Oral & Non-Oral Communication Options Flashcards
Oral communication options for trach patients (3)
- Mouthing
- Electro larynx
- Cuff deflation / fenestration tubes
What do you need to do for oral communication with a trach tube? (3)
- Use finger occlusion
- Use a one-way speaking valve (PMV)
- Capping (of trach tube)
What do you need for cuff deflation of a non-vent dependent patient?
- 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
What should be done concerning the rate / timing of cuff deflation?
- Allow the patient time to adjust to air returning to the upper airway
- Coughing is common
- Allow the patient time to recover / use monitors
A speaking valve cannot be placed unless…
A speaking valve cannot be placed unless the tracheostomy tube cuff is fully deflated.
A speaking valve cannot be used with…
A speaking valve cannot be used with a foam cuff (foam cuffs will not fully deflate and will also auto re-inflate)
What do you do to re-inflate the cuff?
- Insert syringe and re-inflate cuff
- Check cuff pressure using manometry (want to make sure you don’t over-inflate the cuff)
If the patient is on a ventilator, how should cuff inflation be done?
Cuff inflation should be done with either the respiratory therapist or RN with appropriate ventilator adjustments
Open position valves
Maintains an open posture and open further upon the “push” of inspired air during inspiration
Closed position valve (PMV)
- “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
PMV characteristics
- For standard trach
- 15 mm hub
- Approved for ventilator use
- Only one-way valve biased closed position
Different PMVs
- 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
Shiley Phonate One Way Valve
- Standard trach
- 15 mm hub
- Open position valve
Montgomery vent-trach / montgomery speaking valve
- 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.
Eliachar / Hood Speaking Valve
- Hood speaking valve
- Standard trach - 15mm hub
- Open position valve
- Trach tube is modified by the placement of an inner cannula
Shikani-French Speaking Valve
- Fits on a 15mm hub OR can be sized to fit Jackson improved metal trach tube
- Open position design
- Valve contains ball
What can valves be used with?
-Valves can be used w/oxygen & humidified air & w/trach collars
What should not be administered during valve use?
-Respiratory treatments/medications should not be administered during valve use
What is the primary benefit of a one-way valve?
- The restoration of oral communication is the primary benefit
- Also assists in improving quality of life
What needs to be considered when assessing a patient’s airway for one-way speaking valve use?
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
The trach tube should fill no more than / to / of the tracheal lumen.
The trach tube should fill no more than 2/3 to 3/4 of the tracheal lumen.
Placement of the one-way valve will create what?
Placement of the one-way valve will create resistance to airflow
What may be required to compensate for the increase work of breathing?
Downsizing the trach tube may be required to compensate for the increased work of breathing
It’s important to monitor both __ and __ levels when using speaking valves.
It is important to monitor both O2 and CO2 levels.
What do you do for decreased O2 levels?
Increase FI02 or addition of pressure support (if on vent.)
What do you do for increased CO2 levels?
Instruct the patient to “blow out” air quickly to determine if the trend can be reversed - if not, take off the PMV.
When in doubt about the patient’s tolerance for the speaking valve - what should you do immediately?
REMOVE THE VALVE
What are some contraindications for speaking valve use?
- 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
What is an ABSOLUTE contraindication for speaking valve use?
The inability to tolerate cuff deflation is an ABSOLUTE contraindication for speaking valve use
Patent airway is dependent on what?
- 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)
When it seems like the patient has anxiety about the valve, what do you need to do first?
First, rule out a physiological reason for appearance of anxiety with the placement of the one-way valve
How do you handle the patient with anxiety about the PMV?
- 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
Benefits of one-way valve placement (7)
- 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
Secretion Status & Trach tube Occlusion Research - Research question…
Does a 5-point severity secretion scale have any predictive value for subsequent aspiration of food or liquid?
Who was the first to develop a standard 4-pt secretion scale?
Murray et al
What does Murray et al’s standard 4-pt scale assess?
Accumulated oropharyngeal secretions
Visible oropharyngeal secretions as viewed by endoscopy located within the laryngeal vestibule were highly predictive of what…
subsequent aspiration of food / liquid
The Marianjoy 5-point secretion scale does not allow for;
transition of secretions - the score the patient receives reflects the maximum amount of secretions present at the beginning of the exam
The Marianjoy 5-point secretion scale accounts for…
differences between laryngeal penetration & aspiration of secretions
Level 1 Secretions - Normal
Range from thin, clear secretions, <10% pooling
Level 2 Secretions - Mild
Pooling of pharyngeal secretions from 10-25%
Level 3 Secretions - Moderate
Pooling of secretions greater than 25% - No endolaryngeal secretions present
Level 4 Secretions - Severe
Laryngeal penetration of secretions; Intermittent laryngeal penetration upon inhalation; No aspiration of secretions
Level 5 Secretions - Profound
Secretions present on or below the vocal folds - Tracheal aspiration of secretions
Secretion Scale Development
-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
What are the 2 major dimensions of the secretion scale?
