vercoming b s valve use 12/12/13 success through teamwork · • chronic respiratory failure •...

OVERCOMING BARRIERS TO SPEAKING VALVE USE

Success Through Teamwork

12/12/13

Katy Peck, M.A., CCC‐SLP, CBIS, CLE, BRS‐SPassy‐Muir Inc. Clinical Consultant 1

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Katy Peck, M.A., CCC-SLP, CBIS, CLE, BRS-S

Katy Peck, M.A., CCC-SLP, CBIS, CLE, BRS-S

o Disclosure:• Financial -Received a

ki f f Pspeaking fee from Passy-Muir Inc. for this presentation.

• Nonfinancial -No relevant nonfinancial relationship exists.

Passy-Muir, Inc. has developed and patented a licensed technology trademarked as the

Passy-Muir® Tracheostomy and Ventilator Swallowing and Speaking Valve. This g p gpresentation will focus primarily on the biased-closed position Passy-Muir Valve and will include little to no information on other speaking valves.

16 year old Neuromuscular

10 month old 6 year old Goldenhar

5 month old Unknown Dx

10 month old Expremie

Facial Mass


10 month old 6 year old Goldenhar



Facial Mass



12/12/13


Medical History

R i t

• Worsening neuromuscular weakness• Unknown diagnosis, central hypotonia• Scoliosis

• Chronic respiratory failure/ @ 10 fRespiratory

Dysphagia

PMV History

• GT removed due to pain associated• Full oral feeds prior to admission• Unable to self feed• Regular-for-age diet

• Trach/vent @ 10 years of age• Admitted for PNA

• “Did not like the feeling”• Refused to use it

DTE MBSS PMV Therapy MBSS Discharge

Frankaspiration,

delayed swallow,and

maximum residue

Clinicals/s of

aspiration, presumed

PNA

PMV Assessment: 55 minutes

PMV and dysphagia therapy to rehearse

compensatory strategies

Safe withPMV inline

Full oral feeds

Mild oral phase dysphagia

Severe pharyngeal phase dysphagia o Maximum residue after swallow

No PMV

o Frank silent aspiration before 1st swallow puree texture and honey thick liquids

o Recommended PMV Assessment

PMV Wear-time (hours)

2

2.5

3

3.5 Diagnostic Therapyo MBSS reviewo Positiono Mode

S ti

0

0.5

1

1.5

2 o Sensory compensations Rehearsed practice

o Mendelsohn Maneuvero Supraglottic swallows

MBSS readiness/timingo ABX course completeo Independent with strategieso PMV tolerance

5/1/13 5/10/13



12/12/13


Initial MBSS MBSS #2

Puree & Soft Chewable

Bolus formation and

Chilled Honey-Thick: Spoon

Mild residue

Chilled Honey Thick: Med

Cup

Mild residue

PMV in-line

formation and containment

Residue

Retrograde movement

Mild residue

Adequate airway

protection

Mild residue

Adequate airway

protection

Chilled Thin: Spoon

Premature ill

Chilled Thin: Med Cup

Premature ill

Chilled Thin: Single Sips with Straw

Premature ill

PMV in-line

spillage

Adequate airway

protection

spillage

Adequate airway

protection

Mild residue UES- cued supraglottic

spillage

Adequate airway

protection

Oral intake only

AgePrognosisQOLVentilator

DependencyCognition

Controlled volume oral feeds with

supplementation

Enteral feeds

PNASurgeryPain/QOLRespiratory

sequalaeReadmissions

Voice

o Marginal improvement in intensity

Secretion Management

o Reduced endotracheal suction

Cough

o Productive



12/12/13



10 month old Goldenhar

5 month old Genetic Disorder


6 year old Facial Mass

Medical History

• Chronic respiratory failure • Laryngomalacia

• Cleft palate and lip• Severe HL (microtia and anotia)• Low tone• 3.5 month NICCU course

Respiratory

Dysphagia

PMV History

• Laryngomalacia• OSA- supplemental oxygen (1.5lpm at night)• Trach at 9 months of age

• GT• Reflux• Mouthing objects

• Assessed at 9 months- recommendation to wait 6 months to allow growth of the tracheal lumen

• Primarily nonverbal, audible cry, use of ASL signs • Age appropriate cognitive functioning

100

120

140

160

180

9 mo. 14 mo. 16 mo.

