a practical approach to tracheostomy tubes and ventilators

A practical approach to A practical approach to tracheostomytracheostomy tubes and tubes and ventilatorsventilators

Alison McKee, MS CCCAlison McKee, MS CCC--SLPSLPUniversity Specialty Hospital, Baltimore MDUniversity Specialty Hospital, Baltimore MDDepartment of Rehabilitation ServicesDepartment of Rehabilitation Services

Heather Starmer, MA CCCHeather Starmer, MA CCC--SLPSLPJohns Hopkins University, Baltimore, MDJohns Hopkins University, Baltimore, MDDepartment of Otolaryngology Department of Otolaryngology –– Head and Neck SurgeryHead and Neck Surgery

Learner objectivesLearner objectives

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Discuss different communication options for Discuss different communication options for tracheotomizedtracheotomized and ventilator dependent and ventilator dependent patientspatients

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Demonstrate understanding of basic ventilator Demonstrate understanding of basic ventilator settings and their implications on speechsettings and their implications on speech

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Discuss evidence regarding the benefits of voice Discuss evidence regarding the benefits of voice restorationrestoration

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Describe ways to initiate an inDescribe ways to initiate an in--line ventilator line ventilator speaking valve programspeaking valve program

Introduction to Introduction to trachstrachsIndications and typesIndications and types

Indications for Indications for tracheostomytracheostomy

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Prolonged mechanical ventilationProlonged mechanical ventilation��

Acute or chronic airway obstructionAcute or chronic airway obstruction

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Retention of pulmonary secretionsRetention of pulmonary secretions��

Sleep apneaSleep apnea

TracheostomyTracheostomy

Anatomy of a Anatomy of a trachtrach tubetube

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1. Faceplate1. Faceplate

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2. Hub2. Hub

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3. Outer 3. Outer CannulaCannula

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4. Pilot line/pilot 4. Pilot line/pilot balloonballoon

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5. Cuff5. Cuff

11 22

44

55

33

TrachTrach tubes (cont.)tubes (cont.)

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ShileyShiley–– Plastic with white face Plastic with white face

plateplate–– Can be cuffed or Can be cuffed or

cufflesscuffless

1 1 –– obturatorobturator2 2 –– inner inner cannulacannula

11

22

TrachTrach tubes (cont.)tubes (cont.)��

PortexPortex–– Plastic tubePlastic tube–– Clear or white Clear or white

faceplatefaceplate–– Blue pilot balloonBlue pilot balloon


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BivonaBivona aircuffaircuff

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TTS (tight to shaft)TTS (tight to shaft)cuff hugs outer cuff hugs outer cannulacannula


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BivonaBivona fomecufffomecuff (red (red pilot balloon)pilot balloon)–– Used when unable to Used when unable to

maintain seal with maintain seal with standard cuffstandard cuff

–– Reduces risk of Reduces risk of damage from overdamage from over-- inflation of cuffinflation of cuff

–– Passive cuff inflationPassive cuff inflation–– Cannot be used with Cannot be used with

speaking valvesspeaking valves


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Extra lengthExtra length–– Used primarily with Used primarily with

bariatricbariatric patients to patients to ensure proper ensure proper ventilationventilation

–– Made by most Made by most trachtrachmanufacturersmanufacturers


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Bivona/PortexBivona/Portex talking talking trachtrach–– Used for Used for

communication with communication with patients who require patients who require cuff inflationcuff inflation

–– Delivery of nonDelivery of non-- pulmonary air between pulmonary air between the inflated cuff and the inflated cuff and the vocal foldsthe vocal folds


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Fenestrated Fenestrated trachstrachs–– Designed to allow Designed to allow

communication when communication when on venton vent

–– Problematic due to Problematic due to malpositioningmalpositioning of of fenestratesfenestrates

–– Rarely usedRarely used

TrachTrach tubestubes

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Jackson (metal)Jackson (metal)–– Used for nonUsed for non--vent vent

patientspatients–– CufflessCuffless model onlymodel only

TracheostomyTracheostomy speaking speaking valvesvalves

Nature of the problemNature of the problem

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Diversion of airflow away from larynxDiversion of airflow away from larynx

