Ventilator Application of Speaking Valves

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Assessment, trouble-shooting and advanced placement techniques of a speaking valve in-line with mechanical ventilation.

Ventilator Application of Speaking Valves

Patients with tracheostomy and mechanical ventilation often have a difficult time communicating with clinical staff, friends and family.  When the initial tracheostomy is placed a cuffed tracheostomy tube is often inserted in the adult population.  A cuffed tracheostomy tube allows airflow in and out through the tracheostomy tube and prevents significant airflow through the upper airway.  Airflow through the vocal folds and upper airway is required for voicing and therefore individuals with tracheostomy and inflated cuffs are aphonic (no voicing).  The reduced airflow through the upper airway results in many other physiologic complications that are discussed in the section on complications of tracheostomy.  One way of re-establishing voicing on mechanical ventilation is through cuff deflation with use of a speaking valve.  

Passy-Muir® Valves and the Montgomery Venitrach are the only two manufacturers of speaking valves FDA approved for use on individuals with mechanical ventilation.  Both valves can be placed in-line with mechanical ventilation.  The differences in design and benefits between the valves can be read in the Speaking Valve section.   The most significant difference is that the Passy-Muir® Valve is a bias closed position valve and does not leak, restoring positive airway pressure.  The Passy-Muir® Valve opens during inspiration, closes at the end of inspiration, and redirects exhalation through the vocal folds and out the nose and mouth.  Due to this unique design, a column of air remains within the tracheostomy tube, preventing secretions from building inside the tube.  The Mongomery Venitrach is an open position valve.  Airflow leaks out of the tracheostomy because it requires exhalation to close the valve.  

Some clinicians are hesitant to manage individuals with the cuff deflated while on mechanical ventilation.  Some practitioners may be hesitant to try managing mechanical ventilation in the cuff deflation condition, concerned that adequate ventilation cannot be maintained.  In a study done on “unweanable” patients with mechanical ventilation with neuromuscular disease, Bach reported that 91 out of 104 patients were adequately ventilated with either the cuff deflated or with cuffless tracheostomy tubes (Bach & Alba, 1990).  Pediatric patients are typically ventilated with cuffless tracheostomy tubes in order to reduce complications of inflated cuffs.  

The ideal patient to trial a speaking valve is awake, alert and attempting to verbalize.  A team approach can result in the earlier introduction of speaking valves and substantial increase in their use (Cameron T et al, 2009; Speed et al, 2013)

Benefits of Using the Passy-Muir Valve during Mechanical Ventilation

The Passy-Muir® Valve may facilitate weaning from mechanical ventilation.  Although the primary purpose of the valve was for speech when it was first invented, many other benefits have been realized.  Since the Passy-Muir® Valve remains in a closed position at the end of inspiration, no air leaks back out through the tracheostomy tube.  Other benefits during mechanical ventilation include: Restored positive airway pressure, facilitates ventilator weaning, may improve oxygenation, restored cough reflex, facilitates secretion management, improved swallowing and may reduce aspiration, improved smell and taste and facilitates infection control.

Sutt, L et al (2016) demonstrated improved ventilation with the Passy-Muir valve in individuals on mechanical ventilation.  The researchers measured end expiratory lung volumes with end expiratory lung impedance and reported improved lung recruitment when using the Passy Muir® speaking valve. Improved lung recruitment was maintained for at least 15 minutes, even after the valve was removed. The researchers attribute this maintenance to the return of a more normal upper airway resistance since exhalation occurred through the larynx and upper airway. 

In terms of quality of life and speech, in a retrospective study, patients on mechanical ventilation reported that being unable to communicate evoked feelings of insecurity, fear and panic, and anxiety which made it difficulty to sleep and rest. The isolation due to communication difficulties was reported to be a greater problem than any direct airway related issues and was ranked worse than pain, suctioning and difficulty breathing (Bergbom- Engberg, I & Haljamäe H., 1989).  This frustration can be reduced by providing a means of communication.  A recent study [74] reports increased satisfaction and quality of life for tracheostomised ICU patients once able to verbally communicate using a SV. 

