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Trachs & Vents > Oral & Non-Oral Communication Options > Flashcards

Oral & Non-Oral Communication Options Flashcards

1
Q

Oral communication options for trach patients (3)

A
  • Mouthing
  • Electro larynx
  • Cuff deflation / fenestration tubes
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2
Q

What do you need to do for oral communication with a trach tube? (3)

A
  • Use finger occlusion
  • Use a one-way speaking valve (PMV)
  • Capping (of trach tube)
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3
Q

What do you need for cuff deflation of a non-vent dependent patient?

A
  • Obtain MD order
  • Have appropriate medical back-up (RN / respiratory care, pre-oxygenation if needed, monitor respiration / oxygen levels, suction, rate/timing of deflation)
  • Provide additional suctioning as needed
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4
Q

What should be done concerning the rate / timing of cuff deflation?

A
  • Allow the patient time to adjust to air returning to the upper airway
  • Coughing is common
  • Allow the patient time to recover / use monitors
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5
Q

A speaking valve cannot be placed unless…

A

A speaking valve cannot be placed unless the tracheostomy tube cuff is fully deflated.

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6
Q

A speaking valve cannot be used with…

A

A speaking valve cannot be used with a foam cuff (foam cuffs will not fully deflate and will also auto re-inflate)

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7
Q

What do you do to re-inflate the cuff?

A
  • Insert syringe and re-inflate cuff

- Check cuff pressure using manometry (want to make sure you don’t over-inflate the cuff)

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8
Q

If the patient is on a ventilator, how should cuff inflation be done?

A

Cuff inflation should be done with either the respiratory therapist or RN with appropriate ventilator adjustments

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9
Q

Open position valves

A

Maintains an open posture and open further upon the “push” of inspired air during inspiration

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10
Q

Closed position valve (PMV)

A
  • “Positive closure”
  • Silastic membrane of speaking valve maintains a biased closed position at all times except during inspiration
  • Membrane only opens when inspiratory pressures are sufficiency; immediately after inhalation, the membrane resumes its closed position
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11
Q

PMV characteristics

A
  • For standard trach
  • 15 mm hub
  • Approved for ventilator use
  • Only one-way valve biased closed position
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12
Q

Different PMVs

A
  • 005 is the original and isn’t really used anymore

- use PMA 2020-S adaptor for metal trachs so the PMV 2020 can be used

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13
Q

Shiley Phonate One Way Valve

A
  • Standard trach
  • 15 mm hub
  • Open position valve
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14
Q

Montgomery vent-trach / montgomery speaking valve

A
  • All valves provide 1 way airflow using a thin silicone hinged diaphragm that opens on inspiration & closes on expiration
  • Available in premium silicone or medical grad plastic models
  • All valves feature a unique cough-release feature, eliminating valve or tube displacement following a forceful cough or excessive airway pressure.
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15
Q

Eliachar / Hood Speaking Valve

A
  • Hood speaking valve
  • Standard trach - 15mm hub
  • Open position valve
  • Trach tube is modified by the placement of an inner cannula
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16
Q

Shikani-French Speaking Valve

A
  • Fits on a 15mm hub OR can be sized to fit Jackson improved metal trach tube
  • Open position design
  • Valve contains ball
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17
Q

What can valves be used with?

A

-Valves can be used w/oxygen & humidified air & w/trach collars

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18
Q

What should not be administered during valve use?

A

-Respiratory treatments/medications should not be administered during valve use

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19
Q

What is the primary benefit of a one-way valve?

A
  • The restoration of oral communication is the primary benefit
  • Also assists in improving quality of life
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20
Q

What needs to be considered when assessing a patient’s airway for one-way speaking valve use?

A

The size of the trach needs to be considered when assessing the patient’s airway for one-way speaking valve use
*Trach tube usually should fill NO MORE than 2/3 to 3/4 of the tracheal lumen

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21
Q

The trach tube should fill no more than / to / of the tracheal lumen.

