joanna spain sc 33
DESCRIPTION
tqtTRANSCRIPT
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 2
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 3
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)
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 4
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 ?
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 5
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 6
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 7
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 8
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 9
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 10
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 11
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 12
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 13
Cuff Over-Inflation
Break
APPLICATION OF THE PASSY-MUIR®
TRACHEOSTOMY & VENTILATOR
SWALLOWING AND SPEAKING VALVE
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 14
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)
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 15
APPLICATION AND PLACEMENT OF THE PASSY-MUIR® VALVE
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
APPLICATION AND PLACEMENT OF THE PASSY-MUIR® VALVE
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 16
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
APPLICATION AND PLACEMENT OF THE PASSY-MUIR® VALVE
• 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.
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 17
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 18
APPLICATION AND PLACEMENT OF THE PASSY-MUIR® VALVE
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 19
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 20
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 21
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 22
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!!
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 23
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 24
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 25
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 26
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 27
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 28
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 29
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
Assessment and Intervention of Speech and Swallowing for the Tracheostomy Patient
3/7/2015
Joanna Spain, MA CCC-SLP 30
CEU Information
http://pmed.us/sem3359