Joanna Spain Sc 33

Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient

3/7/2015

Joanna Spain, MA CCC-SLP 1

Assessment and Intervention of Speech

and Swallowing for the Tracheostomy

Patient

Joanna Spain, MA CCC-SLPClinical EducatorPassy-Muir, [email protected]

www.passy-muir.com1-800-634-53971-949-833-8255

Disclosure: Financial — Employee of Passy-Muir Inc.Nonfinancial — No relevant nonfinancial relationship exists.

Agenda

• Tracheostomy: Procedures, Timing and Tubes

• Negative impacts of tracheostomy on communication and swallowing

• Benefits of the Passy-Muir® Valve • Passy-Muir® assessment criteria for spontaneous and

ventilator dependent patients.– Break

• Assessment and treatment planning across the continuum of care

• Team Approach and Early Rehabilitation

• Discussion

• CEU Information

mailto:[email protected]

http://www.passy-muir.com/


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General Outline

• Indications for Tracheostomy

• Clinical Complications of Tracheostomy and Cuff

• Increased Aspiration Risk

• Bias-Closed Position No Leak Design

• Benefits of the PMV® valve

• Patient Selection and Airway Assessment Criteria

• Spontaneously breathing and Ventilator Application

• Placement, transitioning, trouble-shooting

• Care of PMV® valve

• Assessment & treatment of dysphagia

• Multidisciplinary teams

• Education Opportunities

Learning Outcomes:

• Participants will be able to identify the negative impact that a tracheostomy may have on their current and future patients’ communication and swallowing.

• Participants will be able to identify patients that meet the inclusion or exclusion criteria for initiating or continuing use of the Passy-Muir Ventilator Swallowing and Speaking Valve. This would include being able to trouble shoot barriers to meeting the criteria for inclusion.

• Participants will be able to evaluate and develop meaningful treatment plan across patient types and clinical settings.

TRACHEOSTOMY:

PROCEDURES, TIMING AND TUBES


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Endotracheal Tube Factors Cited To Contribute To Swallowing Impairment and Aspiration

• Oral, pharyngeal, and laryngeal

mucosal injury.

• Injury to the vocal folds which

may be transient or permanent-mucosal bowing, ischemia

• Tracheal edema, ulceration

and stenosis

• Cuff may cause mucosal injury

due to excessive mucosal perfusion pressures

Laryngeal Intubation Granuloma

Reproduced with permission from Houston Otolaryngology www.ghorayeb.com

Indications for Tracheostomy

• Prolonged mechanical ventilation

• Inability to perform trans-laryngeal intubation (trauma, max/fax deformity)

• Upper airway obstruction (temporary or permanent)

• Secretion management (neuromuscular disease)

http://www.ghorayeb.com/


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WHEN: TIMING OF TRACHEOTOMY

21 Days ?

7-10 Days ?

2-3 Days ?

Does timing affect outcomes ?

What does the literature say ?

• Diaz-Prieto et al. Critical Care 2014, 18:585

• Durbin et al. Respiratory Care 2010, 55(1):76-83

Reputed Benefits

• Improved patient comfort/less need for sedation

• Lower WOB/faster weaning from MV

• Improved safety

• Improved oral hygiene and oral intake

• Less long term laryngeal damage

• Lower VAP rates

• Lower mortality

• Reduced ICU and overall LOS

• Earlier ability to speak/ Improved participation

Durbin, C. Resp Care 2010;55(8):1056-1068

HOW: TRACHEOTOMY PROCEDURES

Open or Surgical Tracheotomy

Tried and True Method

Percutaneous Dilatation or Balloon Dilatation

Tracheotomy Less costly and more convenient

CricothyroidotomyAs seen on ER Shows

Does the method of tracheotomy affect outcomes ?


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Parts of a tracheostomy tube - I SO STANDARDS

Routine Tracheostomy Tube Changes

• Initial tracheotomy by surgeon/MD

– to assure stoma and tract established

– For down-sizing

• Subsequent changes every 60-90 days

– To reduce complication of granulation tissue

– For down-sizing

• Difficult airways and special considerations

White, A., et al. (2010) Respiratory Care 55(8): 4069-1075.

Morris, L., et al. 2013 Critical Care Nurse; 33(5): 18-22, 24-31.

