Application of the Passy-Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients

3/7/2013

APPLICATION OF THE PASSY-MUIR® SWALLOWING AND SPEAKING VALVES FOR TRACHEOSTOMIZED AND VENTILATED PATIENTS Leigh Anne Baker, M.S., CCC-SLP, BRS-S Passy-Muir Inc. Clinical Consultant

LOUISIANA STATE U NIVERSITY – HEALTH SCIENCES CENTER NEW ORLEANS, LOUISIANA

[email protected] 225-610-8770

Disclosure: Financial — Received a speaking fee from Passy-Muir, Inc. for this presentation. Nonfinancial — No relevant nonfinancial relationship exists.

Course Outline

David A. Muir

I NVENTOR OF THE PASSY-M UIR® VALVE

• • • • • • • • • • • • • • •

Physiology of Swallow Aspiration Risk Trach Tubes: Clinical Complications and Swallow PMV Design PMV Benefits Types of PMV Patient Assessment Application of PMV Troubleshooting/Treatment Planning Respiratory Failure Types of ventilation Modes of ventilation RT terminology Optimal vent settings for PMV placement Vent Connections

The Aerodigestive Tract Is a Shared System

Physiology of Swallow

Leigh Anne Baker, M.S., CCC-SLP, BRS-S Passy-Muir Inc. Consultant

• Respiratory system shares a common functional space with the digestive tract and the vocal tract. • We never fully exhale (i.e. physiological PEEP)

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Application of the Passy-Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients

The Upper-Aerodigestive Tract Is a Valving System • Beginning at the lips and ending at the UES, the valves are always permitting or preventing airflow, food, or liquids from going one direction to another.

Pharyngeal Stage of Swallowing • Hyo-laryngeal anterior motion provides some airway protection and opens UES sphincter • Bolus pressure widens opening of UES • Closure of the laryngeal valving system.

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Oral Preparatory & Oral Stage of Swallowing • Readiness to accept the bolus, including level of alertness. • Positioning, dentition, and medications may affect this stage. • Valving system: lip closure, lingual propulsion, velopharyngeal closure.

Respiratory Pause •

•

In healthy adults there is a respiratory “pause” during the swallow, with swallowing occurring most often in mid-expiration There is evidence that swallows occurring at lower lung volumes such as exhalation to inhalation transition are more likely to result in aspiration

Esophageal Phase of Swallowing • Reflexive phase transports the bolus via peristaltic wave through the esophagus to the stomach.

Leigh Anne Baker, M.S., CCC-SLP, BRS-S Passy-Muir Inc. Consultant

Aspiration Risks

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Application of the Passy-Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients

Effects of Tracheostomy on Normal Swallowing Function • A Tracheostomy is often preceded by an endotracheal tube intubation (oral or nasal)

Aspiration Pneumonia Is an Opportunistic Infection • Something must be aspirated. • Aspirate must contain a respiratory pathogen. • Must be able to overwhelm patient’s normal defense/immune system.

Tracheostomy and Aspiration • • •

Does a cuff prevent aspiration? Definition Incidence of aspiration – 50% - 87% rate for trach and vent patients

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Well Documented Complications Associated with Endotracheal Tubes: • Mucosal injury • Blunting of glottic reflexes • Free passage (aspiration) of oralpharyngeal secretions into the upper airway with a heightened risk for Ventilator Associated Pneumonia (VAP)

Additional Identified Risk Factors Predisposing Patients to Aspiration Include: • Witnessed aspiration secondary to emesis or reflux. • Supine position and coma. • Enteral nutrition (i.e., presence of a nasogastric tube). • Multiple intubations or self-extubation.

Aspiration • Is this a causal relationship? Some researchers think so; However… • Other factors cited to contribute to aspiration include intubation and underlying critical illness

(Elpern et al., 1987, 1994, 2000; Tolep et al., 1996)

– 75% silent aspiration (Davis & Stanton, 2004; Elpern et aI., 1994).

