Clinicians are often uncertain of how to make appropriate ventilator adjustments for cuff deflation and placement of the Valve in-line.
An inflated cuff is typically used during mechanical ventilation to ensure that all air is delivered through the tracheostomy tube, to the lungs, and then returned to the ventilator to be monitored and measured.
For in-line Passy Muir® Valve placement, the cuff must be completely deflated to allow airflow through the upper airway upon exhalation.
Studies have shown that adequate ventilation can still be achieved with the tracheostomy tube cuff deflated.1In an additional study, cuff deflation during continuous positive airway pressure has been associated with stable respiratory parameters and allowed patients to vocalize and swallow.2,3
In a bench study testing the performance of several brands of ventilators with the Passy Muir Valve in-line, all ventilators in the study focused satisfactorily with restrictions on certain modes and alarm settings.
Multidisciplinary teams that incorporate the Valve as a routine strategy in ventilator weaning have improved outcomes.4-7
When using the Passy Muir Valve during mechanical ventilation, respiratory therapists may make some adjustments under physician direction to improve patient comfort and safety. Common simple adjustments include:
Reduce or eliminate PEEP: The establishment of a closed respiratory system and exhalation through the oronasopharynx, creates physiologic PEEP. This enables the clinician to reduce/eliminate set mechanical PEEP. This adjustment may also eliminate any unnecessary continuous airflow within the circuit. Continuous flow in the circuit may make it difficult for the patient to close his vocal cords and may stimulate continuous coughing and autocycling of the ventilator.
Volume Compensation: For patients with inspiratory volume loss, after cuff deflation, additional tidal volume can be added until adequate voicing can be heard, good chest expansion is noted, or baseline peak inspiratory pressure is reached. This assures adequate alveolar ventilation with the cuff deflated. An increase in delivered tidal volume may be a temporary adjustment until strength of the pharyngeal and laryngeal muscles is regained. NOTE: 400cc is the maximum recommended additional volume.
Alarm Adjustments: All alarms on the ventilator must be re-evaluated for appropriate adjustments before, during, and after use of the Valve. Since exhaled volumes are not returned to the ventilator, some alarms can be adjusted or silenced to stop unnecessary alarming. The high and low pressure alarms should remain intact and adjusted appropriately to detect and alert caregivers to disconnects, patient fatigue, or changes in peak airway pressures.
- Bach, J. & Alba, J. (1990). Tracheostomy Ventilation: A study of efficacy with deflated cuffs and cuffless tubes. Chest, 97: 679-83.
- Conway, D. & Mackie, C. (2004). The effects of tracheostomy cuff deflation during continuous positive airway pressure. Anaesthesia, 59: 652-657.
- Grilliot, K. et al (2012, November). Ventilator function and effect of alarms during speaking valve use in a critical care setting: A bench study. Poster presented at the 58th International Congress of the Association of Respiratory Care. New Orleans, LA.
- Stevens, M., et al. (2011). Use of the Passy Muir® Valve in the neonatal intensive care unit. Neonatal Intensive Care, 24 (7): 22-23.
- Windhorst, C., et al (2009). Patients requiring tracheostomy and mechanical ventilation: a model for interdisciplinary decision making. The ASHA Leader, 14 (1), 10-13. Black, C. et al. (2012). A Multidisciplinary team approach to weaning from prolonged mechanical ventilation. British Journal of Hospital Medicine. Aug;, 73(8): 462-466.
- Atito-Narh, E. et al (2008). Slow ventilator weaning after cervical spinal cord injury. British Journal of Intensive Care. 95-102.
- Kobak, J. & Dean, L. (2011). Use of the Passy Muir® Valve for weaning in long term acute care hospital. Respiratory Therapy. 6 (4):44, 57.
- Gurnari, D. & Martin, C. (October, 2011). Early collaboration of respiratory and rehabilitation department improves ventilator weaning rates. Poster presented at the Conference of the National Association of Long Term Hospitals, New Orleans, LA.