Tracheostomy Tubes

• Single Lumen/Cannula • Double Lumen/Cannula


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Types of Tubes

• MATERIALS– PVC, Silicone, Metal

– Metal Reinforced

• SHAPE– Curved, Angular, Non-

pre formed

• LENGTH– Standard

– Extra length

• Proximal

• Distal

• Adjustable Flange

• SINGLE LUMEN

• DOUBLE LUMEN

• FENESTRATED

• MRI COMPATIBLE

• Subglottic Suction

• Trach Talk

• CUFFS– Air, water, or foam

– Double cuffed

– Un-cuffed

• Custom Made

Calculating Tube Size

• ATS Consensus: The

tracheostomy tube

should take up no more

than 2/3 the ID of the

trachea.

(for pediatrics, no adult standard)

• AP Diameter of trachea

– Male: 18 +/- 5 mm

– Female: 12 +/- 3 mm

tube

I.D.O.D.

trachea

Not all size 6 trachs are equal !!

Size 6.0 Tracheostomy

ID OD L

Portex 6.0 8.3 55.0

Bivona 6.0 8.8 70.0

Shiley 6.4 10.8 74.0

SCT 6.0 8.3 67.0


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Extra Length Tubes

distal proximal

Increased skin-to-tracheal-wall distanceTracheal Malacia or Stenosis

Image used by permission from Nellcor Puritan Bennett LLC, Boulder, Colorado, doing business as Covidien.

Adjustable Flange Tube

Cuff Choices

• AIR FILLED – minimal leak

• TTS™ : WATER FILLED –minimal occlusion (can be air filled)

• FOME-Cuff® – self sealing


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Air Filled Cuffs

• Cuff Deflated• Cuff Inflated

Water Filled Cuffs TTS

• Cuff Up • Cuff Deflated

Cuff: Choices and Management

• Cuff up or down ?

– Purpose of cuff

– Cuffs and aspiration

• Cuff pressures

– 18-22* cm H20

– Minimal Leak

– Minimal occlusion


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Cuff Management – Minimal Leak

Cuff Management – Direct Measure

Late Complications

• Stenosis caused by granulation tissue formation (65%)

– At the level of the stoma

– At the level of the cuff

– At the level of the tip of the tracheostomy tube

• Tracheal malasia

• Tracheal-esophageal fistula

• Tracheal-innonimant artery fistula


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Breathing and Swallowing: A Shared System

• Anatomy

• Timing

• Pressures

• CNS Control

• Dysphagia – difficulty swallowing

• Aspiration – any material that penetrates below the level of the vocal folds.

Normal Respiration

APPLICATION AND PLACEMENT OF THE PASSY-MUIR® VALVE

MECHANICS OF A SWALLOW

• Phases of swallow

– Anticipatory

– Oral Preparatory

– Oral

– Pharyngeal

– Esophageal


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Subglottic Pressure: Role in Swallow

• Positive Pressure-

Subglottic

– Lung recoil: pressure

increases

• Negative pressure-Esophageal

– Opening of UES: pressure decreases

Timing of Swallow

The usual pattern in healthy adults is to time swallows to occur at mid-exhalation.

Healthy individuals also nearly exclusively follow each swallow with exhalation.

This pattern assures there is sufficient air pressure below the vocal folds during a swallow to inhibit aspiration of food residue after the swallow.

Inhale - Exhale – Swallow – Exhale

Inhale – Swallow - Exhale

Dr. Roxann Diez Gross 2009

Timing of Swallow

In natural tasks such as cup drinking, the onset of breathing cessation seemed to be variable.

When instructed to take a cup and bring it to their mouth, many patients discontinue breathing well before it reaches the lips.

Dr. Bonnie Martin-Harris 2007


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IMPACT OF TRACHEOSTOMY ON THE

AERO-DIGESTIVE TRACT

Clinical Complications

• Reduced Airflow

– Taste, Smell, Sensation

– Voice

• Negative psychological wellbeing

• Reduced Positive Airway Pressure

– Physiologic Peep

– Cough

– Valsalva

– Positive subglottic and negative esophageal pressure during swallowing

Airflow

Clinical Complications - Cuff

• Esophageal impingement

• Reflux

• Necrosis and Trauma

• Laryngeal tethering

• Reduced airway

protection


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Cuff Over-Inflation

Break

APPLICATION OF THE PASSY-MUIR®

TRACHEOSTOMY & VENTILATOR

SWALLOWING AND SPEAKING VALVE


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INVENTOR OF THE

PASSY-MUIR® VALVE

David Muir’s Original Design

• Opens only during active inspiration

• Closes at end inspiration

• Remains closed throughout the expiratory cycle

• Air is re-directed thru the upper airway

• Offers a buffer to secretions

• Patented “no leak” design

PMV® 007 (Aqua color™)

