, C. (2004). The effects of tracheostomy cuff deflation during continuous positive airway pressure. Anaesthesia, 59: 652-657.
The Passy-Muir® Tracheostomy & Ventilator
Swallowing and Speaking Valve
PMV 2000 (clear) and PMV 2001 (Purple)
PMA 2000 Oxygen Adapter PMV ® 007 (Aqua Color ™ )
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PMV 2020 with Jackson Improved Care, Cleaning, and Lifetime of the Passy-Muir Speaking Valves
• Average lifetime of 2 months
How Does The Valve Work?
Patented “no leak” design
Opens only during active
inspiration
Closes at end inspiration
Remains closed t/o
expiratory cycle
Air is re-directed thru the
upper airway
Offers a buffer to
secretions
DESIGN VIDEO
Physiologic Benefits of Passy-Muir ® valve
• Restores Voice/Communication
• Improves Swallowing • Restores Physiologic PEEP
• Improves Secretion Management
• Improves Oxygenation • Promotes Weaning and
Decannulation
• May Decrease Risk of Aspiration
• May improve exercise and balance
• Improves Smell & Taste
“Set Yourself and Your Patient Up For Success!”
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Team Approach
Respiratory Therapist
Dietician Physical
Therapist
Nurse Occupational
Therapist
Physician Speech
Therapist
Patient
Patient Selection
Cognitive Status-Awake, Responsive
Attempting to Communicate
– limited sedation needs
Medically Stable
Able to Tolerate Cuff
Deflation
Able to Manage Secretions
orally
Have a patent upper airway
Placement Guidelines
• Patient education
• Peer education
• Patient position
• Suctioning
• Achieve complete cuff
deflation
• Use the warning label
provided with packaging
Patient Assessment
• Oxygenation
• Vital Signs
• Breath Sounds
• Color
• WOB - abdominals
• Patient Responsiveness
To Assess for Upper Airway Patency
• Deflate cuff
• Ask patient to inhale
• Finger occlude and voice or cough on exhalation
• Use mirrors, cotton, whistles or bubbles to assist with the oral exhalation process
• Pressure from trach (whoosh)
Factors Affecting Upper Airway Patency
• Tracheostomy tube size
• Edema
• Granulation tissue
• Vocal fold paresis in adductor position
• Tracheal stenosis
• Secretions
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Downsizing the Tracheostomy
• Improves expiratory pressures1
• Improves speaking valve and capping recommendations, comfort and tolerance1
• Associated with earlier oral intake and reduced length of stay2
• Improves weaning for spontaneous breathing trials3
1. Johnson , JD et al. (2009). The Clinical Respiratory Journal 2009; 3: 8–14. 2. Fisher, D. et al. (2013). Respiratory Care. 2013 Feb;58(2):257-63. 3. Hernandez, G. et al. (2013). Intensive Care Medicine. Jun;39(6):1063-70
Other Considerations to Increase Airflow
• Cuffless
• Fenestrated
• Consider ENT consult
Ventilator Criteria Suggestions
• Patient on <.60 FiO2
• PEEP requirements of
<10cm H2O
• PIP less than 40cm H2O
Patient Guidelines
• Patient Education
• Peer Education – team approach!
• Body Position and Posture
• Position of Head and Neck
• Achieve Cuff Deflation – slowly! (Pulmonary Toilet)
• 100% Cuff Deflation is Mandatory
Tube Position is Important Placement of Passy-Muir® Valve
• Gentle quarter turn twist while stabilizing the flange of tracheostomy tube
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Ventilation Terminology “Must Knows” for Passy-Muir® Valve Use!
• FiO2 = oxygen % (<60%)
• PEEP = positive end expiratory pressure (<10cmH2O)
– Pressure in our lungs at end exhalation (the air we can
never exhale that maintains lung inflation)
• Vt = volume of delivered vent breath (cc’s)
• PIP/PAP = peak airway pressure (<40)
– How much driving pressure from the machine is required
to deliver the set Vt
Assessment Criteria
• Observe pre-cuff deflation PIP
• Observe pre-cuff deflation exhaled Vt
• Achieve cuff deflation – slowly over 5 minutes
• Look for 40 - 50% loss of exhaled Vt
• Look for significant drop in PIP
Q: What does this indicate?
Assessment Criteria
A: This assessment indicates that the
patient can exhale around the properly
sized tracheostomy tube, and the airway
above the cuff is most likely patent.
