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Multi-Disciplinary Approach to Speaking Valves

Laura Schwickerath MS, CCC-SLPSpeech-Language PathologistDepartment of Otolaryngology – Head & Neck CancerUniversity of Iowa Hospitals and Clinics

Nick Behne MBA, RRTRespiratory Care Practice LeaderDepartment of Respiratory Care University of Iowa Hospitals and Clinics

An opportunity to improve care for

patients with tracheostomy

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Objectives

1. Understand the importance of multidisciplinary

approach with placement of speaking valve

2. Understand the process and procedure of speaking

valve placement while patient is on trach mask or

ventilator

3. Understand the benefits from speaking valve

placement

Learners will:

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Multidisciplinary Team

1. SLP

2. RT

3. RN

4. PT/OT

5. ARNP

6. MD

Disciplines Involved

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Respiratory Therapist

1. Evaluate respiratory status

2. Manage ventilator and make adjustments

3.Suction

4. Troubleshoot

Roles

SLP

1. Evaluate speech, communication, voice,

cognition

2. Swallow function and secretion management

3. Troubleshoot

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Nurse, ARNP, MD

1. Assist in identification

2. Evaluation of candidacy

3. Participate in interventions

4. Troubleshoot

Roles

PT/OT1. Assist in identification

of patient

2. Assist with positioning

3. Therapeutic interventions

4. Troubleshoot

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Multidisciplinary Team

1. Effect of co-morbidities

2. Determine appropriate interventions

3. Troubleshoot

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Benefits of Multidisciplinary Approach

1. Earlier identification

2. Earlier intervention

3. Improved patient care

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Speaking Valve

One-way valve that allows for restoration of upper

airflow for patients with a tracheostomy

Current Use at UIHC

• Non-ventilated patients

• Placement by SLP or RT

In-Line Ventilator Use

• Ventilated patients

• Collaborative placement by SLP and RT

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CANDIDACY/GUIDELINES

Awake and Alert48 hours s/p trach placement

Patent Upper AirwayManageable Secretions

If on ventilator:<60% FiO2<10 PEEP<40 PIP

Other Considerations:Pain managed?Positioning/body alignmentAnxiety, understanding, cognition

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Common Misconceptions

1. The cuff can't be deflated because the patient 'will aspirate'

2. The patient has 'a lot' of secretions

3. The tracheostomy tube is too large

4. You have to wait until the patient is off the ventilator

5. The ventilator will alarm

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• Prolonged periods of hospitalization• Loss of ability to voice and

communicate• Limited ability to participate in own

care• Poor pain management• Anxiety and depression

Effects of Vent & Trach Dependence

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Application Process

Collaboration Patient Education Cuff Deflation

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Application Process

Finger occlusion Patient Education Placement

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Application Process

Breathing Voicing Tolerance

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In-line Evaluation Process

Collaboration Patient Education Cuff Deflation

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In-line Evaluation Process

Patency of upper airway via change in tidal volume

Ventilator adjustments

Placement of PMV

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In-line Evaluation Process

Breathing, voicing, tolerance

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Troubleshooting

1. Inadequate exhalation or breath stacking

2. Coughing

3. Anxiety or depression

4. Weak Voice

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Benefits

• Respiration

• Swallowing

• Physical Rehabilitation

• Communication

• Hospital Dependence

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Respiration

• Facilitates lung recruitment

• Restoration of physiological PEEP

• Improved diaphragm involvement

Sutt et al., 2016Sutt et al., 2015

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Swallowing

1. Restoration of subglottic pressure

2. Restoration of smell/taste

3. Opportunity to manage secretions

4. Ability to participate in strengthening exercises

Perme 2009Elpern et al., 2000Dettelbach et al., 1995Lichtman et al., 1995

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Physical Rehabilitation

1. Restores pressure support in the trunk and core

2. Naturally increased intra-thoracic pressure and intra-abdominal pressures

Massery, 2006.

