Overcoming Barriers to Speaking Valve Use: 8/8/13 … · 2016-08-15 · Overcoming Barriers to Speaking Valve Use: Success Through Teamwork ... How to implement a Passy-Muir protocol

Overcoming Barriers to Speaking Valve Use: Success Through Teamwork

8/8/13

Nicole Riley, MS CCC-SLP Director of Clinical Education Passy-Muir Inc. 1

SUCCESS THROUGH TEAMWORK

OVERCOMING BARRIERS TO SPEAKING VALVE USE 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 biased-

closed position Passy-Muir Valve and will

include little to no information on other

speaking valves.

Presenter

Nicole Riley, MS CCC-SLP Director of Clinical Education

Passy-Muir Inc.

[email protected]

(949) 783-3755

Disclosure: Financial — Employee of Passy-Muir Inc.

Nonfinancial — No relevant nonfinancial relationship exists.

Course Outline

1. Evidence for Passy-Muir Protocols

2. Common barriers and practical strategies to overcome barriers to

Passy-Muir® Valve Use

3. How to implement a Passy-Muir protocol

4. Forming a tracheostomy team

5. Outcomes and Case Studies

My Story at Barlow

Why make the Passy-Muir® Valve a standard of care?

Benefits of the valve:

• Voice/Speech Production

• Improved swallowing

• Secretion management

• Restores positive airway pressure

• Restores PEEP

• Weaning

• Decannulation

• Quality of Life


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Goal Common Barriers to this Goal

• Myths, misconceptions and ex cuses

• Sociological Issues

Barrier 1: “We can’t deflate the cuff because

the patient will aspirate”

VENTILATOR APPLICATION OF THE PASSY-MUIR® VALVE

Cuff Deflation Benefits

• Reduced aspiration1, 2 • Improved laryngeal

elevation 2, 3 • Weaning time was shorter-

average of 3 days vs 8 days3

• Fewer respiratory infections including ventilator associated pneumonia (20% vs. 36%) 4

• Swallowing better in cuff deflated group and improve more from baseline4

1. Davis, et al. (2002). Journal of Intensive Care Medicine. 17(3): 132-135. 2. Ding, R. & Logeman, J. (2005). Head & Neck. 27(9):809 -13 3. Amathieu, R., et al. British journal of anaesthesia109.4 (2012): 578-583. 4. Hernendez, et al. (2013). Intensive Care Medicine. 39(6):1063-70

One Way Valve Reduces Aspiration Further

• Improved scores on

penetration-aspiration scale1

• Restores expiratory airflow2

• Improves laryngeal

clearance2

• Improved secretion rating

scale3

• Maintains lung volumes4

• Restores subglottic air

pressure5

1. Suiter, D. Head and Neck. 2005. Sep;27(9):809-13

2. Pr igent, Helene. Intensive Care Med. 2012 June38(1):85-90.

3. Blumenfeld, L. Oral Abstract Presented at Dysphagia Research Society Annual Meeting 2012 4. Gross, R., et al. (2006). The Laryngoscope, 116:753-761

5. Eibling, D., & Gross, R. (1996). Annals of Otology, Rhinology, & Laryngology, 105(4):253-8.

Barrier 2: “The patient has too

many secretions”


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Before Passy-Muir Valve

After Passy-Muir Valve

Barrier 3: “We need to wait until the

patient is on a trach collar” Disuse Atrophy

• Mechanical ventilation

can cause atrophy, and

injury of diaphragmatic

muscle fibers

• “Patients in intensive

care lose about 2% of

muscle mass a day

during their illness.”1

• Muscle weakness

predicts pharyngeal

dysfunction2

1. Jaber, S.et al, 2011; Griff iths, BMJ, 1999

2. Mirzakhani, H. et al Anesthesiology . 2013

Passy-Muir Valve facilitates weaning

• Greater tolerance of weaning attempts leading to

independent breathing

• Patients have reported that breathing is easier and

have been able to tolerate trials of CPAP longer

• Multidisciplinary teams incorporating the valve

have had improved outcomes

1 . Fre y, J. & Wo o d , S. We an in g fro m M e ch an ical Ve n ti latio n Au gme n te d b y th e P assy-M u ir Sp e akin g Valve (1 9 9 1 ). Ab stract at th e In te rn atio n al C o n fe re n ce o f

