Application of the Passy-Muir Tracheostomy and Ventilator

APPLICATION OF THE PASSY-MUIR®
TRACHEOSTOMY AND VENTILATOR
SWALLOWING AND SPEAKING VALVES
Julie A. Kobak
Vice President of Clinical Education
Passy-Muir Inc.
jkobak@passy-muir.com
(949) 833-8255
Disclosure: Financial — Employee of Passy-Muir Inc.
Nonfinancial — No relevant nonfinancial relationship exists.
Gail M. Sudderth RRT
Clinical Specialist
Passy-Muir Inc.
gsudderth@passy-muir.com
(949) 833-8255
Disclosure: Financial — Employee of Passy-Muir Inc.
Nonfinancial — No relevant nonfinancial relationship exists.
Disclosure Statement
• Passy-Muir, Inc. has developed and patented
a licensed technology trademarked as the
Passy-Muir® Tracheostomy and Ventilator
Swallowing and Speaking Valve. This
presentation will focus primarily on the biasedclosed position Passy-Muir Valve and will
include little to no information on other
speaking valves.
General Outline
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Clinical Complications of Tracheostomy and Cuff
Bias-Closed Position No Leak Design
Benefits of the Passy-Muir® Valve
Patient Selection and Airway Assessment Criteria
Ventilator Application
Placement, transitioning, trouble-shooting
Case Studies
Types of Tubes
• MATERIALS
– PVC, Silicone, Metal
– Metal Reinforced
• SHAPE
– Curved, Angular, Nonpre formed
• LENGTH
– Standard
– Extra length
• Proximal
• Distal
• Adjustable Flange
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SINGLE LUMEN
DOUBLE LUMEN
FENESTRATED
MRI COMPATIBLE
Subglottic Suction
Trach Talk
CUFFS
– Air, water, or foam
– Double cuffed
– Un-cuffed
• Custom Made
Not all size 6 trachs are equal !!
Size 6.0 Tracheostomy
ID
OD L
Portex
6.0 8.3 55.0
Bivona
6.0
Shiley
6.4 10.8 74.0
SCT
6.0
8.8
8.3
70.0
67.0
Cuff: Choices and Management
• Cuff up or down ?
– Purpose of cuff
– Cuffs and aspiration
• Cuff pressures
– 18-22* cm H20
– Minimal Leak
– Minimal occlusion
Clinical Complications
• Lack of vocal
productioncommunication
• Psychological-agony,
fear, panic, frustration
• Decreased sense of
smell/taste
Tracheostomy and Aspiration
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Does a cuff prevent
aspiration?
Definition
Incidence of aspiration
– 50% - 87% rate for trach
and vent patients
(Elpern et al., 1987, 1994, 2000; Tolep et
al., 1996)
– 75% silent aspiration
(Davis & Stanton, 2004; Elpern et aI.,
1994).
– Aspiration around the cuff
(Bone, Davis, Zuidema, & Cameron,
1974; Elpem et al.,1987; Nash, 1988;
Pavlin, VanNimwegan, & Hombein,
1975; Ross & White, 2003)
Swallowing Complications
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Laryngeal Tethering
(Bonanno, 1971; Cameron et aI., 1973;
Ding & Logemann, 2005; Nash, 1988)
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Decreased Sensation in
the Oropharynx
2
(Siebens, Tippet, Kirby, & French, 1993)
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Reduced Airway Closure
3
4
(Sasaki and Buckwalter,1984)
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Reduced Subglottic Air
Pressure
(Eibling & Gross,1996; Gross, Atwood,
Grayhack, & Shaiman ,2003)
1
Decreased Secretion Control
• Removal of natural
filtration and
humidification system
• Decreases effectiveness
of cough
• Cycle of irritation and
secretion production
Decreased Physiologic PEEP
• Decreased gas
exchange due to
reduced surface area of
alveoli
• Poor oxygenation
• Possible atelectasis
Mrs. Duval
David Muir’s Original Design
• Opens only during
active inspiration
• Closes at end inspiration
• Remains closed
throughout the
expiratory cycle
• Air is re-directed through
the upper airway
• Offers a buffer to
secretions
• Patented “no leak”
design
PMV® 007 (Aqua color™)
The Passy-Muir® Tracheostomy & Ventilator
Swallowing and Speaking Valve
Patient Care Kit
Benefits of Passy-Muir® Valve
Clinical Benefits
• Restoration of voice
• 100% airflow through
vocal tract on
exhalation
• Improved sense of smell
and taste
Improved Swallowing
• Decreased Laryngeal
Tethering
• Increased Sensation in
the Oropharynx1
• Improved Airway
Closure2
• Restored Subglottic Air
Pressure3
2
3
4
1
1.
