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Tracheostomy Tubes and Speaking Valves

Mississippi Speech-Language-Hearing Association

April 1, 2015

Presenter

• Leigh Anne Baker, M.S., CCC-SLP, BCS-S

• Passy-Muir Inc. Clinical Consultant

• Director of Clinical Education at Southern

University in Baton Rouge, LA

lbaker@passy-muir.com

Financial Disclosure: Passy-Muir, Inc. has provided financial support for my travel to Jackson and a speaking fee for this presentation. Non-Financial Disclosure: I receive a salary from Southern University as the Director of Clinical Education for the Department of Speech-Language Pathology

Disclosure Statement

• Passy-Muir, Inc. has developed and patented

a licensed technology trademarked as the Passy-Muir® Tracheostomy and Ventilator

Swallowing and Speaking Valve. This presentation will focus primarily on the biased-closed position Passy-Muir® Valve and will

include little to no information on other speaking valves.

Learning Objectives:

• Tracheotomy and Tracheostomy Tubes

• Passy-Muir® Valves

• Interprofessional

Education and Practice

Tracheostomy and mechanical ventilation can have devastating effects on communication and swallowing.

Indications for Tracheostomy Tube

• Prolonged intubation

• Long-term mechanical ventilation

• Permanent tracheostomy tube

• Inability to intubate due to trauma

• Airway protection/

secretion removal

• Airway anomaly

• Patient comfort

• Facilitate weaning

• Oral feeding and communication options

• A tracheostomy tube does not prevent aspiration

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There are many choices of tubes!!!! Parts of a tracheostomy tube

15 mm connector

Pilot port with one way valve

Tube shaft

Cuff Inflation line

Neck flange

Tracheostomy Tubes

• Single Lumen/Cannula • Double Lumen/Cannula

Types of Tubes

• MATERIALS – PVC, Silicone, Metal

– Metal Reinforced

• SHAPE – Curved, Angular, Non-

pre formed

• LENGTH – Standard

– Extra length

• Proximal

• Distal

• Adjustable Flan

• SINGLE LUMEN • DOUBLE LUMEN

• FENESTRATED • MRI COMPATIBLE

– Conditional

• Subglottic Suction • TRACH TALK

• CUFFS – Air, water, or foam

– Double cuffed – Un-cuffed

• Custom Made

Calculating Tube Size

• ATS Consensus: The tracheostomy tube should take up no more than 2/3 the inner diameter of the trachea.

(for pediatrics, no adult standard)

• Anterior/Posterior Diameter of trachea

– Male: 18 +/- 5mm

– Female: 12 +/- 3 mm

Kamel, et al 2009

tube

I.D.

trachea

Jackson Metal Tracheostomy Tubes

• Original Style

• Improved

• Permanent 15mm

Adapter

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Cuff Choices

• AIR FILLED – minimal

leak

• TTS™ : WATER FILLED – minimal occlusion (can

be air filled)

• FOME-Cuff® – self sealing

– Contraindicated for

Passy-Muir® Valve use

Not all Trach Sizes are Equal

Size 6.0 Tracheostomy Tube

ID OD L

Portex 6.0 8.3 55.0

Bivona 6.0 8.8 70.0

Shiley 6.4 10.8 74.0

SCT 6.0 8.3 67.0

Early Tracheostomy (7-10 days) May: • Reduce incidence of

Hospital-Acquired Pneumonia

• Reduce injury to larynx

• Improve patient comfort

• Allow for oral communication and oral diet and requirement for less sedation

• Improve oral hygiene

• Improve secretion management

Complications of the Tracheostomy Tube

Clinical Complications of the Tracheostomy

• Lack of vocal production-communication

• Decreased sense of smell/taste

• Limited airflow through upper airway

• Reduced cough effectiveness

• Complications of long term cuff inflation

• Psychological complications-agony, fear, panic, frustration

Airflow

Clinical Complications (Continued)

• Removal of natural filtration and

humidification system

• Cycle of irritation and

secretion production

• Decreased Sensation in

the oropharynx

• Poor secretion

management

(Siebens, Tippet, Kirby, & French, 1993)

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Clinical Complications (Continued)

• Lack of subglottic pressure (0cmH20)

