session 406: rehab strategies for patients with
TRANSCRIPT
Microsoft PowerPoint - BO6_406_Quellier1
To comply with professional boards/associations standards: • I declare that I (or my family) do not have a financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all planners involved do not have any financial relationship. •Requirements for successful completion are attendance for the full session along with a completed session evaluation. •Vyne Education and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity.
Session 406: Rehab Strategies for Patients with Tracheostomies & Ventilators Jerome Quellier, MS, CCC/SLP
Leading the Way in Continuing Education and Professional Development. www.Vyne.com
Advanced Management
o Introductions
o Any specifics you wish to learn today?
o Housekeeping Phones Off, Temperature, Volume, Timing of Breaks, Stand up/Walk if Sleepy
Paperwork collected at end of day, Pens/Coffee/Tea
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o Explain the assessment, safety precautions and utilization of speaking valves
o Discuss dysphagia evaluations and risks for the tracheotomized patient
o Provide a framework for a multidisciplinary care plan to manage safe swallowing and maintain verbal communication
o Recognize what you see and what Q’s to ask
o Encourage critical thinking
Course Objectives
Population and timing
1. SPEAKING VALVES
Speaking Valves: Anatomy of a speaking valve Tracheostomy companies may offer some sort of valve
for speaking compatible with their product
Passy-Muir Speaking Valves (PMSV) most commonly used although it is not the only valve available
Universal 15 mm hub
One way valve generally rests in closed position meaning it allows air to come into trach but not leave trach – air is exhaled through mouth/nose
Low profile – does not “stick out” far from end of trach
Aqua vs. purple vs. white PMSV
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Patient Selection Criteria for Speaking Valves (in line and off vent)
Pt 48 hours post tracheotomy procedure
Without significant tracheal or laryngeal abnormality
Tolerates suctioning, stable vital signs
Able to maintain an alert state
Emerging communication attempts
Able to phonate around tube/deflated cuff
Demonstrates adequate patency of airway
Contraindications for speaking valve use Total laryngectomy Copious secretions that cannot be minimized Bilateral vocal cord paralysis Presence of a foam – filled cuff Upper airway obstruction (e.g., tumor, stenosis, granulation) Inability to tolerate cuff deflation Instability of vitals and ventilation after cuff deflation Active emesis or gross aspiration of tube feeds or saliva due
to severe dysphagia Hypoxia, mucous plugs
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a valve: Increased transtracheal
pressures Upper airway resistance
from post op edema Stenosis Reconstructive flap bulk
• Adaptations historically successful with pediatric by drilling 1.6 mm drill bit holes
Buswell, C., Powell, J., & Powell, S. (2016) • Holes acted as release ports for excess air egress
Stranix, J., Danzinger, K., et.al. (2016)
Controversial Adaptations to Valves Discussion:
+ Replicating drill adaptation successful for adults after intraoral oncologic resection and free flap construction
+ Did improve valve tolerance - Decreased amt and pressure of air passing to VC - Compromised voice quality and volume = breathier
voice, reduced volume Stranix, J., Danzinger, K., et.al. (2016)
May extend successful placement of valve for pediatrics population by 41%
Buswell, C., Powell, J., & Powell, S. (2016)
*Practice neither endorsed/refuted by the Passy-Muir company
Tracoe Adjustable Pressure Speaking Valve
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“Biased Closed No Leak Design”
Video Clip #8 ”Passy Muir Valve
Placement”
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Speaking Valves - Advantages Clearer voice, increased volume, better vocal quality Improved swallow Aids in secretion management Restored positive airway pressure – Positive End Expiratory
Pressure (PEEP) Can be used in line with ventilator Expedites weaning Psychological benefits (confidence, motivation,
communication) Infection control (avoid self occlusion with finger) Improved olfaction Improved quality of life when verbal communication
restored Passy Muir Clinical In service Outline
Background: Mechanical ventilator is commonly used during the acute
management of cervical spinal cord injury and is required on an ongoing basis in the majority of patients with injuries at or above C3
Voicing is disrupted until patients are able to tolerate cuff deflation (or a cuffless or fenestrated tracheostomy tube) that allows diversion of some airflow to the upper airway and larynx
Leak speech is only possible where there is sufficient airflow to generate adequate subglottic pressure to trigger cord adduction and vibration
Such pressure is limited to the inspiratory and the beginning of the exhalatory ventilator cycles
Leak speech alone does not restore normal voicing capacity
Optimizing speech production in the ventilator-assisted individual following cervical SCI MacBean, N (2009)
Aim: To provide preliminary evidence of any benefits gained
through the addition of positive end expiratory pressure (PEEP) and/or speaking valve to the condition of leak speech
Methods and Procedures: Speech productions in three conditions were compared in
two ventilator-assisted subjects using instrumental (words per minute, duration of phonation, volume) and perceptual speech (intelligibility) measures
Optimizing speech production in the ventilator-assisted individual following cervical SCI MacBean, N (2009)
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Methods (con’t): • leak speech alone (speech produced by fully or partially
deflating the tracheostomy cuff) • use of a one way speaking valve (e.g., Passy Muir
Speaking Valve) • addition of PEEP
Outcomes and Results: • The addition of PEEP and /or the use of a speaking valve
resulted in speech that was superior to leak speech for both subjects
Optimizing speech production in the ventilator-assisted individual following cervical SCI MacBean, N (2009)
Return of Voice for Ventilated Tracheostomy Patients in ICU; A Randomized Controlled Trial of Early-Targeted Intervention Freeman-Sanderson, A.L., Togher, L., et al (2016)
Goal: Define the effects of targeted early communication intervention
for the restoration of voice in vented patients in the ICU
Study: Compared patients allowed early cuff deflation and in line
speaking valve vs waiting until off vent to place speaking valve
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Return of Voice for Ventilated Tracheostomy Patients in ICU; A Randomized Controlled Trial of Early-Targeted Intervention Freeman-Sanderson, A.L., Togher, L., et al (2016)
Outcomes: Focused early intervention for communication during mechanical
ventilation allows the restoration of phonation significantly sooner than standard treatment
No increase in complications, no expediency in decannulation, no reduction of LOS in ICU or negative impact on speed of return to oral intake
Speaking Valves In Mechanically Vented ICU Patient’s – Improved Communication and Improved Lung Recruitment Sutt, A.L., Cornwell, P., et al. (2015)
Goal Investigate the effect of speaking valves on respiratory mechanics in tracheotomized
mechanically ventilated patients
Study 18 trach’d patients weaning off mechanical ventilation who were able to tolerate
speaking valves for 30 minutes Patients assessed bedside before, during and post speaking valve placement in-line
with their usual ventilation (PS or high flow oxygen) using electrical impedance tomography and respiratory inductance plethysmography for a total of 1 hour
Data also collected re: Sao2, End tidal CO2 and respiratory rate
Speaking Valves In Mechanically Vented ICU Patient’s – Improved Communication and Improved Lung Recruitment Sutt, A.L., Cornwell, P., et al. (2015)
Study (con’t) Electrical Impedance Tomography: non-invasive radiation-free imaging tool that
measures changes in end expiratory lung volumes Respiratory inductance plethysmography : abdominal-chest movement ratio
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Speaking Valves In Mechanically Vented ICU Patient’s – Improved Communication and Improved Lung Recruitment Sutt, A.L., Cornwell, P., et al. (2015)
Findings Universal improvement in lung recruitment with the speaking valve in place Sustained improvement in lung recruitment post speaking valve use completed to
baseline regardless of vent needs Abdomen mobility increased significantly with the speaking valve in on, suggesting
increased diaphragm involvement in breathing Significant reduction in respiratory rate with speaking valve in place Success with health-related communication also rated significantly higher
Use of Speaking Valve on Preventing Respiratory Infections in Critical Tracheotomized Patients. An Edisval study Fernandez-Carmona, A., Arias-Diaz, M. et al. (2015).
Goal Determine utility of speaking valve in preventing respiratory nosocomial infections in
critical tracheotomized patients diagnosed with dysphagia secondary to an artificial airway
Study 19 patients included in study:
Speaking valve group (SVgroup) Identical protocol without the speaking valve (decannulation protocol DPgroup)
Use of Speaking Valve on Preventing Respiratory Infections in Critical Tracheotomized Patients. An Edisval study Fernandez-Carmona, A., Arias-Diaz, M. et al. (2015).