– Aspiration around the cuff (Bone, Davis, Zuidema, & Cameron, 1974; Elpem et al.,1987; Nash, 1988; Pavlin, VanNimwegan, & Hombein, 1975; Ross & White, 2003)

Leigh Anne Baker, M.S., CCC-SLP, BRS-S Passy-Muir Inc. Consultant

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Application of the Passy-Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients

Additional Identified Risk Factors Predisposing Patients to Aspiration Include: • COPD, age > 60 years, and acute respiratory distress syndrome • Prior exposure to antibiotics which predispose the patient to colonization of the upper aerodigestive tract. • Infection control lapses, including hand washing and non-sterile tracheal suctioning

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Ventilator Associated Pneumonia (VAP) •

•

VAP is defined as nosocomial (hospital acquired) pneumonia occurring in patients after 48 hours of mechanical ventilation via endotracheal tube or tracheostomy tube Oral-pharyngeal secretions colonized with bacteria bypass the cuff on the ET tube or tracheostotmy tube and pass into the lower respiratory tract.

Factors Related to Dysphagia Which May Influence Cost of Care for Tracheostomized Patients: • Pulmonary complications from aspiration, use of antibiotics, reduced weaning, and prolonged ICU/hospital stay. • Late onset aspiration due to undiagnosed laryngeal injury or impairment. • Depression and reduced patient participation in care, reduced quality of life and impaired communication and loss of control over decision making.

Tracheostomy Basics •

What is a tracheotomy?

– “the making of an incision into the trachea through the neck below the larynx allowing access to the airway1”

•

What is a tracheostomy?

•

What is a tracheostomy tube?

– “an artificial airway created by a surgical opening through the neck for insertion of a tube”

Tracheostomy Tubes and Swallow

Indications for Tracheostomy • Prolonged mechanical ventilation • Inability to perform trans-laryngeal intubation (trauma, max/fax deformity)

• Upper airway obstruction (temporary or permanent) • Secretion management (neuromuscular disease)

– “a tube placed in the trachea to keep the airway to the lungs open following a tracheotomy surgery”

1Singh,

S. and Kent, R. Singular’s Pocket Dictionary of Speech-Language Pathology (2000). Singular Publishing Group.

Leigh Anne Baker, M.S., CCC-SLP, BRS-S Passy-Muir Inc. Consultant

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Application of the Passy-Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients

HOW: TRACHEOTOMY PROCEDURES

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Percutaneous Tracheotomy

Open or Surgical Tracheotomy Tried and True Method Percutaneous Dilatation or Balloon Dilatation Tracheotomy Less costly and more convenient Cricothyoidotomy As seen on ER Shows Does the method of tracheotomy affect outcomes ?

Permission for use granted by Cook Medical Incorporated, Bloomington, Indiana

Parts of a tracheostomy tube - ISO STANDARDS

• Single Lumen/Cannula

Neck flange Tube shaft

Cuff

Tracheostomy Tubes • Double Lumen/Cannula

15 mm connector

Inflation line

Pilot balloon

Pilot port with one way valve

Types of Tubes • MATERIALS – PVC, Silicone, Metal – Metal Reinforced

• SHAPE – Curved, Angular, Nonpre formed

• LENGTH – Standard – Extra length • Proximal • Distal • Adjustable Flange

Calculating Tube Size • • • • • • •

SINGLE LUMEN DOUBLE LUMEN FENESTRATED MRI COMPATIBLE Subglottic Suction Trach Talk CUFFS – Air, water, or foam – Double cuffed – Un-cuffed

• Custom Made

Leigh Anne Baker, M.S., CCC-SLP, BRS-S Passy-Muir Inc. Consultant

• ATS Consensus: The tracheostomy tube should take up no more than 2/3 the ID of the trachea. (for pediatrics, no adult standard)

trachea

O.D. I.D.

• AP Diameter of trachea – Male: 18 +/- 5mm – Female: 12 +/- 3 mm

tube

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Application of the Passy-Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients

Cuff Choices

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Air Filled Cuffs • AIR FILLED – minimal leak

• Cuff Inflated

• Cuff Deflated

• TTS™ : WATER FILLED – minimal occlusion (can be air filled)

• FOME-Cuf® – self sealing

Water Filled Cuffs TTS • Cuff Up

Early Tracheostomy (7-10 days) May: • Cuff Deflated

•

•

• •

A Tracheostomy Alters Physiological Function of Upper AeroDigestive Tract • Aphonia • Reduced ability to expectorate secretions • Reduced sense of taste and smell

Leigh Anne Baker, M.S., CCC-SLP, BRS-S Passy-Muir Inc. Consultant

Reduce incidence of VAP and further injury to the larynx caused by the ET tube. Improve patient comfort including possibility for oral communication and oral diet and requirement for less sedation Improve oral hygiene Improve secretion management

