Assessment of cognitive function may begin very early in patients with severe traumatic brain injury, often as soon as patients begin emerging from a deep coma.1-3 One assessment that may be used with this patient population is The Rappaport Coma/Near Coma Scale, a rating tool that assists with monitoring patient response to various stimuli across all sensory domains.1 A patient’s ability to vocalize or verbalize is included as a factor in this assessment. Responses to strong odors, visual, tactile, and painful stimuli are also rated.
Often patients who are minimally conscious require a tracheostomy to support respiratory function. However, an open tracheostomy tube does not allow airﬂow through the oral and nasal tracts which impacts access to sensory inputs such as olfaction and taste and diminishes the ability to vocalize or verbalize responses. Since sensory awareness and verbalizations are often included in the assessment of these low-level TBI patients, measurement of function may be altered, and therapeutic plans based on the assessment may be misguided.
Use of the Passy Muir® Valve can begin after the original placement of the tracheotomy tube and when the multidisciplinary team deems the patient ready. Early placement of the Passy Muir Valve can restore airﬂow to the upper airway allowing increased vocalizations and awareness of sensory stimulation, thus providing more complete and meaningful assessment and impacting recovery.
The presence of a tracheostomy tube with an inﬂated cuff has signiﬁcant effects on swallowing frequency and effectiveness due to decreased laryngeal excursion, subglottic pressure and oropharyngeal sensitivity.4-6 In a study by Seidl, Nusser-Müller-Busch, and Ernst,4 tracheostomy tubes were determined to affect swallowing function in vegetative patients. The researchers reported that for patients with a Glasgow Coma Scale score below eight points, the presence of the tracheotomy tube decreased the swallowing frequency. Removal of the tracheostomy tube signiﬁcantly improved swallowing frequency for this group of patients.
Therefore, Seidl et al. recommend deﬂation of the cuff or removal of the tracheostomy tube as a therapeutic measure to improve swallow function based on the improved sensitivity that occurs with re-established physiology in the upper airway. For patients not ready for decannulation, cuff deﬂation and early use of the Passy Muir Valve may signiﬁcantly contribute to the improvement of swallow safety and efficiency by not only restoring expiratory airﬂow physiology but also re-establishing the beneﬁts of subglottic pressure.5 With these noted potential benefits, use of the Passy Muir Valve early in recovery should be considered.
Mike Harrell was formerly Director of Respiratory Care with Charlotte Regional Medical Center (CRMC) in Punta Gorda, FL prior to joining the Passy Muir Educational Team as a Clinical Specialist in 2005. Mike also previously presided as president of the Florida Society of Respiratory Care, where he brought his clinical knowledge and strong advocacy for patient care together to improve respiratory care in the state of Florida.
- Rappaport, M. (2005). The disability rating scale and Coma/Near Coma scales in evaluating severe head injury. Neuropsychological Rehabilitation, 15(3-4): 442-453.
- Rappaport, M., Dogherty, A., & Kelting, D. (1992). Evaluation of coma and vegetative states. Archives of Physical Medicine and Rehabilitation, 73:628-634.
- Talbot, L., & Whitaker, H. (1994). Brain-injured persons in an altered state of consciousness: Measures and intervention strategies. Brain Injury, 8 (8), 689-699.
- Seidl, R.O., Nusser-Müller-Busch, R., & Ernst, A. (2005). The inﬂuence of tracheostomy tubes on the swallowing frequency in neurogenic dysphagia. Otolaryngology Head Neck Surgery, 132 (3), 484-6.
- Eibling, D., & Gross, R. (1996). Subglottic air pressure: A key component of swallowing efﬁciency. Annals of Otology Rhinology Laryngology, 105(4), 253-258
- Dettelbach, M., Gross, R., Mahlmann, J., et. al. (1995). The effect of the Passy Muir® Valve on aspiration in patients with tracheostomy. Head & Neck, 17(4), 297-302.