Ame rican Lu n g Asso ciatio n an d Ame rican Th o racic So cie ty

2 . B lack, C . e t al . (2 0 1 2 ). A M u ltid iscip l in ary te am ap p ro ach to we an in g fro m p ro lo n ge d me ch an ical ve n ti latio n . B ri ti sh Jo u rn al o f Ho sp ital M e d icin e . Au g;,

7 3 (8 ): 4 6 2 -4 6 6 .

3 . Ati to -Narh , E. e t al (2 0 0 8 ). Slo w ve n ti lato r we an in g afte r ce rvical sp in al co rd in ju ry. B ri ti sh Jo u rn al o f In te n sive C are . 9 5 -1 0 2 .

4 . K o b ak, J. & De an , L. (2 0 1 1 ). Use o f th e P assy-M u ir Valve fo r we an in g in lo n g te rm acu te care h o sp ital . R e sp irato ry Th e rap y. 6 (4 ):4 4 , 5 7

5 . Win d h o rst, C ., e t al (2 0 0 9 ). P atie n ts re q u irin g trach e o sto my an d me ch an ical ve n ti latio n : a mo d e l fo r in te rd iscip l in ary d e cisi o n makin g. Th e ASHA Le ad e r, 1 4

(1 ), 1 0 -1 3 .

6 . Gu rn ari , D. & M artin , C . (Octo b e r, 2 0 1 1 ). Early co l lab o ratio n o f re sp irato ry an d re h ab i l i tatio n d e p artme n t imp ro ve s ve n ti lato r we an i n g rate s. P o ste r

p re se n te d at th e C o n fe re n ce o f th e Natio n al Asso ciatio n o f Lo n g Te rm Ho sp itals, Ne w Orle an s, LA.

http://www.passy-muir.com/sites/default/files/early_slp_intervention.html





8/8/13


Use of the Passy-Muir can facilitate weaning

Barrier 4: “The patients are too sick”

Patients should be medically stable

Barrier 5: “The Ventilator will

continuously alarm”

0 cm H20

PEEP

.30 FiO2

PIP 10cm H2O

VT

500cc

0cc

500cc

Set your pressure alarms appropriately Barrier 6: “Tracheostomy tube is too large”


8/8/13


Downsizing the Tracheostomy

• Improves expiratory

pressures1

• Improves speaking valve and capping recommendations,

comfort and tolerance1

• Associated with earlier oral intake and reduced length of stay2

• Improves weaning for spontaneous breathing trials3

1. Johnson , JD et al. (2009). The Clinical Respiratory Journal 2009; 3: 8–14.

2. Fisher, D. et al. (2013). Respiratory Care. 2013 Feb;58(2):257-63. 3. H ernandez , G . et al. (2013). Intens ive Care Medicine. Jun;39(6):1063-70

Not all Trach Sizes 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

Other Recommendations to Increase Airflow

• Cuffless

• Fenestrated

• Consider ENT consult

Barrier 7: “Absence of a Team”

Tracheostomy Teams

• Affordable Care Act

• Joint Commission

Tracheostomy Teams

• Increased speaking valve use

• Improved decannulation time

• Reduce Length of Stay (LOS)

• Reduced costs

Speed, Lauren, and Kather ine E. Harding. Journal of Cr itical Care (2012).


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Tracheostomy Team

Role of Speech-Language Pathologist

• Help assess airway

patency

• Assess swallow ability and diet recommendations

• Assess vocal ability

– Speech/swallow exercises

• Monitor tolerance

• Recommend wear time

• Educate caregivers

Role of Respiratory Therapist

• Help assess airway

patency

• Adjust and monitor

ventilator

• Technical

troubleshooting

• Monitoring of pt status

• Cough/breathing

techniques

Barrier 8: Lack of Knowledge/Inconsistency

Educate

• Be a leader

• Physician support is KEY!