Study (con’t) Patients were decannulated when they fulfilled strict criteria (NOTE: this was
undefined in abstract) including dysphagia normalization. Infection rate: SVgroup 18%, DPgroup 37% Decannulation Time: SVgroup 4.4 days, DPgroup 6 days Mortality: SVgroup=0, DPgroup = 3
Conclusion Incidence of respiratory infectious complications and mortality may be lessened by
patients wearing speaking valves
Special Considerations for Communication with Speaking Valves Patients with new tracheotomies usually are hoarse
because of oral intubation, have excessive phlegm from the body identifying the trach as a foreign body
Patients are often groggy, cognitively impaired and acutely ill or even medically fragile
General safety issues surrounding valve/ teaching family and staff is vital
Weaning the patients back into speaking. Due to cognitive reasons or prolonged aphonia the patients need voice therapy
Jackson vs. Shiley Use of a PMA 2020-S Adapter
PMA -2020S Adaptor
untrained family member can be very dangerous
It is the role of the SLP to educate the medical team and families on the proper use of a speaking valve before leaving the valve in the room for use
Instructions should be posted and all training is documented in chart (who, what, where)
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Speaking Valves: Population and Timing For the patient who is able to sustain consciousness
and remain alert
If patient is cognitively compromised likely need 1:1 intermittent/direct supervision while speaking valve is in use – SLP may also choose to not leave valve in room and use only with SLP until more appropriate
Ideal if family member or patient can be taught removal and precautions
Speaking Valve Assessment Schedule co- treatment with RN or RT
Position patient to maximize diaphragmatic movement
Gloves on, appropriate sized suction catheter opened, and wall/portable suction ready
Anticipate cough response – stand perpendicular to patient, never in front of patient’s tracheostomy
Fully deflate cuff (non vent assessment)
Excess aspirated secretions above the cuff should be suctioned via deep suctioning and/or oral suctioning
Speaking Valve Assessment The patient can be encouraged to cough once
cuff is deflated to move secretions into mouth for easy removal
SLP instructs patient to take a deep breath, occludes hub of tracheostomy tube with a gloved finger, then instructs patient to blow air out through mouth
If exhalation around tracheostomy tube is with ease, cue to phonate /a/ to determine cord adduction/quality
Continuously monitor SpO2% and maintain >90%
Speaking valve may then be placed snuggly on the inner cannula
May need to encourage cough with valve on if aphonic
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Speaking Valve Assessment Voice training as needed to increase quality of phonation and
duration of valve use
Duration of placement should be based on ability to maintain SpO2% >90%, maintain RR/HR at patient’s pre-placement baseline, and cognitive status
Monitor for obvious signs of discomfort – ask patient’s perception
Patient may breath-stack once valve is placed if tracheostomy tube- to-trachea fit is tight
Communicate to MD and document inability to place valve due to need for downsizing as soon as medically possible
Remember some patients cannot have downsizing due to ongoing surgeries and/or mechanical ventilation
Trouble Shooting Difficult Placements Patient can’t breath with ease around deflated cuff Verify full cuff deflation, patient fully upright Verify tracheostomy tube at midline in trachea Suction to ensure the airway is clear of plugs
If patient has respiratory infection/thick/tenacious secretions, eval may need to wait until Pt better managed
Anxiety: some patient feel panicked by the re- establishment of air flow through upper airway Education, fan blowing on Pt, MD may consider
anxiolytic
Trouble Shooting Difficult Placements Patient can’t breath with ease around deflated cuff ENT/MD may need to assess for granulation or
tracheomalacia blocking air flow Downsizing to smaller tube may help Consider cuffless/TTS tracheostomy tube Recent tracheotomy or downsizing may lead to
edema, wait several days to re attempt evaluation
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once again sense pooled secretions Allow coughing/attempt to suction Monitor thickness of secretions, may need
aggressive pulmonary toileting or humidification Consider downsizing, could be tight trachea to
tracheostomy tube fit If on vent, train voicing during leak speech to
desensitize cough response, progressing volume of deflation
Trouble Shooting Difficult Placements Valve makes strange noise Clean valve – could have secretions dried on
filament causing unnecessary oscillation May need to replace valve with new one Patient may be exerting too much force on
exhalation or when voicing Train gentle onset of voicing
Air may be escaping around stoma if recent downsizing has occurred
Trouble Shooting Difficult Placements Breathing ok, but no voice or very little voicing Disuse of cords causes weakness, voice therapy Time voicing on exhalatory cycle if on vent During finger occlusion see if patient can cough
and elicit a glottic coup to eval for adduction ENT Consultation for cord paresis/paralysis
Had good voicing but progressive loss of voice Discontinue valve use until cause determined ENT assess for stenosis, granulation, medical issue
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support Needs training on deep breath before voice
onset Vented Pt may need to increase PEEP support
Initiate compensatory techniques to maximize speech clarity Over exaggeration Slowing rate Pacing
Speaking Valve Assessment in Line with Ventilator
Respiratory Therapist: Manage vent settings (e.g., increase tidal volume) Silence tidal volume alarms Determine tolerance of cuff deflation Suctioning Manage vent tubing to minimize tugging
RN: Monitor SpO2% >90 Monitor RR/HR/additional pressures (ICP/MAP)
Speaking Valve Assessment in Line with Ventilator
Respiratory Therapist considers the following pre-cuff deflation for candidacy: Pt on <0.60 FiO2 (fraction of inspired oxygen) Pt requires a PEEP <10 cm H2O Observe pre-cuff deflation PIP (peek inspiratory pressure)
PIP should be <40 cm H2O Observe pre-cuff deflation exhaled Vt (tidal volume) Achieve cuff deflation – slowly After 100% cuff deflation: Look for 40 - 50% loss of exhaled Vt (now escaping upwards) Look for significant drop in PIP
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Ventilator Assessment and Adjustments after PMV placed: 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) Consider using pressure versus flow trigger Pressure Support - Use E-Sense, inspiratory cycle off, or set I-time to
time limit PS breath Consider NIPPV mode (Non Invasive Positive Pressure Ventilation)
Speaking Valve Assessment in Line with Ventilator
SLP:
Determine ability to produce leak speech
Coach patient to time voice onset with exhalation cycle Dispense and place valve between vent tubing and hub of
tracheostomy tube
Post precautions
RT resumes pre-trial vent setting
Document duration of trial, tolerance
Determine wearing schedule with RN/RT Verify with MD and order use per parameters
established in trial
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Ventilation”
Video Clip # 10 ”Clinical Benefits of Passy Muir Valve”
W A R N I N G: Tracheostomy cuff must be completely deflated before placing
speaking valve; the patient will be unable to breath if cuff is not COMPLETELY deflated
Do not use speaking valve if the Patient becomes lethargic which may be a symptom of desaturation , ensure SpO2% >90%
Patient is in prone position (laying flat in bed, face down)
Patient is sleeping
Remove speaking valve before all medicated aerosol treatments
Supervise patients not able to remove speaking valve independently
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Foam Filled Cuff
Cleaning and Maintenance of a Speaking Valve Patient frequently cough or drop valve on to floor It is important to pick up and wash with warm water
and a gentle soap before replacing on trach due to risk of introducing infectious material to patient’s tracheostomy from off of the floor
If the valve has obvious trach secretions on it, it should be cleaned to prevent secretions from clogging the valve and resulting in faulty operation
Gentle fragrance-free foaming soap, thorough rinsing, air dry
DO NOT USE: bleach, hydrogen peroxide, hot water, alcohol, vinegar, brushes or cotton swabs
FYI: Speaking Valves and Costs Although the actual cost to order a PMSV is approximately $70/valve, the
patients can be charged $250 and up for the device by the dispensing agent.
If cost is a factor in using valve, research manufacturer of the patient’s tracheostomy tube to investigate alternatives
Consider training finger occlusion if replacement cannot be made
It is vital that staff does not lose the valve and thus recharge for additional equipment due to neglect - family should likewise be trained
Discard the valve after the patient is decannulated
Valves CANNOT BE REUSED with a new patient, even if cleaned with anti- microbial soaps, per most Infectious Control Depts
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Precautions Inflation of the cuff pilot does not indicate the amount of
air in the cuff or the cuff pressure!
It merely shows that air is present in the cuff
Important to continuously verify deflation before placement of valve
It is not safe to reinsert the same amount of air that is withdrawn from the cuff unless manometry has been used to verify volume
For the patient: Trach downsizing could lead to a mismatch between the
tube size and the tracheal wall which leads to over-inflation of the cuff to meet the tracheal wall
SOLUTION: Leave cuff deflated after initial trach change
EXCEPTION: Tube feedings, patient with identified aspiration risk, prolonged time in supine position, turning to prone position, returning to the OR for additional surgery
GOAL: DECANNULATION – Get that tube out of my neck!
Decannulation For patients who were tracheotomized for acute respiratory
failure, the long term goal is decannulation after stabilization
This may be complicated if there is not a decannulation process or policy
Local practice and opinions tend to vary regarding the most appropriate times and methods for this procedure
Lack of medical follow up in specialized areas (i.e., ENT) and also a lack of scientific evidence to guide decision making about the optimal process and timing
Key Considerations: patient’s consciousness level, cough effectiveness, secretions, supplementary oxygen needs, plugging trials
Paul, F. (2010)
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Ten Steps Toward Decanulation Morris, L.L., McIntosh, E., & Whitmer, A. (2014). The Importance of Tracheostomy Progression in the Intensive Care Unit. Critical Care Nurse, 34 (1), 40-49.
For a patient to be considered for progression the initial need for the tracheostomy must have been resolved
In order to begin progression a simple checklist should be considered
Nurses (and respiratory therapists) are important facilitators and motivators to encourage progress toward decannulation
Ten Steps Toward Decanulation Morris, L.L., McIntosh, E., & Whitmer, A. (2014)
Question Response Date 1. Is the patient free from ventilator support? Yes No 2. Can the cuff be deflated? Yes No 3. Can the tracheostomy tube be changed to cuffless or TTS?
Yes No
4. Does the patient tolerate prolonged capping of the cuffless (or TTS) tracheostomy tube?
Yes No
5. Is the vital capacity at least 1 liter? (maximum amount of air a person can expel from the lungs after a maximum inhalation)
Yes No
6. Can the patient manage his/her own secretions? Yes No 7. Has the initial need for the tracheostomy been resolved, with no further need for the tracheostomy?
Yes No
Trials of trach plugging during daytime of increasing duration
Periodic pulse oximetry to determine SpO2% >90%
Continuous oximetry to be considered if plugging overnight
Consider nasal cannula oxygen during weaning
If patient can tolerate own secretions (no suctioning) and maintain SaO2% >90% for >24 hours consider decannulation
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Weaning in LTACH’s (Long Term Acute Care Hospitals)
Jubran, A., Grant, B.J., et al., (2013). Effect of Pressure Support vs. Unassisted Breathing Through a Tracheostomy Collar on Weaning Duration in Patients Requiring Prolonged Mechanical Ventilation. JAMA, 309 (7), 671-677.
Importance: Patients requiring prolonged mechanical ventilation are commonly
weaned at LTACHs. There has not been an objective measure for identifying the most effective method
Objective: Compare weaning duration with pressure support vs. unassisted
breathing through a trach collar
Weaning in LTACH’s (Long Term Acute Care Hospitals) Jubran, A., Grant, B.J., et al. (2013)
Conclusion: Among patients requiring prolonged mechanical
ventilation and treated at a LTACH unassisted breathing through the tracheostomy with a collar in place supplying supplemental oxygen, compared with pressure support, resulted in: shorter median weaning time no effect on survival rate at 6 and 12 months
2. FENESTRATED TRACHEOSTOMY TUBES
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Fenestrated Tracheostomy Tube Option for the patient who can’t be downsized
Fenestrated inner cannula hub is green/blue if using a Shiley product
Inner and outer cannula have matching hole in top curve of tube
When matching inner/outer cannula are in line the patient is able to divert air around and through the tube for speech
Generally have non-disposable inner cannulas
Difficult for nursing to suction, extra cares
Non-Fenestrated inner cannula should be placed prior to suctioning if catheter cannot be bent/twisted into an arch
Due to extra care/lack of education MD/RN may be reluctant to place
Fenestrated Tracheostomy
Effect of cervical bracing on tracheotomized patient
Assessment of swallowing Blue Dye vs. FEES vs. MBSS
Use of speaking valve and swallowing
3. DYSPHAGIA AND THE TRACHEOTOMIZED PATIENT
Dysphagia Post Extubation Prolonged oral intubation desensitizes the gag reflex
Trauma patients who have been intubated for >24 hours are at a higher risk of:
-overt aspiration -silent aspiration
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Dysphagia Post Extubation Alterations in glottic anatomy caused by VF ulceration
and laryngeal edema
Decreased pharyngeal peristalsis, resulting in pooling in the valleculae and pyriform sinuses
In-coordination and diminished proprioception (awareness of where something is)
Dysphagia Post Extubation Miles, A., McLellan, N., et. al. (2018). Dysphagia and laryngeal pathology in post-surgical cardiothoracic patients. Journal of Critical Care, (45). 121-127. Method: 106 patients (age range 18–87 yrs; mean 63 yrs; SD 15 yrs) Standardized measures of laryngeal A&P via FEES, New Zealand
Secretion Scale, Penetration-Aspiraton scale and Yale Residue Scale
Results Prevalence of abnormality included
39% silent aspiration 65% laryngeal edema 61% vocal paralysis 36% incidence of pneumonia 14% post-operative stroke rate 40% of patients resumed a regular diet by d/c from acute care 24% continued to require enteral feeding
Vocal fold motion impairment was significantly associated with ventilation time and tracheostomy tube duration
Dysphagia and Tracheostomy Prolonged tracheostomy leads to weakening of the
pharyngeal musculature from limited use while patient is NPO
“Nearly 40% of nonneurologic critically ill patients requiring (tracheostomy) for prolonged mechanical ventilation presented swallowing dysfunction and experienced a significant delay in their tracheostomy decannulation process”
Romero, C., et al (2010)
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Dysphagia and Tracheostomy Bergl, P., Kumar, G., Zane, A., Shah, K., Zellner, S., Taneja, A., Dagar, G., Nanchal, R. (2018). Acquired dysphagia after mechanical ventilation. Critial Care Medicine. 46 (1). 243.