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Inadequate Inadequate subglotticsubglottic pressure to cause vocal pressure to cause vocal fold vibrationfold vibration

The solutionThe solution

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ReRe--establish airflow establish airflow through the larynxthrough the larynx

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Substitute alternative Substitute alternative vibration source if vibration source if larynx is not larynx is not accessibleaccessible

Speaking Valve Function Speaking Valve Function

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Patient can continue to breath in through Patient can continue to breath in through the the trachtrach tubetube

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Exhalation is then redirected up through Exhalation is then redirected up through the trachea the trachea –– creating a closed systemcreating a closed system

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Promotes a more Promotes a more ““normalnormal”” respiratory respiratory pattern for breathing and expelling pattern for breathing and expelling secretionssecretions

Currently prevalent speaking valvesCurrently prevalent speaking valves

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Passy Muir Speaking Valve Passy Muir Speaking Valve –– Biased closed valveBiased closed valve–– Perceptually best quality voicePerceptually best quality voice–– Fewest clinically relevant mechanical problemsFewest clinically relevant mechanical problems–– Reduced effort required to initiate voiceReduced effort required to initiate voice((ZajacZajac et al. et al. Journal of Speech, Language, and Hearing ResearchJournal of Speech, Language, and Hearing Research 1999;1999;LederLeder. . Journal of Speech and Hearing ResearchJournal of Speech and Hearing Research 1994)1994)

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Montgomery Speaking Valve Montgomery Speaking Valve –– Biased open Biased open valvevalve–– Good to use for patients with mild upper airway Good to use for patients with mild upper airway

obstruction due to cough release mechanismobstruction due to cough release mechanism

Passy Muir Speaking ValvePassy Muir Speaking Valve

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Four different stylesFour different styles1.1. PMV 2001PMV 20012.2. PMV 005PMV 0053.3. PMV 007 (vent)PMV 007 (vent)4.4. PMV 2000 (low PMV 2000 (low

profile)profile)

111 2

3 4

Montgomery Speaking ValveMontgomery Speaking Valve

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2 different styles2 different styles1.1. TracheostomyTracheostomy valvevalve2.2. Ventilator valveVentilator valve

1

2

Speaking ValvesSpeaking Valves

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Primary benefitPrimary benefit–– CommunicationCommunication

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Successful restoration of verbal communication in vented and Successful restoration of verbal communication in vented and trachtrach dependent patientsdependent patients

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Patient reported improvement in psychosocial functions and Patient reported improvement in psychosocial functions and emotional statusemotional status

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Improvements noted in adults as well as pediatric patientsImprovements noted in adults as well as pediatric patients

((ManzanoManzano et al. et al. Critical Care MedicineCritical Care Medicine 1993;1993;Passy et al. Passy et al. LaryngoscopeLaryngoscope 1993; 1993; Hull, et al. Hull, et al. Pediatric rehabilitationPediatric rehabilitation 2005)2005)

Speaking ValvesSpeaking Valves

�� Secondary benefits (Passy Muir only)Secondary benefits (Passy Muir only)–– SwallowingSwallowing��

Reduced occurrence of laryngeal Reduced occurrence of laryngeal penetration/aspirationpenetration/aspiration��

Reduced amount aspiratedReduced amount aspirated

((SuiterSuiter, McCullough, & Powell. , McCullough, & Powell. DysphagiaDysphagia 2003; 2003; StachlerStachler, Hamlet, , Hamlet, ChoiChoi, & Fleming. , & Fleming. LaryngoscopeLaryngoscope 1996; 1996; DettlebachDettlebach, Gross, , Gross, MahlmannMahlmann, & , & EiblingEibling. . Head and NeckHead and Neck 1995)1995)

Speaking valvesSpeaking valves

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Secondary benefits (Passy Muir only)Secondary benefits (Passy Muir only)–– Secretion managementSecretion management��

Subjective patient report of reduced oral and nasal Subjective patient report of reduced oral and nasal secretionssecretions (Passy et al. (Passy et al. LaryngoscopeLaryngoscope 1993)1993)

