A practical approach to tracheostomy tubes and ventilators

1
A practical approach to
tracheostomy tubes and ventilators
Alison McKee, MS CCC-SLP University Specialty
Hospital, Baltimore MD Department of
Rehabilitation Services
Heather Starmer, MA CCC-SLP Johns Hopkins
University, Baltimore, MD Department of
Otolaryngology Head and Neck Surgery
2
Learner objectives

• Discuss different communication options for
  tracheotomized and ventilator dependent patients
• Demonstrate understanding of basic ventilator
  settings and their implications on speech
• Discuss evidence regarding the benefits of voice
  restoration
• Describe ways to initiate an in-line ventilator
  speaking valve program

3
Introduction to trachs

• Indications and types

4
Indications for tracheostomy

• Prolonged mechanical ventilation
• Acute or chronic airway obstruction
• Retention of pulmonary secretions
• Sleep apnea

5
Tracheostomy
6
Anatomy of a trach tube

• 1. Faceplate
• 2. Hub
• 3. Outer Cannula
• 4. Pilot line/pilot balloon
• 5. Cuff

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1
3
5
4
7
Trach tubes (cont.)

• Shiley
• Plastic with white face plate
• Can be cuffed or cuffless
• 1 obturator
• 2 inner cannula

1
2
8
Trach tubes (cont.)

• Portex
• Plastic tube
• Clear or white
• faceplate
• Blue pilot balloon

9
Trach tubes (cont.)

• Bivona aircuff
• TTS (tight to shaft)
• cuff hugs outer
• cannula

10
Trach tubes (cont.)

• Bivona fomecuff (red pilot balloon)
• Used when unable to maintain seal with standard
  cuff
• Reduces risk of damage from over- inflation of
  cuff
• Passive cuff inflation
• Cannot be used with speaking valves

11
Trach tubes (cont.)

• Extra length
• Used primarily with bariatric patients to ensure
  proper ventilation
• Made by most trach
• manufacturers

12
Trach tubes (cont.)

• Bivona/Portex talking trach
• Used for communication with patients who require
  cuff inflation
• Delivery of non-pulmonary air between the
  inflated cuff and the vocal folds

13
Trach tubes (cont.)

• Fenestrated trachs
• Designed to allow communication when on vent
• Problematic due to malpositioning of fenestrates
• Rarely used

14
Trach tubes

• Jackson (metal)
• Used for non-vent patients
• Cuffless model only

15
Tracheostomy speaking valves
16
Nature of the problem

• Diversion of airflow away from larynx
• Inadequate subglottic pressure to cause vocal
  fold vibration

17
The solution

• Re-establish airflow through the larynx
• Substitute alternative vibration source if larynx
  is not accessible

18
Speaking Valve Function

• Patient can continue to breath in through the
  trach tube
• Exhalation is then redirected up through the
  trachea creating a closed system
• Promotes a more normal respiratory pattern for
  breathing and expelling secretions

19
Currently prevalent speaking valves

• Passy Muir Speaking Valve Biased closed valve
• Perceptually best quality voice
• Fewest clinically relevant mechanical problems
• Reduced effort required to initiate voice
• (Zajac et al. Journal of Speech, Language, and
  Hearing Research 1999
• Leder. Journal of Speech and Hearing Research
  1994)
• Montgomery Speaking Valve Biased open valve
• Good to use for patients with mild upper airway
  obstruction due to cough release mechanism

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Passy Muir Speaking Valve

• Four different styles
• PMV 2001
• PMV 005
• PMV 007 (vent)
• PMV 2000 (low profile)

1
2
1
1
4
3
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Montgomery Speaking Valve

• 2 different styles
• Tracheostomy valve
• Ventilator valve

1
2
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Speaking Valves

• Primary benefit
• Communication
• Successful restoration of verbal communication in
  vented and trach dependent patients
• Patient reported improvement in psychosocial
  functions and emotional status
• Improvements noted in adults as well as pediatric
  patients
• (Manzano et al. Critical Care Medicine 1993
• Passy et al. Laryngoscope 1993
• Hull, et al. Pediatric rehabilitation 2005)

23
Speaking Valves

• Secondary benefits (Passy Muir only)
• Swallowing
• Reduced occurrence of laryngeal
  penetration/aspiration
• Reduced amount aspirated
• (Suiter, McCullough, Powell. Dysphagia 2003
• Stachler, Hamlet, Choi, Fleming. Laryngoscope
  1996
• Dettlebach, Gross, Mahlmann, Eibling. Head and
  Neck 1995)