Studied a group of 707 mechanically vented patients with acquired dysphagia not present on admission
Mechanical ventilation was associated with greater odds of acquiring dysphagia
Risk appeared to increase with duration of MV > 96 hours
Tracheostomy was associated with the highest risk of acquired dysphagia (vs orally intubated patients)
Effect of Tracheostomy on Swallowing Suiter, D.M., (2003) Effects of Cuff Deflation and One-Way Tracheostomy Speaking Valve Placement on Swallowing Physiology. Dysphagia 18 (1), 284-292.
Decreased elevation and anterior rotation of the larynx due to the anchoring of the trachea to the strap muscles and skin of the neck created by the inflated tracheostomy tube cuff
Esophageal compression created by impingement of the tracheostomy cuff on the tracheoesophageal wall
Significant extinction of the adductor vocal cord reflex resulting from a lack of airflow through the upper airway
Gradual decrease in abductor vocal cord activity
Reduction in subglottic air pressure
14 non-ventilator dependent patients complete video fluoroscopic swallow studies (VFSS) under three conditions: (1) cuff inflated, (2) cuff deflated, and (3) one-way valve in place
4 additional patients with cuffless tracheostomy tubes completed VFSS with and without the one-way valve in place
All swallows were analyzed for the severity of penetration/aspiration using an 8-point penetration-aspiration scale
Effect of Tracheostomy on Swallowing Suiter, DM. (2003)
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Penetration Aspiration Scale Score Description of Events 1. Material does not enter airway 2. Material enters the airway, remains above the vocal folds,
and is ejected from the airway 3. Material enters the airway, remains above the vocal folds,
but is not ejected from the airway 4 Material enters the airway, contacts the vocal folds,
and is ejected from the airway 5. Material enters the airway, contacts the vocal folds,
but is not ejected from the airway 6. Material enters the airway, passes below the vocal folds,
and is ejected into the larynx or out of the airway 7. Material enters the airway, passes below the vocal folds,
but is not ejected from the trachea despite effort 8. Material enters the airway, passes below the vocal folds,
and no effort is made to eject Rosenbek, J.C., Robbins, J., Roecker, E.V., et al., (1996). A Penetration-Aspiration Scale. Dysphagia, 11, 93-98.
One-way valve placement significantly reduced scores on the penetration-aspiration scale for the liquid bolus
Patients who are unable to tolerate thin liquids may be able to safely take thin liquids when the valve is in place
Conclusion:
Clinicians who complete VFSS with tracheotomized patients should include several bolus presentations with a one-way speaking valve in place before making decisions regarding the use of the valve as a means to reduce aspiration
Effect of Tracheostomy on Swallowing Suiter, DM. (2003)
Pediatric Swallowing And Valve Use Ongkasuwan, J., Turk, C.L., et al. (2013). The Effect of a Speaking Valve on Laryngeal Aspiration and Penetration in Children With Tracheostomies. The Laryngoscope, 124, 1469- 1474.
Objective: Determine if the PMSV has similar effect on laryngeal
penetration and aspiration in tracheotomized children
Method: Prospective case-study study of pediatric patient who were
able to tolerate wearing the PMSV MBSS were performed with/without the PMSV for 3
presentations of thin liquids and 3 presentations of purees All swallows were analyzed for the severity of
penetration/aspiration using an 8-point penetration-aspiration scale
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Pediatric Swallowing And Valve Use Ongkasuwan, J., Turk, C.L., et al. (2013) Method (con’t) A sham valve was also used, which appeared same as an actual
PMSV under fluoro as to not bias researcher analyzing/scoring
Results: For 12 patients who were studied:
Laryngeal penetration and aspiration was decreased for purees as compared to liquids whether wearing the sham valve or the PMSV
Presence of a PMSV decreased pyriform sinus residual however it did not decrease laryngeal aspiration or penetration
Note: Limited study, n=12, no report of etiology resulting in tracheostomy (i.e., were results influenced by diagnosis vs presence of PMSV?)
Cuff Pressures and Swallowing Amathieu R., Sauvat S., et al. (2012). Influence of The Cuff Pressure On The Swallowing Reflex In Tracheostomized Intensive Care Unit Patients. British Journal of Anesthesia 109 (4). 578-583.
Purpose: Determine influence of the tracheostomy tube cuff pressure on
the swallowing reflex in tracheotomized patients
Conclusion: Latency time, EMG of peak activity, and amplitude of
laryngeal elevation during the swallowing reflex were influenced by tracheostomy tube cuff pressure (i.e., how fast, how strong, how far muscles moved)
Swallow reflex was progressively more difficult to elicit as cuff pressure increased
When activated, the resulting motor swallowing activity and efficiency of laryngeal elevation were depressed
Cuff Pressures and Swallowing Ding, R., & Logemann, J., (2005). Swallow Physiology in Patients with Trach Cuff Inflated or Deflated: A Retrospective Study. Head & Neck, 27 (9). 809-813.
Purpose: Investigate the differences in swallow physiology between
patients with trach cuff-inflated and trach cuff–deflated conditions with respect to four medical diagnostic categories:
neuromuscular disorder head and neck cancer respiratory diseases general medical diagnosis
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Results: Frequencies of reduced laryngeal elevation and silent
aspiration were found to be significantly higher in the cuff-inflated condition than the cuff– deflated condition
Speaking Valves & Swallowing Whenever possible encourage use of a speaking valve while
taking any oral intake
The valve’s closed position more closely approximates normal physiology during the swallowing process
The normalizing of subglottic air pressure improves swallowing and decreases aspiration risk
Allows full benefit of reflexive cough to move foreign material superiorly towards mouth for removal or additional swallowing/clearing
Blue Dye Evan’s Blue Dye test (EBDT): the patient's oral secretions are
stained by placing blue dye on the tongue and observing the patient over a period of time, with serial suctioning of tracheal secretions
Modified Evan’s Blue Dye Test (MEBDT): the blue contrast is added to boluses of food or liquid, with serial suctioning of tracheal secretions
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Blue Dye Variations of term “Blue Dye” FD&C Blue #1 a synthetic dye produced using aromatic hydrocarbons from petroleum Dye is poorly absorbed from the gastro-intestinal tract 95% of the ingested dye can be found in the feces Methylene blue Formulated in 1876 by German chemist Heinrich Caro Component of medications for malaria, cancer, psoriasis, etc Also used as a tissue stain - can be used within procedures Methyl blue
Used as a lab stain in histology, stains collagen blue in tissue sections (not for use with oral intake)
Blue Dye A “blue dye test” can be helpful in determining aspiration,
both frank aspiration and “leakage” from pharyngeal secretions
Is used as a bedside screening to assess who may be ready to begin oral trials as well as gross aspiration
Completed during a co-treatment with RN or RT
If the patient is non-vented the cuff should be deflated
Vent dependence would preclude this study – false negative
Medical facilities may not allow use of blue dye due to risk of fatality
Blue Dye Maloney J.P., Halbower A.C., et al. (2000). Systemic Absorption of Food Dye in Patients with Sepsis. New England Journal of Medicine, 343(14). 1047-1048.
Case 1: A 54-year-old woman with chronic renal failure was hospitalized for congestive heart failure and confusion
Hemodialysis and nasogastric feeding were initiated Later, staphylococcal pneumonia with sepsis was attributed to aspiration Blue dye no. 1 added to her enteral feedings Patient was febrile but hemodynamically stable Two days later her skin and serum turned green Pt died of refractory hypotension (low BP that does not respond to tx) and acidosis that day
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Blue Dye Maloney J.P., Halbower A.C., et al. (2000).
Case 2: A 12-month-old boy with trisomy 21 underwent tracheostomy for obstructive apnea
Pseudomonas pneumonia with sepsis developed Aspiration was believed to have occurred Blue dye no. 1 was added to his enteral feedings He remained hemodynamically stable, with normal renal function The next day his skin, serum, and urine became blue and hyperthermia developed
(rectal temperature, 47°C) Pt died of refractory hypotension and acidosis that day
Blue Dye Maloney J.P., Halbower A.C., et al. (2000).
• FD&C blue dye no. 1 approved by the FDA for use in food after experiments showed that the dye was nontoxic and was not absorbable (these experiments were performed in healthy animals)
• Artificial food dyes can inhibit mitochondrial respiration by blocking electron transport, or by inhibiting energy transformation by blocking the generation of ATP
• Blue dye no. 1, is a potent inhibitor of mitochondrial respiration in vitro and reduces oxygen consumption by a factor of eight in mitochondrial preparations in vitro
Blue Dye Maloney J.P., Halbower A.C., et al. (2000).
• Maloney, et al hypothesized that the refractory hypotension and metabolic acidosis seen in these patients may be explained by the known biochemical effects of this dye
• “We encourage judicious use of this food dye in patients with sepsis or other illnesses associated with increased gastrointestinal permeability”
ju·di·cious [joo-dish-uhs]: adjective having, exercising, or characterized by good or discriminating judgment; wise, sensible, or well-advised
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Blue Dye Maloney J.P., Ryan T.A., et al. (2002). Food Dye Use In Enteral Feedings: A Review and Call For a Moratorium. Nutrition in Clinical Practice 17(3). 169-181.
