V' Special Populations

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V. Special Populations
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Special PopulationsA. Tracheostomy
Ventilator-Dependent Patients

• Impaired ability to communicate orally can result
  when tracheotomy is performed for severely
  impaired respiratory function of the pharynx and
  larynx as well as for ventilating patients who
  cannot breathe independently.
• Tracheostomy populations are sizeable, their
  etiologies are diverse, and the durations of
  ventilator dependency are substantial.
• Communication is critical to an individuals
  overall medical care, psychological function, and
  social interactions.

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Special PopulationsA. Tracheostomy
Ventilator-Dependent Patients

• When speech is compromised, assistive devices or
  voice prostheses (e.g., talking tracheotomy tubes
  or one-way speaking valves) can be used to
  promote the production of intelligible oral
  communication in patients who have been
  tracheotomized.
• Indeed, it is the position of ASHA (1993) that
  collaboration in selecting, evaluating, and
  treating patients being considered for voice
  prostheses to allow for production of
  intelligible oral communication is within the
  scope of practice for certified SLPs.

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Special PopulationsA. Tracheostomy
Ventilator-Dependent Patients

• Following referral from and in collaboration with
  medical specialists, the SLP determines the need
  for and appropriate type of voice prostheses.
• The SLP also assesses the effectiveness of these
  communication devices and provides rehabilitation
  to help the patient obtain an optimum level of
  communication function.

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Special PopulationsA. Tracheostomy
Ventilator-Dependent Patients

• It is the responsibility of the individual
  practitioner to determine whether she has
  obtained sufficient education/ training to
  provide competent evaluation and treatment to
  patients who are ventilator-dependent or
  tracheotomized.
• ASHA CCC-SLPs who treat persons who are
  tracheotomized with or without ventilatory
  dependence are bound by the ASHA Code of Ethics
  to maintain patient welfare and competent
  services.

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Tracheostomy Ventilator-Dependent Patients1.
Definitions

• Tracheostomy tubes come in many varieties,
  including cuffed, uncuffed and fenestrated.
• A cuff is a soft balloon around the distal (far)
  end of the tube that can be inflated to allow for
  mechanical ventilation in patients with
  respiratory failure.

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Tracheostomy Ventilator-Dependent Patients1.
Definitions

• When the cuff is inflated, a seal is created in
  the trachea which permits air to flow in and out
  of the lungs through the tracheal tube, but not
  out of the upper airway and mouth.
• Over inflation of the cuff can cause unequal
  pressure against the tracheal and esophageal
  walls and result in tissue damage.

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Tracheostomy Ventilator-Dependent Patients1.
Definitions

• Because air cannot be routed out through the
  upper airway and vocal folds when the cuff is
  inflated, or if the cuff is too tight, the cuff
  must be deflated in order to achieve
  vocalization.
• The cuff also limits the elevation of the larynx
  during swallowing, so it should also be deflated
  during eating.

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Tracheostomy Ventilator-Dependent Patients1.
Definitions

• Cuffed tracheostomy tubes are used infrequently
  in children because of the risk of damage to the
  developing trachea.
• Thus they are only used when adequate ventilation
  cannot be achieved without a cuffed trach tube.

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Tracheostomy Ventilator-Dependent Patients1.
Definitions

• A special type of foam cuff (Bivona Medical
  Technology, Inc.) is made to reinflate on its
  own.
• Children wearing a foam cuff are not candidates
  for a one-way speaking valve or for occlusion of
  the cannula for speaking.

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Tracheostomy Ventilator-Dependent Patients1.
Definitions

• A fenestrated tracheostomy tube is designed to
  allow airflow to be shunted through the upper
  airway via a single port on the convex surface of
  the cannula when the external opening is blocked.

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Tracheostomy Ventilator-Dependent Patients1.
Definitions

• Air flows through the port and passes into the
  upper airway for speech production during
  exhalation.
• Fenestrated tubes are not recommended for small
  children, as aspiration of secretions can occur.

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Tracheostomy Ventilator-Dependent Patients1.
Definitions

• Mechanical ventilation is the process whereby
  equipment is used to supply air to the lungs when
  the child or adult experiences inadequate
  ventilation or hypoxia.
• Mechanical ventilation is used for acute or
  impending ventilatory failure
• Severe oxygenation deficit in spite of
  administration of enriched oxygen mixtures
• Secretion/Airway Control
• Apnea, Respiratory Arrest (especially in
  neonates)

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Tracheostomy Ventilator-Dependent Patients1.
Definitions

• Invasive ventilatory support refers to mechanical
  ventilation via an endotracheal or tracheostomy
  tube.
• Noninvasive ventilation refers to ventilation
  without an endotracheal tube and includes
  negative pressure ventilation and positive
  pressure ventilation administered through a mask.
• In negative pressure ventilation, negative
  pressure is applied outside the chest, which
  causes air to be sucked into the chest and lungs
  on inspiration.
• The chest and lungs recoil naturally on
  expiration.