• Decreased physiologic PEEP (positive end

expiratory pressure)

Eibling & Gross,1996; Gross, Atwood, Grayhack, & Shaiman ,2003

Airflow

Tracheostomy Tube Effect on Swallowing:

• Scar tissue formation from the tracheotomy

procedure may affix the

trachea to overlying tissues and the larynx may not

move freely

• If the tube is too large for the patient’s trachea,

patient may feel

discomfort and may compensate with reduced

laryngeal excursion

Tracheostomy Tube Effect on Swallowing

• Impaired oral-pharyngeal pressure

• Impaired hyolaryngeal elevation/excursion

• Impaired glottic closure

• Reduced subglottic

pressures and reduced sensation

• Muscle disuse atrophy

Tracheostomy and Aspiration

• Does a cuff prevent aspiration?

• Definition

• Incidence of aspiration

– 50% - 87% rate for trach and vent patients1

– 75% silent aspiration2

– Aspiration around the

cuff3

1.Elpern et al., 1987, 1994, 2000; Tolep et al., 1996 2.Davis & Stanton, 2004; Elpern et aI., 1994 3.Bone, Davis, Zuidema, & Cameron, 1974; Elpem et al.,1987; Nash, 1988; Pavlin, VanNimwegan, & Hombein, 1975; Ross & White, 2003

Complications of Cuff

• Inflated cuffs can tether larynx – Larynx does not elevate

• Epiglottis does project down to protect airway

– Larynx does not move anteriorly • Esophagus does not

increase its diameter, creating the vacuum environment for food bolus transition

• Esophageal impingement • Reflux • Necrosis and Trauma

Amathieu, R. et al. (2012). British Journal of Anaesthesia. 109(4):578-83.

Cuff mismanagement associated with:

• Tracheal stenosis

• Granulation tissue

formation

• Tracheal erosion

• Tracheoesophageal

fistula

• Tracheal dilation

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Cuff Deflation Benefits

• Reduces aspiration1, 2

• Improves laryngeal elevation2,3

• Weaning time was shorter -average of 3 days versus 8 days4

• Fewer respiratory infections including ventilator associated pneumonia (20% vs. 36%) 4

• Swallowing better and improved more from baseline4

1. Davis, et al. (2002). Journal of Intensive Care Medicine. 17(3): 132-135. 2. Ding, R. & Logeman, J. (2005). Head & Neck. 27(9):809-13 3. Amathieu, R., et al. British journal of anaesthesia109.4 (2012): 578-583.

4. Hernendez, et al. (2013). Intensive Care Medicine. 39(6):1063-70

Cuff deflation

• Adequate ventilation can still be achieved with

the tracheostomy tube cuff deflated.1

• Cuff deflation during continuous positive airway

pressure (CPAP) has been associated with stable respiratory parameters and allowed patients to vocalize and swallow. 2

1. Bach, J. & Alba, J. (1990). Tracheostomy Ventilation: A study of efficacy with deflated cuffs and cuffless tubes. Chest, 97: 679-83. 2. Conway, D. & Mackie, C. (2004). The effects of tracheostomy cuff deflation during continuous positive airway pressure. Anaesthesia, 59: 652-657.

The Passy-Muir® Tracheostomy & Ventilator

Swallowing and Speaking Valve

PMV 2000 (clear) and PMV 2001 (Purple)

PMA 2000 Oxygen Adapter PMV ® 007 (Aqua Color ™ )

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PMV 2020 with Jackson Improved Care, Cleaning, and Lifetime of the Passy-Muir Speaking Valves

• Average lifetime of 2 months

How Does The Valve Work?

Patented “no leak” design

Opens only during active

inspiration

Closes at end inspiration

Remains closed t/o

expiratory cycle

Air is re-directed thru the

upper airway

Offers a buffer to

secretions

DESIGN VIDEO

Physiologic Benefits of Passy-Muir ® valve

• Restores Voice/Communication

• Improves Swallowing • Restores Physiologic PEEP

• Improves Secretion Management

• Improves Oxygenation • Promotes Weaning and

Decannulation

• May Decrease Risk of Aspiration

• May improve exercise and balance

• Improves Smell & Taste

“Set Yourself and Your Patient Up For Success!”