Procedure for Placing a Speaking Valve during Mechanical Ventilation

Prior to placing a speaking valve, obtain an order for speaking valve placement in-line with mechanical ventilation.  A protocol to specify ventilator setting changes is best practice in order to make possible ventilator changes for patient comfort.  Some facilities use the speaking valve within weaning protocols to streamline the process and to make certain all individuals are assessed.  Review the chart for any information that may result in difficulty exhaling through the upper airway such as vocal fold paresis, upper airway edema, granulation tissue, or tracheal stenosis.  The clinician should always check for airway patency, but these factors are considered for further steps if the patient does not tolerate a speaking valve.

A speaking valve and ventilator changes require a physician order. 

Procedure Rationale
Explain the procedure to the patient and gain consent if feasible. For patient rights and to reduce anxiety.
Monitor baseline vital signs: Heart rate, respiratory rate, breathing pattern, oxygen saturations and airway pressures. For patient safety. Only place the valve if the patient and vitals are stable.
Suction the tracheostomy tube as needed. Suction above the cuff if subglottic suction is in place. To remove secretions and prevent secretions from falling into the lower airways.
Fully and slowly deflate the tracheostomy tube cuff (if present) using a 10ml syringe and suction simultaneously as needed. If the cuff is not deflated the patient will be unable to breathe. If the patient has a large amount of secretions, suctioning may be required simultaneously during cuff deflation. If the cuff is not completely deflated the patient will be unable to breathe.
Remove PEEP to zero PEEP provides continuous airflow and may result in patient discomfort and autocycling of the vent. The Passy-Muir provides physiologic PEEP.
Observe Peak Inspiratory Pressure (PIP) now that cuff has been deflated. A drop of PIP by 40-50% indicates a patent upper airway and indicates that airflow is escaping around the tracheostomy tube, through the vocal folds and upper airway. Also observe for exhaled airflow through the mouth/nose and voicing. This step allows the clinician to assess if airflow is able to pass around the trach tube and through the upper airway.
Place the speaking valve in-line with mechanical ventilation if airway patency has been established. See ventilator connections
If in volume control, volume may need to be increased to meet the PIP prior to cuff deflation. 400cc is the maximum recommended increase in volume. To provide adequate alveolar ventilation.
Encourage coughing and clearing of the throat as necessary. Suction orally as needed. To remove secretions in the airway
Continue to monitor for vital signs: Heart rate, respiratory rate, breathing pattern, oxygen saturations, and airway pressures. For patient safety. Remove valve if any significant change in vitals or patient's breathing.
Encourage voicing through the upper airway and coordinating speech on exhalation. For patient to communicate more effectively
Once the scheduled time is completed, or the patient shows signs of respiratory distress / fatigue: -Remove the PMV and reconnect ventilator tubing -Return to original ventilator settings -Reinflate cuff and check cuff pressure -Document the time the PMV was removed and the ventilator was returned to baseline setting.

 

Passy-Muir™ suggests increasing tidal volume (TV) in volume controlled ventilation modes until the peak inspiratory pressures (PIP) match those prior to cuff deflation.  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.  400cc is the maximum recommended additional volume.

 It is only possible to increase the TVs of mandatory breaths.  In pressure control ventilation, the pressure does not typically require increasing.

PEEP provides continuous airflow within the circuit.  This can make it difficult for the patient to close the vocal folds and can be uncomfortable during cuff deflation, resulting in coughing and autocycling of the ventilator.  Passy-Muir also suggests  turning off ventilator delivered PEEP, as physiologic PEEP is restored with the Passy-Muir Valve.   

 
In-line policies and procedures from various facilities designated by Passy-Muir as “Centers of Excellence” are located on the Passy-Muir website here.

Ventilator Alarms with Speaking Valve

All alarms on the ventilator must be re-evaluated for appropriate adjustments before, during, and after use of the Valve. Exhaled volumes are not returned to the ventilator since all exhaled air is redirected through the upper airway.  Low volume alarms will likely alarm since exhaled volume is no longer delivered back through the tracheostomy tube and through the circuit. Some alarms can be adjusted or silenced to stop unnecessary alarming (Passy-Muir, Inc.).

However, 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 (Passy-Muir, Inc).  An external low pressure alarm may be put into place if a low pressure alarm is not available on a specific ventilator.  The high and low pressure alarms set tight to the peak airway pressure (5- 10cmH2O below and above) are important for patient safety.  