Decreased Physiologic PEEP • Decreased gas exchange due to reduced surface area of alveoli • Poor oxygenation • Possible atelectasis

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Application of the Passy-Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients

Tracheostomy Effect on Swallowing: •

•

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Tracheostomy Effect on Swallowing: “Many physicians conceive of a tracheostomy as a solution to long term aspiration, but in reality, it may increase the problem rather than solve it.” Nash, 1998

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 oralpharyngeal pressure • Impaired hyolaryngeal elevation/excursion • Impaired glottic closure • Reduced subglottic pressures and reduced sensation • Muscle disuse atrophy

Swallowing Complications •

Laryngeal Tethering (Bonanno, 1971; Cameron et aI., 1973; Ding & Logemann, 2005; Nash, 1988)

•

Decreased Sensation in the Oropharynx

2

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

•

Reduced Airway Closure

3 4

(Sasaki and Buckwalter,1984)

•

Reduced Subglottic Air Pressure

1

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

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.

Leigh Anne Baker, M.S., CCC-SLP, BRS-S Passy-Muir Inc. Consultant

The Cuff on the Tracheostomy Tube Is Indicated During Mechanical Ventilation • The cuff is designed to create a “closed” system, so the volume of air delivered to the lungs is not lost due to an upper airway leak. • The cuff may reduce the impact of aspiration, but cannot prevent aspiration because it sits below the level of the true vocal folds.

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Application of the Passy-Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients

Aspiration of Liquid or Food Around the Tracheostomy Tube Cuff Has Been Well Documented • •

•

The tracheal lumen is not static during respiration. Aspiration around the tracheal cuff may be due to the leak caused by tracheal dilation during inspiration, and/or due to secretions which pool above the cuff. The cuff may create a reservoir for pooled or stagnate secretions to colonize and eventually enter the lower respiratory tract.

Mismanagement of Cuff Pressures •

•

Distention caused by the cuffed tracheostomy tube against the esophagus may cause liquids to overflow the UES and fall into the trachea. Refluxed tube feedings or gastric contents may also enter the airway via the same mechanism

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Cuff Mismanagement Has Been Associated with: • Damage to the tracheal mucosa • Tracheal stenosis • Granulation tissue formation • Tracheal erosion • Tracheoesophageal fistula • Tracheal dilation

Evaluation and Rehabilitation of Swallowing in the Tracheostomized Patient “All tracheostomy patients should be referred for speech therapy prior to surgical placement of the tracheostomy or soon thereafter. “ Respiratory Care, April 2005.

Passy-Muir® Valve and Swallowing •

Placing the Passy-Muir valve before your swallowing assessment may enhance your patient’s swallowing performance

Leigh Anne Baker, M.S., CCC-SLP, BRS-S Passy-Muir Inc. Consultant

Passy-Muir® Valve Design

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Application of the Passy-Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients

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Biased Closed Position-No Leak Design

Benefits of Passy-Muir® Valve

Clinical Benefits • Restoration of voice • 100% airflow through vocal tract on exhalation • Improved sense of smell and taste

Improved Swallowing • Decreased Laryngeal Tethering • Increased Sensation in the Oropharynx1 • Improved Airway Closure2 • Restored Subglottic Air Pressure3

2 3 4

1

1. 2. 3.

Improved Swallowing

Synderman & Eibling, 1994; Baker et al., 1994; Detelbach, et al., 1995; Lichtman and colleagues,1995 Sasaki et al., 1977 Gross et al., 2003, 2006

Improved Swallowing

• Laryngeal Elevation • Improved Sensation

Reduced Aspiration

• Vocal Cord Closure • Restored Subglottic Pressure

Dettelbach et al., 1995; Stachler et al., 1996; Elpern et al., 2000; Suiter et al., 2003; Gross et al., 2003

Leigh Anne Baker, M.S., CCC-SLP, BRS-S Passy-Muir Inc. Consultant

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Application of the Passy-Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients

Restored physiological PEEP • Improved gas exchange • Improved oxygen saturation levels • Decreased risk of atelectasis

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Improved Secretion Management • Improved sensation and cough • Decreased suctioning needs • Decreased risk of tracheal damage

Lichtman et al., 1995 Frey and Wood, 1995

Expedites Weaning and Decannulation • Restoration of normal physiology • Utilization of expiratory muscles • Accustomed to a more normal breathing pattern • Able to communicate • Develops confidence and motivation

Cost Savings $9,155/day

About $1 a day

1. Tube Feeding 2. Antibiotics/ ICU stay 3. Vent days/LOS

• Passy-Muir Valve

4. Suctioning Supplies

Frey & Wood, 1991; Sierros, et. al. 2007; Light et al., 1989

Quality of Life…

Types of Passy-Muir® Valves

PRICELESS!!!

