Tracheostomy Tubes: Managing Communication and Swallowing Issues

Tracheostomy Tubes: Managing Communication and Swallowing Issues
Carmin Bartow, MS, CCC-SLP Speech Pathologist Vanderbilt University Medical Center Nashville, TN trach MTL 4

Objectives Describe changes in physiology after tracheotomy regarding speech, swallowing and respiration 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 Describe how the Passy-Muir Speaking Valve works and explain the physiologic benefits of the valve trach MTL 4

Topics Trach overview Communication Options Passy-Muir Speaking Valves
Pediatrics (brief ) Mechanical Ventilation Dysphagia Management Conclusion / Hands-on time trach MTL 4

Tracheostomy Overview
Tracheostomy Tubes Physiologic Changes after Tracheotomy Must have a solid foundation and understanding of trach tubes before we can address communication and swallowing issues trach MTL 4

Tracheotomy Indications for tracheotomy Prolonged intubation
Need for long term mechanical ventilation Need for permanent tracheostomy tube Upper airway obstruction / edema Why does someone need a tracheotomy? Prolonged intub – 2 weeks (Intubation – an endotracheal tube is inserted through the patient’s mouth and into the airway, through the vfs. That tube is connected to a ventilator and serves as an artificial airway) Need for long term mechanical ventilation – ALS, SCI Need for permant trach – sleep apnea Upper airway obstruction – H and N ca / sx trach MTL 4

Trach Tube Components Demo with TOM
Cuff balloon-like component that when inflated acts as a seal to eliminate airflow into the upper airway ( ***important component for SLPs) Inflation-line – thinlplastic line connected to the cuff, pilot balloon and luer valve which allows the cuff to be filled with air. Pilot balloon – Plastic sac-like component connected to the inflation line that indicates cuff inflation or deflation Hub – the part of the trach that protrudes out from stoma site. Typically proximal end of the inner cannula. Standard 15 mm size. Inner Cannula – Fits inside the outer cannula. Used for cleaning. Can be disposable or reusable. Outer Cannula – The main body of the trach tube Flange / Neck plate – assists in fastening the tube around the neck. Also provides info re: size and type of trach trach MTL 4

Tracheostomy Tube Inflated Cuff
trach MTL 4

Tracheostomy Tube Deflated Cuff
trach MTL 4

Tracheostomy Tube Over-inflated cuff
Over-inflation can result in damage to tracheal walls. Worst case can result in TE fistula due to excess pressure trach MTL 4

Trach Tubes - Shiley Now, let’s look at various tubes. There are a variety of brands of trachs currently on the market. We will review only a few. Trachs can be cuffed, cuffless, fenestrated and vary in size. Sizing is not universal. Shiley – quick review Some info on fenestrated trachs Pros – improved airflow to upper airway for phonation Cons – Concern for granulation tissue, concern for secretions clogging holes, fenestration often not in the airway trach MTL 4

Trach Tubes - Bivona Bivona – made of silicone. Can be air-filled, saline-filled or foam filled Foam - for patients that need extremely low pressure against tracheal walls, usually in the case of severe tracheomalacia (softening of the cartilaginous rings). Cuff does not remain deflated. trach MTL 4

Trach Tubes – Portex Portex – also have the “blue-line” trach
trach MTL 4

Trach Tubes – Jackson Metal
Left – 15 mm hub Right – Jackson “New Improved” trach – has small, flatter hub trach MTL 4

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 Respiration – all air now travels in and out of the lungs via the trach tube. The entire upper airway is bypassed. - not breathing through the larynx - Not breathing through the nose, so the system that naturally filters and humidifies air is bypassed Widespread implications for the entire respiratory and phonatory system trach MTL 4

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 trach MTL 4

Swallowing – many research studies regarding trach tubes and swallowing report a negative impact on swallowing efficiency Aspiration Pressure Differences Airflow Differences Cuff issues Laryngeal Sensitivity trach MTL 4

