Articles Representing International Research on Tracheostomy, Mechanical Ventilation and Passy Muir® Valves
Kristin King, PhD, CCC-SLP
Impact of the Speaking Valve on the Use of Medications:
Kinneally, T. (2018). Do speaking valves reduce sedative drug use in ICU? A retrospective data analysis. Australian Critical Care, 31(2), 131–132.
It has been reported by patients that the inability to communicate effectively with healthcare professionals has led to misunderstandings as to their needs, causing increased administration of pain medications and other factors negatively impacting their care. Kinneally reports that use of a tracheostomy tube, instead of an endotracheal tube, enables less use of sedation. This article reports that early use of speaking valves (SV) has become common practice in his ICU. By using SVs earlier during patient care in the ICU, Kinneally reports that the return of verbal communication has been observed to improve patient care and has increased patient and family engagement. He also describes how this appears to be associated with reduced agitation. Because of these changes in patient access to communication, Kinneally reports that the use of sedatives and pain medications has been reduced significantly. Overall, less sedatives are being used when patients have access to their voice, communication, and interaction in their care. These findings suggest that early intervention of SV use with patients in the ICU will improve overall care by reducing the need for pain and sedating medications.
Use of Speaking Valves and Impact on Length of Stay:
Alabdah, M., Lynch, J., & McGrath, B. (2018). Reduction in hospital length of stay via tracheostomy quality improvement collaborative. British Journal of Anaesthesia, 120(5), e25 – e 26. DOI: https://doi.org/10.1016/j.bja.2017.11.058
The Global Tracheostomy Collaborative (GTC) has initiated a program at a global level to improve the care of patients with tracheostomy. In the UK through the National Health System, the UK has the Improving Tracheostomy Care (ITC) project to improve the care of patients, and 20 facilities within this project also have GTC resources. The GTC analyzed data comparing the global GTC data on tracheostomy care to those facilities with GTC resources while participating in the Improving Tracheostomy Care (ITC) project. The global program of the GTC reports that these facilities used speaking valves in-line with ventilation in 6.6% of their patients while the ITC reported 0% use with patients on mechanical ventilation. Through analysis of this data from the participating medical facilities, the GTC reports that the use of the Valve with in-line mechanical ventilation appears to positively impact decannulation rates and length of stay for patients. The GTC also suggests that establishing an international/global standard of care will improve overall education, training, and care of patients with tracheostomy.
Quality of Life Considerations:
Kenny, B. (2018). Quality of life improves for tracheostomy patients with return of voice: A mixed methods evaluation of the patient experience across the care continuum. Intensive and Critical Care Nursing, 46, 10-16. doi:10.1016/j. iccn.2018.02.004.
Freeman-Sanderson, A.L., Togher, L., Elkins, M.R., & Phipps, P.R. (2016). An intervention to allow early speech in ventilated tracheostomy patients in an Australian intensive care unit (ICU): A randomised controlled trial. Australian Critical Care, 29(2), 114. doi:10.1016/j.aucc.2015.12.012
Freeman-Sanderson, A. L., Togher, L., Elkins, M. R., & Phipps, P.R. (2016). Quality of life improves with return of voice in tracheostomy patients in intensive care: An observational study. Journal of Critical Care, 33, 186-191. doi:10.1016/j.jcrc.2016.01.012
Freeman-Sanderson, A.L., Togher, L., Elkins, M.R., & Phipps, P.R. (2016). Return of voice for ventilated tracheostomy patients in ICU: A randomized, controlled trial of early-targeted intercention. Critical Care Medicine, 44(6), 1075-1081. doi:10.1097/ccm.0000000000001610
Sutt, A., Cornwell, P.L., Mullany, D., Kinneally, T., & Fraser, J.F. (2015). The use of tracheostomy speaking valves in mechanically ventilated patients results in improved communication and does not prolong ventilation time in cardiothoracic intensive care unit patients. Journal of Critical Care, 30(3), 491-494. doi:10.1016/j.jcrc.2014.12.017
This group of publications investigated the use of a Passy Muir Valve® in the Intensive Care Units (ICU). The premise behind the undertaking of these studies was to examine the effects of targeted early communication intervention for the restoration of voice in tracheostomy patients with mechanical ventilation in the ICU. Freeman-Sanderson et al. discuss the negative impact of cuffed tracheostomy tubes for prolonged mechanical ventilation on the ability to voice – in actuality – prolonged voicelessness. After establishing randomized trials to investigate the effect of providing early intervention for cuff deflation and use of the Passy Muir Valve in-line with mechanical ventilation, the initial studies report benefits when addressing these concerns early in patient care. These studies report a compilation of findings, from restoring voice earlier during patient care to the positive impact of voice restoration on mood, outlook, and sense of recovery.
Sutt et al. investigated the impact of early use of the Valve in-line with mechanical ventilation on communication and on duration of ventilation time. The authors reported that while the patients achieved earlier communication, they did not observe an impact on ventilation time or time to decannulation.
These studies provide support for early intervention and the need to provide patients with the access to their voice for participation in their medical care and for socialization with family and caregivers. The authors advocate that early intervention and restoration of voice in the ICU may improve the experience of patients in the ICU following tracheostomy and improve psychosocial functions.
