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1 Tracheostomy Tubes: Managing Communication and Swallowing Issues Carmin Bartow, MS, CCC-SLP Speech Pathologist Vanderbilt University Medical Center Nashville,

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Presentation on theme: "1 Tracheostomy Tubes: Managing Communication and Swallowing Issues Carmin Bartow, MS, CCC-SLP Speech Pathologist Vanderbilt University Medical Center Nashville,"— Presentation transcript:

1 1 Tracheostomy Tubes: Managing Communication and Swallowing Issues Carmin Bartow, MS, CCC-SLP Speech Pathologist Vanderbilt University Medical Center Nashville, TN

2 2 Objectives Describe changes in physiology after tracheotomy regarding speech, swallowing and respiration Describe changes in physiology after tracheotomy regarding speech, swallowing and respiration Differentiate between various communication options for trach and vent dependent patients Differentiate between various communication options for trach and vent dependent patients Determine the most appropriate swallowing evaluation and treatment techniques for trach and vent dependent patients Determine the most appropriate swallowing evaluation and treatment techniques for trach and vent dependent patients Describe how the Passy-Muir Speaking Valve works and explain the physiologic benefits of the valve Describe how the Passy-Muir Speaking Valve works and explain the physiologic benefits of the valve

3 3 Topics Trach overview Trach overview Communication Options Communication Options Passy-Muir Speaking Valves Passy-Muir Speaking Valves Pediatrics (brief ) Pediatrics (brief ) Mechanical Ventilation Mechanical Ventilation Dysphagia Management Dysphagia Management Conclusion / Hands-on time Conclusion / Hands-on time

4 4 Tracheostomy Overview Tracheostomy Tubes Tracheostomy Tubes Physiologic Changes after Tracheotomy Physiologic Changes after Tracheotomy

5 5 Tracheotomy Indications for tracheotomy Prolonged intubation Prolonged intubation Need for long term mechanical ventilation Need for long term mechanical ventilation Need for permanent tracheostomy tube Need for permanent tracheostomy tube Upper airway obstruction / edema Upper airway obstruction / edema

6 6 Trach Tube Components

7 7 Tracheostomy Tube Inflated Cuff

8 8 Tracheostomy Tube Deflated Cuff

9 9 Tracheostomy Tube Over-inflated cuff

10 10 Trach Tubes - Shiley

11 11 Trach Tubes - Bivona

12 12 Trach Tubes – Portex

13 13 Trach Tubes – Jackson Metal

14 Physiologic Changes after Tracheotomy 14

15 15 Physiologic Changes after Tracheotomy Respiration – breathing in and out through trach tube Speech – inability to produce phonation due to lack of airflow through vocal folds

16 16 Physiologic Changes after Tracheotomy Smell/taste – decreased sense of smell and taste due to lack of airflow into upper airway Smell/taste – decreased sense of smell and taste due to lack of airflow into upper airway Secretion management – inability to mobilize secretions effectively due to decreased cough effort Secretion management – inability to mobilize secretions effectively due to decreased cough effort

17 17 Physiologic Changes after Tracheotomy Swallowing – many research studies regarding trach tubes and swallowing report a negative impact on swallowing efficiency Aspiration Aspiration Pressure Differences Pressure Differences Airflow Differences Airflow Differences Cuff issues Cuff issues Laryngeal Sensitivity Laryngeal Sensitivity

18 18 Aspiration An association b/t aspiration and trachs has been well documented An association b/t aspiration and trachs has been well documented  Trach associated with increased risk of aspiration and pneumonia (Muz et al, 1987)  Delayed laryngeal vestibule closure which was associated with tracheal aspiration (Abraham and Wolf, 2000)  Disruption of vocal fold function (Nash 1988, Shaker, 2000)

19 19 Pressure Differences Aerodigestive tract is a set of tubes and valves (Logemann, 1988); swallowing is a pressure driven event Aerodigestive tract is a set of tubes and valves (Logemann, 1988); swallowing is a pressure driven event There is an inability to build up adequate pressure to propel the bolus through the pharynx with an open trach (Eibling and Gross, 1996) There is an inability to build up adequate pressure to propel the bolus through the pharynx with an open trach (Eibling and Gross, 1996) When subglottic pressure is altered with a trach, neuroregulation of pharyngeal swallow physiology is likewise altered (Gross, et al, 2003) When subglottic pressure is altered with a trach, neuroregulation of pharyngeal swallow physiology is likewise altered (Gross, et al, 2003)