Leigh Anne Baker, M.S., CCC-SLP, BRS-S Passy-Muir Inc. Consultant

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Application of the Passy-Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients

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PMV ® 2000 (clear) & PMV ® 2001 (Purple Color™)

PMV® Secure It®

PMA® 2000 Oxygen Adapter

PMV® 007 (Aqua Color™)

Metal Tubes

Patient Care Kit

Original Jackson

Original with 15mm hub and PMV®2000

Improved Jackson with PMV®2020

Leigh Anne Baker, M.S., CCC-SLP, BRS-S Passy-Muir Inc. Consultant

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Application of the Passy-Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients

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Team Approach

Patient Assessment

Speech Therapist Occupational Therapist

Physician Nurse

Patient

Physical Therapist

Dietician Respiratory Therapist

Patient Selection • Awake, responsive, attempting to communicate • Medically stable • Able to tolerate cuff deflation – Vent status – Aspiration status

• Able to manage secretions • Have a patent upper airway

Factors Affecting Upper Airway Patency • Size of Tracheostomy Tube • Presence and Degree of Obstruction • Edema • Secretions • Foam-Filled Cuff

To Assess for Upper Airway Patency • Deflate cuff • Ask patient to inhale • Apply digital occlusion to trach and ask patient to voice or cough on exhalation • Use mirrors, cotton, whistles or bubbles to assist with the oral exhalation process.

Leigh Anne Baker, M.S., CCC-SLP, BRS-S Passy-Muir Inc. Consultant

Application

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Application of the Passy-Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients

Placement Guidelines Patient education Peer education Patient position Suctioning Achieve complete cuff deflation • Use the warning label provided with packaging • • • • •

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Baseline Measurements • • • • • •

Oxygenation Vital Signs Breath Sounds Color Work of Breathing (WOB) Patient Responsiveness

Placement of Passy-Muir® Valve •

Gentle quarter turn twist while stabilizing the flange of tracheostomy tube

Transitioning and Troubleshooting • • • •

Anxiety Airway patency Depression Breathing pattern changes

Swallowing and Passy-Muir® Troubleshooting and Treatment Planning

Cuff Up or Down? • Our pulmonologist directs the nurses to feed the patient with the cuff up. • A clinician asks: Q: How do we educate them about the risks/benefits of cuff deflation? – Review the role of the cuff during mechanical ventilation. – Request a trial of cuff deflation and Passy-Muir® Valve use to restore more normal physiology. – Perform an instrumental exam, and document findings under both conditions.

Leigh Anne Baker, M.S., CCC-SLP, BRS-S Passy-Muir Inc. Consultant

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Application of the Passy-Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients

Treatment Short Term Goals: • • • •

Patient will tolerate cuff deflation and Passy-Muir® Valve placement during supervised trials with speech therapy(30 min), twice daily, to enhance communication. Patient will have functional voice and laryngeal responses (cough, throat clear) when using Passy-Muir Valve, 75% of the time to enhance communication. Patient will expectorate pulmonary secretions when using the Passy-Muir Valve with reduced need for tracheal suctioning, 80% of the time to improve secretion management. Patient will participate in bedside bolus trials, demonstrating prompt and efficient swallow, without signs/symptoms of aspiration, 80% of the time to promote oral feedings.

Treatment Short Term Goals: •

• • •

Patient will tolerate cuff deflation and Passy-Muir® Valve placement during t-piece trials, 30 minutes, twice per day, with maintenance of baseline vital signs, 80% of the time to restore upper airflow/sensation. Patient will participate in respiratory support exercises (diaphragmatic breathing), 10-15 min. per day while using the Passy-Muir Valve to strengthen respiratory muscles. Patient will participate in bedside swallow exam while using Passy-Muir Valve without signs/symptoms of aspiration to determine po readiness. Patient will tolerate ice chip trials, while wearing the PassyMuir Valve , without signs/symptoms of aspiration, 80% of the time to promote oral feedings.