Assessment Criteria
• 100% cuff deflation • Patient must be able to exhale past the
tracheostomy tube and through upper airway
• Assess air leak/decreased ventilation
• Compensate with ventilator changes
Cuff Inflated-Closed Circuit
500cc 500cc 25cm
H2O
Vt PIP
5 cm H20
PEEP
.30 FiO2
Cuff Deflated-Open Circuit
250cc
250cc 500cc 10cm
H2O
Vt PIP
0 cm H20
PEEP
.30 FiO2
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Passy-Muir® Valve In-line
500cc
0cc 500cc 10cm
H2O
Vt PIP
0 cm H20
PEEP
.30 FiO2
Ventilator Adjustments
700cc
0cc 700cc 20cm
H2O
Vt PIP
0 cm H20
PEEP
.30 FiO2
15cm H20 30cm H20
Ventilator Assessment and Adjustments
• PEEP on/off
• Volume compensation during cuff deflation
– Increase Vt in small increments to achieve pre-cuff
deflation pressures (PIP)
• Use low pressure alarm as disconnect/indirect low
exhaled Vt alarm (set above 10cm H20)
• Set high pressure limit appropriately (10–15cm H20
above the PIP)
Ventilator Assessment and Adjustments
• Pressure versus flow trigger
• Pressure Support (PS)
– Use E-Sense, inspiratory cycle off, or set I-time to time limit
PS breath
• Pressure Control
– Set I-Time
• Consider NIPPV mode
Review
• Adjust PEEP
• Slow cuff deflation
• Monitor pressure/volume
loss
• Place Passy-Muir® Valve
• Compensate for volume/pressure loss
• Time limit PS breaths
• Set alarms appropriately
Ventilator Alarms for Passy-Muir® Valve Applications
• Low exhaled Vt
• Low pressure alarm – MUST be set 5 to 10 cm below
PIP
• High pressure alarm – Should be set 10cm above
PIP
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Humidification
• Heat/moisture exchanger (HME) is ineffective
• Use heated humidified system
• Remove Passy-Muir® Valve for medicated
treatment
Ventilator Connections
22/22mm Silicone Adaptor
Omni-Flex™
Dual-Axis Swivel
15mmx22mm Step Down Adapter
Cuff Inflated-Closed Circuit
300cc
300cc
25cmH2O
VT PIP
5 cm H20
PEEP
Cuff Deflated-Open Circuit
300cc
150cc
VT PIP
12cmH2O
150cc PEEP
0 cm H20
PMV In-line
300cc
0 cc
12cmH2O
VT PIP
300cc 0 cm H20
Ventilator Adjustments
450cc
0 cc
20cmH2O
VT PIP
15cmH2O 30cmH2O
0 cm H20
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Ventilator Assessment and Adjustments
• PEEP Off
• Volume compensation during cuff deflation
• Use low pressure alarm as
disconnect/indirect low exhaled Vt alarm (set above
10cm H20)
• Set high pressure limit appropriately (10-15cm H20
above the PIP)
Ventilator Assessment and Adjustments
• Volume Compensation During Cuff Deflation
– Increase VT in small increments to achieve pre-cuff
deflation pressures (PIP)
• Pressure Compensation During Cuff Deflation
– Seldom increase PC (sometimes decrease) in small
increments to achieve audible voice and adequate
ventilation
Flow/Time Limit Pressure Support Breaths
Flow limit
• The pressure support
breath by increasing the % flow deceleration that
must be reached prior to breath termination
– Ranges 20 to 80%
Time limit
• Set Ti time
– A typical setting for most adults is 1 second
Review
• Adjust PEEP
• Slow cuff deflation
• Monitor pressure/volume
loss
• Place Passy-Muir® Valve
• Compensate for volume/pressure loss
• Time/flow limit PS breaths
• Set alarms appropriately
Patient Assessment
• Oxygenation
• Vital Signs
• Breath Sounds
• Color
• WOB - abdominals
• Patient Responsiveness
• Assess for back pressure
(PSSH sound)
Limiting Pressure Support Breaths
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Interdisciplinary Education and Practice
The IHI Triple Aim®
• http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/
default.aspx
#1
Strategies to Improve Patient Experience of Care
Patient/Family Engagement
• Promote patient/family engagement for self-management and assistance with functional goal setting with a focus on – Function
– Impact on the patient’s ability to participate in life
– Outcomes that matter to the patient.