20 20 Airflow differences The loss of expiratory airflow through the upper airway for normal respiration has been linked to increased pooling of secretions within the larynx and pharynx (Siebens, et al, 1993) The loss of expiratory airflow through the upper airway for normal respiration has been linked to increased pooling of secretions within the larynx and pharynx (Siebens, et al, 1993)

21 21 Cuff issues  Reduced laryngeal elevation and silent aspiration were significantly higher in cuff inflated vs. cuff deflated condition (Logemann, 2005)  The cuff DOES NOT prevent aspiration (Ross & White, 2003); it is not “watertight”

22 22 Laryngeal sensitivity Normal laryngeal sensitivity = Cough Normal laryngeal sensitivity = Cough Trach tubes result in reduced pharyngeal / laryngeal sensation (Tippet et al, 1991) Trach tubes result in reduced pharyngeal / laryngeal sensation (Tippet et al, 1991)

23 VFSS - aspiration 23

24 Communication Options Non-Verbal Non-Verbal  Writing  AAC  Communication board  Mouthing Verbal  Leak speech  Finger occlusion  Talking Trach  Blom Trach System  Speaking valves  Plugging / capping 24

25 25 Leak Speech Ability to produce voice with airflow “leaking” around a trach tube into upper airway Ability to produce voice with airflow “leaking” around a trach tube into upper airway Occurs most often with cuffless tubes, deflated cuffs or fenestrated trachs Occurs most often with cuffless tubes, deflated cuffs or fenestrated trachs Airflow takes path of least resistance through trach tube typically making speech breathy and weak Airflow takes path of least resistance through trach tube typically making speech breathy and weak

26 26 Finger Occlusion Placing finger over the hub of the trach tube to allow for increased airflow into the upper airway for phonation Placing finger over the hub of the trach tube to allow for increased airflow into the upper airway for phonation

27 27 Talking Tracheostomy Tube Used for vent dependent patients who cannot tolerate cuff deflation (will discuss further during mechanical ventilation section) Used for vent dependent patients who cannot tolerate cuff deflation (will discuss further during mechanical ventilation section) Portex Trach-Talk Bivona Trach with talk Portex Trach-Talk Bivona Trach with talk attachment attachment

28 Blom Trach System - Fenestrated Cuffed Tube Kit - Non-Fenestrated Uncuffed Tube Kit - Subglottic Suctioning Cannula - Speech Cannula - LPV - SoftTouch™ Tube Holder - Exhaled Volume Reservoir™ (EVR™) - Training Disk 28

29 29 Capping / Plugging Capping – placing a “cap” or “plug” on the trach to seal off airflow Capping – placing a “cap” or “plug” on the trach to seal off airflow

30 30 Passy-Muir Valves

31 31 Passy-Muir Valve Valve opens during inhalation with less than normal inspiratory pressure Closes at the end of inhalation Allows airflow to pass through vocal folds for phonation

32 32 Passy-Muir Valve Remains in closed position except when patient inhales Remains in closed position except when patient inhales No leakage of air through valve No leakage of air through valve Restoration of a closed system Restoration of a closed system Restoration of subglottic pressure Restoration of subglottic pressure

33 33 Passy-Muir Valve Use on and off ventilator Use on and off ventilator FDA indicated for use in communication and swallowing treatment FDA indicated for use in communication and swallowing treatment Medicare/Medicaid reimbursable Medicare/Medicaid reimbursable Supported by research as providing the best speech quality as compared with other speaking valves (Leder, 1994) Supported by research as providing the best speech quality as compared with other speaking valves (Leder, 1994)

34 34 Passy-Muir Valves

35 35 Passy-Muir Patient Care Kit

36 36 Patient Criteria Awake and alert Awake and alert Medically stable Medically stable Able to tolerate cuff deflation Able to tolerate cuff deflation

37 37 Patient Assessment Can the patient exhale around the trach into their upper airway? Can the patient exhale around the trach into their upper airway? How to establish upper airway patency: How to establish upper airway patency:  Deflate the cuff  Finger occlude the trach  Listen for exhalation and/or phonation

38 38 Upper Airway Patency Issues Sizing of trach tube -the #1 Issue Sizing of trach tube -the #1 Issue - Often requires downsizing trach - Often requires downsizing trach Other possibilities Other possibilities  Upper airway edema / obstruction  Granulation tissue  Foam filled cuff  Partially inflated cuff  Secretions

39 39 Valve Placement Team involvement is key to successful use of valve!