Amount & Location
Procedure of secretions article:
- ENT inserted flexible endoscope
- Prior to presentation of food/liquid, patient given initial score of secretions
- Two judges independently rated
Data analysis: Evaluated the relationship between:
Secretion level and the presence of laryngeal penetration, aspiration, tracheostomy tube status, and diet outcome recommendations
Data analysis: Association between:
Secretion levels, hospitalization status, and initial feeding status
Patients with ______ secretion levels tended to demonstrate _________ ___________ and ________ __________ more frequently.
Patients with higher secretion levels tended to demonstrate laryngeal penetration and tracheal aspiration more frequently.
Patients receiving ____ ________ vs. ____ ________ were ____ likely to demonstrate ______ secretions levels.
Patients receiving tube feeding vs. oral feedings were more likely to demonstrate high secretion levels.
** IMPORTANT **
Patients with a tracheostomy tube tended to have ______ secretion levels.
Patients w/a tracheostomy tube tended to have HIGHER secretion levels.
Patients with _____ secretion levels were ____ likely to receive a ____ restrictive diet recommendations.
Patients with lower secretion levels were more likely to receive a less restrictive diet recommendation.
3 major findings from the secretion study!
- 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.
Clinical applications of secretion study findings:
-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)
What is the purpose of “Secretions, occlusion status & swallowing in patients w/a trach tube” research study?
To describe the relationship between:
- Secretion level & laryngeal penetration / aspiration status
- Secretion level & occlusion status
- Occlusion status & aspiration status
Results: Secretion level & Aspiration status
- Overall 47.5% of patients aspirated
- 79% of the time it was SILENT
Conclusions: Secretion level & Aspiration status
- 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
Duration of the tracheostomy (was/wasn’t) related to secretion level.
Duration of the tracheostomy was NOT related to secretion level
Even though ______ occlusion had the highest aspiration rate, a significant relationship (was/wasn’t) observed.
Even though FINGER occlusion had the highest aspiration rate, a significant relationship was NOT observed.
Aspiration rate for the profound secretion level was ______ ______ distributed between the 3 types of occlusions (open, finger, capped)
Aspiration rate for the profound secretion level was fairly evenly distributed between the 3 types of occlusions (open, finger, capped)
An ___________ was observed between occlusion status and secretion level, not a _________.
An association was observed between occlusion status and secretion level, not causation.
Additional factors that may affect accumulated oral pharyngeal secretions (8)
- Pulmonary secretions
- Infection
- Patient mobility
- Medical instability
- Vocal fold mobility / glottal closure
- Swallowing frequency
- Laryngeal sensation
- Cognitive / alertness level
Oral comm option w/vent dependent patients: Ventrach speaking valve
- 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
Cuff deflation for vent dependent patients requires what?
- MD orders for cuff deflation / vent modifications
- Respiratory therapist / RN
Steps to cuff deflation for a vent dependent patient
- 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)
What do vent modifications do?
- Assess airway pressure
- Increase tidal volumes
What does the SLP do during cuff deflation for vent dependent patients
- 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
What do you monitor with cuff deflation on vent dependent patients
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)
Considerations in valve placement w/vent use
- 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)
Potential complications to consider in valve placement w/vent use.
- Barotrauma
- CO2 retention
- Hypoxemia
- Cardiac symptoms b/c of increased work of breath
Issues w/valve placement & vent use
- 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
Vent adjustments
- 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
What to consider when you increase tidal volume with ventilator adjustments
- 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
Vent adjustments: Increase oxygen settings
- 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
Vent adjustments: PEEP
- 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
Vent adjustments: Pressure Support
- May enhance the patient’s comfort & tolerance of the speaking valve
- Pressure support reduces the word of breathing
Vent adjustments: Sensitivity Setting
-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
PMV & Vent Alarms
All vent alarms are operable w/the exception of the *EXHALED RETURN TIDAL VOLUME ALARM
All vent alarms are operable w/the exception of the exhaled return tidal volume alarm because…
- 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.
Care & Cleaning of PMV
- 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.
Speaking valves: Trouble shooting - Anxiety
- 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
Speaking valves: Trouble shooting - Shortness of Breath / Breath Stacking
- 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)
Blom - Speech cannula
- 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)
Blom - Speech Cannula: How it works w/cuff inflation - INHALATION
- Bubble valve expands
- Flap valve opens
- Air delivered to lungs
Blom - Speech Cannula: How it works w/cuff inflation - EXHALATION
- Flap valve closes
- Bubble valve collapses
- Air goes through fenestration to vocal cords allowing phonation
Patient candidacy for use of the Blom Speech Cannula: Patient Requirements
-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
Patients who require ____ should be placed on vents w/ ____ _______ or ____________ _____ in oxygen.
Patients who required PEEP should be placed on vents w/ Flow Trigger or supplemental bled in oxygen
Non-Oral Communication Options
- 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)
Low Tech / Non-Electronic non-oral communication options
-Picture boards / word boards / communication boards / pages
Advantages to low tech - non-electronic non-oral comm options.
- 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