• RESULT: – Quicker weaning and increased speaking valve use (Speed
& Harding, 2012)
– Shorter decannulation time and length of stay (Tobin & Santamaria, 2008)
Roles/Responsibilities
• Speech-Language Pathologist
• Respiratory Therapist
• Nurse
• Certified Nursing Assistant
• Physician
• Physical Therapist
• Occupational Therapist
• Rehabilitation Technologist
• Dietitian
Promise Tracheostomy Team
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Specialized Role of the Speech-Language Pathologist
• Completing communication and swallowing
evaluations and treatments specific to the patient with a tracheostomy tube and mechanical
ventilation
• Leading or facilitating the communication between the team and the patients in many
aspects of care, including patient education on tracheostomy care, speaking valve placement
and safety for oral intake.
Things I needed to know but didn’t…
• Transdisciplinary skills
– Oral and tracheal suctioning
– PEG tubes
– Nasogastric tubes
– IVs
– Ventilators (what it did, what the setting meant)
– Interaction between the tracheostomy tube and
ventilator
Tracheostomized/Ventilated Patient
• Tracheostomy tube size and fit
• Presence or absence of a cuff
• Upper airway patency
• Ventilator settings (mode, respiratory rate, PEEP, FiO2)
Specialized Role of the Speech-Language Pathologist
• Result:
– Individualized care
– Early intervention (Burkhead, L, 2011)
– Increase staff efficiency
– Burkhead, L. (2011). Swallowing Evaluation and Ventilator Dependency – Considerations and Contemporary Approaches.
Perspectives on Swallowing and Swallowing Disorders
(Dysphagia) March 2011 20:18-22.
Documentation/Technology
• Speech-Language Pathologists must streamline
the documentation process and utilize innovative technology to reduce the per capital cost of
health care (e.g., team meetings, rounds, ongoing competency trainings, policies and procedures).
– Ad Hoc Committee on Reframing the
Professions (December 2013)
Documentation
• General staffing meetings
• Tracheostomy team meetings
• Competency training
• Policies and procedures
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Technology
• Benefits of cuff deflation
• Speaking valve use
• Decannulation
Collaborative Education
• Benefits of speech therapy services for the
tracheostomized and ventilated patient:
– Cuff deflation and speaking valve use
– Tracheostomy systems
– Augmentative and alternative communication
• Result:
– Improved patient outcomes
Expertise of the Speech-Language Pathologist
• Higher level of skilled training and competency
– Post-graduation through continuing education efforts and
on-the-job training.
– My expertise came from:
• Continuing education courses
• On-The-Job training
• Consulting work
• Speaking engagements
SLP can provide specialized training for other disciplines
Skills that SLP may need training on
Suctioning
Indications for tracheostomy
Complications of tracheostomy tubes
Relationship between respiration and swallowing
Technology and interventions
Cuff management
Speaking valve use
Tracheostomy care
Ventilator settings and alarms
RT Training Group of SLPs
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Things SLP can train RT on
• Speaking valve use
• Techniques for speaking and swallowing
• Airway patency
• Benefits of cuff deflation
Joint Roles and Responsibilities
• Speech-Language Pathologist and Respiratory
Therapist
– Result:
• Indications for early intervention.
• Discipline-specific and transdisciplinary roles and
responsibilities
• Specialized collaborations between SLPs and Respiratory
Therapists
Tracheostomy Teams
• Positive Outcomes: – increased speaking valve use
– quicker weaning and decannulation
– reduction in adverse events
– potential for financial savings for institutions
Cameron et al. (2009) - Tracheostomy Review and Management Service
Yu, M. (2010)
Wilcox and Schmidt (2009)
(Speed and Harding, 2012; Leblanc et al., 2010; Garrubba et al., 2009; Tobin and Santamaria, 2008; Norwood et al., 2004).
#2
Strategies for Reducing Per Capita Costs
Direct vs. Consultative Model
• Speech-Language Pathologists must shift the focus
from direct service to a consultative model
– (Ad Hoc Committee on Reframing the Professions of
Speech-Language Pathology and Audiology, December
2013)
• The patient and family are educated and trained to practice between visits, for example: use of
speaking valves, tracheostomy care, and oral/tracheal suctioning.
