Presentation on theme: "TRACHEOESOPHAGEAL PUNCTURE VOICE PROSTHESIS (TEP VP) AND SPEAKING VALVES An introduction to the Speech Language Pathologist’s role in working with patients."— Presentation transcript:
1TRACHEOESOPHAGEAL 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
2Tracheoesophageal Voice Prosthesis For patients that have had laryngectomiesTrachea is redirected through the neckStoma to lungsMouth to esophagus
4Low 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.
5In-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.
7TEP 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).
8Cont.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).
9Special 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.
10Cont.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.
11CONTACT INFORMATIONSMH FVCC SLPs: Celia Moore and Reena ParharPhone: extPager:On-call Mon-Fri 0800 – 1800On-call Weekends and Holidays
12Speaking 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 RSLPVoice (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 stayMaladaptive voicing/breathing behaviours (e.g. phonation on inhalation, muscle tension/strain, short/odd phrasing, shallow resps)
13Speaking Valves - PMV Procedure RSLP to be paged in the morning when speaking valve trial is consideredNo formal order is neededRT and RSLP to screen for speaking valve candidacy and if passes, educate pt re: PMVTrial valvePost head of bed sign, provide education to pt/RN re: care/cleaning
14Speaking 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 AssessmentCriteriaDoes not tolerate corking48 hours post tracheostomy placementTolerates cuff deflationNo upper airway obstructionRichmond Agitation and Sedation Scale score (-1 to +1)Attempts communication (via writing, mouthing words, gesturing, etc.)Vitals signs are stableHemodynamically stablePatient does NOT have thick secretionsPatient can voice when tracheostomy is occluded with the finger (cuff must be deflated while assessing this)Able to sit upFi02 < 40Tolerate PEEP 0For palliative patients: Consider above however, exceptions may be made to allow for brief monitored periods of communication.
15Interdisciplinary 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.
16Head 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 distressMay 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 sleepingDO NOT use with inflated cuffDO NOT use with thick and copious secretionsDO NOT use during chest physiotherapyFor further information contact Respiratory Therapy at pager_____________ or Speech-Language Pathology at local ________
17References http://www.inhealth.com/featuredprdvppage1new.htm SMH Speech-Language Pathology Department