session 44

4/2/2015

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May 1, 2015

Speaking Valves in the Pediatric Patient: Assessment and Therapy

Considerations

Kimberly L Duffy, MA, CCC/SLP

Kimberly Duffy, MA, CCC-SLPreceives a salary from the Children's Hospital of Philadelphia. She is a Speech Language Pathologist in the Center for Childhood Communication.

,

Describe how a speaking valve functions List the benefits of a speaking valve Describe the role of the Speech Language Pathologist

Why use a speaking valve What is a speaking valve and how does it work Candidacy and Contraindications Evaluation: Intra-disciplinary Approach SLP Role: Evaluation and Therapy Case Studies

Indications for Tracheostomy

yFunctional Issue: Prolonged mechanical ventilation

yStructural Issue: Acute or chronic airway obstruction

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Indications: Functional Issues

Lung Conditionsy Bronchopulmonary Dysplasiay Chronic Lung Diseasey Congential Diaphragmatic y Hernia

Muscular Conditions Myasthenia gravis Cerebral Palsy Muscular Dystrophies

Neurological Conditions Brain Injury Spinal Cord Injury Congenital Hypoventilation

Syndrome Spinal Muscular Atrophy

Indications: Structural Issues Congenital Airway

Obstruction Subglottic stenosis Vocal cord paralysis Laryngo/

tracheomalacia Laryngeal or

subglottic web Glossoptosis Tumors

y Acquired Airway Obstructiony Subglottic stenosisy Vocal cord paralysisy Caustic Ingestiony Traumay Burn/Inhalation

Injury

Parts of a Tracheostomy Redirection of

Airflow away from larynx

Lack of subglottic pressure

Problem for Voice Production

Speech/Language Development

Expressive

Expressive Language

Birth3 Months Makes pleasure sounds (cooing, gooing) Has different cried Smiles 46 Months Babbling sounds more speech-like Chuckles and laughs Vocalizes excitement and displeasure Makes gurgling sounds when left alone and when playing with you7 Months1 Year Babbling has both long and short groups of sounds Uses speech or non-crying sounds to get and keep attention Uses gestures to communicate Imitates different speech sounds Has one or two words around first birthday, although sounds may

not be clear

Speech/Language Development with a Tracheostomy

Expressive

Expressive Language

Birth3 Months Makes pleasure sounds (cooing, gooing) Has different cries Smiles 46 Months Babbling sounds more speech-like Chuckles and laughs Vocalizes excitement and displeasure Makes gurgling sounds when left alone and when playing with you7 Months1 Year Babbling has both long and short groups of sounds Uses speech or non-crying sounds to get and keep attention Uses gestures to communicate Imitates different speech sounds Has one or two words around first birthday, although sounds may

not be clear

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Speech/Language Acquisition with a Tracheostomy

y Delayed language acquisition (Hill and Singer, 1990)y Lack of opportunity for vocal playy Lack of auditory feedbacky Lack of oral motor feedback

y Slow development of sounds acquisitiony Excessive us of phonological processes (Kertoy et al,

1999)y Speech/language delay, Expressive greater than

receptive

Problem for Feeding Development

Feeding is not initiated until the baby is fairly stable with tolerance of gastric feeds and a deflated cuff. Many times this is after many of these milestones already should have been achieved.

Age Feeding Milestones

2 - 3 months of age

Demonstrates many reflexes to protect the airway Responds to stimulation in and around the mouth Consumes breast milk or formula using a nipple Coordinates breath support with 2-3 sucks of liquid

before swallowing and breathing


4-6 months of age

Brings both hands up to clasp the bottle but requires some assistance

Consumes rice cereal or pureed fruit and pureed vegetable baby foods

Eats from a small infant/toddler spoon

6-7 months of age

(6-9 months) Holds the bottle independently Cleans the spoon with the upper lip Eats pureed meats and a variety of pureed baby

foods


10-12 months of age

(9-12 months) Demonstrates lip closure when swallowing liquids and soft

solids Begin self-feed by using fingers to grab (ie, soft crackers,

cereal-Cheerios) Begins to experiment drinking liquids from a sippy cup Begins to consume mashed table foods Drinks out of a sippy cup and attempts to hold the handle

independently Begins to drink from a straw

Effect of tracheostomy on long-term speech language developmenty Comorbidities have a high incidence of speech/language disordersy Research has shown that the presence of tracheostomy alone affects

speech language developmenty Factors affecting speech/language developmenty Age of cannulationy Duration of tracheostomy dependencey Age of decannulation