• Result: Continuum of Care
Interprofessional Education
• Examples of interprofessional education
– Co-curricular education (in-services, webinars with
multidisciplinary attendance)
– Core competences for collaborative practice
– Formal vs. informal activities
• Staff meetings
• Lunch and Learn with vendors
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Educating Future Clinicians
• Benefits of having clinical practicum participants
engaged in transdisciplinary care
• Concurrent supervision by Speech-Language
Pathologists and professionals outside of communication sciences and disorders (Ad Hoc Committee on Interprofessional Education,
November 2013).
– Respiratory Therapist – tracheostomy care
– Nurse – PEG tube
– Dietitian – diet modifications
#3
Strategies to Improve the Health of Populations
Facilitate Communication
• If speech-language pathologists facilitate communication between
health care providers and patients – enhance medical environments (e.g., ICU) for better
communication.
• Result: Health care providers and patients will
comprehend and participate more effectively in managing their medical conditions and care
Outcome Measures
• Speech-language pathologists must utilize
outcomes measures with data collection that focuses on quality care with reduced costs to
patients and to healthcare.
• Results: weaning rates, decannulation rates, adverse event rates, aspiration rates, oral intake
progression, and length of stay.
Team Development
• Prove process success by:
– Collecting outcome measures
– Obtaining media coverage for public education
– Presentations at health care conferences to further changes in healthcare practices.
• Results:
– Buy-In from other professionals
– Marketing opportunities
– Successful programs
Where we are today
• New mind sets
• Faster consults
• More aggressive treatments sooner
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Interprofessional Education and Practice
Respiratory Therapist
Dietician Physical
Therapist
Nurse Occupational
Therapist
Physician Speech
Therapist
Patient
Respiratory Mobility
Tracheostomy Teams
• Increased speaking valve use
• Improved decannulation time
• Reduce Length of Stay (LOS)
• Reduced costs
Speed, Lauren, and Katherine E. Harding. Journal of Critical Care (2012).
Interprofessional Practice
• What the SLP and RT can do together:
– Co-treat during speech and swallowing treatments
– Collaboratively reassess as needed
– Provide interprofessional treatment plans
Multi-disciplinary Tracheostomy Weaning Protocols • Increase amount of
patients decannulated
• Reduce time to decannulation
• Assign clear responsibilities to team members
• “The tracheostomy tube decannulation process is well suited for therapist-implemented protocols.”
Christopher, KL. (2005). Respiratory Care, Vol 50
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Now that my patient has on the Passy-Muir valve, and I have a successful
interprofessional team in place, what
treatment should I do?
Speech Techniques to Increase Vocalization
What’s the problem?
• Is the patient mouthing words?
• Airway patency issues?
• Vocal fold paresis/paralysis?
• Poor breath support?
• Poor coordination?
• Cognitive/linguistic issues?
• Candidate for downsize or decannulation?
• Candidate for vocal techniques/technologies?
Is the patient mouthing words? Yes…
Patient Assessment:
• The patient tolerates the
valve and vitals are WFL
• No voice
Techniques:
• Ask the patient to cough,
hum, blow
• For children: Play, tickle
Sebastian Airway patency issues
• Noted by desaturation, difficulty breathing,
incomplete exhalation through upper airway,
pressure from trach tube upon removal of valve
• Diagnosis of tracheal malacia or stenosis
• Muffled voice
• What can I do:
• Assess airway patency
• Downsize
• XLT Distal trach to bypass an obstruction
• ENT consult/bronchoscopy
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Tube Position is Important Video: Patency Issues
Video: Patency Issue Resolved Vocal fold paresis/paralysis
• Vocal Folds in abducted position
– Good tolerance of valve
– Whispery voice
– Cough is weak
• What can I do:
• ENT consult
• Vocal fold adduction
exercises once assessed
by ENT
Poor Breath Support
• Voice “runs out of air”
• Typical for patients with
spinal cord injury, neuromuscular disorders
• What can I do:
• Diaphragmatic breathing
exercises
• Expiratory muscle
strength training
Poor breathing/speaking coordination
• Vent may cause incoordination
• Patient may speak on inhalation and
exhalation
• What can I do?
• Set i-time on ventilator
• Increase/decrease set
respiratory rate
• Coordinate speech on
exhalation
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Cognitive-Linguistic Deficits:
• Traumatic brain injury
• Stroke
• Apraxia
• What can I do?