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Team Approach

Respiratory Therapist

Dietician Physical

Therapist

Nurse Occupational

Therapist

Physician Speech

Therapist

Patient

Patient Selection

Cognitive Status-Awake, Responsive

Attempting to Communicate

– limited sedation needs

Medically Stable

Able to Tolerate Cuff

Deflation

Able to Manage Secretions

orally

Have a patent upper airway

Placement Guidelines

• Patient education

• Peer education

• Patient position

• Suctioning

• Achieve complete cuff

deflation

• Use the warning label

provided with packaging

Patient Assessment

• Oxygenation

• Vital Signs

• Breath Sounds

• Color

• WOB - abdominals

• Patient Responsiveness

To Assess for Upper Airway Patency

• Deflate cuff

• Ask patient to inhale

• Finger occlude and voice or cough on exhalation

• Use mirrors, cotton, whistles or bubbles to assist with the oral exhalation process

• Pressure from trach (whoosh)

Factors Affecting Upper Airway Patency

• Tracheostomy tube size

• Edema

• Granulation tissue

• Vocal fold paresis in adductor position

• Tracheal stenosis

• Secretions

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Downsizing the Tracheostomy

• Improves expiratory pressures1

• Improves speaking valve and capping recommendations, comfort and tolerance1

• Associated with earlier oral intake and reduced length of stay2

• Improves weaning for spontaneous breathing trials3

1. Johnson , JD et al. (2009). The Clinical Respiratory Journal 2009; 3: 8–14. 2. Fisher, D. et al. (2013). Respiratory Care. 2013 Feb;58(2):257-63. 3. Hernandez, G. et al. (2013). Intensive Care Medicine. Jun;39(6):1063-70

Other Considerations to Increase Airflow

• Cuffless

• Fenestrated

• Consider ENT consult

Ventilator Criteria Suggestions

• Patient on <.60 FiO2

• PEEP requirements of

<10cm H2O

• PIP less than 40cm H2O

Patient Guidelines

• Patient Education

• Peer Education – team approach!

• Body Position and Posture

• Position of Head and Neck

• Achieve Cuff Deflation – slowly! (Pulmonary Toilet)

• 100% Cuff Deflation is Mandatory

Tube Position is Important Placement of Passy-Muir® Valve

• Gentle quarter turn twist while stabilizing the flange of tracheostomy tube

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Ventilation Terminology “Must Knows” for Passy-Muir® Valve Use!

• FiO2 = oxygen % (<60%)

• PEEP = positive end expiratory pressure (<10cmH2O)

– Pressure in our lungs at end exhalation (the air we can

never exhale that maintains lung inflation)

• Vt = volume of delivered vent breath (cc’s)

• PIP/PAP = peak airway pressure (<40)

– How much driving pressure from the machine is required

to deliver the set Vt

Assessment Criteria

• Observe pre-cuff deflation PIP

• Observe pre-cuff deflation exhaled Vt

• Achieve cuff deflation – slowly over 5 minutes

• Look for 40 - 50% loss of exhaled Vt

• Look for significant drop in PIP

Q: What does this indicate?

Assessment Criteria

A: This assessment indicates that the

patient can exhale around the properly

sized tracheostomy tube, and the airway

above the cuff is most likely patent.

Assessment Criteria

• 100% cuff deflation • Patient must be able to exhale past the

tracheostomy tube and through upper airway

• Assess air leak/decreased ventilation

• Compensate with ventilator changes

Cuff Inflated-Closed Circuit

500cc 500cc 25cm

H2O

Vt PIP

5 cm H20

PEEP

.30 FiO2

Cuff Deflated-Open Circuit

250cc

250cc 500cc 10cm

H2O

Vt PIP

0 cm H20

PEEP

.30 FiO2

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Passy-Muir® Valve In-line

500cc

0cc 500cc 10cm

H2O

Vt PIP

0 cm H20

PEEP

.30 FiO2

Ventilator Adjustments

700cc

0cc 700cc 20cm

H2O

Vt PIP

0 cm H20

PEEP

.30 FiO2

15cm H20 30cm H20

Ventilator Assessment and Adjustments

• PEEP on/off

• Volume compensation during cuff deflation

– Increase Vt in small increments to achieve pre-cuff

deflation pressures (PIP)