Summary: • Pulmonary aspiration of gastric contents is common in enterally fed patients • Tinting enteral feedings with blue dye is thought to aid the early detection of aspiration in hospitalized
patients • Presence of blue and green skin and urine, and serum discoloration has been linked with death • FD&C Blue No.1 and related dyes have toxic effects on mitochondria, suggesting that dye absorption is
harmful.
Conclusion: • The use of blue dye in enteral feedings should be abandoned and replaced by evidence-based methods
for the prevention of aspiration.
Blue Dye – Controversial Why does research of validity varies greatly in results & recommendations for MEBDT? Variability in cuff deflation, use of speaking valve Variability in use of FEES vs MBSS to verify aspiration Variability of patients on vent/on room air Variability in time from presentation to time of suctioning Etc, etc, etc… must carefully consider the study design before
quoting data.
Blue Dye O'Neil-Pirozzi, T.M., Lisiecki, D.J., et. al., (2003). Simultaneous modified barium swallow and blue dye tests: A determination of the accuracy of blue dye test aspiration findings. Dysphagia, 18, 32–38.
MEBDT does have fairly good reliability 70% for gross aspiration MEBDT does not have good sensitivity for trace aspiration About 30% of aspiration goes unnoticed
Ultimately ~ lack of a specific protocol
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Blue Dye “…it is best considered a screening test that can identify gross amounts of aspiration with a fair degree of precision, but for patients who do not aspirate gross amounts, there is a considerable risk that they will be misidentified as non-aspirators. Given the high variability among patients, it can also be used on a case-by-case basis to make clinical decisions regarding such things as candidacy or readiness for instrumental evaluation” Matthews, C. T. & Coyle, J. L. (2010, May 18). Reducing Pneumonia Risk Factors in Patients with Dysphagia Who Have A Tracheotomy: What Role Can SLPs Play? : Online Exclusive. The ASHA Leader.
Blue Dye - safety Aspiration identification aside there is concern about contamination of
the stain used Important to minimize cross contamination Consider use of a central storage location with single syringe serving
taken to bedside Watch expiration dates Use clean technique when handling dye (wash hands, gloves) If needed have pharmacy control and dispense if in a hospital
Video Fluoroscopic Swallow Study Modified Barium Swallow Study FEES study
A formal study should ultimately be completed to assess oral- pharyngeal-upper esophageal transit after tracheostomy to assess for:
Aspiration risks
The effect of compensation techniques
The effect of altered textures and liquid consistencies
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Aspirating Tracheotomized Patients
For those patients who actively aspirate their secretions and require their cuffs to be inflated, use of oral suctioning and elevation of the HOB during tube feedings should occur
Tube feedings may also need to be advanced into the duodenum (confirmed by XRAY) to prevent reflux
Managing cuff pressures becomes more of a challenge and consistent inflation with manometry is vital for good seal
It is important that the amount of air in a cuff is checked each shift on acute patient
Aspirating Tracheotomized Patients Cuff up, consider subglottic drainage system
Effect Of Cervical Bracing on Swallowing Stambolis, V., Brady, S., Klos, D., et al., (2003). The effects of cervical bracing upon swallowing in young, normal, healthy volunteers. Dysphagia. 18, 39-45.
Purpose: Evaluate radiographically the effects of cervical bracing upon swallowing of thin liquids and solid foods in 17 normal adults under three cervical bracing conditions:
• Philadelphia collar
• Halo-vest brace
Effect of Cervical Bracing On Swallowing
Philadelphia Collar SOMI brace Halo Vest
Findings: 82% of the subjects demonstrated radiographic changes under one or more of the bracing conditions. As the study was completed with normal subjects this was a repeated study for each subject in non braced and various braced positions. • 47% demonstrated changes with point of initiation of a
swallow response • 59% demonstrated increased pharyngeal residue • 23.5 demonstrated changes in bolus flow with laryngeal
penetration present
Effect Of Cervical Bracing on Swallowing Stambolis, V., et al., (2003)
Discussion: Various bracing conditions resulted in subjects presenting altered patterns of physiology of swallowing: The soft collar or Philadelphia brace resulted in reduced
hyolaryngeal elevation
The SOMI brace resulted in reduced hyolaryngeal elevation and anterior-posterior oropharyngeal narrowing
The Halo vest anterior-posterior oropharyngeal narrowing
Effect Of Cervical Bracing on Swallowing Stambolis, V., et al., (2003)
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Effect Of Cervical Bracing on Swallowing Stambolis, V., et al., (2003)
Conclusions: Cervical bracing alone may change swallowing physiology in normal healthy adults with regards to:
• The point of initiation of the swallow response
• Presence and amount of pharyngeal residue
• Laryngeal penetration
• Hyolaryngeal elevation
Anatomy and Physiology
Brain Voluntary (frontal/motor)
& Involuntary (medulla) Sensory
Trigeminal (CN V) Facial (CN VII) Glossopharyngeal (CN IX) Vagus (CN X)
Motor Vagus (CN X) Glossopharyngeal (CN IX) Hypoglossal nerve (CN
XII)
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Understanding Vent Settings Awareness of special populations
Understanding Vent Settings Conventional Modes of Ventilation PMSV can be used: A/C: Assist/Control SIMV: Synchronized Intermittent Mandatory Ventilation Pressure Support CPAP: Continuous Positive Airway Pressure PEEP: Positive End Expiratory Pressure
Tidal volume: lung volume representing the normal volume of air displaced between normal inspiration and expiration when extra effort is not applied
A/C: Assist Control Every breath the patient receives is a full ventilator breath The rate set on the ventilator is the minimum rate the
patient will receive In A/C the patient may assist the initiation of a breath, by
generating a slight negative pressure at the beginning of inspiration; this causes the ventilator to 'trigger' and give a full ventilator breath.
Advantage of cycling the ventilator when the patient is ready, lessens the need to suppress the patient's own drive to breathe
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A/C: Assist Control Both a tidal volume and a minimal respiratory rate must be
selected in case the patient stops breathing
Example: if vent is set for 12 breaths/min with a tidal volume of 500 cc, the patient will receive this as a minimum. If the patient chooses to breathe 20 times a minute, 20 will be the respiratory rate, and the volume of each breath will be 500 cc.
A/C ventilation has the advantage of allowing the patient to participate in the respiratory rate, with each initiated breath guaranteeing an adequate tidal volume
SIMV: Synchronized Intermittent Mandatory Ventilation
More interactive mode which adjusts to increasing effort made by patient to take unassisted breaths
Ventilator breath is delivered in synchrony with the patient's own inspiratory effort
Both the tidal volume and the number of machine breaths are also set, but they are only delivered intermittently, alternating with the patient's own breathing efforts
Patient receives: 1) the controlled (mandatory) breath 2) the assisted (synchronized) breath 3) the spontaneous breath Depending on the number of spontaneous breaths the patient is
making this is a mode of weaning
Pressure Support Method of assisting a spontaneously breathing ventilated
patient
Partial or full support
Patient controls all parts of the breath except the pressure limit
The patient triggers the breath and the ventilator supplies a preset pressure limit (e.g.,10cm H20) and allows the patient to continue the breath for as long as he wishes
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applied by a constant flow
mode of mechanical ventilation where every breath is spontaneous (i.e., patient triggered and patient cycled)
Ventilator does not cycle during CPAP
No additional pressure above the level of CPAP is given
Patient must initiate all of their own breaths
PEEP Functionally similar to CPAP except PEEP is applied pressure
against exhalation It is pressure in the lungs (alveolar pressure) above
atmospheric pressure (the pressure outside of the body) that exists at the end of expiration
A small amount of applied PEEP (3 to 5 cmH2O) is used in most mechanically ventilated patients to mitigate end- expiratory alveolar collapse
A higher level of applied PEEP (>5 cmH2O) is sometimes used to improve hypoxemia or reduce ventilator- associated lung injury in patients with acute lung injury, acute respiratory distress syndrome, or other types of hypoxemic respiratory failure
Respiratory Special Considerations
SLP should always involve a RT, RN or MD before altering O2 levels
The #1 problem with patency is positioning
SpO2% in adult/elderly is >90%
In elderly the circulatory system is not as functional
In presence of respiratory disease SpO2% will decrease
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Respiratory Considerations for the Elderly
Decreased elasticity of the chest and lungs due to decrease in collagen
Scar tissue from lung disease decreases gas exchange
Decrease in total lung capacity produces decreased function
Kyphotic changes may interfere with volumes inhaled
Decreased blood flow to lungs contributes to arrhythmias
COPD: Chronic Obstructive Pulmonary Disease
COPD patients have difficulty with Sp02%
Parenchymal damage leads to decreased blood gas exchange
CO2% increase as a result of decreased gas exchange
In severe COPD on room air SpO2% may be 82-90%
Less than 88-89% SpO2% on room air may indicate need for home O2
Monitoring Difficulty Breathing Patients may demonstrate distress via: Diaphoresis Increased respiratory rate Changes in color Use of accessory muscles Increased H/R Increased Resistance inhaling/exhaling
If the patient is having difficulty breathing… IN: mucous plugs, patency OUT: mucous plugs, COPD, asthma
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5. MULTIDISCIPLINARY CARE OF A PATIENT
WITH TRACHEOSTOMY Role of MD/RN Role of RT Role of OT/PT/SLP
Multidisciplinary Care of a patient with a tracheostomy
Physician: Determining necessity Placement of tracheostomy Determining decannulation Medication management (mucolytics)
Nursing: Daily cares/cleaning Education of family Suctioning Carry over of Speech Therapy recommendations Font line monitoring of secretions/SpO2%
Respiratory Therapist: Initial placement of the tracheostomy if percutaneous Secretion management Vent management Neb treatments Humidification options
Trained family members or PCA’s in homecare: Daily cares Primary trouble shooting Encouraging use of speaking valve
Multidisciplinary Care of a patient with a tracheostomy
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requiring trunk control
control and stability, valsalva
Speech-Language Pathologist:
Language assessment
Oral motor function
ASHA Position - Intervention Capitalize on strengths and address weaknesses related to the
use of a prosthetic/adaptive device as it affects communication and/or swallowing
Facilitate the individual's activities and participation by assisting the person to acquire new skills and strategies using the device
Modify contextual factors to reduce barriers and enhance facilitators of successful communication/swallowing and participation, and to provide appropriate accommodations and other supports, as well as training in how to use them.