Aspiration 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) trach MTL 4

Pressure Differences 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) When subglottic pressure is altered with a trach, neuroregulation of pharyngeal swallow physiology is likewise altered (Gross, et al, 2003) Read Logemann quote “swallowing is a pressure driven event”. If that is true, an open hole in that system would completely alter its efficiency. Sub-glottic pressure: Gross describes this as a key element in swallowing. She and her collegues report numerous problems with an open trach. trach MTL 4

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) trach MTL 4

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” So what does this tell us? Patients swallow BETTER with the cuff DEFLATED. trach MTL 4

Laryngeal sensitivity
Normal laryngeal sensitivity = Cough Trach tubes result in reduced pharyngeal / laryngeal sensation (Tippet et al, 1991) Let’s talk about the cough for a moment. If it goes down the wrong way, we cough. For a trach patient they 1) may not sense the aspiration due to decreased laryngeal sensitivity and 2) If they do sense it, they cannot cough effectively. trach MTL 4

VFSS - aspiration trach MTL 4

Communication Options
Non-Verbal Writing AAC Communication board Mouthing Verbal Leak speech Finger occlusion Talking Trach Blom Trach System Speaking valves Plugging / capping Now that you have a more thorough understanding of trach, we’ll begin discussion on communication options trach MTL 4

Leak Speech 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 Airflow takes path of least resistance through trach tube typically making speech breathy and weak trach MTL 4

Finger Occlusion Placing finger over the hub of the trach tube to allow for increased airflow into the upper airway for phonation When appropriate: pending decannulation soon, when cannot tolerate speaking valve, but can achieve brief strained voice with finger occlusion trach MTL 4

Talking Tracheostomy Tube
Used for vent dependent patients who cannot tolerate cuff deflation (will discuss further during mechanical ventilation section) Portex Trach-Talk Bivona Trach with talk attachment trach MTL 4

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

Capping / Plugging Capping – placing a “cap” or “plug” on the trach to seal off airflow trach MTL 4

Passy-Muir Valves Read quote from David trach MTL 4

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 trach MTL 4

Passy-Muir Valve Remains in closed position except when patient inhales No leakage of air through valve Restoration of a closed system Restoration of subglottic pressure trach MTL 4

Passy-Muir Valve Use on and off ventilator
FDA indicated for use in communication and swallowing treatment Medicare/Medicaid reimbursable Supported by research as providing the best speech quality as compared with other speaking valves (Leder, 1994) trach MTL 4

Passy-Muir Valves trach MTL 4

Passy-Muir Patient Care Kit
trach MTL 4

Patient Criteria Awake and alert Medically stable
Able to tolerate cuff deflation trach MTL 4

Patient Assessment Can the patient exhale around the trach into their upper airway? How to establish upper airway patency: Deflate the cuff Finger occlude the trach Listen for exhalation and/or phonation trach MTL 4

Upper Airway Patency Issues
Sizing of trach tube -the #1 Issue - Often requires downsizing trach Other possibilities Upper airway edema / obstruction Granulation tissue Foam filled cuff Partially inflated cuff Secretions trach MTL 4

Valve Placement Team involvement is key to successful use of valve!
trach MTL 4

Valve Placement Educate patient and family
Obtain baseline measurements Oxygen saturation (O2 sats) RR HR Color WOB Responsiveness trach MTL 4

Valve Placement Suction (if needed) Deflate cuff
Suction again (if needed) Place valve Let’s briefly discuss suctioning here. Often get question – “can SLPs suction?”. Yes – IF you have been thoroughly trained and obtain approval by a qualified medical professional (RN, RRT, MD). Need a written policy in your facility re: this) trach MTL 4

Placement of Speaking Valve
trach MTL 4

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 trach MTL 4

Troubleshooting Decreased O2 with cuff deflation – may need to increase FI02 (must check with RT) Inadequate exhalation/phonation Check for: Complete cuff deflation Trach tube size Suctioning needs Need for MD assessment Patient position Trach position trach MTL 4