• Use low pressure alarm as disconnect/indirect low

exhaled Vt alarm (set above 10cm H20)

• Set high pressure limit appropriately (10–15cm H20

above the PIP)

Ventilator Assessment and Adjustments

• Pressure versus flow trigger

• Pressure Support (PS)

– Use E-Sense, inspiratory cycle off, or set I-time to time limit

PS breath

• Pressure Control

– Set I-Time

• Consider NIPPV mode

Review

• Adjust PEEP

• Slow cuff deflation

• Monitor pressure/volume

loss

• Place Passy-Muir® Valve

• Compensate for volume/pressure loss

• Time limit PS breaths

• Set alarms appropriately

Ventilator Alarms for Passy-Muir® Valve Applications

• Low exhaled Vt

• Low pressure alarm – MUST be set 5 to 10 cm below

PIP

• High pressure alarm – Should be set 10cm above

PIP

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Humidification

• Heat/moisture exchanger (HME) is ineffective

• Use heated humidified system

• Remove Passy-Muir® Valve for medicated

treatment

Ventilator Connections

22/22mm Silicone Adaptor

Omni-Flex™

Dual-Axis Swivel

15mmx22mm Step Down Adapter

Cuff Inflated-Closed Circuit

300cc

300cc

25cmH2O

VT PIP

5 cm H20

PEEP

Cuff Deflated-Open Circuit

300cc

150cc

VT PIP

12cmH2O

150cc PEEP

0 cm H20

PMV In-line

300cc

0 cc

12cmH2O

VT PIP

300cc 0 cm H20

Ventilator Adjustments

450cc

0 cc

20cmH2O

VT PIP

15cmH2O 30cmH2O

0 cm H20

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Ventilator Assessment and Adjustments

• PEEP Off

• Volume compensation during cuff deflation

• Use low pressure alarm as

disconnect/indirect low exhaled Vt alarm (set above

10cm H20)

• Set high pressure limit appropriately (10-15cm H20

above the PIP)

Ventilator Assessment and Adjustments

• Volume Compensation During Cuff Deflation

– Increase VT in small increments to achieve pre-cuff

deflation pressures (PIP)

• Pressure Compensation During Cuff Deflation

– Seldom increase PC (sometimes decrease) in small

increments to achieve audible voice and adequate

ventilation

Flow/Time Limit Pressure Support Breaths

Flow limit

• The pressure support

breath by increasing the % flow deceleration that

must be reached prior to breath termination

– Ranges 20 to 80%

Time limit

• Set Ti time

– A typical setting for most adults is 1 second

Review

• Adjust PEEP

• Slow cuff deflation

• Monitor pressure/volume

loss

• Place Passy-Muir® Valve

• Compensate for volume/pressure loss

• Time/flow limit PS breaths

• Set alarms appropriately

Patient Assessment

• Oxygenation

• Vital Signs

• Breath Sounds

• Color

• WOB - abdominals

• Patient Responsiveness

• Assess for back pressure

(PSSH sound)

Limiting Pressure Support Breaths

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Interdisciplinary Education and Practice

The IHI Triple Aim®

• http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/

default.aspx

#1

Strategies to Improve Patient Experience of Care

Patient/Family Engagement

• Promote patient/family engagement for self-management and assistance with functional goal setting with a focus on – Function

– Impact on the patient’s ability to participate in life

– Outcomes that matter to the patient.

• RESULT: – Quicker weaning and increased speaking valve use (Speed

& Harding, 2012)

– Shorter decannulation time and length of stay (Tobin & Santamaria, 2008)

Roles/Responsibilities

• Speech-Language Pathologist

• Respiratory Therapist

• Nurse

• Certified Nursing Assistant

• Physician

• Physical Therapist

• Occupational Therapist

• Rehabilitation Technologist

• Dietitian

Promise Tracheostomy Team

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Specialized Role of the Speech-Language Pathologist

• Completing communication and swallowing

evaluations and treatments specific to the patient with a tracheostomy tube and mechanical

ventilation

• Leading or facilitating the communication between the team and the patients in many

aspects of care, including patient education on tracheostomy care, speaking valve placement

and safety for oral intake.