(Jiang and Morrison, 2003)

y Retrospective review of 80 infants/toddlers (0-3 years). y 70% cannulated within first year of life y 64 of 80 patients (80%) demonstrated a form of

dysphagia y 81.25% oral dysphagia, 60.9 % pharyngeal

dysphagia , 79.7% esophageal dysphagia

(Norman, Louw & Kritzinger, 2007)

Effect of Tracheostomy on Swallowing

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Tracheostomies: Bypassing the Upper Airway

Speaking

Breathing

Swallowing

Physiologic functions performed by the upper airway

Warming humidification of air Filtering of debris Coughing Sneezing Smelling Tasting Swallowing Voicing

How does a speaking valve work?

Patient breathes in through the tracheostomy

Speaking valve redirects airflow up through trachea to allow for phonation as the airflow passes through the vocal cords

Closed system is created

Types of Speaking Valves

Passy Muir Speaking Valve Montgomery Speaking Valve Shikani Speaking Valve

Passy Muir Speaking Valve

y Bias-closed position valve: maintains a closed position except during inspiration.

y The bias closed position of restores a more normal closed respiratory system for the patient

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Montgomery Speaking Valvey Bias-open position valve: maintains an open

position except during exhalation

y An exclusive feature of this valve is a "cough-release" mechanism, eliminating valve or tube dislodgment as a result of coughing or excessive airway pressure

Shikani Speaking Valve Designed to be small

and less visible

Adjustable flow and closure characteristics

Light weight ball design: lower resistance during inhalation

Benefits of a Speaking Valve

Improved Swallow/Reduced Aspiration Improved Voice/Speech Production Facilitates Secretion Management Restored Positive Airway Pressure Expedites Weaning Reduced Decannulation Time Facilitates infection Control Improved Olfaction Facilitates Speech/Language Development Improved Quality of Life

Impact on Swallow Function

Presence of tracheostomy leads to Reduced positive subglottic

air pressure Reduced

laryngeal/pharyngeal sensation Anchoring of the larynx

hindering laryngeal elevation

Use of PMV Restores positive subglottic

air pressure

Restores laryngeal & pharyngeal sensation

Cuff must be deflated = reduced anchoring effect

Improves taste and smell which facilitates better acceptance of oral feeding



y Allows access to vocal cordsy Better vocal quality and increased volume

compared to open tracheostomy with no speaking valve

y Closed system allows patient to work on improving breath support for speech

Improved Voice/Speech Production Facilitates Secretion Management

y Stronger more effective coughy Promotes evaporation

of secretionsy Facilitates sensation in

oropharyngeal areayMay reduce secretions

and suctioning needs


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y Physiologic PEEP is restoredy Retaining for exhalation through upper airwayy Respiratory muscle strengtheningy Step toward capping

Expedites Weaning and Reduces

Decannulation Time


y Eliminates the need for finger occlusiony Acts as a filter to prevent debris from entering the

trachea

y Secretions are redirected through the upper airway allowing for oral expectoration

Facilitates Infection Control


y Improved sense of smell by re-establishing airflow through the oral/nasal cavities during exhalation.

y May lead to an increase in sense of taste, appetite and caloric intake

Improves OlfactionFacilitates Speech & Language Development

y Supports pre-linguistic language development:y First criesy Cooingy Babbling

y Facilitates child/caregiver interactions


Candidacy and ContraindicationsCandidacy: Cognitive Status

y Awake and responsivey Attempting to communicatey Speaking valve should not be used with

neurologically devastated patients or patients in a coma

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Candidacy: Medical Statusy Stabley Vital signs y Oxygen saturation y Work of breathing y Breath sounds y Proper positioning of patient and tracheostomy tube y Patient psychological and motivational issues

Candidacy: Tolerance of Cuff Deflation

Mandatory to allow air to pass around the tracheostomy to the oropharynx

Reasons why patient may not be able to tolerate cuff deflation: Gross aspiration of

secretions

Ventilation

Candidacy: Swallowing/Secretion Management

y Thin manageable secretions: speaking valve placement can facilitate movement and oral expectoration or secretions

y Patient should have a swallow reflex and swallow status should be assessed prior to use of speaking valve