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Reduced secretion production over 24 hour period Reduced secretion production over 24 hour period ((LichtmanLichtman and and BirnbaumBirnbaum. . Journal of Speech and Hearing ResearchJournal of Speech and Hearing Research 1995)1995)

–– Olfaction Olfaction ((LichtmanLichtman and and BirnbaumBirnbaum. . Journal of Speech and Hearing Journal of Speech and Hearing ResearchResearch 1995; Passy et al. 1995; Passy et al. LaryngoscopeLaryngoscope 1993)1993)

Speaking valvesSpeaking valves

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Secondary benefits (Passy Muir only)Secondary benefits (Passy Muir only)–– Vent weaning/Vent weaning/decannulationdecannulation

((FukumotoFukumoto, Ota, & , Ota, & ArimaArima. . Critical Care ResuscitationCritical Care Resuscitation 2006)2006)

Speaking Valve CandidacySpeaking Valve Candidacy

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Can be used with Can be used with trachtrach patients on and off patients on and off the ventthe vent

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Pt should be awake, alert, and attempting Pt should be awake, alert, and attempting to communicateto communicate

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Airway Airway patencypatency –– trachtrach size/# of size/# of intubationsintubations

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Can be used for Can be used for decannulationdecannulation purposes in purposes in patients who are not communicativepatients who are not communicative

Contraindications for speaking Contraindications for speaking valve usevalve use

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Cuff inflationCuff inflation��

FomeFome cuff cuff trachtrach

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Thick, copious secretionsThick, copious secretions��

Total Total laryngectomylaryngectomy

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Laryngeal masses, Laryngeal masses, stenosisstenosis, inadequate , inadequate patencypatency of upper airwayof upper airway

Communication restoration in the Communication restoration in the trachtrach patientpatient

–– Assess size and type of Assess size and type of tracheostomytracheostomy tubetube��

Patients with Patients with FomeFome cuff cuff trachstrachs are not candidates are not candidates for speaking valves secondary to passive inflation for speaking valves secondary to passive inflation of cuffof cuff��

Larger diameter Larger diameter trachstrachs may result in inadequate may result in inadequate airflow through the upper airway (ideal size of airflow through the upper airway (ideal size of trachtrach is 2/3 size of tracheal lumen)is 2/3 size of tracheal lumen)��

Specialty Specialty trachstrachs can be utilized for abnormal can be utilized for abnormal airways (e.g. extra length, double cuff, stoma cuff, airways (e.g. extra length, double cuff, stoma cuff, TTS)TTS)

Speaking Valve AssessmentSpeaking Valve Assessment

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Verify and record baseline vital signsVerify and record baseline vital signs

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Slowly deflate cuff (~1cc at a time) and monitor Slowly deflate cuff (~1cc at a time) and monitor ptpt’’s vitals and work of breathings vitals and work of breathing

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Suction patient if necessarySuction patient if necessary

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Verify voice by digital occlusion of Verify voice by digital occlusion of trachtrach

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Apply speaking valve and monitor for changes in Apply speaking valve and monitor for changes in voice, vitals, or work of breathingvoice, vitals, or work of breathing

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Advance time of use as toleratedAdvance time of use as tolerated

Communication options Communication options for ventilator dependent for ventilator dependent

patientspatients

First stepsFirst steps

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Assess size and type of tracheostomy tubeAssess size and type of tracheostomy tube��

Determine reason for trach/vent Determine reason for trach/vent dependencedependence

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Assess vent settings and recent weaning Assess vent settings and recent weaning coursecourse

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Discuss patient status with respiratory Discuss patient status with respiratory therapist and pulmonary teamtherapist and pulmonary team

Ventilator modesVentilator modes

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Assist control (AC) Assist control (AC) –– Machine does all the Machine does all the work. If the pt attempts to trigger a work. If the pt attempts to trigger a breath the vent will deliver the volume breath the vent will deliver the volume predetermined by the vent setting at the predetermined by the vent setting at the preset ratepreset rate

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Pressure Regulated Volume Control Pressure Regulated Volume Control (PRVC), adjusts pressure delivered during (PRVC), adjusts pressure delivered during each breath to ensure target volumeeach breath to ensure target volume