Things I needed to know but didn’t…

• Transdisciplinary skills

– Oral and tracheal suctioning

– PEG tubes

– Nasogastric tubes

– IVs

– Ventilators (what it did, what the setting meant)

– Interaction between the tracheostomy tube and

ventilator

Tracheostomized/Ventilated Patient

• Tracheostomy tube size and fit

• Presence or absence of a cuff

• Upper airway patency

• Ventilator settings (mode, respiratory rate, PEEP, FiO2)

Specialized Role of the Speech-Language Pathologist

• Result:

– Individualized care

– Early intervention (Burkhead, L, 2011)

– Increase staff efficiency

– Burkhead, L. (2011). Swallowing Evaluation and Ventilator Dependency – Considerations and Contemporary Approaches.

Perspectives on Swallowing and Swallowing Disorders

(Dysphagia) March 2011 20:18-22.

Documentation/Technology

• Speech-Language Pathologists must streamline

the documentation process and utilize innovative technology to reduce the per capital cost of

health care (e.g., team meetings, rounds, ongoing competency trainings, policies and procedures).

– Ad Hoc Committee on Reframing the

Professions (December 2013)

Documentation

• General staffing meetings

• Tracheostomy team meetings

• Competency training

• Policies and procedures

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Technology

• Benefits of cuff deflation

• Speaking valve use

• Decannulation

Collaborative Education

• Benefits of speech therapy services for the

tracheostomized and ventilated patient:

– Cuff deflation and speaking valve use

– Tracheostomy systems

– Augmentative and alternative communication

• Result:

– Improved patient outcomes

Expertise of the Speech-Language Pathologist

• Higher level of skilled training and competency

– Post-graduation through continuing education efforts and

on-the-job training.

– My expertise came from:

• Continuing education courses

• On-The-Job training

• Consulting work

• Speaking engagements

SLP can provide specialized training for other disciplines

Skills that SLP may need training on

Suctioning

Indications for tracheostomy

Complications of tracheostomy tubes

Relationship between respiration and swallowing

Technology and interventions

Cuff management

Speaking valve use

Tracheostomy care

Ventilator settings and alarms

RT Training Group of SLPs

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Things SLP can train RT on

• Speaking valve use

• Techniques for speaking and swallowing

• Airway patency

• Benefits of cuff deflation

Joint Roles and Responsibilities

• Speech-Language Pathologist and Respiratory

Therapist

– Result:

• Indications for early intervention.

• Discipline-specific and transdisciplinary roles and

responsibilities

• Specialized collaborations between SLPs and Respiratory

Therapists

Tracheostomy Teams

• Positive Outcomes: – increased speaking valve use

– quicker weaning and decannulation

– reduction in adverse events

– potential for financial savings for institutions

Cameron et al. (2009) - Tracheostomy Review and Management Service

Yu, M. (2010)

Wilcox and Schmidt (2009)

(Speed and Harding, 2012; Leblanc et al., 2010; Garrubba et al., 2009; Tobin and Santamaria, 2008; Norwood et al., 2004).

#2

Strategies for Reducing Per Capita Costs

Direct vs. Consultative Model

• Speech-Language Pathologists must shift the focus

from direct service to a consultative model

– (Ad Hoc Committee on Reframing the Professions of

Speech-Language Pathology and Audiology, December

2013)

• The patient and family are educated and trained to practice between visits, for example: use of

speaking valves, tracheostomy care, and oral/tracheal suctioning.

• Result: Continuum of Care

Interprofessional Education

• Examples of interprofessional education

– Co-curricular education (in-services, webinars with

multidisciplinary attendance)

– Core competences for collaborative practice

– Formal vs. informal activities

• Staff meetings

• Lunch and Learn with vendors

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Educating Future Clinicians

• Benefits of having clinical practicum participants

engaged in transdisciplinary care

• Concurrent supervision by Speech-Language

Pathologists and professionals outside of communication sciences and disorders (Ad Hoc Committee on Interprofessional Education,

November 2013).