ASHA: Preferred Practice Patterns for the Profession of Speech-Language Pathology Position #29 Prosthetic/Adaptive Device Intervention
To comply with professional boards/associations standards: • I declare that I (or my family) do not have a financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all planners involved do not have any financial relationship. •Requirements for successful completion are attendance for the full session along with a completed session evaluation. •Vyne Education and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity.
Session 406: Rehab Strategies for Patients with Tracheostomies & Ventilators Jerome Quellier, MS, CCC/SLP
Leading the Way in Continuing Education and Professional Development. www.Vyne.com
Advanced Management
o Introductions
o Any specifics you wish to learn today?
o Housekeeping Phones Off, Temperature, Volume, Timing of Breaks, Stand up/Walk if Sleepy
Paperwork collected at end of day, Pens/Coffee/Tea
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o Explain the assessment, safety precautions and utilization of speaking valves
o Discuss dysphagia evaluations and risks for the tracheotomized patient
o Provide a framework for a multidisciplinary care plan to manage safe swallowing and maintain verbal communication
o Recognize what you see and what Q’s to ask
o Encourage critical thinking
Course Objectives
Population and timing
1. SPEAKING VALVES
Speaking Valves: Anatomy of a speaking valve Tracheostomy companies may offer some sort of valve
for speaking compatible with their product
Passy-Muir Speaking Valves (PMSV) most commonly used although it is not the only valve available
Universal 15 mm hub
One way valve generally rests in closed position meaning it allows air to come into trach but not leave trach – air is exhaled through mouth/nose
Low profile – does not “stick out” far from end of trach
Aqua vs. purple vs. white PMSV
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Patient Selection Criteria for Speaking Valves (in line and off vent)
Pt 48 hours post tracheotomy procedure
Without significant tracheal or laryngeal abnormality
Tolerates suctioning, stable vital signs
Able to maintain an alert state
Emerging communication attempts
Able to phonate around tube/deflated cuff
Demonstrates adequate patency of airway
Contraindications for speaking valve use Total laryngectomy Copious secretions that cannot be minimized Bilateral vocal cord paralysis Presence of a foam – filled cuff Upper airway obstruction (e.g., tumor, stenosis, granulation) Inability to tolerate cuff deflation Instability of vitals and ventilation after cuff deflation Active emesis or gross aspiration of tube feeds or saliva due
to severe dysphagia Hypoxia, mucous plugs
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a valve: Increased transtracheal
pressures Upper airway resistance
from post op edema Stenosis Reconstructive flap bulk
• Adaptations historically successful with pediatric by drilling 1.6 mm drill bit holes
Buswell, C., Powell, J., & Powell, S. (2016) • Holes acted as release ports for excess air egress
Stranix, J., Danzinger, K., et.al. (2016)
Controversial Adaptations to Valves Discussion:
+ Replicating drill adaptation successful for adults after intraoral oncologic resection and free flap construction
+ Did improve valve tolerance - Decreased amt and pressure of air passing to VC - Compromised voice quality and volume = breathier
voice, reduced volume Stranix, J., Danzinger, K., et.al. (2016)
May extend successful placement of valve for pediatrics population by 41%
Buswell, C., Powell, J., & Powell, S. (2016)
*Practice neither endorsed/refuted by the Passy-Muir company
Tracoe Adjustable Pressure Speaking Valve
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“Biased Closed No Leak Design”
Video Clip #8 ”Passy Muir Valve
Placement”
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Speaking Valves - Advantages Clearer voice, increased volume, better vocal quality Improved swallow Aids in secretion management Restored positive airway pressure – Positive End Expiratory
Pressure (PEEP) Can be used in line with ventilator Expedites weaning Psychological benefits (confidence, motivation,
communication) Infection control (avoid self occlusion with finger) Improved olfaction Improved quality of life when verbal communication
restored Passy Muir Clinical In service Outline
Background: Mechanical ventilator is commonly used during the acute
management of cervical spinal cord injury and is required on an ongoing basis in the majority of patients with injuries at or above C3
Voicing is disrupted until patients are able to tolerate cuff deflation (or a cuffless or fenestrated tracheostomy tube) that allows diversion of some airflow to the upper airway and larynx
Leak speech is only possible where there is sufficient airflow to generate adequate subglottic pressure to trigger cord adduction and vibration
Such pressure is limited to the inspiratory and the beginning of the exhalatory ventilator cycles
Leak speech alone does not restore normal voicing capacity
Optimizing speech production in the ventilator-assisted individual following cervical SCI MacBean, N (2009)
Aim: To provide preliminary evidence of any benefits gained
through the addition of positive end expiratory pressure (PEEP) and/or speaking valve to the condition of leak speech
Methods and Procedures: Speech productions in three conditions were compared in
two ventilator-assisted subjects using instrumental (words per minute, duration of phonation, volume) and perceptual speech (intelligibility) measures
Optimizing speech production in the ventilator-assisted individual following cervical SCI MacBean, N (2009)
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Methods (con’t): • leak speech alone (speech produced by fully or partially
deflating the tracheostomy cuff) • use of a one way speaking valve (e.g., Passy Muir
Speaking Valve) • addition of PEEP
Outcomes and Results: • The addition of PEEP and /or the use of a speaking valve
resulted in speech that was superior to leak speech for both subjects
Optimizing speech production in the ventilator-assisted individual following cervical SCI MacBean, N (2009)
Return of Voice for Ventilated Tracheostomy Patients in ICU; A Randomized Controlled Trial of Early-Targeted Intervention Freeman-Sanderson, A.L., Togher, L., et al (2016)
Goal: Define the effects of targeted early communication intervention
for the restoration of voice in vented patients in the ICU
Study: Compared patients allowed early cuff deflation and in line
speaking valve vs waiting until off vent to place speaking valve
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Return of Voice for Ventilated Tracheostomy Patients in ICU; A Randomized Controlled Trial of Early-Targeted Intervention Freeman-Sanderson, A.L., Togher, L., et al (2016)
Outcomes: Focused early intervention for communication during mechanical
ventilation allows the restoration of phonation significantly sooner than standard treatment
No increase in complications, no expediency in decannulation, no reduction of LOS in ICU or negative impact on speed of return to oral intake
Speaking Valves In Mechanically Vented ICU Patient’s – Improved Communication and Improved Lung Recruitment Sutt, A.L., Cornwell, P., et al. (2015)
Goal Investigate the effect of speaking valves on respiratory mechanics in tracheotomized
mechanically ventilated patients
Study 18 trach’d patients weaning off mechanical ventilation who were able to tolerate
speaking valves for 30 minutes Patients assessed bedside before, during and post speaking valve placement in-line
with their usual ventilation (PS or high flow oxygen) using electrical impedance tomography and respiratory inductance plethysmography for a total of 1 hour
Data also collected re: Sao2, End tidal CO2 and respiratory rate
Speaking Valves In Mechanically Vented ICU Patient’s – Improved Communication and Improved Lung Recruitment Sutt, A.L., Cornwell, P., et al. (2015)
Study (con’t) Electrical Impedance Tomography: non-invasive radiation-free imaging tool that
measures changes in end expiratory lung volumes Respiratory inductance plethysmography : abdominal-chest movement ratio
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Speaking Valves In Mechanically Vented ICU Patient’s – Improved Communication and Improved Lung Recruitment Sutt, A.L., Cornwell, P., et al. (2015)
Findings Universal improvement in lung recruitment with the speaking valve in place Sustained improvement in lung recruitment post speaking valve use completed to
baseline regardless of vent needs Abdomen mobility increased significantly with the speaking valve in on, suggesting
increased diaphragm involvement in breathing Significant reduction in respiratory rate with speaking valve in place Success with health-related communication also rated significantly higher
Use of Speaking Valve on Preventing Respiratory Infections in Critical Tracheotomized Patients. An Edisval study Fernandez-Carmona, A., Arias-Diaz, M. et al. (2015).
Goal Determine utility of speaking valve in preventing respiratory nosocomial infections in
critical tracheotomized patients diagnosed with dysphagia secondary to an artificial airway
Study 19 patients included in study:
Speaking valve group (SVgroup) Identical protocol without the speaking valve (decannulation protocol DPgroup)
Use of Speaking Valve on Preventing Respiratory Infections in Critical Tracheotomized Patients. An Edisval study Fernandez-Carmona, A., Arias-Diaz, M. et al. (2015).