A

The trach tube should fill no more than 2/3 to 3/4 of the tracheal lumen.

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22
Q

Placement of the one-way valve will create what?

A

Placement of the one-way valve will create resistance to airflow

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23
Q

What may be required to compensate for the increase work of breathing?

A

Downsizing the trach tube may be required to compensate for the increased work of breathing

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24
Q

It’s important to monitor both __ and __ levels when using speaking valves.

A

It is important to monitor both O2 and CO2 levels.

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25
Q

What do you do for decreased O2 levels?

A

Increase FI02 or addition of pressure support (if on vent.)

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26
Q

What do you do for increased CO2 levels?

A

Instruct the patient to “blow out” air quickly to determine if the trend can be reversed - if not, take off the PMV.

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27
Q

When in doubt about the patient’s tolerance for the speaking valve - what should you do immediately?

A

REMOVE THE VALVE

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28
Q

What are some contraindications for speaking valve use?

A
  • Severe tracheal / laryngeal stenosis
  • Airway obstruction (resulting in + work of breathing & - ability to exhale leading to + CO2 levels)
  • Inability to tolerate cuff deflation
  • Endstage pulmonary disease
  • Unstable medical & pulmonary status
  • Not for use w/laryngectomy
  • Severe anxiety
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29
Q

What is an ABSOLUTE contraindication for speaking valve use?

A

The inability to tolerate cuff deflation is an ABSOLUTE contraindication for speaking valve use

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30
Q

Patent airway is dependent on what?

A
  • The size of the trach tube in relationship to the tracheal lumen
  • Position of the cuff when deflated
  • Presence of a fenestrated trach tube
  • Presence of airway obstruction (tissue test, ENT consult)
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31
Q

When it seems like the patient has anxiety about the valve, what do you need to do first?

A

First, rule out a physiological reason for appearance of anxiety with the placement of the one-way valve

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32
Q

How do you handle the patient with anxiety about the PMV?

A
  • Distraction often required when deflating cuff & placing valve
  • Work on quiet breathing w/valve on (help patient get used to redirecting airflow)
  • Advance to voicing
  • Gradually + amount of time of cuff deflation & valve use
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33
Q

Benefits of one-way valve placement (7)

A
  • Elimination of need for finger occlusion
  • Normalization of airflow
  • Facilitating voice / communication
  • Improve smell / taste
  • Assist w/decannulation process
  • Improve secretions
  • Improve quality of life
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34
Q

Secretion Status & Trach tube Occlusion Research - Research question…

A

Does a 5-point severity secretion scale have any predictive value for subsequent aspiration of food or liquid?

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35
Q

Who was the first to develop a standard 4-pt secretion scale?

A

Murray et al

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36
Q

What does Murray et al’s standard 4-pt scale assess?

A

Accumulated oropharyngeal secretions

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37
Q

Visible oropharyngeal secretions as viewed by endoscopy located within the laryngeal vestibule were highly predictive of what…

A

subsequent aspiration of food / liquid

38
Q

The Marianjoy 5-point secretion scale does not allow for;

A

transition of secretions - the score the patient receives reflects the maximum amount of secretions present at the beginning of the exam

39
Q

The Marianjoy 5-point secretion scale accounts for…

A

differences between laryngeal penetration & aspiration of secretions

40
Q

Level 1 Secretions - Normal

A

Range from thin, clear secretions, <10% pooling

41
Q

Level 2 Secretions - Mild

A

Pooling of pharyngeal secretions from 10-25%

42
Q

Level 3 Secretions - Moderate

A

Pooling of secretions greater than 25% - No endolaryngeal secretions present

43
Q

Level 4 Secretions - Severe

A

Laryngeal penetration of secretions; Intermittent laryngeal penetration upon inhalation; No aspiration of secretions

44
Q

Level 5 Secretions - Profound

A

Secretions present on or below the vocal folds - Tracheal aspiration of secretions

45
Q

Secretion Scale Development

A

-Scale was designed to be ordinal in nature, however, further testing also suggested that the scale might fit a linear model as well - meaning secretion scale ratings could be considered as continuous

46
Q

What are the 2 major dimensions of the secretion scale?