– Respiratory Therapist – tracheostomy care

– Nurse – PEG tube

– Dietitian – diet modifications

#3

Strategies to Improve the Health of Populations

Facilitate Communication

• If speech-language pathologists facilitate communication between

health care providers and patients – enhance medical environments (e.g., ICU) for better

communication.

• Result: Health care providers and patients will

comprehend and participate more effectively in managing their medical conditions and care

Outcome Measures

• Speech-language pathologists must utilize

outcomes measures with data collection that focuses on quality care with reduced costs to

patients and to healthcare.

• Results: weaning rates, decannulation rates, adverse event rates, aspiration rates, oral intake

progression, and length of stay.

Team Development

• Prove process success by:

– Collecting outcome measures

– Obtaining media coverage for public education

– Presentations at health care conferences to further changes in healthcare practices.

• Results:

– Buy-In from other professionals

– Marketing opportunities

– Successful programs

Where we are today

• New mind sets

• Faster consults

• More aggressive treatments sooner

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Interprofessional Education and Practice

Respiratory Therapist

Dietician Physical

Therapist

Nurse Occupational

Therapist

Physician Speech

Therapist

Patient

Respiratory Mobility

Tracheostomy Teams

• Increased speaking valve use

• Improved decannulation time

• Reduce Length of Stay (LOS)

• Reduced costs

Speed, Lauren, and Katherine E. Harding. Journal of Critical Care (2012).

Interprofessional Practice

• What the SLP and RT can do together:

– Co-treat during speech and swallowing treatments

– Collaboratively reassess as needed

– Provide interprofessional treatment plans

Multi-disciplinary Tracheostomy Weaning Protocols • Increase amount of

patients decannulated

• Reduce time to decannulation

• Assign clear responsibilities to team members

• “The tracheostomy tube decannulation process is well suited for therapist-implemented protocols.”

Christopher, KL. (2005). Respiratory Care, Vol 50

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Now that my patient has on the Passy-Muir valve, and I have a successful

interprofessional team in place, what

treatment should I do?

Speech Techniques to Increase Vocalization

What’s the problem?

• Is the patient mouthing words?

• Airway patency issues?

• Vocal fold paresis/paralysis?

• Poor breath support?

• Poor coordination?

• Cognitive/linguistic issues?

• Candidate for downsize or decannulation?

• Candidate for vocal techniques/technologies?

Is the patient mouthing words? Yes…

Patient Assessment:

• The patient tolerates the

valve and vitals are WFL

• No voice

Techniques:

• Ask the patient to cough,

hum, blow

• For children: Play, tickle

Sebastian Airway patency issues

• Noted by desaturation, difficulty breathing,

incomplete exhalation through upper airway,

pressure from trach tube upon removal of valve

• Diagnosis of tracheal malacia or stenosis

• Muffled voice

• What can I do:

• Assess airway patency

• Downsize

• XLT Distal trach to bypass an obstruction

• ENT consult/bronchoscopy

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Tube Position is Important Video: Patency Issues

Video: Patency Issue Resolved Vocal fold paresis/paralysis

• Vocal Folds in abducted position

– Good tolerance of valve

– Whispery voice

– Cough is weak

• What can I do:

• ENT consult

• Vocal fold adduction

exercises once assessed

by ENT

Poor Breath Support

• Voice “runs out of air”

• Typical for patients with

spinal cord injury, neuromuscular disorders

• What can I do:

• Diaphragmatic breathing

exercises

• Expiratory muscle

strength training

Poor breathing/speaking coordination

• Vent may cause incoordination

• Patient may speak on inhalation and

exhalation

• What can I do?

• Set i-time on ventilator

• Increase/decrease set

respiratory rate

• Coordinate speech on

exhalation

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Cognitive-Linguistic Deficits:

• Traumatic brain injury

• Stroke

• Apraxia

• What can I do?

