1. TRACHEOESOPHAGEAL PUNCTURE VOICE PROSTHESIS (TEP VP) AND SPEAKING VALVES
An introduction to the Speech Language Pathologist’s role in working with patients who have either a voice prosthesis or who are appropriate for wearing a speaking valve

2. Tracheoesophageal Voice Prosthesis
For patients that have had laryngectomies
Trachea is redirected through the neck
Stoma to lungs
Mouth to esophagus

3. Before and After Laryngectomy

4. Low pressure Voice Prosthesis
A small surgical passage is created just inside the stoma (from the back wall of the trachea into the esophageal wall)
A voice prosthesis can then be placed into this passage to enable tracheoesophageal speech.
Voice is produced by temporarily blocking the stoma, either with a finger or an adjustable tracheostoma valve, so that exhaled air from the lungs can be directed from the trachea through the prosthesis into the esophagus (where vibrations are produced) and then out through the mouth.

5. In-Dwelling Voice Prosthesis
clinician-placed voice prosthesis.
This variant is designed for patients who have had a laryngectomy and are unable or unwilling to routinely remove, clean, and reinsert a patient-changeable voice prosthesis.

7. TEP VP Trouble shooting
When to call:
The TEP VP has become dislodged.
The pt is having difficulty talking or is unable to talk and flushing the prosthesis does not improve voice quality.
The TEP VP is leaking either through or around the device.
The TEP VP is fitting too long or too short (flange is not fitting flush against the TEP).

8. Cont.
Who to call?
Call SMH TEP pager to schedule appointment date & time with Reena/Celia.
Call SMH Ambulatory Day Care Booking ( ext ) to advise them re: TEP change appointment with SMH Speech-Language Pathologist for patient.
If the patient is medically stable and transportation to SMH for TEP VP management will not interfere with patient’s hospital treatment plan or increase length of stay, please arrange for appointment to SMH by non-ambulance transport. If patient would require ambulance transfer to SMH, please call Celia/Reena and they will arrange to come to your site instead.
Ensure a Care Aide accompanies patient to appointment and back.
Return to check on patient once back at on unit (ensure correct diet ordered, patient tolerating everything well, patient voicing adequately, liquids not leaking from prosthesis, etc).

9. Special Considerations with TEP VP
Do not remove the TEP VP.
Always ensure the white tab of the TEP VP is securely taped above the patient’s stoma.
If the TEP VP falls out, as soon as possible ask the patient’s RN to insert a red rubber 14 or 16 French catheter ¾ of the way into patient’s TEP and tie off the proximal end before taping it to patient’s chest to secure in place. This will ensure that the TEP doesn’t begin to close (which can occur in as little as one hour). With the catheter in place, patient may eat and drink after 1 hour as they normally would.

10. Cont.
An SLP without an Advanced Competency in Voice Restoration - Voice Prostheses may not place any device or instrument beyond the patient’s stoma opening, rather should advise/instruct nursing on TEP VP care/cleaning/flushing per SMH SLP direction.
Ensure that over-bed signage is in place –Alert notice re: neck breathing. If you don’t have copies of this sign, contact the SLP department.

11. CONTACT INFORMATION
SMH FVCC SLPs: Celia Moore and Reena Parhar
Phone: ext
Pager:
On-call Mon-Fri 0800 – 1800
On-call Weekends and Holidays

12. Speaking Valves - PMV Main RSLP objectives: Role of RSLP
Improve quality of life and communication for ICU patients who fail corking;
Work collaboratively within interdisciplinary team to identify and manage pts with the potential to use a PMV (RTs have a large role in identification since RSLP are not regularly on ICU);
Use of PMV is a step towards a safer swallow (p.o. intake) for those ICU pts who fail corking;
PMV consideration for pts with vents.
Role of RSLP
Voice (quality, pitch, volume, breath support):
If voice poor post-PMV, risks for continued PMV use?
WOB;
Maladaptive voicing/breathing behaviours;
Damage to vocal folds.
Communication (speech, expr/recep language, AAC)
Swallowing  PMV creates a positive closure “no leak” system which helps to:
Improve swallowing function;
Reduce aspiration;
Increase pharyngeal/laryngeal sensation;
Strengthen airway clearance mechanisms (e.g. cough, throat-clear) and secretion management;
Improve olfaction.
90% of ICU pts rated “difficulty in communicating” as the most stressful aspect of their ICU stay
Maladaptive voicing/breathing behaviours (e.g. phonation on inhalation, muscle tension/strain, short/odd phrasing, shallow resps)

13. Speaking Valves - PMV Procedure
RSLP to be paged in the morning when speaking valve trial is considered
No formal order is needed
RT and RSLP to screen for speaking valve candidacy and if passes, educate pt re: PMV
Trial valve
Post head of bed sign, provide education to pt/RN re: care/cleaning

14. Speaking Valve (PMV) Candidacy
IMPORTANT: All criteria below MUST be met before considering speaking valve placement. If criteria are met, proceed to the Interdisciplinary Speaking Valve Assessment
Criteria
Does not tolerate corking
48 hours post tracheostomy placement
Tolerates cuff deflation
No upper airway obstruction
Richmond Agitation and Sedation Scale score (-1 to +1)
Attempts communication (via writing, mouthing words, gesturing, etc.)
Vitals signs are stable
Hemodynamically stable
Patient does NOT have thick secretions
Patient can voice when tracheostomy is occluded with the finger (cuff must be deflated while assessing this)
Able to sit up
Fi02 < 40
Tolerate PEEP 0
For palliative patients: Consider above however, exceptions may be made to allow for brief monitored periods of communication.

15. Interdisciplinary Assessment (SMH form used as guide)
Before PMV:
Deflate cuff, check tolerance, suction as needed (RT);
Oral Motor and Cogn-Comm Status (RSLP).
Put PMV on, observe:
Resps (O2 sats, RR, HR, breath sounds, cough);
Voice (quality, pitch, volume, breath support);
Speech/Language (automs, rep, convo, rdg).
Monitor for ~30mins, checking resps/voice.
After initial PMV trial:
Monitor resps and PMV tolerance longer-term (RT).
RSLP F/U 1-2 days post- to check PMV tolerance wrt voice and breath support:
Setup PMV wearing schedule if needed;
Setup voice/speech therapy if needed.

16. Head of Bed Signage The Passy-Muir Valve (PMV) Information
_______________________________________has a Passy Muir Valve (PMV) attached to the trache tube to allow for speech. Please refer to the PMV pamphlet for details.
WEARING SCHEDULE:______________________________
Deflate cuff prior to PMV placement.
Remove PMV if patient is in respiratory distress
May be worn when eating or drinking.
CARE OF VALVE:
Swish PMV in mild soap and warm water. Rinse thoroughly with warm water. Allow PMV to air dry thoroughly. Do not apply heat to dry the PMV. Do not use hot water, peroxide, bleach, vinegar, alcohol, brushes or Q-tips to clean the PMV. Do not autoclave.
WARNINGS:
DO NOT use when sleeping
DO NOT use with inflated cuff
DO NOT use with thick and copious secretions
DO NOT use during chest physiotherapy
For further information contact Respiratory Therapy at pager_____________ or Speech-Language Pathology at local ________

17. References http://www.inhealth.com/featuredprdvppage1new.htm
SMH Speech-Language Pathology Department