Benefits of the Passy-Muir® Valve

• Restores

– Taste, Smell, Sensation

– Voice

• Restores Positive Airway Pressure

– Physiologic Peep

– Cough

– Valsalva

– Positive subglottic and negative esophageal pressure during swallowing

• Is “physical therapy” for the upper airway

(Burkhead 2004)


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Expedites Weaning and Decannulation

• Rehabilitation tool for

respiratory muscles

• Rehab tool for upper airway muscles

• Reduces decannulation

time

• Easier to tolerate than

capping/corking

• Develops confidence

and motivation

Frey & Wood, 1991; Sierros, et. al. 2007; Light et al., 1989

IMPROVES PSYCHOLOGICAL WELLBEING

Communication with family

Participation in decision making

Reduced sense of isolation and

anxiety

Better sense of well-being

Communication with care-givers


Cost Savings

About $1 a day

• Passy-Muir Valve

$ 220,000/28 days

1. Tube Feeding

2. Antibiotics/ ICU stay

3. Vent days/Length of stay

4. Suctioning Supplies

HCUP 2009 acute care statistics


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Professions That Benefit

• RCP - secretion management, oxygenation, weaning tool, more normal breathing patterns and use of respiratory muscles

• SLP – allows for more functional assessment and rehabilitation of voice/swallow

• OT/PT - participation• RN – communication,

facilitate productive BM, oral medications

• MD - communication• Dietary – initiate or

advance diet

Overall Plan – Pre assessment

• Have a plan SLP/ RCP: who does what ?

• Block the time

• Educate, Educate, Educate

• Reassure the patient

• Do oral care and suctioning as necessary

• Pick a good time of the day for the patient

• Good body alignment

• Pain control

• Reduce noise and interference


• Selection/Baseline Data collection

Patient Selection Criteria

• Arousable, responsive, basic

attempts to communicate.

• ≥ 6° post percutaneous, 24-

48° post-surgical trach.

• Hemodynamically stable.

• Tolerate cuff deflation.

• Vitals:

– BP stable- specific to

patients history

– Respiratory rate ≤30

– FiO2 ≤ 50%

• SpO2 ≥ 90

Stop Criteria

• Heart rate increase

>20 BPM from baseline

• RR >35 BPM sustained

• SPO2 < 88% sustained

• Fio2 >50%

• Evidence of “air

trapping”.

• Patient report of

difficulty breathing, or

increased respiratory

effort.


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To Assess for Upper Airway Patency

• Deflate cuff

• Ask patient to inhale

• Finger occlude and speak or cough on exhalation

Use mirrors, cotton, feathers, whistles or bubbles to assist with the oral exhalation process.

PMV® valve placement

Mrs. Duval


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Factors Affecting Airway Patency

• Size of tracheostomy tube

• Presence or degree of

obstruction

• Edema

• Secretions

• Type of tracheostomy

tube: foam cuff-absolute contraindication

TRANSITIONING AND TROUBLESHOOTING

• Inadequate exhalation or breath stacking

• Coughing

• Anxiety or depression

• Weak voice

Ventilator Application of the Passy-

Muir® Valve

A Team Approach


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Ventilator Application-TEAM APPROACH

• Adjust peep

• Slow cuff deflation

• Monitor pressure/volume loss

• Place PMV® valve

• Compensate forvolume/pressure loss

• Set alarms appropriately

Michelle- Case Study

35 year old female in ICU

Dx: Guillian Barre’ Syndrome

Size 8.0 cuffed TT – s/p tracheotomy 2 weeks

Vented on SIMV/PS

Also has Bell’s Palsy on left side of face

Michelle


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Neurologic – Guillain-Barré (Refractory to plasma-phoresis)

Definition:

• 40 yr old male

• No significant previous

medical history

• # 7 TTS/NPO - peg fed

• 100% Ventilator

Dependent

• Vital signs stable

• Alert and oriented

Erasmo Counting

Erasmo-Quad Dysphagia Therapy


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USE IT OR LOSE IT !REHABILITATION BEGINS IN THE ICU

Dysphagia Assessment

Diagnostic tools• Bedside evaluation with Blue Dye (?)

Pre/post suctioningo Degree of aspiration

• Traditional bedside evaluationSigns and Symptoms of Aspiration

• Wet sounding voice• Drooling

• Multiple swallows

• Coughing while eating• Recurrent RLL pneumonia

• Instrumental assessment• FEES

• MBS

“If you do nothing, you will improve nothing.”