0

20

40

60

80

Trial 1 (Dx-1)

Trial 2 (Dx-1)

Trial 3 (Dx-2)

Trial 4 (Tx 1)

Trial 5 (Tx 2)

Baseline HR (bpm) Max Trial HR (bpm)

Baseline SpO2 Low Trial SpO2

Duration (min)

Assessment#2

Assessment #1

Therapy Initiated

tom

ical

olog

ica

l

nd F

ear

ehav

ior

Ana

t

Phy

sio

Anx

iety

an

Lear

ned

Be



12/12/13


tom

ical

olog

ica

l

nd F

ear

ehav

ior

Ana

t

Phy

sio

Anx

iety

an

Lear

ned

Be

8

10

12

Duration (minutes)

Trial 1

Trial 2

Fear and crying

0

2

4

6

Tri

al 1

Tri

al 2

Tri

al 3

Tri

al 4

Tri

al 5

Tri

al 6

Tri

al 7

Trial 2

Trial 3

Trial 4

Trial 5

Trial 6

Trial 7

Increased HR and

diaphoretic

Increased secretions and

WOB

tom

ical

olog

ica

l

nd F

ear

ehav

ior

Ana

t

Phy

sio

Anx

iety

an

Lear

ned

Be

Gloves Hospital setting Poor PMV tolerance

Settingo Garden, FRC, and

hallway

Medical playo Vibrating frog inside g g

gloveso Cleanup routineo Caregiver/child PMV

placement

PMV toleranceo Lower expectationso Family education

Physiologic Changes?

Behavior?



12/12/13


tom

ical

olog

ica

l

nd F

ear

ehav

ior

Ana

t

Phy

sio

Anx

iety

an

Lear

ned

Be

Minimal tolerance

6 month therapy hold recommended

Isolated 7 minute trial Refusal

No expectations

Group

Fake PMV and functional

communication

Airway patency

ENT workupo Wait for MORE

tracheal lumen growth

o Downsize trach tube

Learned behaviorAnxiety

Diagnostic therapy to determine causeo Use fake PMV

o Place when in a light sleep






Medical History

• Retrognathia, microglossia, & hypotonia• NICCU stay for stridor & increased WOB• Genetic and neurology w/u negative

• No significant upper airway obstruction• Epiglottis “somewhat retroflexed”Respiratory

Dysphagia

PMV History

• Enteral feeds (GT)• Receiving feeding/swallowing therapy

without use of PMV

• Epiglottis somewhat retroflexed• Normal VFs and subglottis• Suction 5-7x/day

• ENT from OSH said pt was too young• Patients mother continued to research

and requested assessment• Nonverbal

5 months 10 months

HRI follow

and OT at CHLA

ENT declinedreferral

PMV Dx: 1st sounds

Therapy and

DysphagiaAssessment

MBSS

Early communication & enteral feed

wean



12/12/13


Oral Motor Swallowing

R d d l

Speech/Voice

Hypotonic

Open mouth posture

Mouthing toys

Reduced oral secretion management

Enteral feeds only- learned caregivers provided tastes

Aphonic- no audible cry

PMV- Effortful vocalizations and cry

Cognition Physiology Tolerance

Excellent

Typical for developmental age

Reddish cheeks: consistent with baseline

Excellent

Cried without voice once removed

Appeared upset

5

6

7

8

Wear-time (hours)

0

1

2

3

4

5

5 months 6 months 7 months 8 months

Wear-time (hours)

Familiaro Faceso Utensilso Tastes

Feeder seato Feeder seat

Sensoryo Preferred coldo Homemade options

Presentationo Distractionso Positive feedback



12/12/13


Chilled Puree (Thick and

Thin)

Delayed bolus formation and

transfer

Chilled Nectar-Thick

Premature spillage

Chilled ½ Nectar Thick

Mild residue

Chilled Thin Liquid

Increased premature

spillage

PMV in-line

Reduced oral containment and pooling

Mild residue

Adequate airway

protection

Adequate airway

protection

Moderate residue

Adequate airway

protection

Mild to moderate residue

Laryngeal penetration before the swallow

Micro-aspiration before the swallow

Suzanne Abraham (2009)

50 children with trach Age Range: 2 month-

4:9 60

70

80

90

100

24/50 PMV candidateso Wear-time success

achieved• All waking hours• Daily/consistently

o Secretion management • Established within 2

weeks on average0

10

20

30

40

50

PMV candidates

Secretion Management

49%

98%






Clinical Findings

• Prematurity: 28 week expremie• Neuro: Grade III IVH (left) and Grade II (right)• Cardiac: VSD and PDA • Adrenal suppression

Respiratory

GI

• Respiratory insufficiency• Chronic lung disease• Supraglottic and arytenoid edema (GERD)• Tracheotomy and mechanical ventilation dependency• Suction every 1-2 hours

• Delayed gastric emptying• GERD• GT and JT

10 months

NonnutritiveStimulation & no sound

play

OT recommended

PMV

PMVAssessment

PMV and dysphagia

therapy

Scanttastes

Early communication

& outpatientreferrals

2025303540

Wear-time Across 10 Sessions

05

101520

Wear-time (minutes)