• Place the Passy-Muir®

Valve

• Continue with speech

therapy treatment

APPLICATION AND PLACEMENT OF THE PASSY-MUIR® VALVE

Patient in Coma with Passy-Muir® Valve

Downsizing the Tracheostomy Tube

• Improves expiratory pressures1

• Improves speaking valve and capping recommendations, comfort and tolerance1

• Associated with earlier oral intake and reduced length of stay2

• Improves weaning for spontaneous breathing trials3

1. Johnson , JD et al. (2009). The Clinical Respiratory Journal 2009; 3: 8–14. 2. Fisher, D. et al. (2013). Respiratory Care. 2013 Feb;58(2):257-63. 3. Hernandez, G. et al. (2013). Intensive Care Medicine. Jun;39(6):1063-70

Other Considerations to Increase Airflow

• Cuffless

• Fenestrated

• Consider ENT consult

Decannulation

• Improves cough and swallow which are indicators

of decannulation

• Removal of the trach is first recommendation by

CDC to reduce pneumonia

• How can we decannulate faster?

• -Early speaking valve use

• -Protocols

• -Tracheostomy team

Pre-Decannulation

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Post Decannulation Candidates for Decannulation

• Consider the original reason for the trach

• Weaned from mechanical ventilation, effective coughing, no significant upper airway lesion1

• Absence of distress, stable arterial blood gases, hemodynamic stability, absent fever1

• A peak cough flow of 160 liters/minute2

• Survey: patient’s level of consciousness, cough

effectiveness, secretions, oxygenation3

1. Christopher, K.(2005). Respiratory Therapy. 50(4):538 –54. 2. Bach & Saporito, (1996). Chest. 110(6): 1566-71. Stelfox, H. et al (2009). Respiratory Care. 54(12): 1658-68.

Vocal Technologies/Techniques:

• Technologies:

– Blom Trach

– Capping

– AAC devices

• Techniques:

– Blowing activities with visual feedback

– Digital occlusion

– Visual and tactile sensory feedback to elicit voice onset

Techniques for Swallow Management

Disuse Atrophy

• Mechanical ventilation can cause atrophy, and

injury of diaphragmatic muscle fibers

• “Patients in intensive care lose about 2% of

muscle mass a day during their illness.”1

• Muscle weakness predicts pharyngeal

dysfunction2

1. Jaber, S.et al, 2011; Griffiths, BMJ, 1999

2. Mirzakhani, H. et al Anesthesiology. 2013

Cuff deflation

• Cuff deflation must be achieved to fully assess

the pharyngeal stage of the swallow.

• “An individual who is so medically fragile as to

preclude cuff deflation is not usually a

candidate for significant oral intake.”

Dikeman, K, Kazandjian, M, 2003

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Effect of Mechanical Ventilation on Swallowing:

• Ventilator modes with a pre-set breath may push air at a time the patient is trying to maintain airway closure for a swallow.

• If the cuff is deflated, without a Passy-Muir® valve, a translaryngeal leak may occur on inspiration and expiration.

Cuff Deflation Benefits for Swallow

• Reduces aspiration1, 2

• Improves laryngeal elevation

• Weaning time was shorter in cuff deflated -average of 3 days versus 8 days3

• Fewer respiratory infections including ventilator associated pneumonia in cuff deflated group (20% vs. 36%) 3

• Swallowing better in cuff deflated group and improved more from baseline3

1. Davis, et al. (2002). Journal of Intensive Care Medicine. 17(3): 132-135. 2. Ding, R. & Logeman, J. (2005). Head & Neck. 27(9):809-13

3. Hernendez, et al. (2013). Intensive Care Medicine. 39(6):1063-70

Swallowing Treatment

Early placement of the Passy-Muir® Valve may

provide “physical therapy” to the upper airway, helping to reduce effect of muscle atrophy, and

improve pharyngeal and laryngeal swallowing function.”

Burkhead, 2007

Early Use of a Passy-Muir® Valve for Swallowing Evaluation and Rehabilitation

• Re-connects the upper and lower airway and normalizes the aerodigestive tract and prevents disuse atrophy.

• Allow patients to communicate orally and actively participate in healthcare decision making.

• Perform swallow treatment as if your patient did not have a tracheostomy tube once the Passy-Muir® Valve is in place.