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Used in the most compromised pulmonary Used in the most compromised pulmonary patientspatients

Ventilator modes (continued)Ventilator modes (continued)

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Synchronized Intermittent Mandatory Synchronized Intermittent Mandatory Ventilation (SIMV) Ventilation (SIMV) –– Vent will deliver a Vent will deliver a predetermined number of breaths per predetermined number of breaths per minute at a certain volume. If pt initiates minute at a certain volume. If pt initiates breaths, those breaths will be at the ptbreaths, those breaths will be at the pt’’s s spontaneous volumesspontaneous volumes

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Used in beginning of weaningUsed in beginning of weaning


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Continuous Positive Airway Pressure (CPAP)Continuous Positive Airway Pressure (CPAP)-- Pt Pt determines how many breaths per minute will be determines how many breaths per minute will be taken. No preset volumes are presented to the taken. No preset volumes are presented to the patient. Pt is given continuous positive air patient. Pt is given continuous positive air pressure to maintain integrity of gas exchange pressure to maintain integrity of gas exchange at alveoli.at alveoli.

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Weaning step before trach collarWeaning step before trach collar


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Pressure support Pressure support –– Can be utilized with Can be utilized with other vent modes to provide pressure other vent modes to provide pressure support to overcome resistance from vent support to overcome resistance from vent tubing. Pressure support is to minimize tubing. Pressure support is to minimize respiratory muscle fatigue.respiratory muscle fatigue.

Ventilator settingsVentilator settings

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Rate Rate –– Predetermined, minimum number of Predetermined, minimum number of breaths per minute which will be delivered to the breaths per minute which will be delivered to the patient.patient.

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Tidal volume Tidal volume –– The volume of air delivered with The volume of air delivered with every mechanical breath.every mechanical breath.

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Pressure support Pressure support -- The pressure delivered with The pressure delivered with each inspiration.each inspiration.

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Positive end expiratory pressure (PEEP) Positive end expiratory pressure (PEEP) –– Positive pressure which is present at the end of Positive pressure which is present at the end of expirationexpiration

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Fraction of inspired oxygen (FI02) Fraction of inspired oxygen (FI02) –– percentage percentage of oxygen delivered with each breath.of oxygen delivered with each breath.

Vent setting implications for verbal Vent setting implications for verbal communicationcommunication

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Tidal volume Tidal volume –– Patients who require high Patients who require high tidal volumes may have more difficulty tidal volumes may have more difficulty with cuff deflation due to difficulty with cuff deflation due to difficulty compensating for loss of volume and compensating for loss of volume and inability to adjust tidal volumes above a inability to adjust tidal volumes above a certain level.certain level.

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Some pulmonologists feel that patients Some pulmonologists feel that patients with tidal volumes greater than 800 are with tidal volumes greater than 800 are not candidates for cuff deflation/inline not candidates for cuff deflation/inline PMVPMV


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PEEP PEEP –– The PMV adds ~2 cm of PEEP. The PMV adds ~2 cm of PEEP. PEEP >7 can lead to barotrauma. Patients PEEP >7 can lead to barotrauma. Patients receiving >5 of PEEP at baseline may receiving >5 of PEEP at baseline may need to have the vent adjusted for the need to have the vent adjusted for the added PEEP from the PMV.added PEEP from the PMV.

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Pressure support Pressure support –– As with PEEP, high As with PEEP, high airway pressures can lead to barotrauma. airway pressures can lead to barotrauma. In general, patients with PS >10 are not In general, patients with PS >10 are not candidates for inline PMV.candidates for inline PMV.


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FI02 FI02 –– Patients with higher oxygen Patients with higher oxygen requirements often do not tolerate cuff requirements often do not tolerate cuff deflation due to inability to compensate. deflation due to inability to compensate. Generally speaking, patients with FI02 Generally speaking, patients with FI02 >60% don>60% don’’t do well with cuff t do well with cuff deflation/inline PMV.deflation/inline PMV.


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Rate Rate –– Again, patients with higher Again, patients with higher respiratory rate requirements are less respiratory rate requirements are less likely to adjust to changes in ventilation. likely to adjust to changes in ventilation. Generally speaking, patients with set rates Generally speaking, patients with set rates of >16 may not do well with cuff of >16 may not do well with cuff deflation/inline PMV.deflation/inline PMV.