40 40 Valve Placement Educate patient and family Educate patient and family Obtain baseline measurements Obtain baseline measurements  Oxygen saturation (O2 sats)  RR  HR  Color  WOB  Responsiveness

41 41 Valve Placement Suction (if needed) Suction (if needed) Deflate cuff Deflate cuff Suction again (if needed) Suction again (if needed) Place valve Place valve

42 42 Placement of Speaking Valve

43 Placement Allow patient to adjust to airflow change Continue education and reassurance Establish phonation Continue to monitor for any changes from baseline measurements Remove valve if any significant changes occur 43

44 44 Troubleshooting Decreased O2 with cuff deflation – may need to increase FI02 (must check with RT) Decreased O2 with cuff deflation – may need to increase FI02 (must check with RT) Inadequate exhalation/phonation Inadequate exhalation/phonation Check for:  Complete cuff deflation  Trach tube size  Suctioning needs  Need for MD assessment  Patient position  Trach position

45 45 Session Wrap-up Wear times vary Wear times vary Confer with medical staff as needed Confer with medical staff as needed Post warning labels Post warning labels Storage Storage Care and Cleaning Care and Cleaning

46 Physiologic Benefits of the Passy-Muir Valve Improved voice Improved voice Improved cough Improved cough Improved secretion management Improved secretion management Improved swallowing Improved swallowing Quicker decannulation Quicker decannulation * Can result in improved quality of life! 46

47 47 Pediatric Trachs

48 48 Pediatric Trach Differences Typically no cuff Typically no cuff Typically no inner cannula Typically no inner cannula Sizes vary depending on brand (neonatal 00 – pediatric 4, but now some greater variances) Sizes vary depending on brand (neonatal 00 – pediatric 4, but now some greater variances) More difficulty with tolerance of speaking valves especially at early age due to tiny airways More difficulty with tolerance of speaking valves especially at early age due to tiny airways

49 49 Pediatric Vital Signs Pre-termNewbornInfantChild Weight 6 – – 80 RR 50 –80 40 – HR 125 – BP Systolic 50 – –

50 Effects of Tracheostomy on Communication Development Caregiver interaction – lack of crying, cooing, babbling, vocalizing can impact bonding / caregiver interaction Language – lack of prelinguistic development often results in language delays Voice – Studies report VF atrophy with prolonged tracheostomy tubes

51 Pediatric Speaking Valve Assessment Many similarities to adult assessment   Must have patent airway   Address secretions / cuff status   Monitor vital signs / patient responsiveness   Same valves (no pediatric sizes)

52 Pediatric Speaking Valve Assessment Differences   Babies can “crash” more quickly   Babies / children often can’t tell you their comfort level   Watch closely for distress:   Fear   Stridor   Grunting   Decreased chest movement   Decreased LOA   Change in vital signs, color or WOB

53 Speaking Valve Tolerance SLP must discern whether “tolerance” is behavioral or physiologic. SLP must discern whether “tolerance” is behavioral or physiologic. Recommendations and therapy based on this Recommendations and therapy based on this If poor tolerance physiologically – must either wait for growth or request smaller trach. If poor tolerance physiologically – must either wait for growth or request smaller trach.

54 54 Pediatric Placement Ideas Behavior modification techniques (older children) Behavior modification techniques (older children) Place just before waking Place just before waking Keep child’s hands busy Keep child’s hands busy Blowing games (to increase oral exhalation) Blowing games (to increase oral exhalation) Distraction (PLAY!) Distraction (PLAY!) Toby Tracheasaurus Toby Tracheasaurus

55 “Baby Trach” guru Suzanne Abraham Provides national seminars through NSS on “Baby Trachs: Airway Safety, Secretions, Swallowing in Infants and Young Children with Tracheostomies”

56 56 Mechanical Ventilation Mechanical ventilation Mechanical ventilation Communication options for ventilator dependent patients Communication options for ventilator dependent patients

57 57 Mechanical Ventilation Settings Settings  Rate  Tidal Volume  FIO2  PIP  PEEP

58 58 Mechanical Ventilation Modes Modes  Control Mode  Assist Control  SIMV  Pressure Support

59 59 Communication Options for Ventilator Patients Non-verbal Non-verbal Verbal Verbal  Leak speech  Talking trach  Blom Trach System  Passy-Muir Speaking Valve

60 60 Leak Speech for Ventilator Dependent Patients Need MD order for cuff deflation trials Need MD order for cuff deflation trials Suction if needed Suction if needed Slowly deflate cuff (may only need partial cuff deflation) Slowly deflate cuff (may only need partial cuff deflation) Ventilator adjustments by respiratory therapist (FI02, tidal volume, alarms) Ventilator adjustments by respiratory therapist (FI02, tidal volume, alarms) Encourage vocalization Encourage vocalization Monitor vital signs throughout trial Monitor vital signs throughout trial Establish plan of care for continued leak speech trials Establish plan of care for continued leak speech trials