• Goal of decannulation

One Way Valve Reduces Aspiration Further

• Improved scores on penetration-aspiration scale1

• Restores expiratory airflow2

• Improves laryngeal

clearance2

• Improved secretion rating

scale3

• Maintain lung volumes4

• Restores subglottic air

pressure5

1. Suiter, D. Head and Neck. 2005. Sep;27(9):809-13

2. Prigent, Helene. Intensive Care Med. 2012 June38(1):85-90.

3. Blumenfeld, L. Oral Abstract Presented at Dysphagia Research Society Annual Meeting 2012

4. Gross, R., et al. (2006). The Laryngoscope, 116:753-761

5. Eibling, D., & Gross, R. (1996). Annals of Otology, Rhinology, & Laryngology, 105(4):253-8.

What’s the problem?

• Reduced base of tongue strength?

• Reduced laryngeal elevation?

• Reduced vocal fold closure?

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Therapy: Frequent Swallow Techniques with the Passy-Muir® Valve

• Base of tongue weakness

– Masako Maneuver

• Laryngeal excursion

– Pitch gliding

– Effortful swallow

– Mendelsohn Maneuver

Frequent Swallow Techniques with the Passy-Muir® Valve

• Vocal fold adduction exercises

– Forceful phonation (/ha-ha)

– Coughing, throat clearing

– Pressure against a resisting force

• Vocal Fold abduction

– Sniff and breathe out through mouth

Video from Madonna swallow exercise

• https://www.youtube.com/watch?v=d168L1E8tX0

&list=UUrJ_BmcqlCosF1heNCiLWKg&feature=c4-overview

VENTILATOR APPLICATION OF THE PASSY-MUIR® VALVE

Compensatory Strategies and Diet Modifications

• Generally the same as non-trach/non-ventilator

dependent patients

Compensatory swallowing strategies

• No Straws • Small Bites/Sips • Assistance/Supervision with

Meals • Sit Upright • Don’t Talk While Eating • Eat Slowly • Alternate Solids & Liquids • Double/Multiple Swallows • Clear Throat after Swallowing • Effortful Swallow • Lingual sweep • Straw progression • Liquid wash • Visual inspection s/p swallow • Imposed rest breaks

• Chin Tuck to ______________ • Head Tilt to L R • Chew food on the L R • Head Turn to L R • Check for Dentures • Crush medications-Consult MD

first • Avoid foods with small pieces • Remain upright for _____ minutes • Thicken Liquids ____________ • Avoid certain foods • Verbal/Visual/Tactile Cues • Bite size awareness • Posture or position during and

after eating

Modifications in diet textures

• NDD Level 1: Dysphagia-Pureed (homogenous, very cohesive, pudding-like, requiring very little chewing ability).

• NDD Level 2: Dysphagia-Mechanical Altered (cohesive, moist, semisolid foods, requiring some chewing).

• NDD Level 3: Dysphagia-Advanced (soft foods that require more chewing ability).

• Regular (all foods allowed).

• McCullough, G. , Pelletier, C. & Steele, C. (2003,

November 04). National Dysphagia Diet: What to Swallow?. The ASHA Leader

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Liquids

• Proposed terms for liquids and correlating viscosity ranges: 1. Thin 1-50 centiPoise (cP) 2. Nectar-like 51-350 cP 3. Honey-like 351-1,750 cP 4. Spoon-thick >1,750 cP

• McCullough, G. , Pelletier, C. & Steele, C. (2003, November 04). National Dysphagia Diet: What to

Swallow?. The ASHA Leader

Treatment Considerations

• Coordinate breathing and swallowing.

• Time the swallow with higher lung volumes.

• Improve cough.

• Mobilize lung and oral-pharyngeal secretions.

• Expiratory muscle strength training.

– The Breather

– Acapella

– EMT

Assessing Cough Strength

Peak Cough Expiratory Flow

• Greater than 160L/min are needed to

clear secretions

Miller, R.G. et.al.(2009). Neurology 13; 73(15): 1218-1226

VENTILATOR APPLICATION OF THE PASSY-MUIR® VALVE

Respiratory Muscle Training

• Therapy to assist in lung expansion, coughing

and airway clearance

– Acapella

– The Breather

FEES Before and After Passy-Muir ® Valve

• http://www.passy-muir.com/pmvideos

• Liza Blumenfeld, MS, CCC-SLP, Scripps Memorial

Hospital, La Jolla, CA

Sensory Awareness

• Non‐food taste stimulation

• Thermal stimulation

• Taste stimulation

• Tactile and verbal cues

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Q and A Thank you!