A

Amount & Location

47
Q

Procedure of secretions article:

A
  • ENT inserted flexible endoscope
  • Prior to presentation of food/liquid, patient given initial score of secretions
  • Two judges independently rated
48
Q

Data analysis: Evaluated the relationship between:

A

Secretion level and the presence of laryngeal penetration, aspiration, tracheostomy tube status, and diet outcome recommendations

49
Q

Data analysis: Association between:

A

Secretion levels, hospitalization status, and initial feeding status

50
Q

Patients with ______ secretion levels tended to demonstrate _________ ___________ and ________ __________ more frequently.

A

Patients with higher secretion levels tended to demonstrate laryngeal penetration and tracheal aspiration more frequently.

51
Q

Patients receiving ____ ________ vs. ____ ________ were ____ likely to demonstrate ______ secretions levels.

A

Patients receiving tube feeding vs. oral feedings were more likely to demonstrate high secretion levels.

52
Q

** IMPORTANT **

Patients with a tracheostomy tube tended to have ______ secretion levels.

A

Patients w/a tracheostomy tube tended to have HIGHER secretion levels.

53
Q

Patients with _____ secretion levels were ____ likely to receive a ____ restrictive diet recommendations.

A

Patients with lower secretion levels were more likely to receive a less restrictive diet recommendation.

54
Q

3 major findings from the secretion study!

A
  • Use of 5-point scale correlated highly to subsequent aspiration & diet outcome recommendations
  • Patients w/tube feedings or a trach tube tended to have + secretion levels than non-tubed patients
  • Patients w/+ secretion levels tended to receive a more restrictive diet recommendation.
55
Q

Clinical applications of secretion study findings:

A

-Secretion level can be very helpful in determining the risk/benefit ratio for the decision to present a certain bolus size / consistency (ex: profound secretions - may defer - minimal / normal secretions - may be more aggressive)

56
Q

What is the purpose of “Secretions, occlusion status & swallowing in patients w/a trach tube” research study?

A

To describe the relationship between:

  • Secretion level & laryngeal penetration / aspiration status
  • Secretion level & occlusion status
  • Occlusion status & aspiration status
57
Q

Results: Secretion level & Aspiration status

A
  • Overall 47.5% of patients aspirated

- 79% of the time it was SILENT

58
Q

Conclusions: Secretion level & Aspiration status

A
  • Higher secretion level, more likely NPO and demonstrate laryngeal penetration & aspiration
  • Secretion levels for patients w/a tracheostomy tube were also similar to initial study
59
Q

Duration of the tracheostomy (was/wasn’t) related to secretion level.

A

Duration of the tracheostomy was NOT related to secretion level

60
Q

Even though ______ occlusion had the highest aspiration rate, a significant relationship (was/wasn’t) observed.

A

Even though FINGER occlusion had the highest aspiration rate, a significant relationship was NOT observed.

61
Q

Aspiration rate for the profound secretion level was ______ ______ distributed between the 3 types of occlusions (open, finger, capped)

A

Aspiration rate for the profound secretion level was fairly evenly distributed between the 3 types of occlusions (open, finger, capped)

62
Q

An ___________ was observed between occlusion status and secretion level, not a _________.

A

An association was observed between occlusion status and secretion level, not causation.

63
Q

Additional factors that may affect accumulated oral pharyngeal secretions (8)

A
  • Pulmonary secretions
  • Infection
  • Patient mobility
  • Medical instability
  • Vocal fold mobility / glottal closure
  • Swallowing frequency
  • Laryngeal sensation
  • Cognitive / alertness level
64
Q

Oral comm option w/vent dependent patients: Ventrach speaking valve

A
  • Offers vent-dependent, tracheostomized patients the opportunity to speak during inspiration & expiration w/out interruption
  • Valve is placed in-line between the trach tube & the vent & features a low-resistant diaphragm
65
Q

Cuff deflation for vent dependent patients requires what?