Other considerationsOther considerations

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Peek airway pressures Peek airway pressures –– Patients with Patients with baseline peak airway pressures >40 are baseline peak airway pressures >40 are not candidates for inline PMV secondary to not candidates for inline PMV secondary to risks of barotrauma (as measured at rest, risks of barotrauma (as measured at rest, not during phonation attempts or not during phonation attempts or coughing)coughing)

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Secretions Secretions –– Patients with excessive Patients with excessive secretions may not be able to tolerate cuff secretions may not be able to tolerate cuff deflation or inline PMV.deflation or inline PMV.

Verbal communication options for Verbal communication options for vent dependent patientsvent dependent patients

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Leak speech/cuff deflationLeak speech/cuff deflation��

Inline Passy Muir Valve Inline Passy Muir Valve

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Talking trach tubesTalking trach tubes��

ElectrolarynxElectrolarynx

Leak speech/cuff deflationLeak speech/cuff deflation

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Requires:Requires:-- Intact or relatively unimpaired Intact or relatively unimpaired

articulatorsarticulators-- Fairly stable pulmonary statusFairly stable pulmonary status-- Patent upper airwayPatent upper airway-- Functional vocal fold mobilityFunctional vocal fold mobility

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Contraindications:Contraindications:-- High oxygen requirementsHigh oxygen requirements-- High tidal volumesHigh tidal volumes

Leak speech assessmentLeak speech assessment

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Consult with pulmonary or respiratory Consult with pulmonary or respiratory departments to determine pt stabilitydepartments to determine pt stability

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Verify and record vent settingsVerify and record vent settings��


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Suction orally and via Suction orally and via trachtrach if necessaryif necessary��

Slowly deflate cuff (~1cc at a time) and Slowly deflate cuff (~1cc at a time) and monitor ptmonitor pt’’s ability to phonate as well as s ability to phonate as well as ptpt’’s VS and WOB s VS and WOB –– suction again if neededsuction again if needed

Leak Speech Assessment cont.Leak Speech Assessment cont.

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Disable low minute volume alarm. Disable low minute volume alarm. ��

Monitor pt 1:1 during initial trial and Monitor pt 1:1 during initial trial and discontinue if HR or RR increase, if SaO2 discontinue if HR or RR increase, if SaO2 decreases, if pt has severe and intractable decreases, if pt has severe and intractable coughing, or if the pt c/o excessive SOB.coughing, or if the pt c/o excessive SOB.

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Advance time gradually according to Advance time gradually according to tolerancetolerance

Keep in mind with leak speechKeep in mind with leak speech

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Vent settings, particularly tidal volume and Vent settings, particularly tidal volume and pressure support will impact the ptpressure support will impact the pt’’s voice s voice production.production.

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If pt is unable to achieve any voice If pt is unable to achieve any voice (particularly if low minute volume does not (particularly if low minute volume does not alarm at all), suspect excessive trach size. alarm at all), suspect excessive trach size.

Keep in mind with leak speech Keep in mind with leak speech cont.cont.

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Tidal volumes may be adjusted to assist Tidal volumes may be adjusted to assist with voice production.with voice production.

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ENT consultation if persisting ENT consultation if persisting dysphonia/aphoniadysphonia/aphonia..

Inline PMVInline PMV��

Requires:Requires:-- Intact or relatively unimpaired articulatorsIntact or relatively unimpaired articulators-- Fairly stable pulmonary statusFairly stable pulmonary status-- Patent upper airwayPatent upper airway-- Functional vocal fold mobilityFunctional vocal fold mobility-- Good tolerance of cuff deflation Good tolerance of cuff deflation

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Contraindications:Contraindications:-- High oxygen requirementsHigh oxygen requirements-- High tidal volumesHigh tidal volumes-- High PEEPHigh PEEP-- High pressure supportHigh pressure support

Inline PMV assessmentInline PMV assessment

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Consult with pulmonary or respiratory Consult with pulmonary or respiratory departments to determine pt stabilitydepartments to determine pt stability