12/12/13


PMV Wear-time

Narcotic weano Unpredictable transitions in

neurobehavioral regulation

Ph i l i t

Acute Vs. Outpatient Status

1. Staff availability

2. Frequency and consistency of trials

3. Build confidenceo Physiologic parameters

o Diaphoretic

Variable secretions

Caregiver involvement

Not a candidate for MBSS

4. Initiate speech and swallow therapy

1. Underlying diagnosis

2. Generalized weakness

3. Pharmaceutical intervention(s)

4. Reduced activity

Oral Feeding/Swallowing Sensory responses

o Gago Shaking head

New oral feeder

Baseline Skill Set

o GI concernso Immature oral motor skills

Safety of swallow concernso MBSS candidacy

Caregiver involvemento Passive

stimulation/massageo Scant tastes o Food play and exploration

Hand to mouth

Massage and stretches

Oral exploration

Smell and taste

S ll

Hand exploration

Toys and tubes

Spoon

Massage

Smelle p o a o

Passive Participant => Orofacial massage and intraoral stretches. Peek-a-boo and sound play.

Guided Participation => Facilitate hand to th T til th l d t tmouth. Tactile, thermal, and gustatory

stimulation. Encourage voicing!

Overwhelmed => Monitor stress signs and facial expression

Disinterest or uncertainty => Balance opportunities






Medical History

• Large facial mass • Closure of right eye• Disfiguring right side mouth, ear, and

nose

• OSA & hypoventilation• Failure to extubate s/p biopsy

Respiratory

Dysphagia

Communication

• Full oral feeds prior to admission• Enteral feeds (NGT) s/p trach• MBSS before and after trach placement

• Failure to extubate s/p biopsy• Trach placed with ventilation dependency• Mechanical ventilation (<1 week)

• Tracheotomy POD #1• Agitation- unable to communicate• Mandarin and English



12/12/13


6 years old

MBSS9/24/13

Clinical BedsideAssessment

9/23/13

Clinical Swallow and SLP

Assessment (s/p trach)

10/1/13

PMV, Bedside Assessment and MBSS

10/8/13

Discharge10/14/13

All nutrition by mouth and 80%

intelligible

Speech and Communication

Oral Motor

Ventilation

Pre-Tracheotomy

Sensation

Safety

Recommendations

Pre-tracheostomy

Thin Liquid• Anterior spillage• Premature spillage• Mild Residue• Adequate airway

protection• Esophageal phase

unremarkable

Puree• Labored, delayed oral

transit• Reduced oral

containment, premature spillage

• No residue• Adequate airway

protection

Soft Chew• Timely and labored• Pocketing• Inconsistent pooling• Delayed pharyngeal

swallow• Mild residue

Functional Communication

Trach/Vent Educationo GWN videos

Pre-tracheotomy

o Anatomy/physiology

o Communication vulnerability

o Voice

o Speech

PMV Wear-time (hours)

4

5

6

7 Initial Assessment

MBSS (before tracheotomy)

0

1

2

3

4

MBSS (PMV in place)

MBSS readiness/timingo Wanted to eat

o No alternative mode

o Caregiver support



12/12/13


Speech and Communication

Oral Motor

Ventilation

After 1st Trach Change

Sensation

Safety

Recommendations

PMV in-line

Puree• Labored, delayed oral

transit• Reduced oral

containment, premature spillage

• No residue• Adequate airway

protection

Thin Liquid• Anterior spillage• Reduced oral

containment/ swallow timing

• Mild Residue• Laryngeal penetration

prior to swallow• Retrograde movement

Soft Chew• Timely and labored• Pocketing• Delayed pharyngeal

swallow• Minimal residue

Talk Muir- Pediatric Issue (Spring 2011). Passy-Muir News, Events and Education,

Passy-Muir, Inc. Pg 1-3.

Reason for tracheotomy Discuss placement Changes in sensation Describe voicing Describe secretion care Define diet progression Socialization

Children with Trachs: Facilitating Speech and Swallowing (December, 2010). Advance Magazine for Speech-Language Pathologists and Audiologists

[Vol. 20, Issue 25, Pg. 5].



12/12/13


Abraham, SS. Clinical and fluoroscopic issues in the management of swallowing disorders in infants and young children with tracheostomies. Perspectives on Swallowing and Swallowing Disorders. 2005;4:19-23.

Abraham, S and Wolf, E. Swallowing Physiology of Toddlers with Long Term Tracheostomies: A Preliminary Study DysphagiaLong-Term Tracheostomies: A Preliminary Study. Dysphagia. 2000;15: 206-212.

Bailey, R. Tracheostomy and Dysphagia: A complex Association. Swallowing and Swallowing Disorders (Dysphagia). 2005;14: 2-7.

Carron JD, Derkay CS, Strope GL, Nosonchuk JE, and Darrow DH. Pediatric Tracheotomies: Changing Indications and Outcomes. Laryngoscope. 2000;110: 1099-1104.

Suiter, D.M. and Easterling, C.S. (2007). Update on current treatment practice patterns for dysphagia. Topics in Geriatric Rehabilitation, 23(3): 197-210.

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vercoming b s valve use 12/12/13 success through teamwork · • chronic respiratory failure •...

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