 

Ventilator Connections with the Passy-Muir Valve

There are a few ways to connect the Passy-Muir Valve in-line with mechanical ventilation.  The PMV 007, PMV 2001, PMV 2000, and PMV 005 can be connected in-line with mechanical ventilation.  The PMV 007 fits into the standard disposable tubing and was designed for easier ventilator application.  The PMV 005, 2000 and 2001 require use of the PMV®AD22 or other 22mm flexible silicone adapter.  These valves can all also be used on spontaneously breathing individuals.  The PMV 2020 is the only Passy-Muir Valve that may not be used for mechanical ventilation and is used for patients with the improved metal Jackson tracheostomy tube.  

Troubleshooting with speaking valves

The table below lists potential difficulties that the clinician may come across during speaking valve placement and potential solutions for improve speaking valve use.  

Problem Troubleshooting Tips
Desaturation during cuff deflation The individual may not tolerate cuff deflation during the first session. Secretions and the new sensation of airflow may cause discomfort in the upper airway. Slow cuff deflation may reduce this discomfort. Suction simultaneously during cuff deflation and provide sufficient time for the individual to recover from suctioning. Consider pre-oxygenation prior to cuff deflation.
Desaturation during valve use Check airway patency. If airway patency is adequate (good exhaled volume losses and PIP during cuff deflation):
1. Work with respiratory care practitioner. 2. Consider increasing set oxygen. 3. Work with patient on breathing techniques to increase deep breathing and coordination of respiration and speech with appropriate pausing

If airway patency is poor (limited reduction in exhaled tidal volume and/or PIP during cuff deflation; if valve was placed, back pressure noted upon removal of valve):
1. Consider downsizing the tracheostomy tube
2. Assess for anxiety, stress or tension as potential causes
3. Consult ENT if no improvement
Patient complains of "too much air" Check that the set PEEP has been eliminated. Reducing or removing PEEP prior to cuff deflation may help to reduce discomfort caused by excessive airflow.
Excessive coughing 1. Check that the set PEEP has been eliminated. The continuous airflow may make it difficult for the patient to close the vocal folds, resulting in coughing or autocycling of the ventilator.
2. Impaired secretion management is another reason. Make sure to slowly deflate the cuff and suction simultaneously. Give the patient frequent breaks when deflating the cuff to allow the patient to accommodate to the new sensation of airflow. If the valve is in place, cue the patient to expel secretions orally if secretions come up. If there are no secretions in the oral cavity, cue patient to swallow.
3. Another reason could be obstructed exhaled airflow through the upper airway. A downsized tracheostomy may alleviate the problem. If coughing persists after trach change, consult ENT.
Poor voicing 1. Poor voicing may be due to underlying weakness. If in volume control, consider adding tidal volume to meet the peak inspiratory pressure prior to cuff deflation. Train patient in inhaling through the nose and taking deep breaths prior to speech.
2. There may be a leak around the tracheostomy tube at the stoma site. Consider hydrophilic dressings or silicone pads to reduce the leak.
3. The patient may be mouthing words. Ask the patient to cough. Secretions may also block airflow resulting in poor voicing. Have the patient clear the airway with a cough.
4. Poor voicing may be due to poor airflow from a large tracheostomy tube. Consider downsizing the trach tube.

Resources:

Bach, John & S Alba, A. (1990). Tracheostomy ventilation. A study of efficacy with deflated cuffs and cuffless tubes. Chest. 97. 679-83. 10.1378/chest.97.3.679.

Bergdom-Engberg I, Haljamae H. Assessment of patients’ experience of discomforts during respirator therapy.  Crit  Care Med. 1989 Oct: 17 (10): 1068-72. PubMed PMID: 2791570

Cameron TS, McKinstry A, Burt SK, et al. Outcomes of patients with spinal cord injury before and after introduction of an interdisciplinary tracheostomy team. Crit Care Resusc. 2009;11(1):14–19.

Harrell M. Ventilator Application of the Passy-Muir Valve. http://www.passymuir.com/ceu, accessed May 2019

 Speed L, Harding KE. Tracheostomy teams reduce total tracheostomy time and increase speaking valve use: a systematic review and meta-analysis. J Crit Care. 2013;28(2):216.e1–216.e10. [PubMed[]