Session Wrap-up Wear times vary Confer with medical staff as needed
Post warning labels Storage Care and Cleaning trach MTL 4

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

Pediatric Trachs trach MTL 4

Pediatric Trach Differences
Typically no cuff Typically no inner cannula 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 trach MTL 4

Pediatric Vital Signs Pre-term Newborn Infant Child Weight 6 –9 8 - 25
25 – 80 RR 50 –80 40 – 60 HR 125 –170 BP Systolic 50 – 90 80 – 90 120 trach MTL 4

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 trach MTL 4

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) trach MTL 4

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 trach MTL 4

Speaking Valve Tolerance
SLP must discern whether “tolerance” is behavioral or physiologic. Recommendations and therapy based on this If poor tolerance physiologically – must either wait for growth or request smaller trach. trach MTL 4

Pediatric Placement Ideas
Behavior modification techniques (older children) Place just before waking Keep child’s hands busy Blowing games (to increase oral exhalation) Distraction (PLAY!) Toby Tracheasaurus trach MTL 4

“Baby Trach” guru Suzanne Abraham
Provides national seminars through NSS on “Baby Trachs: Airway Safety, Secretions, Swallowing in Infants and Young Children with Tracheostomies” trach MTL 4

Mechanical Ventilation
Communication options for ventilator dependent patients This is where we lose our comfort zone. Most of us had not formal training re: mechanical ventilation and feel inadequate in this area. BUT, just because this is less familiear, we CANNOT ignore these patients. JCAHO states that patients have “the right to communicate” – so that includes our vent dependent patients. So, I encourage you to familiarize yourself with the vents at your facility. Find a “helpful” RT and ask questions. trach MTL 4

Settings Rate Tidal Volume FIO2 PIP PEEP Rate: This setting determines the minimum number of mechnical breaths the vent will deliver per minute Tidal Volume: The volumee of air delivered during a volume cycled mechanical breath. Based on patient’s ideal body weight FI02: Fraction of Inspired Oxygen. Referss to the percentage of exygen being delivered with any breath. This can range from 21% (normal room air) to 100% PIP: Peak Inspiratory Pressure. The pressure in the lungs at the end of inspiration PEEP: Positive End Expiratory Pressuer: Thiis setting adds back pressure in the lungs to keep the alveoli from completely emptying. This is also known as CPAP which used during spontaneous breathing. trach MTL 4

Modes Control Mode Assist Control SIMV Pressure Support Control: Breathing is solely controlled by the vent. Set rate and volume. Assist / Control: All breaths are mechanical breaths. The vent will deliver a minimum number of breaths per minute at the present rate. The patient can take as many addition al breaths as desired, but all breaths will be full mechanical breaths SIMV- Synchronized Intermittent Mandatory Ventilation: The vent will deliver a minimum number of breaths per minute. When the patient triggers an additional breath, it will be a spontaneous, independent breath unaided by the vent. Pressure Support: This mode was developed to overcome the resistance of the vent tub ing. The patient triggers the vent by initiating a breath at which time the vent senses this and provides the patient with present amounts of pressure to help augment the spontaneous effort. Often used in conjunction with SIMV. trach MTL 4

Communication Options for Ventilator Patients
Non-verbal Verbal Leak speech Talking trach Blom Trach System Passy-Muir Speaking Valve trach MTL 4

Leak Speech for Ventilator Dependent Patients
Need MD order for cuff deflation trials Suction if needed Slowly deflate cuff (may only need partial cuff deflation) Ventilator adjustments by respiratory therapist (FI02, tidal volume, alarms) Encourage vocalization Monitor vital signs throughout trial Establish plan of care for continued leak speech trials Can be a great option for patients that are uncomfortable with complete cuff deflatation and speaking valve. Often use as a baby step toward PMSV. trach MTL 4

Talking Trach Tube Portex Trach Talk Bivona trach with talk attachment
trach MTL 4

