1. Passy Muir Valve Speaking Valve for Tracheostomy Patients Deidre Dennison, RN Vascular Intensive Care How it WorksContraindications Benefits InitiationMaking Connections References Indications Invented in 1985 by David Muir – 23 year old quadriplegic with muscular dystrophy Unique, one-way speaking valve allows patients to inhale through the speaking valve “No leak” design prevents air from escaping through or around the valve Forces exhaled air up over the vocal cords and through the oronasopharynx Design allows a column of air to be trapped within the valve/tracheostomy space preventing secretions from moving into the tracheostomy and occluding the PMV Available for use in pediatric and adult patients May be applied directly to the tracheostomy with/without oxygen or in-line with the ventilator circuit Inability to tolerate cuff deflation – cuff MUST be deflated Severe airway obstruction Medical/hemodynamic instability Foam –filled cuffed tracheostomy tube Severely non-compliant lungs Unmanageable secretions Endotracheal intubation Not to be used while sleeping Helps to restore more natural “closed respiratory system” Allows patients to regain the ability to communicate and participate more effectively in the plan of care Improves swallow Restores intrinsic PEEP (positive end expiratory pressure) facilitating better oxygenation Reduces tracheal suctioning by assisting patients in developing a more effective cough Aids in ventilator weaning by returning use of the diaphragm and respiratory muscles during exhalation and speaking Allows patients to regain strength & sensation in upper airway Builds confidence and improves quality of life Facilitates pediatric language development May be used on and off the ventilator Requires a multidisciplinary approach involving collaboration between the Speech-Language Pathologist, Physician, Respiratory Therapy, and the Registered Nurse Initial assessment includes the patient’s ability to tolerate cuff deflation – the cuff must ALWAYS be deflated while using the Passy-Muir valve. Failure to do so will prevent inhaled air from being exhaled as it will not be able to pass through the upper airway or out of the tracheostomy tube Quantity and quality of secretions should be considered as the patient will be learning to deal with them differently, for example during a respiratory infection, after mucolytics or after pulmonary tolieting Assessment of airway patency and the patient ‘s ability to breathe around the tracheostomy tube and deflated cuff should be performed prior to placement of the Passy-Muir valve Employed in a variety of settings including rehabilitation, sub-acute care, as well as intensive care; may be initiated as early as 72 hours post tracheostomy Appropriate education for patients regarding change in airways pressure, sensation of upper airway, and change in secretion management should be performed in order to reduce patient anxiety Quadriplegia Mechanically ventilated/dependent patients Tracheomalacia Neuromuscular disorders Head trauma COPD Mild tracheolaryngeal stenosis Bedside assessment before, during, and after valve placement includes: changes in patient’s breathing pattern, work of breathing, oxygen saturation, heart rate, secretions, color & mental status, and patient reaction Patient should be sitting in a semi-Fowler’s or Fowler’s position in order to maximize lung expansion and diaphramatic movement Suctioning should be performed prior to valve placement as needed; suctioning while slowly deflating the tracheostomy cuff may help prevent pooled secretions from entering the lower airway Off the ventilator, the PMV fits directly onto the tracheostomy tube hub; may also be used with humidified oxygen via a trach collar or an oxygen cannula via a PMV oxygen adapter When used during mechanical ventilation the PMV 007 (Aqua) fits directly into the disposable ventilator tubing; other PMV models require non-disposable tubing Requires ventilator alarm adjustments including low volume alarms as the patient is exhaling volumes through the upper airway instead of returning it to the ventilator May be utilized with most conventional modes of ventilation including pressure control (PC), assist/control (AC), pressure support ventilation (PSV), synchronized intermittent mandatory ventilation (SIMV), and continuous positive airway pressure (CPAP) Passy-Muir tracheostomy and ventilator speaking valve resource guide. Passy-Muir Inc., October 1997; revised March, 2003. Hess, D. (2005). Facilitating speech in the patient with a tracheostomy. Respiratory Care, 50(4), 519-525.