• Pulmonologists, RTs, SLPs,

nursing

• U se Passy-Muir

webinars/inservices


8/8/13


Performance Improvement

• Protocol to assess all tracheostomy patients for Passy-Muir Valve within 72

hours of admission

• Criteria:

– Tolerate cuff deflation

– Patent upper airway

– 48-72 hrs post trach

– Medically stable

• FiO2<60%

• PEEP<10

• PIP<40

Competency

Name Watched vent application webinar

Verbalized understanding of protocol

Performs procedure for placing Passy-Muir

Valve

John Doe ❑ ❑ ❑

Matt Smith ❑ ❑ ❑

Jane Jones ❑ ❑ ❑

Henry Cooper ❑ ❑ ❑

Andrea Thompson ❑ ❑ ❑

Margaret Miller ❑ ❑ ❑

Dave Parker ❑ ❑ ❑

Track your compliance

• SLP completes Passy-Muir Valve evaluation form

within 72 hours of admission OR states reason

patient was not a candidate.

• 98% compliance for PMV assessment at Barlow

Barrier 9: No Protocol

VENTILATOR APPLICATION OF THE PASSY-MUIR® VALVE

Multi-disciplinary Tracheostomy Weaning Protocols

• Increase amount of

patients decannulated

• Reduce time to

decannulation

• Assign clear

responsibilities

• “The tracheostomy tube

decannulation process is

well suited for therapist-

implemented

protocols.”

Christopher, KL. (2005). Respiratory Care, Vol 50

http://passymuir.com/policiesandprocedures

Barlow Flow Chart for Decannulation


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Cuff Deflation as Tolerated

• Stop Criteria:

– Respiratory rate greater than 35

– Heart rate changes by

20 bpm

– SpO2 less than 90%

– FiO2 greater than 60%

– Pt complains of

difficulty breathing 6/10

Stop criteria present:

YES: Re-inflate cuff and

reassess patient before

progressing

NO: Advance to One-Way

Valve

Speaking Valve as Tolerated

Stop Criteria:

• Respiratory rate over 35

• Heart rate changes by

20 bpm

• SpO2 less than 90%

• FiO2 greater than 60%

• Pt complains of difficulty

breathing 6/10


• YES: Remove valve and

consult physician for

possible downsizing

• NO: Advance to One

Way Valve as Tolerated

Capping as Tolerated

Stop Criteria:

• Respiratory rate greater

than 35

• Heart rate changes by

20 bpm

• SpO2 less than 90%

• FiO2 greater than 60%

• Pt complains of difficulty

Breathing 6/10


• YES: Reassess patient to

determine barriers.

Patient may need

additional trach tube

downsizing.

• NO: Consider

recommendation for

decannulation from

physician after 24-48hrs

Decannulation!

• Requires an order

Candidates for Decannulation

• Have the indications for trach resolved or

improved?

• Weaned from mechanical ventilation, effective

coughing, no significant upper airway lesion1

• Absence of distress, stable arterial blood gases,

hemodynamic stability, absent fever1

• A peak cough flow of 160 liters/minute2

• Survey: patient’s level of consciousness, cough

effectiveness, secretions, ox ygenation3

1. Christopher, K.(2005). Respiratory Therapy. 50(4):538 –54. 2. Bach & Saporito, (1996). Chest. 110(6): 1566 -71. Stelfox, H. et al (2009). Respiratory Care. 54(12): 1658 -68.

Success!

• Earlier decannulation times

• Reduced restraint use as patients were less anx ious

• Individual success stories


8/8/13


Summary

Be a leader

Provide research to support your information

Educate the clinicians and MDs

-U se Passy-Muir webinars

-Consider live webinars or inservices

Implement a protocol

Competencies

Build your team!

Q and A

Presenter

Nicole Riley, MS CCC-SLP Director of Clinical Education

Passy-Muir Inc.

[email protected]

(949) 783-3755

Disclosure: Financial — Employee of Passy-Muir Inc.

Nonfinancial — No relevant nonfinancial relationship exists.

Documents

Overcoming Barriers to Speaking Valve Use: 8/8/13 … · 2016-08-15 · Overcoming Barriers to Speaking Valve Use: Success Through Teamwork ... How to implement a Passy-Muir protocol