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

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

Before and After Laryngectomy

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.

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.

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).

Cont. Who to call? Call SMH TEP pager 604-571-5031 to schedule appointment date & time with Reena/Celia. Call SMH Ambulatory Day Care Booking (604-585-5666 ext 772445) 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).

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.

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.

CONTACT INFORMATION SMH FVCC SLPs: Celia Moore and Reena Parhar Phone: 604-585-5666 ext 778318 Pager: 604-571-5031 On-call Mon-Fri 0800 – 1800 On-call Weekends and Holidays 1000 - 1800

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)

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

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.

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.

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 ________

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