61 61 Talking Trach Tube Portex Trach Talk Bivona trach with talk attachment

62 62 Talking Trach Used primarily for ventilator dependent patients with adequate oral motor function who cannot tolerate cuff deflation. Used primarily for ventilator dependent patients with adequate oral motor function who cannot tolerate cuff deflation. Description - Cuffed trach tube with an additional tube that connects to an air source. Air travels through this tube and flows out of an opening above level of cuff Description - Cuffed trach tube with an additional tube that connects to an air source. Air travels through this tube and flows out of an opening above level of cuff

63 63 Talking Trach Tube

64 64 Talking Trach Use Educate patient re: airflow Educate patient re: airflow Suction if needed Suction if needed Connect external tube to air source Connect external tube to air source Connect humidification Connect humidification Turn on air source (begin with 6 liters; max 15 liters) Turn on air source (begin with 6 liters; max 15 liters) Occlude port Occlude port Encourage vocalization Encourage vocalization

65 65 Talking Trach – Pros / Cons Pros Can be used with cuff inflation Can be used with cuff inflation Allows for verbal communication while on the vent Allows for verbal communication while on the vent Cons Airflow issues Quality of voice Patient comfort Secretion issues

66 Blom Trach System “How does the Blom Speech Cannula work? “How does the Blom Speech Cannula work?  The Blom Speech Cannula has two unique valves that re-direct air allowing speech for ventilator dependent patients with a fully inflated cuff.  During Inhalation the Flap Valve opens and the Bubble Valve expands into the fenestration sealing it, preventing air escaping to the upper airway.  During Exhalation the Flap Valve closes, the Bubble Valve collapses to unblock the fenestration and air is directed up through the fenestration to the vocal cords allowing speech”. From 66

67 67 Passy-Muir Mechanical Ventilation Video

68 68 Passy-Muir Valve Placement In-Line With Ventilator Respiratory therapist should be present Respiratory therapist should be present Deflate cuff gradually Deflate cuff gradually Suction if needed Suction if needed Place valve with appropriate adapter Place valve with appropriate adapter

69 69 Passy-Muir Adapters for in-line use

70 70 Ventilator Adjustments Respiratory therapist must be present to make vent adjustments Volume compensation during cuff deflation Volume compensation during cuff deflation Alarms Alarms PEEP PEEP Humidification Humidification

71 71 Transitioning/Troubleshooting Typically will have shorter sessions Typically will have shorter sessions Increased airflow through upper airway Increased airflow through upper airway Anxiety Anxiety Airway patency Airway patency

72 72 Removal of Speaking Valve After In-line Placement Replace original circuit set-up Replace original circuit set-up Return ventilator settings and alarms to pre- speaking valve parameters Return ventilator settings and alarms to pre- speaking valve parameters Re-inflate cuff Re-inflate cuff

73 73 Specifics on Cuff Inflation and Deflation Deflation - To make sure the cuff is fully deflated, continue to remove air until resistance is met Deflation - To make sure the cuff is fully deflated, continue to remove air until resistance is met Inflation - An over-inflated cuff can result in damage to the tracheal walls. Recommended cuff pressure is approximately 20 – 25 mmHg. Techniques to measure cuff inflation include: Inflation - An over-inflated cuff can result in damage to the tracheal walls. Recommended cuff pressure is approximately 20 – 25 mmHg. Techniques to measure cuff inflation include:  Minimal leak technique  Cuff manometry

74 74 Dysphagia Management Assessment Assessment Treatment Treatment

75 75 Dysphagia Assessment Clinical bedside assessment (with or without blue dye) Clinical bedside assessment (with or without blue dye) FEES FEES VFSS VFSS

76 76 Blue Dye Test No set standards; varies from facility to facility No set standards; varies from facility to facility Involves use of blue food coloring to dye secretions, liquids or foods Involves use of blue food coloring to dye secretions, liquids or foods Tracheal secretions that are either coughed or suctioned from trach are monitored for signs of aspiration Tracheal secretions that are either coughed or suctioned from trach are monitored for signs of aspiration

77 77 Clinical Bedside Swallowing Assessment Diagnosis Diagnosis Physical, medical and nutritional status Physical, medical and nutritional status Underlying pulmonary disease Underlying pulmonary disease Ability to manage secretions Ability to manage secretions H/o dysphagia H/o dysphagia Type of trach tube Type of trach tube Mechanical ventilation Mechanical ventilation H/o endotracheal intubation H/o endotracheal intubation  How long?  How many times?