24
Speaking valves

• Secondary benefits (Passy Muir only)
• Secretion management
• Subjective patient report of reduced oral and
  nasal secretions (Passy et al. Laryngoscope 1993)
• Reduced secretion production over 24 hour period
  (Lichtman and Birnbaum. Journal of Speech and
  Hearing Research 1995)
• Olfaction (Lichtman and Birnbaum. Journal of
  Speech and Hearing Research 1995 Passy et al.
  Laryngoscope 1993)

25
Speaking valves

• Secondary benefits (Passy Muir only)
• Vent weaning/decannulation
• (Fukumoto, Ota, Arima. Critical Care
  Resuscitation 2006)

26
Speaking Valve Candidacy

• Can be used with trach patients on and off the
  vent
• Pt should be awake, alert, and attempting to
  communicate
• Airway patency trach size/ of intubations
• Can be used for decannulation purposes in
  patients who are not communicative

27
Contraindications for speaking valve use

• Cuff inflation
• Fome cuff trach
• Thick, copious secretions
• Total laryngectomy
• Laryngeal masses, stenosis, inadequate patency of
  upper airway

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Communication restoration in the trach patient

• Assess size and type of tracheostomy tube
• Patients with Fome cuff trachs are not candidates
  for speaking valves secondary to passive
  inflation of cuff
• Larger diameter trachs may result in inadequate
  airflow through the upper airway (ideal size of
  trach is 2/3 size of tracheal lumen)
• Specialty trachs can be utilized for abnormal
  airways (e.g. extra length, double cuff, stoma
  cuff, TTS)

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Speaking Valve Assessment

• Verify and record baseline vital signs
• Slowly deflate cuff (1cc at a time) and monitor
  pts vitals and work of breathing
• Suction patient if necessary
• Verify voice by digital occlusion of trach
• Apply speaking valve and monitor for changes in
  voice, vitals, or work of breathing
• Advance time of use as tolerated

30
Communication options for ventilator dependent
patients
31
First steps

• Assess size and type of tracheostomy tube
• Determine reason for trach/vent dependence
• Assess vent settings and recent weaning course
• Discuss patient status with respiratory therapist
  and pulmonary team

32
Ventilator modes

• Assist control (AC) Machine does all the work.
  If the pt attempts to trigger a breath the vent
  will deliver the volume predetermined by the vent
  setting at the preset rate
• Pressure Regulated Volume Control (PRVC), adjusts
  pressure delivered during each breath to ensure
  target volume
• Used in the most compromised pulmonary patients

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Ventilator modes (continued)

• Synchronized Intermittent Mandatory Ventilation
  (SIMV) Vent will deliver a predetermined number
  of breaths per minute at a certain volume. If pt
  initiates breaths, those breaths will be at the
  pts spontaneous volumes
• Used in beginning of weaning

34
Ventilator modes (continued)

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

35
Ventilator modes (continued)

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

36
Ventilator settings

• Rate Predetermined, minimum number of breaths
  per minute which will be delivered to the
  patient.
• Tidal volume The volume of air delivered with
  every mechanical breath.
• Pressure support - The pressure delivered with
  each inspiration.
• Positive end expiratory pressure (PEEP)
  Positive pressure which is present at the end of
  expiration
• Fraction of inspired oxygen (FI02) percentage
  of oxygen delivered with each breath.

37
Vent setting implications for verbal communication

• Tidal volume Patients who require high tidal
  volumes may have more difficulty with cuff
  deflation due to difficulty compensating for loss
  of volume and inability to adjust tidal volumes
  above a certain level.
• Some pulmonologists feel that patients with tidal
  volumes greater than 800 are not candidates for
  cuff deflation/inline PMV

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Vent setting implications for verbal communication

• PEEP The PMV adds 2 cm of PEEP. PEEP gt7 can
  lead to barotrauma. Patients receiving gt5 of
  PEEP at baseline may need to have the vent
  adjusted for the added PEEP from the PMV.
• Pressure support As with PEEP, high airway
  pressures can lead to barotrauma. In general,
  patients with PS gt10 are not candidates for
  inline PMV.

