5 Beginnings of clinical questions! Company claims ‘ Passy Muir Valves aid in the weaning process’…It is considered negligent not to provide a valve…denying the right of communication.What does the literature say?
6 Evidence: Clinical question In ventilated tracheostomy patients, do Passy Muir valves reduce the time of mechanical ventilation?
8 GREAT…but what does it mean? PMV’s reduce time MV?Frey, JA et al. 1991Level IV evidence (below)Clinical bottom line: Placement of PMV may assist weaning of some respiratory patients to independently tolerate CPAP mode.GREAT…but what does it mean?Different levels of ventilation – weaning to last ‘mechanical mode’, power to discuss with consultants, early SP involvment, start on communication and swallowing earlier! Able to use at RPA to wean ptIdeas for research
9 Evidence: Clinical questions Does an inflated cuff exacerbate/increase aspiration at the level of the vocal folds?
10 Inflated cuff exacerbate/increase aspiration? Davis et al 2002 Level IV evidenceClinical bottom line:Cuff inflation may exacerbate/increase aspiration at the level of the vocal folds and an MBS should be pursued.Pts weaned from ventilation, stable. N=12Completed 8 mbs per pt; 4 consistencies trialled (thin, thick, puree, solids) cuff inflated and deflatedRadiologist blind to cuff statusNEWS FLASH – EVIDENCE GROWS DAILY!!!!
11 New evidence to critique ASHA conference 2007 Skoretz. S & Coyle. J – Assessment of patients with tracheostomy: Dispelling the myths. Ding & Logemann (2005): Inflated cuff status leads to significant increased frequency of silent aspiration and less hyolaryngeal elevation
12 Changes in PracticeChanges in Practice = EBP + Discussion + clinical experience + time!What are TDG doing?
13 Changes in Practice Do you use blue dye in your assessment? 63% No 37% Yes, as an adjunct to bedside swallowing assessmentThis is a big change in our clinical practice, because of a CAT completed by the TDG
14 Changes in PracticeDo you use Modified Barium Swallow (MBS) or Flexible Endoscopic Evaluation of Swallowing (FEES)?VariesFEES appears to be used with more acute patients, MBS down the trackMany CAP’s/CAT’s indicate MBS or FEES is necessary for accurate assessment of a patient with a tracheostomy. There are practical issues with adopting this EBP (eg very unwell patients in ICU can’t always be transported to x-ray for an MBS).
15 Changes in PracticeDo you use a cap or speaking valve during oral intake?88% Yes, usually a Passy Muir Speaking ValveMajority of the group adopting EBP based on a CAT
16 Changes in Practice Are you involved with ventilated patients? 75% Yes: for feeding, weaning and communicationEarlier intervention by SP’sDo you use a Passy Muir Speaking Valve to assist weaning from the ventilator?Of those SP’s involved with ventilated with patients, ALL are trialling PMSV to assist with weaningBased on most recent CAP done by the TDG
17 Tracheostomy patients: Are we really their voice?
18 Future directionsCritical care and tracheostomy discussion & EBP group