78 78 Clinical Bedside Swallowing Assessment Deflate cuff (if cannot deflate cuff, must proceed with instrumental assessment) Deflate cuff (if cannot deflate cuff, must proceed with instrumental assessment) Suction as needed Suction as needed Place speaking valve if present Place speaking valve if present Oral mech exam Oral mech exam

79 79 Clinical Bedside Swallowing Assessment Begin po trials with or without blue dye Begin po trials with or without blue dye Observe for s/s of aspiration Observe for s/s of aspiration  Vocal quality  Cough  Evidence of aspiration in tracheal secretions (immediate and delayed assessment)

80 80 The Blue Dye Dilemma False negatives False negatives Availability Availability Potential systemic effects Potential systemic effects Limitations Limitations Use results cautiously Use results cautiously

81 81 VFSS/FEES Objective results Can be performed on vent and non-vent patients Identifies etiology of aspiration (not just presence of aspiration) Can implement therapeutic maneuvers and strategies Anecdotal evidence re: FEES vs VFSS in vent patients

82 82 Eating while on the vent 66% of patients swallowed successfully; no aspiration. Of the patients that did aspirate (33%), 80% was silent aspiration (Leder, 2002) This indicates: This indicates: 1) MANY patients can eat even when on the vent 2) Need for instrumental assessment for our vent dependent patients

83 83 Treatment Oral hygiene program Oral hygiene program Traditional swallow therapy Traditional swallow therapy Compensatory strategies Compensatory strategies Diet modifications Diet modifications Restoration of a closed system Restoration of a closed system

84 84 Oral hygiene Considerable evidence exists to support a relationship between poor oral health, the oral microflora and bacterial pneumonia, especially ventilator-associated pneumonia in institutionalized patients Considerable evidence exists to support a relationship between poor oral health, the oral microflora and bacterial pneumonia, especially ventilator-associated pneumonia in institutionalized patients A number of studies have shown that the mouth can be colonized by respiratory pathogens and serve as a reservoir for these organisms. Other studies have demonstrated that oral interventions aimed at controlling or reducing oral biofilms can reduce the risk of pneumonia in high-risk populations. Taken together, the evidence is substantial that improved oral hygiene may prevent pneumonia in vulnerable patients. A number of studies have shown that the mouth can be colonized by respiratory pathogens and serve as a reservoir for these organisms. Other studies have demonstrated that oral interventions aimed at controlling or reducing oral biofilms can reduce the risk of pneumonia in high-risk populations. Taken together, the evidence is substantial that improved oral hygiene may prevent pneumonia in vulnerable patients.

85 85 Traditional Swallow Therapy General tips: - Most traditional swallow exercises are fine - Don’t do Shaker with this population - Mendelsohn - don’t do it if it causes pain (if in doubt, don’t do it) - Breath holding techniques like the supraglottic won’t work with open trach

86 86 Compensatory Strategies and Diet Modifications Same as non-trach / non vent dependent patients Same as non-trach / non vent dependent patients  Head turns, chin tucks, reduce bolus size, multiple swallows, etc  Diet changes

87 87 Restoration of a closed system Decannulation Decannulation Plug Plug Passy-Muir Valve Passy-Muir Valve

88 88 Restoration of a closed system Open trach vs closed trach Open trach vs closed trach  Muz et al (1989)  Muz et al (1994)  Logemann et al (1998)  Dettelbach et al (1995)  Stachler et al (1996)  Elpern et al (2000)  Gross et al (2003)  Suiter et al (2003) All report improved swallow function with a closed trach

89 Use of Passy-Muir to aid swallowing function  Restored airflow through vfs to prevent further vf atrophy  Improved sensation in the oropharynx allows the patient to sense pooled secretions  Restored subglottic pressure  Cuff issues negated due to always having cuff down with PMSV  Restored cough function 89

90 90 Treatment “The predisposition to aspirate with an open tracheostomy tube is now well recognized. Decannulation is known to benefit many of these patients by reducing or eliminating aspiration. Moreover, we have now shown that the use of a one-way speaking valve will also result in improvement.” (Gross, 1996)

91 91 Speech Pathologists play a key role in intervention with the tracheostomized and ventilator dependent population

92 92 Quality of Life Ventilator dependent patients’ feelings of anxiety, fear, panic and insecurity caused by inability to talk and communicate “Assessment of Patients’ Experience of Discomforts During Respirator Therapy” (Bergbom-Engberg, Haljamai, 1989)

93 93 SLP Intervention Improved communication Improved communication Improved swallowing Improved swallowing Improved cough and secretion management Improved cough and secretion management Improved ability to participate in decision making Improved ability to participate in decision making Improved quality of life Improved quality of life

94 94 Thank You!


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