“Things can get worse as you wait for the patient to get better.”

Lori Burkhead Morgan, PhD. CCC-SLP


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Treatment “What will make the biggest impact?”

Traditional Dysphagia Therapy

• Oral Motor exercises• Oropharyngeal/laryngeal awareness of secretions

• Oral/pharyngeal/laryngeal strengthening

Traditional Speech/Voice Therapy

• Phonation time• Compensatory speech/voice strategies

Expiratory Muscle Strength Training (EMST)

• 5 reps/5 sets 5x/wk for 4 weeksPitts, T., et al. Chest 2009; 135: 1301-1308

Troche, M., et al. Neurology 2010; 75: 1912-1919

Sapienza, C. Perspectives on Swallowing and Swallowing Disorders 20--,

“Start with what the patient is capable of doing”

Breathing Techniques

• Pursed lip breathing

– Coordinate breathing and activity

• Diaphragmatic breathing

• Lateral costal breathing

Warren,V. Physical Therapy 2002;

82: 590-600

UTMB (2005) P&P

Exercise Training

• Rehab can begin in the bed….

– Bed rest exercises

– Moving in the bed for simple ADL’s

– Sitting on the side of the bed to dangle

– Progress to standing

– Chair exercises

– Begin short walks

Mobilization and exercise!!


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Respiratory Muscle Training (exp)

ALS

Why Is Body Position Important?

• Daily tasks that require

trunk control:

– Breathing

– Coughing

– Eating

– Talking

– Moving-reaching

– Bowel and bladder emptying


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Assessment Challenges

• Age

• Acute Medical Illness

• Multiple Comorbidities

• ICU Acquired Weakness

– 50% of mechanically ventilated patients have

Systemic Inflammatory Response syndrome (SIRS)

– 50-70% of these patients will develop pathological

muscle weakness and peripheral nerve disorder.Bolton, C. Muscle & Nerve 2005; 32: 140-163; Leijten, F. et al. Journal of Intensive

Care Nursing1996; 22: 856-861; Witt, N. et al Chest Journal;99: 176-184.

Negative Effects of Bed Rest

• The negative impact of bed rest is well known- muscle atrophy, pressure ulcers, atelectasis, and bone demineralization.

• Negative impacts may persist for years post discharge.

• Electromyographic/nerve conduction studies reveal increased neuromyopathy in the presence of systemic inflammatory response syndrome and organ failure.

• No evidence exists in the literature that supports efficacy of bed rest.

• Disuse atrophy at the cellular level begins within 4 hours of implementing bed rest.

(Truong, A. et al. Critical Care 2009, 13: 216)

• Health adults, bed rest (Griffiths et al. Nutrition 1995: 11:428-432)

– Strength declined by 1 – 1.5% per day– Mood changes

– Loss of coordination, balance and work tolerance– Casting: Strength declines by 25% in 7 days (De Jonghe et al. CCM

2000; S309-315)

Early Activity: Feasible and Safe

• Prospective cohort study of 103 MV patients. MV >4 days

• Total of 1449 activity events in 103 patients– 16% sit on bedside

– 31% sit in chair– 53% ambulation

– 69% of survivors could ambulate > 100 ft at discharge

• Adverse events - < 1%– Fall to knees, feeding tube removal, Systolic BP changes,

desaturation to <80%

– No extubations

Baily et al. CCM 2007; 35:139


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Outcomes: Early Exercise and Mobilization

• Functional

– Earlier time OOB

– Earlier time walking

– Independence at

discharge

– Greater walking distance

– More likely discharge to

home

Morris et al. CCM 2008; 36:2238

Morris et al. Am J Med Sci. 2011; 34(5):373

Needham et al. Arch Phys Med Rehab 2010; 91:536

• Neurocognitive

– Shorter duration of

delirium

• Hospital Dependence

– Reduced ICU days

– Reduced hospital LOS

– Reduced duration of MV

– Less readmission or death

Minimum Criteria for Initiating Early

Mobilization (William D. Schweickert, MD. NALTHA 2013 Presentation)

• M – Myocardial stability

– No evidence of myocardial ischemia

– Stable heart rate and rhythm

• O - Oxygenation

– FIO2 < 60%

– PEEP </= 10

• V - Vaso-pressors Minimal

– No need for increased dose within 2 hours

• E - Engages to voice

– Patient responds to verbal stimuli

Rehabilitation in the ICU – Cost Savings

• Johns Hopkins University Hospital MICU– Admit 900 patients per year

– Dedicated rehab team in ICU added $ 358,000

– First year results:

• Reduced Length of stay by 23%

• Net savings – $ 818,000

Reported in Critical Care Medicine 2013

Dale Needham PhD, MD, Critical Care Specialist


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TEAM DEVELOPMENT &

REHABILITATION BEGINS IN THE ICU

Decannulation Plan

• Begins at Intubation-What is the Plan ?Morris, L. (2014). The importance of tracheostomy progression in the ICU. Critical Care Nursing.