Study (con’t) Patients were decannulated when they fulfilled strict criteria (NOTE: this was
undefined in abstract) including dysphagia normalization. Infection rate: SVgroup 18%, DPgroup 37% Decannulation Time: SVgroup 4.4 days, DPgroup 6 days Mortality: SVgroup=0, DPgroup = 3
Conclusion Incidence of respiratory infectious complications and mortality may be lessened by
patients wearing speaking valves
Special Considerations for Communication with Speaking Valves Patients with new tracheotomies usually are hoarse
because of oral intubation, have excessive phlegm from the body identifying the trach as a foreign body
Patients are often groggy, cognitively impaired and acutely ill or even medically fragile
General safety issues surrounding valve/ teaching family and staff is vital
Weaning the patients back into speaking. Due to cognitive reasons or prolonged aphonia the patients need voice therapy
Jackson vs. Shiley Use of a PMA 2020-S Adapter
PMA -2020S Adaptor
untrained family member can be very dangerous
It is the role of the SLP to educate the medical team and families on the proper use of a speaking valve before leaving the valve in the room for use
Instructions should be posted and all training is documented in chart (who, what, where)
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Speaking Valves: Population and Timing For the patient who is able to sustain consciousness
and remain alert
If patient is cognitively compromised likely need 1:1 intermittent/direct supervision while speaking valve is in use – SLP may also choose to not leave valve in room and use only with SLP until more appropriate
Ideal if family member or patient can be taught removal and precautions
Speaking Valve Assessment Schedule co- treatment with RN or RT
Position patient to maximize diaphragmatic movement
Gloves on, appropriate sized suction catheter opened, and wall/portable suction ready
Anticipate cough response – stand perpendicular to patient, never in front of patient’s tracheostomy
Fully deflate cuff (non vent assessment)
Excess aspirated secretions above the cuff should be suctioned via deep suctioning and/or oral suctioning
Speaking Valve Assessment The patient can be encouraged to cough once
cuff is deflated to move secretions into mouth for easy removal
SLP instructs patient to take a deep breath, occludes hub of tracheostomy tube with a gloved finger, then instructs patient to blow air out through mouth
If exhalation around tracheostomy tube is with ease, cue to phonate /a/ to determine cord adduction/quality
Continuously monitor SpO2% and maintain >90%
Speaking valve may then be placed snuggly on the inner cannula
May need to encourage cough with valve on if aphonic
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Speaking Valve Assessment Voice training as needed to increase quality of phonation and
duration of valve use
Duration of placement should be based on ability to maintain SpO2% >90%, maintain RR/HR at patient’s pre-placement baseline, and cognitive status
Monitor for obvious signs of discomfort – ask patient’s perception
Patient may breath-stack once valve is placed if tracheostomy tube- to-trachea fit is tight
Communicate to MD and document inability to place valve due to need for downsizing as soon as medically possible
Remember some patients cannot have downsizing due to ongoing surgeries and/or mechanical ventilation
Trouble Shooting Difficult Placements Patient can’t breath with ease around deflated cuff Verify full cuff deflation, patient fully upright Verify tracheostomy tube at midline in trachea Suction to ensure the airway is clear of plugs
If patient has respiratory infection/thick/tenacious secretions, eval may need to wait until Pt better managed
Anxiety: some patient feel panicked by the re- establishment of air flow through upper airway Education, fan blowing on Pt, MD may consider
anxiolytic
Trouble Shooting Difficult Placements Patient can’t breath with ease around deflated cuff ENT/MD may need to assess for granulation or
tracheomalacia blocking air flow Downsizing to smaller tube may help Consider cuffless/TTS tracheostomy tube Recent tracheotomy or downsizing may lead to
edema, wait several days to re attempt evaluation
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once again sense pooled secretions Allow coughing/attempt to suction Monitor thickness of secretions, may need
aggressive pulmonary toileting or humidification Consider downsizing, could be tight trachea to
tracheostomy tube fit If on vent, train voicing during leak speech to
desensitize cough response, progressing volume of deflation
Trouble Shooting Difficult Placements Valve makes strange noise Clean valve – could have secretions dried on
filament causing unnecessary oscillation May need to replace valve with new one Patient may be exerting too much force on
exhalation or when voicing Train gentle onset of voicing
Air may be escaping around stoma if recent downsizing has occurred
Trouble Shooting Difficult Placements Breathing ok, but no voice or very little voicing Disuse of cords causes weakness, voice therapy Time voicing on exhalatory cycle if on vent During finger occlusion see if patient can cough
and elicit a glottic coup to eval for adduction ENT Consultation for cord paresis/paralysis
Had good voicing but progressive loss of voice Discontinue valve use until cause determined ENT assess for stenosis, granulation, medical issue
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support Needs training on deep breath before voice
onset Vented Pt may need to increase PEEP support
Initiate compensatory techniques to maximize speech clarity Over exaggeration Slowing rate Pacing
Speaking Valve Assessment in Line with Ventilator
Respiratory Therapist: Manage vent settings (e.g., increase tidal volume) Silence tidal volume alarms Determine tolerance of cuff deflation Suctioning Manage vent tubing to minimize tugging
RN: Monitor SpO2% >90 Monitor RR/HR/additional pressures (ICP/MAP)
Speaking Valve Assessment in Line with Ventilator
Respiratory Therapist considers the following pre-cuff deflation for candidacy: Pt on <0.60 FiO2 (fraction of inspired oxygen) Pt requires a PEEP <10 cm H2O Observe pre-cuff deflation PIP (peek inspiratory pressure)
PIP should be <40 cm H2O Observe pre-cuff deflation exhaled Vt (tidal volume) Achieve cuff deflation – slowly After 100% cuff deflation: Look for 40 - 50% loss of exhaled Vt (now escaping upwards) Look for significant drop in PIP
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Ventilator Assessment and Adjustments after PMV placed: 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) Consider using pressure versus flow trigger Pressure Support - Use E-Sense, inspiratory cycle off, or set I-time to
time limit PS breath Consider NIPPV mode (Non Invasive Positive Pressure Ventilation)
Speaking Valve Assessment in Line with Ventilator
SLP:
Determine ability to produce leak speech
Coach patient to time voice onset with exhalation cycle Dispense and place valve between vent tubing and hub of
tracheostomy tube
Post precautions
RT resumes pre-trial vent setting
Document duration of trial, tolerance
Determine wearing schedule with RN/RT Verify with MD and order use per parameters
established in trial
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Ventilation”
Video Clip # 10 ”Clinical Benefits of Passy Muir Valve”
W A R N I N G: Tracheostomy cuff must be completely deflated before placing
speaking valve; the patient will be unable to breath if cuff is not COMPLETELY deflated
Do not use speaking valve if the Patient becomes lethargic which may be a symptom of desaturation , ensure SpO2% >90%
Patient is in prone position (laying flat in bed, face down)
Patient is sleeping
Remove speaking valve before all medicated aerosol treatments
Supervise patients not able to remove speaking valve independently
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Foam Filled Cuff
Cleaning and Maintenance of a Speaking Valve Patient frequently cough or drop valve on to floor It is important to pick up and wash with warm water
and a gentle soap before replacing on trach due to risk of introducing infectious material to patient’s tracheostomy from off of the floor
If the valve has obvious trach secretions on it, it should be cleaned to prevent secretions from clogging the valve and resulting in faulty operation
Gentle fragrance-free foaming soap, thorough rinsing, air dry
DO NOT USE: bleach, hydrogen peroxide, hot water, alcohol, vinegar, brushes or cotton swabs
FYI: Speaking Valves and Costs Although the actual cost to order a PMSV is approximately $70/valve, the
patients can be charged $250 and up for the device by the dispensing agent.
If cost is a factor in using valve, research manufacturer of the patient’s tracheostomy tube to investigate alternatives
Consider training finger occlusion if replacement cannot be made
It is vital that staff does not lose the valve and thus recharge for additional equipment due to neglect - family should likewise be trained
Discard the valve after the patient is decannulated
Valves CANNOT BE REUSED with a new patient, even if cleaned with anti- microbial soaps, per most Infectious Control Depts
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Precautions Inflation of the cuff pilot does not indicate the amount of
air in the cuff or the cuff pressure!
It merely shows that air is present in the cuff
Important to continuously verify deflation before placement of valve
It is not safe to reinsert the same amount of air that is withdrawn from the cuff unless manometry has been used to verify volume
For the patient: Trach downsizing could lead to a mismatch between the
tube size and the tracheal wall which leads to over-inflation of the cuff to meet the tracheal wall
SOLUTION: Leave cuff deflated after initial trach change
EXCEPTION: Tube feedings, patient with identified aspiration risk, prolonged time in supine position, turning to prone position, returning to the OR for additional surgery
GOAL: DECANNULATION – Get that tube out of my neck!
Decannulation For patients who were tracheotomized for acute respiratory
failure, the long term goal is decannulation after stabilization
This may be complicated if there is not a decannulation process or policy
Local practice and opinions tend to vary regarding the most appropriate times and methods for this procedure
Lack of medical follow up in specialized areas (i.e., ENT) and also a lack of scientific evidence to guide decision making about the optimal process and timing
Key Considerations: patient’s consciousness level, cough effectiveness, secretions, supplementary oxygen needs, plugging trials
Paul, F. (2010)
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Ten Steps Toward Decanulation Morris, L.L., McIntosh, E., & Whitmer, A. (2014). The Importance of Tracheostomy Progression in the Intensive Care Unit. Critical Care Nurse, 34 (1), 40-49.
For a patient to be considered for progression the initial need for the tracheostomy must have been resolved
In order to begin progression a simple checklist should be considered
Nurses (and respiratory therapists) are important facilitators and motivators to encourage progress toward decannulation
Ten Steps Toward Decanulation Morris, L.L., McIntosh, E., & Whitmer, A. (2014)
Question Response Date 1. Is the patient free from ventilator support? Yes No 2. Can the cuff be deflated? Yes No 3. Can the tracheostomy tube be changed to cuffless or TTS?
Yes No
4. Does the patient tolerate prolonged capping of the cuffless (or TTS) tracheostomy tube?
Yes No
5. Is the vital capacity at least 1 liter? (maximum amount of air a person can expel from the lungs after a maximum inhalation)
Yes No
6. Can the patient manage his/her own secretions? Yes No 7. Has the initial need for the tracheostomy been resolved, with no further need for the tracheostomy?
Yes No
Trials of trach plugging during daytime of increasing duration
Periodic pulse oximetry to determine SpO2% >90%
Continuous oximetry to be considered if plugging overnight
Consider nasal cannula oxygen during weaning
If patient can tolerate own secretions (no suctioning) and maintain SaO2% >90% for >24 hours consider decannulation
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Weaning in LTACH’s (Long Term Acute Care Hospitals)
Jubran, A., Grant, B.J., et al., (2013). Effect of Pressure Support vs. Unassisted Breathing Through a Tracheostomy Collar on Weaning Duration in Patients Requiring Prolonged Mechanical Ventilation. JAMA, 309 (7), 671-677.
Importance: Patients requiring prolonged mechanical ventilation are commonly
weaned at LTACHs. There has not been an objective measure for identifying the most effective method
Objective: Compare weaning duration with pressure support vs. unassisted
breathing through a trach collar
Weaning in LTACH’s (Long Term Acute Care Hospitals) Jubran, A., Grant, B.J., et al. (2013)
Conclusion: Among patients requiring prolonged mechanical
ventilation and treated at a LTACH unassisted breathing through the tracheostomy with a collar in place supplying supplemental oxygen, compared with pressure support, resulted in: shorter median weaning time no effect on survival rate at 6 and 12 months
2. FENESTRATED TRACHEOSTOMY TUBES
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Fenestrated Tracheostomy Tube Option for the patient who can’t be downsized
Fenestrated inner cannula hub is green/blue if using a Shiley product
Inner and outer cannula have matching hole in top curve of tube
When matching inner/outer cannula are in line the patient is able to divert air around and through the tube for speech
Generally have non-disposable inner cannulas
Difficult for nursing to suction, extra cares
Non-Fenestrated inner cannula should be placed prior to suctioning if catheter cannot be bent/twisted into an arch
Due to extra care/lack of education MD/RN may be reluctant to place
Fenestrated Tracheostomy
Effect of cervical bracing on tracheotomized patient
Assessment of swallowing Blue Dye vs. FEES vs. MBSS
Use of speaking valve and swallowing
3. DYSPHAGIA AND THE TRACHEOTOMIZED PATIENT
Dysphagia Post Extubation Prolonged oral intubation desensitizes the gag reflex
Trauma patients who have been intubated for >24 hours are at a higher risk of:
-overt aspiration -silent aspiration
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Dysphagia Post Extubation Alterations in glottic anatomy caused by VF ulceration
and laryngeal edema
Decreased pharyngeal peristalsis, resulting in pooling in the valleculae and pyriform sinuses
In-coordination and diminished proprioception (awareness of where something is)
Dysphagia Post Extubation Miles, A., McLellan, N., et. al. (2018). Dysphagia and laryngeal pathology in post-surgical cardiothoracic patients. Journal of Critical Care, (45). 121-127. Method: 106 patients (age range 18–87 yrs; mean 63 yrs; SD 15 yrs) Standardized measures of laryngeal A&P via FEES, New Zealand
Secretion Scale, Penetration-Aspiraton scale and Yale Residue Scale
Results Prevalence of abnormality included
39% silent aspiration 65% laryngeal edema 61% vocal paralysis 36% incidence of pneumonia 14% post-operative stroke rate 40% of patients resumed a regular diet by d/c from acute care 24% continued to require enteral feeding
Vocal fold motion impairment was significantly associated with ventilation time and tracheostomy tube duration
Dysphagia and Tracheostomy Prolonged tracheostomy leads to weakening of the
pharyngeal musculature from limited use while patient is NPO
“Nearly 40% of nonneurologic critically ill patients requiring (tracheostomy) for prolonged mechanical ventilation presented swallowing dysfunction and experienced a significant delay in their tracheostomy decannulation process”
Romero, C., et al (2010)
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Dysphagia and Tracheostomy Bergl, P., Kumar, G., Zane, A., Shah, K., Zellner, S., Taneja, A., Dagar, G., Nanchal, R. (2018). Acquired dysphagia after mechanical ventilation. Critial Care Medicine. 46 (1). 243.