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Coordinate with RT for initial evaluation Coordinate with RT for initial evaluation (recommend assessment of tolerance of cuff (recommend assessment of tolerance of cuff deflation prior to initial inline PMV trials)deflation prior to initial inline PMV trials)

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Verify and record baseline vent settingsVerify and record baseline vent settings

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Suction orally and via Suction orally and via trachtrach if necessaryif necessary

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Slowly deflate cuff (~1cc at a time) and monitor Slowly deflate cuff (~1cc at a time) and monitor ptpt’’s ability to phonate as well as pts ability to phonate as well as pt’’s VS and s VS and WOB WOB ––suction if necessarysuction if necessary

Inline PMV assessment cont.Inline PMV assessment cont.

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Disable low minute volume alarm. Disable low minute volume alarm.

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Monitor pt 1:1 during initial trial and discontinue Monitor pt 1:1 during initial trial and discontinue if HR or RR increase, if SaO2 decreases, if pt has if HR or RR increase, if SaO2 decreases, if pt has severe and intractable coughing, or if the pt c/o severe and intractable coughing, or if the pt c/o excessive SOB.excessive SOB.

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Advance time gradually according to toleranceAdvance time gradually according to tolerance

Problems you may encounterProblems you may encounter

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Problem: Good vital signs but poor Problem: Good vital signs but poor phonationphonationSolutions:Solutions:1. RT can make vent adjustments 1. RT can make vent adjustments including increasing tidal volume or PEEPincluding increasing tidal volume or PEEP2. ST can focus on maximizing respiratory 2. ST can focus on maximizing respiratory support for phonation through traditional support for phonation through traditional voice therapy techniquesvoice therapy techniques3. ENT can assess for glottic closure issues3. ENT can assess for glottic closure issues


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Problem: Severe coughingProblem: Severe coughingSolutions:Solutions:1. Revert back to cuff deflation trials to 1. Revert back to cuff deflation trials to desensitize the upper airwaydesensitize the upper airway2. Keep cuff deflated throughout the day 2. Keep cuff deflated throughout the day for greater desensitizationfor greater desensitization3. Do short, intermittent PMV applications 3. Do short, intermittent PMV applications until pt becomes used to airflowuntil pt becomes used to airflow


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Problem: Good VS with cuff deflation but Problem: Good VS with cuff deflation but inability to tolerate inline PMVinability to tolerate inline PMVSolutions:Solutions:1. Most likely issue is inadequate upper airway 1. Most likely issue is inadequate upper airway patency patency –– recommend ENT consultrecommend ENT consult2. Anxiety may also contribute to this scenario, if 2. Anxiety may also contribute to this scenario, if voice is excellent but pt with increased HR/RR, voice is excellent but pt with increased HR/RR, try relaxation techniques and short, intermittent try relaxation techniques and short, intermittent PMV applicationsPMV applications

Developing an inDeveloping an in--line line protocolprotocol

Protocols and Procedures Protocols and Procedures

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Obtain access to/create PMV policy and Obtain access to/create PMV policy and procedure (see handout)procedure (see handout)

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Determine responsible parties Determine responsible parties –– SLP, RT, SLP, RT, pulmonologistpulmonologist and nursing and nursing

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Determine selection criteria Determine selection criteria –– See previous See previous slide on speaking valve candidacy slide on speaking valve candidacy

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Meet with appropriate committee to Meet with appropriate committee to review draft and determine approval review draft and determine approval process process

Determine responsible partiesDetermine responsible parties

�� PulmonologistPulmonologist: Initiate consultation and : Initiate consultation and communicate any change in status that communicate any change in status that may impact candidacy for valve usemay impact candidacy for valve use


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Speech language pathologist: Conduct a Speech language pathologist: Conduct a clinical evaluation of the PMV candidate, clinical evaluation of the PMV candidate, dispense and apply the PMV and necessary dispense and apply the PMV and necessary adaptors, develop appropriate therapeutic adaptors, develop appropriate therapeutic goals, follow the patientgoals, follow the patient’’s progress, and s progress, and discontinue PMV intervention if changes in discontinue PMV intervention if changes in status occur.status occur.