39
Vent setting implications for verbal communication

• FI02 Patients with higher oxygen requirements
  often do not tolerate cuff deflation due to
  inability to compensate. Generally speaking,
  patients with FI02 gt60 dont do well with cuff
  deflation/inline PMV.

40
Vent setting implications for verbal communication

• Rate Again, patients with higher respiratory
  rate requirements are less likely to adjust to
  changes in ventilation. Generally speaking,
  patients with set rates of gt16 may not do well
  with cuff deflation/inline PMV.

41
Other considerations

• Peek airway pressures Patients with baseline
  peak airway pressures gt40 are not candidates for
  inline PMV secondary to risks of barotrauma (as
  measured at rest, not during phonation attempts
  or coughing)
• Secretions Patients with excessive secretions
  may not be able to tolerate cuff deflation or
  inline PMV.

42
Verbal communication options for vent dependent
patients

• Leak speech/cuff deflation
• Inline Passy Muir Valve
• Talking trach tubes
• Electrolarynx

43
Leak speech/cuff deflation

• Requires
• - Intact or relatively unimpaired
  articulators
• - Fairly stable pulmonary status
• - Patent upper airway
• - Functional vocal fold mobility
• Contraindications
• - High oxygen requirements
• - High tidal volumes

44
Leak speech assessment

• Consult with pulmonary or respiratory departments
  to determine pt stability
• Verify and record vent settings
• Verify and record baseline vital signs
• Suction orally and via trach if necessary
• Slowly deflate cuff (1cc at a time) and monitor
  pts ability to phonate as well as pts VS and
  WOB suction again if needed

45
Leak Speech Assessment cont.

• Disable low minute volume alarm.
• Monitor pt 11 during initial trial and
  discontinue if HR or RR increase, if SaO2
  decreases, if pt has severe and intractable
  coughing, or if the pt c/o excessive SOB.
• Advance time gradually according to tolerance

46
Keep in mind with leak speech

• Vent settings, particularly tidal volume and
  pressure support will impact the pts voice
  production.
• If pt is unable to achieve any voice
  (particularly if low minute volume does not alarm
  at all), suspect excessive trach size.

47
Keep in mind with leak speech cont.

• Tidal volumes may be adjusted to assist with
  voice production.
• ENT consultation if persisting dysphonia/aphonia.

48
Inline PMV

• Requires
• - Intact or relatively unimpaired articulators
• - Fairly stable pulmonary status
• - Patent upper airway
• - Functional vocal fold mobility
• - Good tolerance of cuff deflation
• Contraindications
• - High oxygen requirements
• - High tidal volumes
• - High PEEP
• - High pressure support

49
Inline PMV assessment

• Consult with pulmonary or respiratory departments
  to determine pt stability
• Coordinate with RT for initial evaluation
  (recommend assessment of tolerance of cuff
  deflation prior to initial inline PMV trials)
• Verify and record baseline vent settings
• Verify and record baseline vital signs
• Suction orally and via trach if necessary
• Slowly deflate cuff (1cc at a time) and monitor
  pts ability to phonate as well as pts VS and
  WOB suction if necessary

50
Inline PMV assessment cont.

• Disable low minute volume alarm.
• Monitor pt 11 during initial trial and
  discontinue if HR or RR increase, if SaO2
  decreases, if pt has severe and intractable
  coughing, or if the pt c/o excessive SOB.
• Advance time gradually according to tolerance

51
Problems you may encounter

• Problem Good vital signs but poor phonation
• Solutions
• 1. RT can make vent adjustments including
  increasing tidal volume or PEEP
• 2. ST can focus on maximizing respiratory
  support for phonation through traditional voice
  therapy techniques
• 3. ENT can assess for glottic closure issues

52
Problems you may encounter

• Problem Severe coughing
• Solutions
• 1. Revert back to cuff deflation trials to
  desensitize the upper airway
• 2. Keep cuff deflated throughout the day for
  greater desensitization
• 3. Do short, intermittent PMV applications
  until pt becomes used to airflow

53
Problems you may encounter

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

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Developing an in-line protocol
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Protocols and Procedures

• Obtain access to/create PMV policy and procedure
  (see handout)
• Determine responsible parties SLP, RT,
  pulmonologist and nursing
• Determine selection criteria See previous slide
  on speaking valve candidacy
• Meet with appropriate committee to review draft
  and determine approval process