Talking Trach 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 trach MTL 4

Talking Trach Tube trach MTL 4

Talking Trach Use Educate patient re: airflow Suction if needed
Connect external tube to air source Connect humidification Turn on air source (begin with 6 liters; max 15 liters) Occlude port Encourage vocalization trach MTL 4

Talking Trach – Pros / Cons
Can be used with cuff inflation Allows for verbal communication while on the vent Cons Airflow issues Quality of voice Patient comfort Secretion issues trach MTL 4

Blom Trach System “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

Passy-Muir Mechanical Ventilation Video
Show animation from PMSV site trach MTL 4

Passy-Muir Valve Placement In-Line With Ventilator
Respiratory therapist should be present Deflate cuff gradually Suction if needed Place valve with appropriate adapter trach MTL 4

Passy-Muir Adapters for in-line use
Show TOM with aqua valve trach MTL 4

Ventilator Adjustments
Respiratory therapist must be present to make vent adjustments Volume compensation during cuff deflation Alarms PEEP Humidification These are only suggestions or guidelines which MAY help your patient tolerate an in-line speaking valve. A patient specific approach is essential. Considerations: Increase tidal volume. Because of the leak created by cuff deflation, the patient does not receive the full amount of air that was present on the vent. The respiratory therapist can gradually increase the tidal volume to compensate for this loss. Alarms – the exhaled volume alarms will sound b/c the vent is no longer receiving exhaled volume. The alarm can either be turned off during speaking valve trials or the sensitivity of the alarms can be turned down PEEP – consider reducing peep by 5. When a valve is introduced, physiologic PEP or natural airway pressure is restored. The patient is now exhaling against upper airway structures, so some air is trapped in the airway and lungs. The patient may not need as much PEEP with valve in place. Humidification: may need to change humidification system. The HME (heat moisture exchange filters) which are commonly used will not be effective. The HME works by trapping moisture form expired air. Since the patient will be exhaling through the MHE, it will not serve to humidify the inspired air. Can change to a “bubble humidifier”. trach MTL 4

Transitioning/Troubleshooting
Typically will have shorter sessions Increased airflow through upper airway Anxiety Airway patency Shorter sessions – remember the goal is to allow the patient to verbally communicate, even for moments. Especially at the beginning, airflow may be uncomfortable. With continued trials, patients will typically gradually become more accustomed to the airflow change. trach MTL 4

Removal of Speaking Valve After In-line Placement
Replace original circuit set-up Return ventilator settings and alarms to pre-speaking valve parameters Re-inflate cuff trach MTL 4

Specifics on Cuff Inflation and Deflation
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: Minimal leak technique Cuff manometry Deflation – important to remove ALL air Inflation – Minimal leak technique – insert air slowly into the cuff as the patient is exhaling. When air can no longer be detected through the mouth or nose, a seal is assumed. Then a small amount of air is removed creating the minimal leak. Manometry – connect a manometer to the pilot ballon. The amount of pressure exerted on the tracheal wall is displayed on the manometer. Should not exceed mm of mercury trach MTL 4

Dysphagia Management Assessment Treatment trach MTL 4

Dysphagia Assessment Clinical bedside assessment (with or without blue dye) FEES VFSS There are other swallow assessment tools such as monometry, scintigraphy, etc but will focus on these most commonly used tools at this time. trach MTL 4

Blue Dye Test No set standards; varies from facility to facility
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 Will look at pros/ cons in a minute, let’s first just review the basics. What is it? trach MTL 4

Clinical Bedside Swallowing Assessment
Diagnosis Physical, medical and nutritional status Underlying pulmonary disease Ability to manage secretions H/o dysphagia Type of trach tube Mechanical ventilation H/o endotracheal intubation How long? How many times? History taking is ESSENTIAL for all of our patients, but especially for our trach patients that may have a compromised pulmonary system. Want to make your decision on the WHOLE PICTURE not just whether they cough or not during the b/s eval. Some things to look at:… trach MTL 4