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Communication

1. Restoration of upper airflow allowing for phonation and verbal communication

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Reasons to Address Communication

1. Safety Concerns2. Patient Rights3. Quality of Life/Depression4. ICU Delirium5. Potential to reduce ICU and hospital stay

Grossbach et al., 2011Bartlett et al., 2008Magnus et al., 2006Freeman-Sanderson et al., 2018

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• 64 year old male

• Spinal Cord Injury 11/2019

• Admitted 06/2020 to UIHC

• “Difficult to get history from the patient given his issues with speech”

• SLP consult Day 2

Case Study

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Next Steps

1. Increasing Awareness

2. Ongoing Education

3. Identification of Candidates

4. Finalization of Policy

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Questions?Laura Schwickerath, MS CCC-SLPLaura-Schwickerath@uiowa.eduVoalte #84086Pager #9905

Nick Behne, MBA RRTNicholas-Behne@uiowa.eduVoalte #63474Pager # 4692

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ReferencesBartlett, G., Blais, R., Tamblyn, R., Clermont, R. J., & MacGibbon, B. (2008). Impact of patient communication problems on the risk of preventable

adverse events in acute care settings. Canadian Medical Association Journal, 178, 1555-1562. doi: 10.1503/cmaj.070690

Elpern, E.H., Borkgren, M., Bacon, M., Gerstung, C. and Skrzynski, M. (2000). Effect of the Passy-Muir Valve on pulmonary aspiration in adults

with tracheostomies. Chest, 116(4-S2):365S.

Freeman-Sanderson, A. L., Togher, L., Elkins, M. R., & Kenny, B. (2018). Quality of life improves for tracheostomy patients with return of voice: A

mixed methods evaluation of the patient experience across the care continuum. Intensive Critical Care Nursing, 46:10-16. doi:10.1016/j.

iccn.2018.02.004

Grossbach, I., Stranberg, S., & Chlan, L. (2011). Promoting effective communication for patients receiving mechanical ventilation. Critical Care

Nurse, 31(3): 46-61.

The Joint Commission. (2010). Advancing effective communication, cultural competence, and patient- and family-centered care: A roadmap for

hospitals. [brochure]. Retrieved January 15, 2019 from https://www.jointcommission.org/ assets/1/6/ARoadmapforHospitalsfinalversion727.pdf

Magnus, V. & Turkington, L. (2006). Communication interaction in ICU-patient and staff experiences and perceptions. Intensive Critical Care

Nursing, 22, 167-180.

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ReferencesMassery M. (2006). Multisystem Consequences of Impaired Breathing Mechanics and/or Postural Control. In Cardiovascular and Pulmonary

Physical Therapy Evidence and Practice, ed 4. 4 edition. Edited by Frownfelter D, Dean E. St. Louis, MO.: Elsevier Health Sciences:695-717.

Perme C., and Chandrashekar R.K. (2008). Managing the patient on mechanical ventilation in ICU: early mobility and walking program. Acute Care

Perspectives, 17(1): 10-15.

Santos, A., Harper, D., Gandy, S., & Buchanan, B. (2018). 1214: THE POSITIVE IMPACT OF MULTIDISCIPLINARY TRACHEOSTOMY TEAM IN THE

CARE OF POST-TRACHEOSTOMY PATIENTS. Critical Care Medicine, 46(1), 591-591.

Sutt, A., Caruana, L.R., Dunster, K.R., Cornwell, P.L., Anstey, C.M., and Fraser, J.F. (2016). Speaking valves in tracheostomised ICU patients

weaning off mechanical ventilation - do they facilitate lung recruitment? Critical Care, 20: 91.

Sutt, A., Caruana, L., Dunster, K., Cornwell, P., and Fraser, J. (2015). Improved lung recruitment and diaphragm mobility with an in-line speaking

valve in tracheostomized mechanically ventilated patients – an observational study. Australian Critical Care, 28:1, 45.

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