Treatment Short Term Goals: • •

• •

Passy-Muir®

Patient will tolerate Valve placement 30-90 minutes daily with no decline in baseline vital signs, 80% of the time to promote oral communication. Patient will utilize Passy-Muir Valve and participate in vocal function exercises to increase vocal fold adduction for voice as measured by audible phonation attempts , 45% of the time to enhance communication. Patient will utilize Passy-Muir Valve while participating in laryngeal strengthening exercises 90% of the time for improved airway protection during swallowing. Patient will utilize Passy-Muir Valve to maximize benefit of using compensatory swallowing strategies, with reduced episodes of aspiration for liquid trials, 80% of the time.

Leigh Anne Baker, M.S., CCC-SLP, BRS-S Passy-Muir Inc. Consultant

3/7/2013

Work of Breathing • Our pulmonologist will not let us use the Passy-Muir® Valve with our patients during weaning from mechanical ventilation, stating that: “the valve will increase the work of breathing” • A clinician asks: Q: How do I convince him otherwise? – Work of breathing is multifactoral. – Patients may actually benefit from “exercising” the respiratory and upper airway musculature. – There should be careful monitoring of the patient by respiratory and speech.

Dysphonia–Dysphagia Despite Passy-Muir® Valve Use • I have placed the Passy-Muir Valve on my patient, and she tolerates it well, but she only has whispered voice, and we still document aspiration of thin liquids on a VFSS. • A clinician asks: Q: Should I continue to use the Passy-Muir Valve? – What do you observe?

• s/s of dysphonia and reduced airway protection.

– What do you request? • Intubation history. • ENT consult .

– What do you do? • Vocal function/laryngeal strengthening exercises.

Educate and Document • If you didn’t document it, you didn’t do it. • Utilize the instructions and labels that come packaged with the Passy-Muir® Valve. • Develop multidisciplinary policies and procedures for best outcomes.

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Application of the Passy-Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients

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Care, Cleaning, and Lifetime of the Passy-Muir Speaking Valves

VENTILATOR BASICS FOR THE NON-RT

Average lifetime of 2 months

Ventilation and Respiration •

Structures

Ventilation – The act or process of inhaling and exhaling – Breathing – Inhale O2, exhale CO2

• Respiration – Gas exchange at the cellular level

Respiratory Failure • Defined as inability to maintain adequate ventilation to maintain: – normal oxygenation – carbon dioxide elimination – or a combination of both

Leigh Anne Baker, M.S., CCC-SLP, BRS-S Passy-Muir Inc. Consultant

Indications for Mechanical Ventilation • Respiratory failure / impending respiratory failure – – – – –

Post operative – whatever the duration C-spine injuries – quadriplegia Neuromuscular disease – progressing Central sleep apnea – nocturnal ventilation only Trauma – multiple reasons

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Application of the Passy-Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients

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Non-Invasive Ventilation

Invasive Ventilation

Ventilator Settings: Just What Does The Doctor Order?

Ventilator Settings Things The Doctor Does Not Order

• • • • • •

Mode of Ventilation = AC, SIMV, CPAP, etc. Vt = tidal volume (cc or ml) RR = respiratory rate FiO2 = % oxygen PEEP = positive end expiratory pressure Pressure Support/Pressure Control

Types of Ventilation • Volume ventilation = ventilator delivers the pre-set Vt regardless of the peak pressure required. Volume is a constant.

• Pressure Ventilation = ventilator delivers a pre-set

pressure and volume can vary depending on lung compliance/resistance. Pressure is a constant, volume may be variable.

•

• • • • •

Ventilation Terminology Modes of Ventilation – Alphabet Soup! •

SIMV, IMV, with/without PS – synchronized intermittent mechanical ventilation (pressure support is an option)

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A/C and/or PC– assist control ventilation/pressure control

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PRVC – pressure regulated volume control

•

APRV, Biphasic, BiLevel – airway pressure release ventilation

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CPAP/PS – continuous positive airway pressure/pressure support

•

BIPAP – bi-level positive airway pressure --- to name a few!

The higher the pressure, the sicker the lung…

Leigh Anne Baker, M.S., CCC-SLP, BRS-S Passy-Muir Inc. Consultant

Flow Rate – L/min Alarms Settings Trigger Sensitivity Exp % Sensitivity (time limits PS breaths) PIP – Peak Inspiratory Pressure

– this patient is typically too sick for PMV on this mode.

– this is a spontaneous breathing mode.

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Application of the Passy-Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients

Ventilation Terminology “Must Knows” for Passy-Muir® Valve Use! • FiO2 = oxygen % (