Impact of the PMV® In-Line with Mechanical Ventilation on Lung Recruitment:
Sutt, A.L., Antsey, C., Caruana, L.R., Cornwell, P.L., & Fraser, J. (2017). Ventilation distribution and lung recruitment with speaking valve use in tracheostomised patient weaning from mechanical ventilation in intensive care. Journal of Critical Care, 40. doi: 10.1016/j.jcrc.2017.04.001
Sutt, A., Caruana, L.R., Dunster, K.R., Cornwell, P.L., Anstey, C.M., & Fraser, J. F. (2016). Speaking valves in tracheostomised ICU patients weaning off mechanical ventilation – do they facilitate lung recruitment? Critical Care, 20(1), 91. doi:10.1186/s13054-016-1249-x
Sutt, A., Caruana, L.R., Dunster, K. R., Cornwell, P.L., & Fraser, J.F. (2015). Improved lung recruitment and diaphragm mobility with an in-line speaking valve in tracheostomised mechanically ventilated patients – An observational study. Australian Critical Care, 28(1), 45. doi:10.1016/j.aucc.2014.10.021
Sutt, A., Cornwell, P.L, Caruna, L.R., Dunster, K.R., & Fraser, J.F. (2015). Speaking valves in mechanically ventilated ICU patients- Improved communication and improved lung recruitment. American Journal of Respiratory Critical Care Medicine, 191, A3162.
Sutt, A. & Fraser, J.F. (2015). Speaking valves as part of standard care with tracheostomized mechanically ventilated patients in intensive care unit. Journal of Critical Care, 30(5), 1119-1120. doi:10.1016/j.jcrc.2015.06.015 Sutt and colleagues have published a collection of studies that investigated the impact of a Passy Muir Valve in-line with mechanical ventilation on lung recruitment. The premise behind these studies was to answer the question if deflating the cuff and placing a Valve in-line would cause the lungs to de-recruit? The initial findings reported in 2015 and 2016 demonstrated that with placement of the Valve in-line with mechanical ventilation improvement in lung recruitment was observed. These studies were conducted by using Electrical Impedance Tomography (EIT) to measure lung volumes and muscle activity while using the Valve in-line. EIT readings indicated improved lung recruitment and possible improved use of the diaphragm. The authors also reported increased verbal communication. The 2017 study in the Journal of Critical Care provided a secondary analysis of the data from the earlier studies. This analysis demonstrated that the lung recruitment occurred across all lung sections and that hyperinflation did not occur. These findings support the early use of Valves in-line to provide not only earlier access to communication and other psychological benefits, but also to provide increased lung and alveolar recruitment. The authors did not report any adverse events with early use of the Valve in-line.
Multidisciplinary Team Considerations:
Santos, A., Harper, D., Gandy, S., and Buchanan, B. (2018). 1214: The positive impact of multidisciplinary tracheostomy team in the care of post-tracheostomy patients. Critical Care Medicine, 46 (1), 591.doi: 10.1097/01.ccm.0000529218.20247.15 Santos et al. investigated the impact of a multidisciplinary team on outcomes following tracheostomy. Their team was developed to include surgeons, intensivists, nurses, respiratory therapists, and speech-language pathologists. The purpose of the team was to develop a systematic way to wean patients from mechanical ventilation, introduce and expedite speaking valve use, facilitate weaning and decannulation, provide better transitions from ICU care to the floor, and improve education of patient, family, and caregiver. They followed the impact of the team on 102 patients with tracheostomy. The findings from the study indicated that the patients had decreased ICU length of stay and hospital length of stay, expedited weaning from ventilator, earlier use of the Passy Muir Valve, earlier initiation of oral diet, earlier decannulation, and fewer tracheostomy related adverse events or critical issues. These findings suggest that a multidisciplinary team is essential for improved care of patients with tracheostomy.
Multidisciplinary Team Considerations
Working with patients following tracheostomy and with mechanical ventilation takes a multidisciplinary team (MDT) approach to ascertain that the needs of the patient are well met. Because of the complex nature of working with these patients, having the involvement of different disciplines provides perspective on various aspects of care. Typically, these patients are followed by both the respiratory therapist (RT) and the speech-language pathologist (SLP). However, many other healthcare professionals should be involved with the patient following tracheostomy and with use of the Passy Muir® Valve. To initiate an MDT approach, it takes multiple healthcare professionals, including the physician, nursing, dieticians, physical therapists, occupational therapists, and the patient at the center of it all. In a study conducted by Fröhlich, Boksberger, Barfuss-Schneider, Liem, & Petry (2017), they investigated best practice for early intervention with use of the Passy Muir Valve as a standard of care in the ICU following tracheostomy and mechanical ventilation. Their findings demonstrated that patients improved with voicing and swallowing more quickly than those without MDT intervention. However, since the authors were able to follow the patients over a period of time that included up to 51 trials with the PMV ®, they also reported how the implementation of a team approach had a positive impact on the potential for adverse events, with none occurring. The researchers attributed this to the multidisciplinary team approach and suggested the findings support the idea that two professionals should be at the bedside to provide assessment and intervention with the PMV in-line with mechanical ventilation. Santos, Harper, Gandy, & Buchanan (2018) also investigated the impact of team management on the post-tracheostomy care of patients. Their findings concur with Frohlich, et al (2017) and suggest that having the involvement of an MDT allows the patient to progress faster in multiple areas. The parameters addressed in their study were time in the ICU, total hospital days, days to Valve use, days to verbal communication, oral intake, and decannulation. The group receiving team management were found to have improved care in all areas measured. Patients who received the Valve with the MDT did so earlier in their care and had restored voicing, communication, and the ability to participate in their care. The positive impact of an MDT on the care of patients and the ability to achieve earlier voicing cannot be overstated in its clinical significance.