Candidacy: Airway Patency

Patient must be able to exhale around tracheostomy, through the subglottis, glottis, pharynx and out the nasal/oral cavities

Diagnoses that can cause obstruction: subglottic stenosis, vocal cord paralysis, glottis stenosis, tumors, granulation tissue

Candidacy: Lung ComplianceAdequate elasticity of lungs to avoid air trapping

Candidacy: 48-72 hours post tracheostomy placement

y Time for surgical site to healy Time to allow edema to subside

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Candidacy Screening ToolSpeaking Valve Candidacy Screen

Factor Criteria Meets Criterion

Tolerates cuff deflation or has cuffless trach

As per respiratory doc flow sheet or nursing note tolerates cuff deflation for 30 min twice within a 24 hour period. Per MD orders has cuffless tracheostomy

Awake & Alert During routine care, patient appears awake and interactive Adequate secretion management

As per nursing note, requires suctioning no more than 1 time within a 1-2 hour period

Airway patency As per ENT note or via verbal clearance by ENT, airway within normal limits with no indication of airway obstruction

Adequate ventilator settings (if app)

As per respiratory orders: PIP 40 cm H20PEEP 12 cm H20FiO2 0.5

Trach status As per ENT or medical team daily note, patient is status post 1st tracheostomy change

Patient

MD

SLP

RT

ENT

Family

Pulm

Intra-Disciplinary Teamy Medical Team (if patient is acutely hospitalized)y Speech Language Pathologisty Respiratory Therapisty Otorhinolaryngologisty Pulmonologisty Family

Medical Team y Inpatient: coordinatory Ordering physiciany Decision maker

Speech Language Pathologisty Inpatient and Outpatient y Assess vocal abilityy Assess candidacyy Assess secretion managementy Complete initial speaking valve daily trial with

Respiratory therapist

y The goal of the speaking valve trial is to monitor tolerance, initiate a wear schedule as appropriate, problem solve as needed and educate caregivers

Respiratory Therapisty Inpatient and Outpatient y Cuff deflationy Leak testy Manometry testingy Adjust and monitor ventilator

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OtorhinolaryngologistInpatient Outpatienty Consultanty Airway assessment as

needed

y Decision making regarding changing tracheostomy size to increase leak

y Can be ordering physiciany Airway assessmenty Decision making regarding

changing tracheostomy size to increase leak

PulmonologistInpatient Outpatienty Consultanty Provides input for

ventilationy Provides input regarding

cuff deflation for patients needing max ventilationy Decision making regarding

using speaking valve while on ventilator or while weaning off ventilator

y Can be the ordering physiciany Manages ventilationy Manages cuff deflation for

patients needing max ventilationy Decision making regarding

using speaking valve while on ventilator or while weaning off ventilator

Familyy Carries out plany Provides feedback to the rest of the teamy Participates in decision making

Inpatient Interdisciplinary Assessment

y Medical teams: PICU, PCU, CICUy Medical team consults speechy Speech to coordinate with RT for initial assessmenty SLP and RT report results and recommendations to

medical team following initial assessment

y Consultation with ENT and Pulmonology as neededy Intra-disciplinary team develops plan and wear

schedule

Visit to the Center for Pediatric Airway Disorder

Speech Language Pathologist

Respiratory Therapist

Otorhinolaryngologist

Outpatient Inter-disciplinary Assessment y ENT, SLP and RT present for visity SLP conducts candidacy screeny ENT makes decision to proceed with leak test or

dependent

y RT conducts suctioning and leak testy ENT made decision to order speaking valve and have

patient return for manometry testing in line with ventilator.

y SLP communicates with Pulmonologist for clearance and input given ventilation needs

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Assessment Procedurey Patient Assessmenty Patient Caregiver Educationy Ventilator assessment/adjustment (as

appropriate)

y Suctioningy Cuff Deflationy Placement of speaking valvey Manometry Testing y Patient monitoring and removal of speaking valve

as appropriate

Leak Check with Flow Inflating Bag Initial leak test:

Prior to placing a speaking Valve a leak must be detected

The purpose of the manometer: Monitor and record end

expiratory pressures before and during speaking valve trial

Audible Leak Detection

A tracheal leak should be heard prior to the pressure in the bag reaching 20 cm H2O

Speaking Valve Placement Watch out for:

Increased work of breathing

Breath stacking or breath holding

SpO2 decrease by more than 5% from baseline, or heart rate change 30% from baseline

Manometry Testing with Speaking Valve

Evidence of breath stacking:

An end expiratory pressure that does not equilibrate

High continued pressures can lead to pulmonary damage.