56
Determine responsible parties

• Pulmonologist Initiate consultation and
  communicate any change in status that may impact
  candidacy for valve use

57
Determine responsible parties

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

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Determine responsible parties

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

59
Determine responsible parties

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

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In-line protocol inclusions

• Establish candidacy in conjunction with RT and
  pulmonary
• Determine speaking valve placement guidelines
• Identify troubleshooting tips
• Establish a discontinuation criteria
• Train and educate staff with competencies

61
Importance of multidisciplinary care

• Speech pathologists are experts in voice, speech,
  and swallowing
• Respiratory therapists are experts in trach/vent
  management
• Otolaryngologists are experts in airway
  management
• Pulmonologists are experts in pulmonary
  management
• Nurses are experts in the care of their patients

62
Good studies to cite to your medicine colleagues

• 91/104 patients able to tolerate cuff
  deflation/cuffless trach while on mechanical
  ventilation (Bach and Alba. Chest 1990.)
• A multidisciplinary team approach can be used to
  promote a positive patient outcome in the
  mechanically vented (Bell. Critical Care Nurse
  1996.)
• Cuff deflation increase vocalization without
  compromising respiratory function (Conway and
  Mackey. Anaesthesia 2004)

63
Other communication options
64
Talking trach tubes

• Requires
• - Intact or relatively unimpaired
  articulators
• - Functional vocal fold mobility
• - Relatively patent upper airway
• Contraindications
• - No major contraindications

65
Talking trach tubes

• Made by both Bivona and Portex
• Allows for phonation by presentation of
  non-pulmonary air between the cuff and the vocal
  folds.
• Does not require cuff deflation and will not
  impact ventilation of the patient.

66
Talking trach tube
67
Assessment for talking trach tube

• Once a patient is identified as a candidate,
  trach can be changed by ENT.
• Once the trach is changed, humidified air line
  should be established for the talking trach.

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Assessment for talking trach tube cont.

• The talking trach line is attached via oxygen
  tubing to the humidified air source and the flow
  should be set initially at 7L/min.
• Digitally occlude the port on the talking trach
  line to administer airflow to the upper airway
  and ask pt to phonate.

69
Troubleshooting with a talking trach

• Problem Air does not seem to be flowing through.
• Solution Because the port is located right
  above the cuff, secretions can clog the line.
  Try flushing saline through the line and then
  reverse suction through the talk line.
• Problem Excessively wet vocal quality impacting
  intelligibility
• Solution Suction through the talk line to
  remove secretions from above the cuff.

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Troubleshooting with a talking trach

• Problem Inability to get adequate voicing
• Solution May be due to inadequate airflow. Air
  flow meter may vary between 5-15 L/minute. Try
  increasing the airflow by 1 L/min at a time.
• Problem Excessive coughing
• Solution Airflow may be too high. Try reducing
  the airflow by 1 L/min at a time. Also try
  intermittent application of air rather than
  constant airflow.

71
Troubleshooting with a talking trach

• Problem Intermittent voice breaks
• Solution Because of the design of talking
  trachs, patient position and trach position can
  interfere with uninterrupted phonation. Try
  different head postures and positions while
  sustaining phonation to find the best position.
• Problem Pt complaints of throat irritation with
  prolonged use
• Solution Turn air flow off when not in use to
  minimize air delivery.

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Electrolarynx

• For patients on the vent who are unable to obtain
  restoration of laryngeal communication, an
  electrolarynx can be used to restore alaryngeal
  speech.
• Patients do best with oral adaptors
• Electrolarynx training for vent patients should
  mirror what is done for laryngectomy patients
  (i.e. focus on device placement,
  over-articulation, speaking rate).

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Other non-oral options

• Communication boards
• Writing
• Assistive/augmentative communication devices

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Ethical Considerations

• Quality of life issues (Markstrom et al 2002,
  Kaub-Wittemer 2003)
• Family and caregivers involvement (Rossi Ferrario
  2001)
• Coping with long-term tracheostomy or ventilation

75
Conclusions
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Conclusions

• There are a number of communication options
  available for tracheotomized and ventilator
  dependent patients
• Successful rehabilitation depends upon a
  functional multidisciplinary approach
• The SLPs interventions can extend beyond basic
  communication restoration
• SLPs have the knowledge, passion, and
  communication skills to advocate for their
  patients