2.
3.
Synderman & Eibling, 1994; Baker et al., 1994; Detelbach, et al., 1995; Lichtman and colleagues,1995
Sasaki et al., 1977
Gross et al., 2003, 2006
Improved Swallowing
Restored physiological PEEP
• Improved gas exchange
• Improved oxygen
saturation levels
• Decreased risk of
atelectasis
Frey and Wood, 1995
Improved Secretion Management
• Improved sensation and cough
• Decreased suctioning needs
• Decreased risk of tracheal damage
Lichtman et al., 1995
Expedites Weaning and Decannulation
• Restoration of normal
physiology
• Utilization of expiratory
muscles
• Accustomed to more
normal breathing
pattern
• Able to communicate
• Develops confidence
and motivation
Frey & Wood, 1991; Sierros, et. al. 2007; Light et al., 1989
Cost Savings
$9,155/day
About $1 a day
1. Tube Feeding
2. Antibiotics/ ICU stay
3. Vent days/LOS
4. Suctioning Supplies
• Passy-Muir® Valve
Patient Selection and Assessment
Patient Selection
• Awake, responsive, attempting to communicate
• Medically stable
• Able to tolerate cuff deflation
– Vent status
– Aspiration status
• Able to manage secretions
• Have a patent upper airway
Factors Affecting Upper Airway Patency
• Size of Tracheostomy
Tube
• Presence and Degree of
Obstruction
• Edema
• Secretions
• Foam-Filled Cuff
To Assess for Upper Airway Patency
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Deflate cuff
Ask patient to inhale
Finger occlude and voice or cough on exhalation
Use mirrors, cotton, whistles or bubbles to assist with
the oral exhalation process.
®
Passy-Muir Valve placement
Mrs. Duval
Sebastian
VENTILATOR APPLICATION OF THE
PASSY-MUIR® VALVE
Team Approach
Speech
Therapist
Occupational
Therapist
Physician
Nurse
Patient
Physical
Therapist
Dietician
Respiratory Therapist
Ventilator Application-Team Approach
• Adjust PEEP
• Slow cuff deflation
• Monitor pressure/volume
loss
• Place Passy-Muir® Valve
• Compensate for
volume/pressure loss
• Time limit PS breaths
• Set alarms appropriately
Ventilator Assessment and Adjustments
• PEEP on/off
• Volume compensation during cuff deflation
– Increase VT in small increments to achieve pre-cuff
deflation pressures (PIP)
• Use low pressure alarm as disconnect/indirect low
exhaled VT alarm (set above 10cm H20)
• Set high pressure limit appropriately (10–15cm H20
above the PIP)
Ventilator Assessment and Adjustments
• Pressure versus flow trigger
• Pressure Support (PS)
– Use E-Sense, inspiratory cycle off, or set I-time to time limit
PS breath
• Pressure Control
– Set I-Time
• Consider NIPPV mode
Case Study 2: Michelle
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35 years old
Dx: Guillain-Barré
A & O, healthy, insignificant
medical history
Bell’s Palsy on left side of
face
Trach: Size 8.0 Shiley cuffed
TT – s/p tracheotomy 2
weeks
Vent: pressure
support/peep
Passy-Muir® Valve Placement
• What are some strategies to increase wearing time
of the Passy-Muir® Valve?
• What are some co-treatment strategies?
(RN, RCP, SLP, OT, PT)
Case Study 3: Erasmos
• 44 year old
• Dx: Guillain-Barré (s/p 3
months)
• Trach: 7 TTS
• Vent:
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AC 18
VT 450cc
PEEP 5cm H2O
FiO2 .28
• PIP 15 cm H20
• NPO, Peg tube
Passy-Muir® Valve Placement
Communication Status
Therapeutic Interventions
• PEP tx
FEES
Swallowing Interventions
Amelia-Peds case study
Transitioning and Troubleshooting
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Anxiety
Airway patency
Depression
Breathing pattern changes
Humidification
• Heat/moisture exchanger (HME) is ineffective
• Use heated humidified system
• Remove Passy-Muir® Valve for medicated
treatment
Care, Cleaning, and Lifetime of the Passy-Muir Speaking Valves
Average lifetime of 2 months
Additional Educational Opportunities
• Self-study webinars available on demand
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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, CMSA
and California Board of Nursing Credit