Speaking Valve Trial with Breath Stacking

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Speech Language Pathologisty Developmental advocacyy Knowledge of upper airway supporting speechy Identification of appropriate candidatesy Participation in evaluation

Therapy y Provides input for wear schedule and progressiony Initiates therapy to address developmental speech

& language with speaking valve worn during therapy sessions

y Resuming normal function for communication, oral feeding and swallowing

Therapy Goals: Re-establishing the Upper Airwayy Establishing a leak y Tolerate cuff deflation

y Tolerance of speaking valvey Therapeutic Progressiony Increase in time

y Multi-disciplinary discussions:y Change to cuffless tracheostomyy Tracheostomy downsize

Therapy Goals: Breath Support

y Increasing # of syllables per breathy Imitate respiratory pattern with vocalization on

exhalation

y Coordination of breath with ventilator to produce vocalizations

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Therapy Goals: Vocalizing

y Vocalize with valve in placey Imitate vocalizations, vowels, consonants

Therapy Goals: Oral Aversion

y Provide positive face and oral experiencesy Facial/oral stimulation to decrease any

hypersensitivity

y Pacifier dipsy Start with empty utensilsy Tastes of food on childs fingers and utensils

Therapy Goals: Swallowingy Video Fluoroscopic Swallow Study (VFSS) or

Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

y Conduct with and without speaking valvey Use speaking valve during therapy as found

beneficial by objective assessment

y Incorporate use of speaking valve in feeding plan

Feeding Plan Baby Boys Feeding Plan

State: awake and showing feeding cuesEquipment: Dr Browns bottle with preemie nipple. Speaking valve should be in place

Strategies: Offer breaks as neededPrecautions: Stop with any s/s of aspiration or vital sign changes

Trouble Shooting: Poor tolerancey Inadequate exhalationy Cuffy tracheostomy

y Discomforty Positioningy Anxiety

y Excessive coughingy Gradual cuff deflation for desensitizationy Suctioning

y Excessive air through mouth and nosey Vent adjustment

Case Study: AlexAlex is a 16 year old male with a spinal cord injury status post motor vehicle accident. Upon initial evaluation he was tracheostomy/ventilator dependent with a cuffed tracheostomy.

y Evaluation Results and recommendationsy Therapy Goals and Progressiony Status at time of discharge to rehab

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Referencesy Engleman, S., & Turnage-Carrier, C., (1997).Tolerance of the Passy-Muir

Speaking Valve in Infants and Children Less than 2 Years of Age, Pediatric Nursing, 23(6).

y Hill, B.P., Singer, L. T., (1990) Speech and language development after infant tracheostomy. Journal of Speech & Hearing Disorders 55:15-20.

y Hull et al., (2005). Tracheostomy Speaking Valves for Children: Tolerance and Clinical Benefits, Pediatric Rehabilitation, 8(3), 214-219

y Jiang, D. & Morrison, G.A, J. (2003) the influence of long-term tracheostomy on speech and language development in children. International Journal of Pediatric Otorhinolaryngology 5751, 5217-5220.

y Kertoy, M., Guest C.M., Quart, E, Lieh-Lai, M. (1999) Speech and phonological characteristics of individual children with a history of tracheostomy. Journal of Speech, Language and Hearing Research 42,621-635.

y Norman, V., Louw, B., & Kritzinger ,A. (2007). Incidence and description of dysphagia in infants and toddler with tracheostomies: A retrospective review. International Journal of Pediatric Otorhinolaryngology, (71), 1087-1092.

y Passy-Muir, Inc. (2014). Passy-Muir Tracheostomy and Ventilator Swallowing and Speaking Valves Instruction Booklet. Irvine, CA

y Stevens, M. & Finch, J. (2012). Developing a speaking valve protocol in the NICU. ASHA Convention presentation

y The Airway Company. The Shikani Speaking Valve 2/ Forest Hill, MD

y Torres, L. & Sirbegovic, D. (2004). Clinical Benefits of the Passy-Muir Tracheostomy and Ventilator Speaking Valves in the NICU, Neonatal Intensive Care, 17(4).

session 44

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