Studied a group of 707 mechanically vented patients with acquired dysphagia not present on admission
Mechanical ventilation was associated with greater odds of acquiring dysphagia
Risk appeared to increase with duration of MV > 96 hours
Tracheostomy was associated with the highest risk of acquired dysphagia (vs orally intubated patients)
Effect of Tracheostomy on Swallowing Suiter, D.M., (2003) Effects of Cuff Deflation and One-Way Tracheostomy Speaking Valve Placement on Swallowing Physiology. Dysphagia 18 (1), 284-292.
Decreased elevation and anterior rotation of the larynx due to the anchoring of the trachea to the strap muscles and skin of the neck created by the inflated tracheostomy tube cuff
Esophageal compression created by impingement of the tracheostomy cuff on the tracheoesophageal wall
Significant extinction of the adductor vocal cord reflex resulting from a lack of airflow through the upper airway
Gradual decrease in abductor vocal cord activity
Reduction in subglottic air pressure
14 non-ventilator dependent patients complete video fluoroscopic swallow studies (VFSS) under three conditions: (1) cuff inflated, (2) cuff deflated, and (3) one-way valve in place
4 additional patients with cuffless tracheostomy tubes completed VFSS with and without the one-way valve in place
All swallows were analyzed for the severity of penetration/aspiration using an 8-point penetration-aspiration scale
Effect of Tracheostomy on Swallowing Suiter, DM. (2003)
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Penetration Aspiration Scale Score Description of Events 1. Material does not enter airway 2. Material enters the airway, remains above the vocal folds,
and is ejected from the airway 3. Material enters the airway, remains above the vocal folds,
but is not ejected from the airway 4 Material enters the airway, contacts the vocal folds,
and is ejected from the airway 5. Material enters the airway, contacts the vocal folds,
but is not ejected from the airway 6. Material enters the airway, passes below the vocal folds,
and is ejected into the larynx or out of the airway 7. Material enters the airway, passes below the vocal folds,
but is not ejected from the trachea despite effort 8. Material enters the airway, passes below the vocal folds,
and no effort is made to eject Rosenbek, J.C., Robbins, J., Roecker, E.V., et al., (1996). A Penetration-Aspiration Scale. Dysphagia, 11, 93-98.
One-way valve placement significantly reduced scores on the penetration-aspiration scale for the liquid bolus
Patients who are unable to tolerate thin liquids may be able to safely take thin liquids when the valve is in place
Conclusion:
Clinicians who complete VFSS with tracheotomized patients should include several bolus presentations with a one-way speaking valve in place before making decisions regarding the use of the valve as a means to reduce aspiration
Effect of Tracheostomy on Swallowing Suiter, DM. (2003)
Pediatric Swallowing And Valve Use Ongkasuwan, J., Turk, C.L., et al. (2013). The Effect of a Speaking Valve on Laryngeal Aspiration and Penetration in Children With Tracheostomies. The Laryngoscope, 124, 1469- 1474.
Objective: Determine if the PMSV has similar effect on laryngeal
penetration and aspiration in tracheotomized children
Method: Prospective case-study study of pediatric patient who were
able to tolerate wearing the PMSV MBSS were performed with/without the PMSV for 3
presentations of thin liquids and 3 presentations of purees All swallows were analyzed for the severity of
penetration/aspiration using an 8-point penetration-aspiration scale
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Pediatric Swallowing And Valve Use Ongkasuwan, J., Turk, C.L., et al. (2013) Method (con’t) A sham valve was also used, which appeared same as an actual
PMSV under fluoro as to not bias researcher analyzing/scoring
Results: For 12 patients who were studied:
Laryngeal penetration and aspiration was decreased for purees as compared to liquids whether wearing the sham valve or the PMSV
Presence of a PMSV decreased pyriform sinus residual however it did not decrease laryngeal aspiration or penetration
Note: Limited study, n=12, no report of etiology resulting in tracheostomy (i.e., were results influenced by diagnosis vs presence of PMSV?)
Cuff Pressures and Swallowing Amathieu R., Sauvat S., et al. (2012). Influence of The Cuff Pressure On The Swallowing Reflex In Tracheostomized Intensive Care Unit Patients. British Journal of Anesthesia 109 (4). 578-583.
Purpose: Determine influence of the tracheostomy tube cuff pressure on
the swallowing reflex in tracheotomized patients
Conclusion: Latency time, EMG of peak activity, and amplitude of
laryngeal elevation during the swallowing reflex were influenced by tracheostomy tube cuff pressure (i.e., how fast, how strong, how far muscles moved)
Swallow reflex was progressively more difficult to elicit as cuff pressure increased
When activated, the resulting motor swallowing activity and efficiency of laryngeal elevation were depressed
Cuff Pressures and Swallowing Ding, R., & Logemann, J., (2005). Swallow Physiology in Patients with Trach Cuff Inflated or Deflated: A Retrospective Study. Head & Neck, 27 (9). 809-813.
Purpose: Investigate the differences in swallow physiology between
patients with trach cuff-inflated and trach cuff–deflated conditions with respect to four medical diagnostic categories:
neuromuscular disorder head and neck cancer respiratory diseases general medical diagnosis
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Results: Frequencies of reduced laryngeal elevation and silent
aspiration were found to be significantly higher in the cuff-inflated condition than the cuff– deflated condition
Speaking Valves & Swallowing Whenever possible encourage use of a speaking valve while
taking any oral intake
The valve’s closed position more closely approximates normal physiology during the swallowing process
The normalizing of subglottic air pressure improves swallowing and decreases aspiration risk
Allows full benefit of reflexive cough to move foreign material superiorly towards mouth for removal or additional swallowing/clearing
Blue Dye Evan’s Blue Dye test (EBDT): the patient's oral secretions are
stained by placing blue dye on the tongue and observing the patient over a period of time, with serial suctioning of tracheal secretions
Modified Evan’s Blue Dye Test (MEBDT): the blue contrast is added to boluses of food or liquid, with serial suctioning of tracheal secretions
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Blue Dye Variations of term “Blue Dye” FD&C Blue #1 a synthetic dye produced using aromatic hydrocarbons from petroleum Dye is poorly absorbed from the gastro-intestinal tract 95% of the ingested dye can be found in the feces Methylene blue Formulated in 1876 by German chemist Heinrich Caro Component of medications for malaria, cancer, psoriasis, etc Also used as a tissue stain - can be used within procedures Methyl blue
Used as a lab stain in histology, stains collagen blue in tissue sections (not for use with oral intake)
Blue Dye A “blue dye test” can be helpful in determining aspiration,
both frank aspiration and “leakage” from pharyngeal secretions
Is used as a bedside screening to assess who may be ready to begin oral trials as well as gross aspiration
Completed during a co-treatment with RN or RT
If the patient is non-vented the cuff should be deflated
Vent dependence would preclude this study – false negative
Medical facilities may not allow use of blue dye due to risk of fatality
Blue Dye Maloney J.P., Halbower A.C., et al. (2000). Systemic Absorption of Food Dye in Patients with Sepsis. New England Journal of Medicine, 343(14). 1047-1048.
Case 1: A 54-year-old woman with chronic renal failure was hospitalized for congestive heart failure and confusion
Hemodialysis and nasogastric feeding were initiated Later, staphylococcal pneumonia with sepsis was attributed to aspiration Blue dye no. 1 added to her enteral feedings Patient was febrile but hemodynamically stable Two days later her skin and serum turned green Pt died of refractory hypotension (low BP that does not respond to tx) and acidosis that day
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Blue Dye Maloney J.P., Halbower A.C., et al. (2000).
Case 2: A 12-month-old boy with trisomy 21 underwent tracheostomy for obstructive apnea
Pseudomonas pneumonia with sepsis developed Aspiration was believed to have occurred Blue dye no. 1 was added to his enteral feedings He remained hemodynamically stable, with normal renal function The next day his skin, serum, and urine became blue and hyperthermia developed
(rectal temperature, 47°C) Pt died of refractory hypotension and acidosis that day
Blue Dye Maloney J.P., Halbower A.C., et al. (2000).
• FD&C blue dye no. 1 approved by the FDA for use in food after experiments showed that the dye was nontoxic and was not absorbable (these experiments were performed in healthy animals)
• Artificial food dyes can inhibit mitochondrial respiration by blocking electron transport, or by inhibiting energy transformation by blocking the generation of ATP
• Blue dye no. 1, is a potent inhibitor of mitochondrial respiration in vitro and reduces oxygen consumption by a factor of eight in mitochondrial preparations in vitro
Blue Dye Maloney J.P., Halbower A.C., et al. (2000).
• Maloney, et al hypothesized that the refractory hypotension and metabolic acidosis seen in these patients may be explained by the known biochemical effects of this dye
• “We encourage judicious use of this food dye in patients with sepsis or other illnesses associated with increased gastrointestinal permeability”
ju·di·cious [joo-dish-uhs]: adjective having, exercising, or characterized by good or discriminating judgment; wise, sensible, or well-advised
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Blue Dye Maloney J.P., Ryan T.A., et al. (2002). Food Dye Use In Enteral Feedings: A Review and Call For a Moratorium. Nutrition in Clinical Practice 17(3). 169-181.