A
  • MD orders for cuff deflation / vent modifications

- Respiratory therapist / RN

66
Q

Steps to cuff deflation for a vent dependent patient

A
  • Provide suctioning prior to cuff deflation
  • If the patient has a trach tube w/subglottic suction inner cannula, use that to provide subglottic suctioning prior to & during cuff deflation
  • If not, you can re-insert suction catheter into trach tube (w/out suctioning being applied), then insert syringe into cuff valve and apply intermittent suctioning while slowly deflating the cuff
  • Re-inflate cuff to baseline & allow patient to rest
  • Provide oral suction if needed
  • Insert syringe into cuff valve & slowly withdraw air until cuff is full deflated (1-2cc at a time)
67
Q

What do vent modifications do?

A
  • Assess airway pressure

- Increase tidal volumes

68
Q

What does the SLP do during cuff deflation for vent dependent patients

A
  • Encourage patient to voice w/newly created leak (minimal leak technique / leak speech)
  • May initially have patient voice on inhalation, then instruct to voice on exhalation & time vocalizations w/machine
  • Determine max # of syllables that can be produced on each vent breath
69
Q

What do you monitor with cuff deflation on vent dependent patients

A

Pulse oximetry & capnography

  • Increase oxygen levels if needed
  • Observe for signs of air trapping (℅ tight chest / + trend in CO2 via cap)
  • Unable to voice adequately - review other vent settings (- respiratory rate, - inspiratory flow rate)
70
Q

Considerations in valve placement w/vent use

A
  • When valve is in-line w/vent, air is delivered to the patient in the usual way
  • Air cannot return to the vent upon exhalation
  • Imperative the upper airway is free from obstruction & that the vent settings are adjusted to reflect the presence of the valve in the circuit
  • Potential complications (barotrauma, CO2 retention, hypoxemia, cardiac symptoms b/c of + WOB)
71
Q

Potential complications to consider in valve placement w/vent use.

A
  • Barotrauma
  • CO2 retention
  • Hypoxemia
  • Cardiac symptoms b/c of increased work of breath
72
Q

Issues w/valve placement & vent use

A
  • Maintaining ventilation w/the cuff deflated
    • Difficult for diseased lungs
    • Deflation of cuff (loss of air volume, + WOB / clinical s/s of discomfort)
    • Ventilatory adjustments can effectively compensate for changes associated w/cuff deflation
73
Q

Vent adjustments

A
  • Increase tidal volume
  • Tidal volume should not be automatically increased in the presence of high peak airway pressures reaching above 30-40 cm H20
  • High pressure readings exist because of airway obstruction / non-compliance lungs
74
Q

What to consider when you increase tidal volume with ventilator adjustments

A
  • Compensates for the significant loss of air that occurs when the cuff is deflated
  • W/out increase in tidal volume, patients can often not be adequately ventilated as they the patient is only receiving a portion of air that has been set on the ventilator
  • Careful monitoring of high pressure setting is required to make sure acceptable tidal volume limits are not exceeded
75
Q

Vent adjustments: Increase oxygen settings

A
  • Loss of air from cuff deflation may result in oxygen desaturation
  • Increase in overall FI02 setting of the ventilator
  • Patients w/a FI02 setting above 60% may not do well with cuff deflation
76
Q

Vent adjustments: PEEP

A
  • PMV creates approx. 2cm of PEEP
  • Adjust vent settings to accommodate for additional 2cm of PEEP provided by the PMV
  • a lot of times you don’t want to go over 5
77
Q

Vent adjustments: Pressure Support

A
  • May enhance the patient’s comfort & tolerance of the speaking valve
  • Pressure support reduces the word of breathing
78
Q

Vent adjustments: Sensitivity Setting

A

-Ventilator settings that allow for spontaneous breathing, the placement of the PMV may increase respiratory effort & may gradually fatigue the patient. When the sensitivity setting is reduced, the patient will receive a breath w/less inspiratory effort