Deflate cuff (if cannot deflate cuff, must proceed with instrumental assessment) Suction as needed Place speaking valve if present Oral mech exam Now that you have a thorough hx, start with the clinical exam. trach MTL 4

Begin po trials with or without blue dye Observe for s/s of aspiration Vocal quality Cough Evidence of aspiration in tracheal secretions (immediate and delayed assessment) trach MTL 4

The Blue Dye Dilemma False negatives Availability
Potential systemic effects Limitations Use results cautiously A little more about this controversial topic: False negative have been reported numerous times in the literature. Availabilty – no longer being stocked in the units Potential systemic effects – to date scattered adverse reactions have been reported when patients have been given large amounts of blue dye in TF. Thus far, there are no reports of negative outcomes with limited amounts of blue dye used by SLPs Limitations – results are more subjective. Can see that patient aspirated, but blue dye testing cannot provide info re: amount of aspiration or why aspiration occurred. Use results cautiously – Clinician must interpret results iun the context of the total clinical evaluation. trach MTL 4

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 trach MTL 4

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: MANY patients can eat even when on the vent Need for instrumental assessment for our vent dependent patients What about the vent depend population? trach MTL 4

Treatment Oral hygiene program Traditional swallow therapy
Compensatory strategies Diet modifications Restoration of a closed system Dysphagia treatment could be a lecture of its own, so the following is only a cursory review of treatment techniques with a special focus on treatment techniques specifically relevant to this population. trach MTL 4

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 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. Add oral care into your eval protocols Provide this education to your facility Nation-wide look at VAP; now medicare is refusing to pay for costs related to pneumonia if it was HAP. Must find ways to reduce VAP/ HAP. trach MTL 4

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 trach MTL 4

Compensatory Strategies and Diet Modifications
Same as non-trach / non vent dependent patients Head turns, chin tucks, reduce bolus size, multiple swallows, etc Diet changes trach MTL 4

Restoration of a closed system
Decannulation Plug Passy-Muir Valve Restoration of sub-glottic pressure is esential for normal swallow function. With an open trach, there are overall negative effects on swallow physiology. Numerous studies have shown that by resotring sub-glottic pressure by decannulation or with a plug/ cap or PMSV, swallowing efficiency is improved and aspiration is reduced. trach MTL 4

Restoration of a closed system
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 trach MTL 4

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

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) In a 1996 article published in the Annals of Otolgy, Rhinolgy and Laryngology, Roxeanne Diez Gross stated…. trach MTL 4

Speech Pathologists play a key role in intervention with the tracheostomized and ventilator dependent population trach MTL 4

Quality of Life Ventilator dependent patients’ feelings of anxiety, fear, panic and insecurity caused by inability to talk and communicate Retrospective study: Patients reported that being unable to communicate evoked feelings of insecurity, fear and panic, and anxiety. The isolation due to communication difficulties was reported to be a greater problem than any direct airway related issues. Ranked worse than pain, suctioning and difficulty breathing. Too many times these patients are left frustrated and isolated due to their inability to effectively communicate. They cannot participate in their care of decision making, cannot ask question, cannot talk to loved ones and are left feeling scared, anxious, and insecure. “Assessment of Patients’ Experience of Discomforts During Respirator Therapy” (Bergbom-Engberg, Haljamai, 1989) trach MTL 4

SLP Intervention Improved communication Improved swallowing
Improved cough and secretion management Improved ability to participate in decision making Improved quality of life trach MTL 4

Thank You! I thank you for your time and interest in this wonderful, amazing and at times challenging patient population. Hands – on time and time for questions….. trach MTL 4

Tracheostomy Tubes: Managing Communication and Swallowing Issues

Similar presentations

Presentation on theme: "Tracheostomy Tubes: Managing Communication and Swallowing Issues"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Tracheostomy Tubes: Managing Communication and Swallowing Issues

Similar presentations

Presentation on theme: "Tracheostomy Tubes: Managing Communication and Swallowing Issues"— Presentation transcript:

Similar presentations

About project

Feedback