• Evaluation for Decannulation– Reason for tracheotomy has resolved

– Medically stable

– Patent upper airway

– Tolerates speaking valve

– Can manage oral and tracheal secretions

– Tolerates capping/plugging

– Risk of aspiration assessedStelfox, H., et al. 2009 Respiratory Care, 54(12):1658-1664

Stelfox, H., et al. 2008 Critical Care, 12:R26

Airway Management Team

• “Tracheostomy expertise must follow the patient wherever they go in the hospital.” Heffner, John E.

• Team Approach – Timing and tube selection

– When to downsize

– Plan of care

• Communication

• Swallowing

– Decannulation

– Impacts continuity of care

– Impacts safety, length of stay

and costs


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Benefits of a Multidisciplinary Team

• Tobin, et al. 2008

• Teaching hospital over four year period after implementation of multidisciplinary trach team

– Length of stay after ICU discharge decreased from 30 to

19 days

– Decannulation days after ICU discharge decreased to 7

from 14 days

Benefits of a Multidisciplinary Team

• Le Blanc, et al. 2009

• Level I Tertiary Trauma Center

– Time to decannulation decreased by 6.49 days

– Length of stay decreased by 37.8 days

• Earlier discharge to rehabilitation facility

• Earlier intervention by SLP

• Earlier use of Passy-Muir® Valve

Are Tracheostomized Patients Safe on the

Regular Hospital Wards ?

……”tracheostomized patients should be followed by a dedicated multidisciplinary team that continues to evaluate for decannulation, provides continuity of tracheostomy care and manages emergency situations.”

Wilcox, et al. RESPIRATORY CARE • DECEMBER 2009 VOL 54 NO 12


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Why You Need a Trach Team

1. Communication2. Patient Safety3. Risk of Aspiration

4. Risk Associated with Trach Tube5. Infection Control

6. Mechanical Ventilation7. Long-Term Trach Placement

8. Education9. Staff Confidence/Knowledge10. Plan of Care

11. Continuity of Care12. Quality of Care

13. Quality of Life

Team Members

• Nursing – at bedside, activities of daily living (ADLs) medication

• RCP – mechanical ventilation, weaning

• SLP – swallow/voice evaluation and treatment• OT/PT – Range of Motion (ROM), rehabilitation &

strength, ADL

• Case Manager – discharge planning• Wound Specialist – stoma care

• Family – emotional support

• Physician – orders, consults

• Ancillary Staff – anyone who cares for the patient

• Co-treat & cross train

Routine and Emergency Procedures

• Suctioning

• Broncho-pulmonary Hygiene

• Oxygen and Humidity Therapy

• Trach Care/Stoma Care

• Inner Cannula Change Cleaning

• Oral Care

• Unplanned Decannulation

• Blocked Tube or Inner Cannula


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1. Timing of tracheotomy2. Types of tubes/cuffs used3. Communication Method4. Decannulation Pathway5. SLP Consults6. RT Consults7. OT/PT Consults8. Nutrition Consults9. Wound/Stoma Management10. Trach changes/downsizing11. Cuff maintenance12. Oral care

SuggestedProtocols

13. Bed Control/patient placement14. Suctioning/BPH15. Oxygen and humidity16. Discharge Planning17. Patient/Family Education18. Aspiration/VAP prevention19. Patient Transport Standards20. Passy-Muir® Valve Use21. MD Responsibilities 22. Staff Competencies23. Standard/standing Orders24. Emergency Procedures

Collaborative Protocols

Team Process: Review

Additional Educational Opportunities

• Self-study webinars available on demand

– Getting Started

– Ventilator Application

– Swallowing

– Pediatric

– Special Populations

• Live group webinars

• www.passy-muir.com

• Passy-Muir Inc. is an approved provider of

continuing education through ASHA , AARC and California Board of Nursing Credit

http://www.passy-muir.com/


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CEU Information

http://pmed.us/sem3359

Joanna Spain Sc 33

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