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Respiratory therapist: Assess the respiratory Respiratory therapist: Assess the respiratory status of the patient, make necessary status of the patient, make necessary adjustments to the ventilator after discussion adjustments to the ventilator after discussion with the with the pulmonologistpulmonologist, place and remove the , place and remove the PMV according to recommendations made by PMV according to recommendations made by the SLP, and monitor the status of the patient the SLP, and monitor the status of the patient during inline PMV use in conjunction with the during inline PMV use in conjunction with the SLP.SLP.


�� Nursing: Communicate to the SLP any Nursing: Communicate to the SLP any changes in patient status which may changes in patient status which may impact candidacy for inline PMV use, impact candidacy for inline PMV use, assist in monitoring the patient during assist in monitoring the patient during PMV once established, place and remove PMV once established, place and remove the PMV according to recommendations the PMV according to recommendations made by the SLP, and clean the PMV made by the SLP, and clean the PMV according to SLP recommendations.according to SLP recommendations.

InIn--line protocol inclusions line protocol inclusions

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Establish candidacy in conjunction with RT Establish candidacy in conjunction with RT and pulmonary and pulmonary

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Determine speaking valve placement Determine speaking valve placement guidelinesguidelines

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Identify troubleshooting tipsIdentify troubleshooting tips��

Establish a discontinuation criteria Establish a discontinuation criteria

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Train and educate staff with competencies Train and educate staff with competencies

Importance of multidisciplinary careImportance of multidisciplinary care

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Speech pathologists are experts in voice, Speech pathologists are experts in voice, speech, and swallowingspeech, and swallowing

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Respiratory therapists are experts in Respiratory therapists are experts in trachtrach/vent /vent managementmanagement

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OtolaryngologistsOtolaryngologists are experts in airway are experts in airway managementmanagement

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PulmonologistsPulmonologists are experts in pulmonary are experts in pulmonary managementmanagement

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Nurses are experts in the care of their patientsNurses are experts in the care of their patients

Good studies to cite to your Good studies to cite to your medicine colleaguesmedicine colleagues

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91/104 patients able to tolerate cuff 91/104 patients able to tolerate cuff deflation/deflation/cufflesscuffless trachtrach while on while on mechanical ventilation mechanical ventilation (Bach and Alba. (Bach and Alba. ChestChest 1990.)1990.)

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A multidisciplinary team approach can be A multidisciplinary team approach can be used to promote a positive patient used to promote a positive patient outcome in the mechanically vented outcome in the mechanically vented (Bell. (Bell. Critical Care Nurse Critical Care Nurse 1996.)1996.)

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Cuff deflation increase vocalization Cuff deflation increase vocalization without compromising respiratory function without compromising respiratory function (Conway and Mackey. (Conway and Mackey. AnaesthesiaAnaesthesia 2004)2004)

Other communication Other communication optionsoptions

Talking trach tubesTalking trach tubes

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Requires:Requires:-- Intact or relatively unimpaired Intact or relatively unimpaired

articulatorsarticulators-- Functional vocal fold mobilityFunctional vocal fold mobility-- Relatively patent upper airwayRelatively patent upper airway

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Contraindications:Contraindications:-- No major contraindicationsNo major contraindications

Talking trach tubesTalking trach tubes

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Made by both Bivona and PortexMade by both Bivona and Portex��

Allows for phonation by presentation of Allows for phonation by presentation of nonnon--pulmonary air between the cuff and pulmonary air between the cuff and the vocal folds.the vocal folds.

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Does not require cuff deflation and will not Does not require cuff deflation and will not impact ventilation of the patient.impact ventilation of the patient.

Talking trach tubeTalking trach tube

Assessment for talking trach Assessment for talking trach tubetube

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Once a patient is identified as a candidate, Once a patient is identified as a candidate, trach can be changed by ENT. trach can be changed by ENT.

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Once the trach is changed, humidified air Once the trach is changed, humidified air line should be established for the talking line should be established for the talking trach.trach.

Assessment for talking trach tube Assessment for talking trach tube cont.cont.