• Place the Passy-Muir®
Valve
• Continue with speech
therapy treatment
APPLICATION AND PLACEMENT OF THE PASSY-MUIR® VALVE
Patient in Coma with Passy-Muir® Valve
Downsizing the Tracheostomy Tube
• Improves expiratory pressures1
• Improves speaking valve and capping recommendations, comfort and tolerance1
• Associated with earlier oral intake and reduced length of stay2
• Improves weaning for spontaneous breathing trials3
1. Johnson , JD et al. (2009). The Clinical Respiratory Journal 2009; 3: 8–14. 2. Fisher, D. et al. (2013). Respiratory Care. 2013 Feb;58(2):257-63. 3. Hernandez, G. et al. (2013). Intensive Care Medicine. Jun;39(6):1063-70
Other Considerations to Increase Airflow
• Cuffless
• Fenestrated
• Consider ENT consult
Decannulation
• Improves cough and swallow which are indicators
of decannulation
• Removal of the trach is first recommendation by
CDC to reduce pneumonia
• How can we decannulate faster?
• -Early speaking valve use
• -Protocols
• -Tracheostomy team
Pre-Decannulation
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Post Decannulation Candidates for Decannulation
• Consider the original reason for the trach
• Weaned from mechanical ventilation, effective coughing, no significant upper airway lesion1
• Absence of distress, stable arterial blood gases, hemodynamic stability, absent fever1
• A peak cough flow of 160 liters/minute2
• Survey: patient’s level of consciousness, cough
effectiveness, secretions, oxygenation3
1. Christopher, K.(2005). Respiratory Therapy. 50(4):538 –54. 2. Bach & Saporito, (1996). Chest. 110(6): 1566-71. Stelfox, H. et al (2009). Respiratory Care. 54(12): 1658-68.
Vocal Technologies/Techniques:
• Technologies:
– Blom Trach
– Capping
– AAC devices
• Techniques:
– Blowing activities with visual feedback
– Digital occlusion
– Visual and tactile sensory feedback to elicit voice onset
Techniques for Swallow Management
Disuse Atrophy
• Mechanical ventilation can cause atrophy, and
injury of diaphragmatic muscle fibers
• “Patients in intensive care lose about 2% of
muscle mass a day during their illness.”1
• Muscle weakness predicts pharyngeal
dysfunction2
1. Jaber, S.et al, 2011; Griffiths, BMJ, 1999
2. Mirzakhani, H. et al Anesthesiology. 2013
Cuff deflation
• Cuff deflation must be achieved to fully assess
the pharyngeal stage of the swallow.
• “An individual who is so medically fragile as to
preclude cuff deflation is not usually a
candidate for significant oral intake.”
Dikeman, K, Kazandjian, M, 2003
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Effect of Mechanical Ventilation on Swallowing:
• Ventilator modes with a pre-set breath may push air at a time the patient is trying to maintain airway closure for a swallow.
• If the cuff is deflated, without a Passy-Muir® valve, a translaryngeal leak may occur on inspiration and expiration.
Cuff Deflation Benefits for Swallow
• Reduces aspiration1, 2
• Improves laryngeal elevation
• Weaning time was shorter in cuff deflated -average of 3 days versus 8 days3
• Fewer respiratory infections including ventilator associated pneumonia in cuff deflated group (20% vs. 36%) 3
• Swallowing better in cuff deflated group and improved more from baseline3
1. Davis, et al. (2002). Journal of Intensive Care Medicine. 17(3): 132-135. 2. Ding, R. & Logeman, J. (2005). Head & Neck. 27(9):809-13
3. Hernendez, et al. (2013). Intensive Care Medicine. 39(6):1063-70
Swallowing Treatment
Early placement of the Passy-Muir® Valve may
provide “physical therapy” to the upper airway, helping to reduce effect of muscle atrophy, and
improve pharyngeal and laryngeal swallowing function.”
Burkhead, 2007
Early Use of a Passy-Muir® Valve for Swallowing Evaluation and Rehabilitation
• Re-connects the upper and lower airway and normalizes the aerodigestive tract and prevents disuse atrophy.
• Allow patients to communicate orally and actively participate in healthcare decision making.
• Perform swallow treatment as if your patient did not have a tracheostomy tube once the Passy-Muir® Valve is in place.