79
Q

PMV & Vent Alarms

A

All vent alarms are operable w/the exception of the *EXHALED RETURN TIDAL VOLUME ALARM

80
Q

All vent alarms are operable w/the exception of the exhaled return tidal volume alarm because…

A
  • This alarm cannot be used b/c the patient no longer exhales into the ventilator circuitry
  • One-way valve is closed at all times other than inspiration, prevents the passage of air back through the trach tube & ventilator system. Instead, exhalation now takes place through the upper airway.
  • This alarm must be turned off or ignored.
81
Q

Care & Cleaning of PMV

A
  • Swish valve in pure soap & warm water
  • Rinse valve thoroughly in warm water
  • Allow valve to air dry before placing in storage container
  • Do not use hot water, peroxide, bleach, vinegar, alcohol, or cotton swabs to clean
  • “honk” noise-if valve is < 2 months old, need to clean. If valve is >2 months old, need to replace.
82
Q

Speaking valves: Trouble shooting - Anxiety

A
  • Provide education
  • Recheck physical assessments to establish if anxiety / discomfort is physically related (refer to ENT / pulmonary)
  • Have pt start w/quiet breathing, then advance to vocalizing
  • Distraction - while putting the valve on
83
Q

Speaking valves: Trouble shooting - Shortness of Breath / Breath Stacking

A
  • Cuff might not be fully deflated (if indicated)
  • Tracheostomy tube is too large for patient’s tracheal lumen to allow for adequate airway around the tube for speech production
  • Upper airway obstruction (consult ENT)
84
Q

Blom - Speech cannula

A
  • Used only w/Blom fenestrated cuffed trach
  • Invented for vent dependent patients
  • Allows cog patients w/an intact unobstructed upper airway to speak
  • No cuff deflation required (diminishes risk of asp.)
  • Silicone w/surface treatment (smooth finish for easy insertion - reduces potential area for infection)
85
Q

Blom - Speech Cannula: How it works w/cuff inflation - INHALATION

A
  • Bubble valve expands
  • Flap valve opens
  • Air delivered to lungs
86
Q

Blom - Speech Cannula: How it works w/cuff inflation - EXHALATION

A
  • Flap valve closes
  • Bubble valve collapses
  • Air goes through fenestration to vocal cords allowing phonation
87
Q

Patient candidacy for use of the Blom Speech Cannula: Patient Requirements

A

-Must be vent dependent
-Must have fenestrated cuff blom trach tube
-Must be a rousable & have potential to communicate
-May be in volume/pressure vent in any vent mode
-Does not need to breathing spontaneously
-Does NOT need to be able to tolerate cuff deflation
-Fi02 should NOT exceed 60%
-PEEP should NOT exceed 10
Should NOT have copious, thick secretions requiring suctioning more than 5x / hour
-Should have a patent, unobstructed upper airway

88
Q

Patients who require ____ should be placed on vents w/ ____ _______ or ____________ _____ in oxygen.

A

Patients who required PEEP should be placed on vents w/ Flow Trigger or supplemental bled in oxygen

89
Q

Non-Oral Communication Options

A
  • AAC Systems
  • Evaluation of Motor Function / Access Method (establishment of yes/no response)
  • Emergency Call Systems (standardized call system, switches/call lights/push pads, attention getters)
  • Handwriting
  • Direct Selection
  • Eye gaze board
  • Scanning / Switching / Encoding
  • Low tech / High tech (depends on patient’s status)
90
Q

Low Tech / Non-Electronic non-oral communication options

A

-Picture boards / word boards / communication boards / pages

91
Q

Advantages to low tech - non-electronic non-oral comm options.

A
  • Easily fabricated (Board maker program)
  • Personalized
  • Portable
  • Replaceable
  • Low cost
  • Limited training required
  • Easily modified
  • Generic ones can be mass produced for immediate use by RN & other hospital staff

Trachs & Vents (3 decks)

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