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The talking trach line is attached via The talking trach line is attached via oxygen tubing to the humidified air source oxygen tubing to the humidified air source and the flow should be set initially at and the flow should be set initially at 7L/min. 7L/min.

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Digitally occlude the port on the talking Digitally occlude the port on the talking trach line to administer airflow to the trach line to administer airflow to the upper airway and ask pt to phonate.upper airway and ask pt to phonate.

Troubleshooting with a talking Troubleshooting with a talking trachtrach

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Problem: Air does not seem to be flowing Problem: Air does not seem to be flowing through.through.Solution: Because the port is located right above Solution: Because the port is located right above the cuff, secretions can clog the line. Try the cuff, secretions can clog the line. Try flushing saline through the line and then reverse flushing saline through the line and then reverse suction through the talk line.suction through the talk line.

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Problem: Excessively wet vocal quality impacting Problem: Excessively wet vocal quality impacting intelligibilityintelligibilitySolution: Suction through the talk line to remove Solution: Suction through the talk line to remove secretions from above the cuff.secretions from above the cuff.


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Problem: Inability to get adequate voicingProblem: Inability to get adequate voicingSolution: May be due to inadequate Solution: May be due to inadequate airflow. Air flow meter may vary between airflow. Air flow meter may vary between 55--15 L/minute. Try increasing the airflow 15 L/minute. Try increasing the airflow by 1 L/min at a time.by 1 L/min at a time.

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Problem: Excessive coughingProblem: Excessive coughingSolution: Airflow may be too high. Try Solution: Airflow may be too high. Try reducing the airflow by 1 L/min at a time. reducing the airflow by 1 L/min at a time. Also try intermittent application of air Also try intermittent application of air rather than constant airflow.rather than constant airflow.


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Problem: Intermittent voice breaksProblem: Intermittent voice breaksSolution: Because of the design of talking trachs, Solution: Because of the design of talking trachs, patient position and trach position can interfere patient position and trach position can interfere with uninterrupted phonation. Try different with uninterrupted phonation. Try different head postures and positions while sustaining head postures and positions while sustaining phonation to find the best position.phonation to find the best position.

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Problem: Pt complaints of throat irritation with Problem: Pt complaints of throat irritation with prolonged useprolonged useSolution: Turn air flow off when not in use to Solution: Turn air flow off when not in use to minimize air delivery.minimize air delivery.

ElectrolarynxElectrolarynx

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For patients on the vent who are unable to For patients on the vent who are unable to obtain restoration of laryngeal communication, obtain restoration of laryngeal communication, an electrolarynx can be used to restore an electrolarynx can be used to restore alaryngeal speech.alaryngeal speech.

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Patients do best with oral adaptors Patients do best with oral adaptors

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ElectrolarynxElectrolarynx training for vent patients should training for vent patients should mirror what is done for laryngectomy patients mirror what is done for laryngectomy patients (i.e. focus on device placement, over(i.e. focus on device placement, over-- articulation, speaking rate).articulation, speaking rate).

Other nonOther non--oral optionsoral options

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Communication boardsCommunication boards��

WritingWriting

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Assistive/augmentative communication Assistive/augmentative communication devicesdevices

Ethical ConsiderationsEthical Considerations

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Quality of life issues Quality of life issues ((MarkstromMarkstrom et al 2002, et al 2002, KaubKaub-- WittemerWittemer 2003)2003)

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Family and caregivers involvement Family and caregivers involvement (Rossi (Rossi FerrarioFerrario 2001)2001)

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Coping with longCoping with long--term term tracheostomytracheostomy or or ventilation ventilation

ConclusionsConclusions

ConclusionsConclusions

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There are a number of communication options There are a number of communication options available for available for tracheotomizedtracheotomized and ventilator and ventilator dependent patientsdependent patients

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Successful rehabilitation depends upon a Successful rehabilitation depends upon a functional multidisciplinary approachfunctional multidisciplinary approach

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The The SLPSLP’’ss interventions can extend beyond basic interventions can extend beyond basic communication restorationcommunication restoration

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SLPsSLPs have the knowledge, passion, and have the knowledge, passion, and communication skills to advocate for their communication skills to advocate for their patientspatients

a practical approach to tracheostomy tubes and ventilators

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