• Goal of decannulation
One Way Valve Reduces Aspiration Further
• Improved scores on penetration-aspiration scale1
• Restores expiratory airflow2
• Improves laryngeal
clearance2
• Improved secretion rating
scale3
• Maintain lung volumes4
• Restores subglottic air
pressure5
1. Suiter, D. Head and Neck. 2005. Sep;27(9):809-13
2. Prigent, Helene. Intensive Care Med. 2012 June38(1):85-90.
3. Blumenfeld, L. Oral Abstract Presented at Dysphagia Research Society Annual Meeting 2012
4. Gross, R., et al. (2006). The Laryngoscope, 116:753-761
5. Eibling, D., & Gross, R. (1996). Annals of Otology, Rhinology, & Laryngology, 105(4):253-8.
What’s the problem?
• Reduced base of tongue strength?
• Reduced laryngeal elevation?
• Reduced vocal fold closure?
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Therapy: Frequent Swallow Techniques with the Passy-Muir® Valve
• Base of tongue weakness
– Masako Maneuver
• Laryngeal excursion
– Pitch gliding
– Effortful swallow
– Mendelsohn Maneuver
Frequent Swallow Techniques with the Passy-Muir® Valve
• Vocal fold adduction exercises
– Forceful phonation (/ha-ha)
– Coughing, throat clearing
– Pressure against a resisting force
• Vocal Fold abduction
– Sniff and breathe out through mouth
Video from Madonna swallow exercise
• https://www.youtube.com/watch?v=d168L1E8tX0
&list=UUrJ_BmcqlCosF1heNCiLWKg&feature=c4-overview
VENTILATOR APPLICATION OF THE PASSY-MUIR® VALVE
Compensatory Strategies and Diet Modifications
• Generally the same as non-trach/non-ventilator
dependent patients
Compensatory swallowing strategies
• No Straws • Small Bites/Sips • Assistance/Supervision with
Meals • Sit Upright • Don’t Talk While Eating • Eat Slowly • Alternate Solids & Liquids • Double/Multiple Swallows • Clear Throat after Swallowing • Effortful Swallow • Lingual sweep • Straw progression • Liquid wash • Visual inspection s/p swallow • Imposed rest breaks
• Chin Tuck to ______________ • Head Tilt to L R • Chew food on the L R • Head Turn to L R • Check for Dentures • Crush medications-Consult MD
first • Avoid foods with small pieces • Remain upright for _____ minutes • Thicken Liquids ____________ • Avoid certain foods • Verbal/Visual/Tactile Cues • Bite size awareness • Posture or position during and
after eating
Modifications in diet textures
• NDD Level 1: Dysphagia-Pureed (homogenous, very cohesive, pudding-like, requiring very little chewing ability).
• NDD Level 2: Dysphagia-Mechanical Altered (cohesive, moist, semisolid foods, requiring some chewing).
• NDD Level 3: Dysphagia-Advanced (soft foods that require more chewing ability).
• Regular (all foods allowed).
• McCullough, G. , Pelletier, C. & Steele, C. (2003,
November 04). National Dysphagia Diet: What to Swallow?. The ASHA Leader
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Liquids
• Proposed terms for liquids and correlating viscosity ranges: 1. Thin 1-50 centiPoise (cP) 2. Nectar-like 51-350 cP 3. Honey-like 351-1,750 cP 4. Spoon-thick >1,750 cP
• McCullough, G. , Pelletier, C. & Steele, C. (2003, November 04). National Dysphagia Diet: What to
Swallow?. The ASHA Leader
Treatment Considerations
• Coordinate breathing and swallowing.
• Time the swallow with higher lung volumes.
• Improve cough.
• Mobilize lung and oral-pharyngeal secretions.
• Expiratory muscle strength training.
– The Breather
– Acapella
– EMT
Assessing Cough Strength
Peak Cough Expiratory Flow
• Greater than 160L/min are needed to
clear secretions
Miller, R.G. et.al.(2009). Neurology 13; 73(15): 1218-1226
VENTILATOR APPLICATION OF THE PASSY-MUIR® VALVE
Respiratory Muscle Training
• Therapy to assist in lung expansion, coughing
and airway clearance
– Acapella
– The Breather
FEES Before and After Passy-Muir ® Valve
• http://www.passy-muir.com/pmvideos
• Liza Blumenfeld, MS, CCC-SLP, Scripps Memorial
Hospital, La Jolla, CA
Sensory Awareness
• Non‐food taste stimulation
• Thermal stimulation
• Taste stimulation
• Tactile and verbal cues
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Q and A Thank you!