Summary: • Pulmonary aspiration of gastric contents is common in enterally fed patients • Tinting enteral feedings with blue dye is thought to aid the early detection of aspiration in hospitalized
patients • Presence of blue and green skin and urine, and serum discoloration has been linked with death • FD&C Blue No.1 and related dyes have toxic effects on mitochondria, suggesting that dye absorption is
harmful.
Conclusion: • The use of blue dye in enteral feedings should be abandoned and replaced by evidence-based methods
for the prevention of aspiration.
Blue Dye – Controversial Why does research of validity varies greatly in results & recommendations for MEBDT? Variability in cuff deflation, use of speaking valve Variability in use of FEES vs MBSS to verify aspiration Variability of patients on vent/on room air Variability in time from presentation to time of suctioning Etc, etc, etc… must carefully consider the study design before
quoting data.
Blue Dye O'Neil-Pirozzi, T.M., Lisiecki, D.J., et. al., (2003). Simultaneous modified barium swallow and blue dye tests: A determination of the accuracy of blue dye test aspiration findings. Dysphagia, 18, 32–38.
MEBDT does have fairly good reliability 70% for gross aspiration MEBDT does not have good sensitivity for trace aspiration About 30% of aspiration goes unnoticed
Ultimately ~ lack of a specific protocol
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Blue Dye “…it is best considered a screening test that can identify gross amounts of aspiration with a fair degree of precision, but for patients who do not aspirate gross amounts, there is a considerable risk that they will be misidentified as non-aspirators. Given the high variability among patients, it can also be used on a case-by-case basis to make clinical decisions regarding such things as candidacy or readiness for instrumental evaluation” Matthews, C. T. & Coyle, J. L. (2010, May 18). Reducing Pneumonia Risk Factors in Patients with Dysphagia Who Have A Tracheotomy: What Role Can SLPs Play? : Online Exclusive. The ASHA Leader.
Blue Dye - safety Aspiration identification aside there is concern about contamination of
the stain used Important to minimize cross contamination Consider use of a central storage location with single syringe serving
taken to bedside Watch expiration dates Use clean technique when handling dye (wash hands, gloves) If needed have pharmacy control and dispense if in a hospital
Video Fluoroscopic Swallow Study Modified Barium Swallow Study FEES study
A formal study should ultimately be completed to assess oral- pharyngeal-upper esophageal transit after tracheostomy to assess for:
Aspiration risks
The effect of compensation techniques
The effect of altered textures and liquid consistencies
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Aspirating Tracheotomized Patients
For those patients who actively aspirate their secretions and require their cuffs to be inflated, use of oral suctioning and elevation of the HOB during tube feedings should occur
Tube feedings may also need to be advanced into the duodenum (confirmed by XRAY) to prevent reflux
Managing cuff pressures becomes more of a challenge and consistent inflation with manometry is vital for good seal
It is important that the amount of air in a cuff is checked each shift on acute patient
Aspirating Tracheotomized Patients Cuff up, consider subglottic drainage system
Effect Of Cervical Bracing on Swallowing Stambolis, V., Brady, S., Klos, D., et al., (2003). The effects of cervical bracing upon swallowing in young, normal, healthy volunteers. Dysphagia. 18, 39-45.
Purpose: Evaluate radiographically the effects of cervical bracing upon swallowing of thin liquids and solid foods in 17 normal adults under three cervical bracing conditions:
• Philadelphia collar
• Halo-vest brace
Effect of Cervical Bracing On Swallowing
Philadelphia Collar SOMI brace Halo Vest
Findings: 82% of the subjects demonstrated radiographic changes under one or more of the bracing conditions. As the study was completed with normal subjects this was a repeated study for each subject in non braced and various braced positions. • 47% demonstrated changes with point of initiation of a
swallow response • 59% demonstrated increased pharyngeal residue • 23.5 demonstrated changes in bolus flow with laryngeal
penetration present
Effect Of Cervical Bracing on Swallowing Stambolis, V., et al., (2003)
Discussion: Various bracing conditions resulted in subjects presenting altered patterns of physiology of swallowing: The soft collar or Philadelphia brace resulted in reduced
hyolaryngeal elevation
The SOMI brace resulted in reduced hyolaryngeal elevation and anterior-posterior oropharyngeal narrowing
The Halo vest anterior-posterior oropharyngeal narrowing
Effect Of Cervical Bracing on Swallowing Stambolis, V., et al., (2003)
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Effect Of Cervical Bracing on Swallowing Stambolis, V., et al., (2003)
Conclusions: Cervical bracing alone may change swallowing physiology in normal healthy adults with regards to:
• The point of initiation of the swallow response
• Presence and amount of pharyngeal residue
• Laryngeal penetration
• Hyolaryngeal elevation
Anatomy and Physiology
Brain Voluntary (frontal/motor)
& Involuntary (medulla) Sensory
Trigeminal (CN V) Facial (CN VII) Glossopharyngeal (CN IX) Vagus (CN X)
Motor Vagus (CN X) Glossopharyngeal (CN IX) Hypoglossal nerve (CN
XII)
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Understanding Vent Settings Awareness of special populations
Understanding Vent Settings Conventional Modes of Ventilation PMSV can be used: A/C: Assist/Control SIMV: Synchronized Intermittent Mandatory Ventilation Pressure Support CPAP: Continuous Positive Airway Pressure PEEP: Positive End Expiratory Pressure
Tidal volume: lung volume representing the normal volume of air displaced between normal inspiration and expiration when extra effort is not applied
A/C: Assist Control Every breath the patient receives is a full ventilator breath The rate set on the ventilator is the minimum rate the
patient will receive In A/C the patient may assist the initiation of a breath, by
generating a slight negative pressure at the beginning of inspiration; this causes the ventilator to 'trigger' and give a full ventilator breath.
Advantage of cycling the ventilator when the patient is ready, lessens the need to suppress the patient's own drive to breathe
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A/C: Assist Control Both a tidal volume and a minimal respiratory rate must be
selected in case the patient stops breathing
Example: if vent is set for 12 breaths/min with a tidal volume of 500 cc, the patient will receive this as a minimum. If the patient chooses to breathe 20 times a minute, 20 will be the respiratory rate, and the volume of each breath will be 500 cc.
A/C ventilation has the advantage of allowing the patient to participate in the respiratory rate, with each initiated breath guaranteeing an adequate tidal volume
SIMV: Synchronized Intermittent Mandatory Ventilation
More interactive mode which adjusts to increasing effort made by patient to take unassisted breaths
Ventilator breath is delivered in synchrony with the patient's own inspiratory effort
Both the tidal volume and the number of machine breaths are also set, but they are only delivered intermittently, alternating with the patient's own breathing efforts
Patient receives: 1) the controlled (mandatory) breath 2) the assisted (synchronized) breath 3) the spontaneous breath Depending on the number of spontaneous breaths the patient is
making this is a mode of weaning
Pressure Support Method of assisting a spontaneously breathing ventilated
patient
Partial or full support
Patient controls all parts of the breath except the pressure limit
The patient triggers the breath and the ventilator supplies a preset pressure limit (e.g.,10cm H20) and allows the patient to continue the breath for as long as he wishes
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applied by a constant flow
mode of mechanical ventilation where every breath is spontaneous (i.e., patient triggered and patient cycled)
Ventilator does not cycle during CPAP
No additional pressure above the level of CPAP is given
Patient must initiate all of their own breaths
PEEP Functionally similar to CPAP except PEEP is applied pressure
against exhalation It is pressure in the lungs (alveolar pressure) above
atmospheric pressure (the pressure outside of the body) that exists at the end of expiration
A small amount of applied PEEP (3 to 5 cmH2O) is used in most mechanically ventilated patients to mitigate end- expiratory alveolar collapse
A higher level of applied PEEP (>5 cmH2O) is sometimes used to improve hypoxemia or reduce ventilator- associated lung injury in patients with acute lung injury, acute respiratory distress syndrome, or other types of hypoxemic respiratory failure
Respiratory Special Considerations
SLP should always involve a RT, RN or MD before altering O2 levels
The #1 problem with patency is positioning
SpO2% in adult/elderly is >90%
In elderly the circulatory system is not as functional
In presence of respiratory disease SpO2% will decrease
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Respiratory Considerations for the Elderly
Decreased elasticity of the chest and lungs due to decrease in collagen
Scar tissue from lung disease decreases gas exchange
Decrease in total lung capacity produces decreased function
Kyphotic changes may interfere with volumes inhaled
Decreased blood flow to lungs contributes to arrhythmias
COPD: Chronic Obstructive Pulmonary Disease
COPD patients have difficulty with Sp02%
Parenchymal damage leads to decreased blood gas exchange
CO2% increase as a result of decreased gas exchange
In severe COPD on room air SpO2% may be 82-90%
Less than 88-89% SpO2% on room air may indicate need for home O2
Monitoring Difficulty Breathing Patients may demonstrate distress via: Diaphoresis Increased respiratory rate Changes in color Use of accessory muscles Increased H/R Increased Resistance inhaling/exhaling
If the patient is having difficulty breathing… IN: mucous plugs, patency OUT: mucous plugs, COPD, asthma
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5. MULTIDISCIPLINARY CARE OF A PATIENT
WITH TRACHEOSTOMY Role of MD/RN Role of RT Role of OT/PT/SLP
Multidisciplinary Care of a patient with a tracheostomy
Physician: Determining necessity Placement of tracheostomy Determining decannulation Medication management (mucolytics)
Nursing: Daily cares/cleaning Education of family Suctioning Carry over of Speech Therapy recommendations Font line monitoring of secretions/SpO2%
Respiratory Therapist: Initial placement of the tracheostomy if percutaneous Secretion management Vent management Neb treatments Humidification options
Trained family members or PCA’s in homecare: Daily cares Primary trouble shooting Encouraging use of speaking valve
Multidisciplinary Care of a patient with a tracheostomy
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requiring trunk control
control and stability, valsalva
Speech-Language Pathologist:
Language assessment
Oral motor function
ASHA Position - Intervention Capitalize on strengths and address weaknesses related to the
use of a prosthetic/adaptive device as it affects communication and/or swallowing
Facilitate the individual's activities and participation by assisting the person to acquire new skills and strategies using the device
Modify contextual factors to reduce barriers and enhance facilitators of successful communication/swallowing and participation, and to provide appropriate accommodations and other supports, as well as training in how to use them.
ASHA: Preferred Practice Patterns for the Profession of Speech-Language Pathology Position #29 Prosthetic/Adaptive Device Intervention