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Tracheostomy Ventilator-Dependent Patients1.
Definitions

• A negative pressure ventilator consists of a
  chamber surrounding the patients chest and
  abdomen, and a negative pressure generator.
• The common negative-pressure apparatus is the
  pneumowrap.
• It consists of an open mesh cage that surrounds
  the patient's chest and a large shirt that fits
  over the cage and chest.
• A small vacuum device attached to the shirt
  periodically exerts negative pressure on the
  exterior of the chest cavity, thereby causing
  inspiration for the lungs.

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Tracheostomy Ventilator-Dependent Patients1.
Definitions

• In positive pressure ventilation (PPV), air is
  forced into the lungs to expand the lungs and the
  chest wall.
• When the air is stopped, the lungs and chest wall
  recoil and return the pressure within the lungs
  to its normal state.
• PPV is the ventilatory support most commonly used
  to treat respiratory failure.
• The amount of air delivered may be pressure- or
  volume-controlled as well as continuous or
  intermittent.

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Tracheostomy Ventilator-Dependent Patients1.
Definitions

• With pressure-controlled ventilation (PCV) the
  cycle of breathing is completely controlled by
  the ventilator with no participation form the
  patients.
• With pressure-support ventilation (PSV), the
  patient initiates the breath, and with onset of
  each spontaneous breath, the negative pressure
  generated by the patient opens a valve that
  delivers the inspired gas at a pre-selected
  pressure.
• The primary consideration when choosing a mode of
  ventilation is (1) reduction of the work of
  breathing and (2) patient comfort and synchrony
  with the ventilator.

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Tracheostomy Ventilator-Dependent Patients1.
Definitions

• The delivery of air by a mechanical ventilator is
  not coordinated with speech in the same manner as
  it is when a person talks on expiration.
• The ventilator can be set to delivery a specific
  concentration of O2 at a rate of so many breaths
  per minute, activated with or without the
  assistance of the persons own spontaneous
  breathing.
• Therefore, the synchrony of forced exhalation and
  speech is not the same as the self-coordination
  of talking on exhalation.

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Tracheostomy Ventilator-Dependent Patients1.
Definitions

• Moreover, the individual with a tracheostomy does
  not take in or expel air through the mouth, but
  rather through the stoma.
• The amount of air shunted up passed the cannula
  toward the mouth is far less than that in normal
  exhalation and will sustain only weak speech.

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Tracheostomy Ventilator-Dependent Patients2.
Communication Options

• For those individuals who are able to tolerate
  intermittent or continuous occlusion of the
  tracheal opening, plugging the tracheostomy tube
  is possible for restoring oral communication.
• Occlusion of the external opening permits
  inspiration and expiration through the lower and
  upper airways.
• Oral communication options include plugs,
  buttons, digital occlusion of the stoma/cannula,
  talking tracheotomy tubes, and application of
  unidirectional tracheostomy speaking valves.

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Tracheostomy Ventilator-Dependent Patients2.
Communication Options

• Those individuals able to tolerate continuous
  occlusion of the cannula by such devices are
  usually candidates for decannulation.
• To determine if an individual is a candidate for
  oral communication and/or decannulation, the SLP
  first deflates the trach cuff and finger occludes
  the open cannula.
• This diverts the flow of air through the upper
  airway and the vocal folds.
• Observe the patient for increased respiratory
  rate, shortness of breath, inspiratory stridor,
  or effortful exhalation.

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Tracheostomy Ventilator-Dependent Patients2.
Communication Options

• If respiratory status remains unchanged and
  patient seems comfortable, continue with finger
  occlusion procedures.
• Ask the patient to blow or cough while the
  cannula is occluded digitally.
• Difficulty performing this task suggests
  obstruction above the level of the tracheostomy.
• Try finger occluding the trach again and have the
  patient attempt to sustain /a/.

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Tracheostomy Ventilator-Dependent Patients2.
Communication Options

• The quality of phonation provides information
  about the status of the vocal folds, breath
  support for speech production, and the effect of
  secretions on speech intelligibility.
• If prolonged intubation has occurred prior to
  initiation of speech trials, vibration of the
  vocal folds may be difficult to initiate.
• Retraining of voice production may be necessary.

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Tracheostomy Ventilator-Dependent Patients2.
Communication Options

• During trials of total occlusion via plugging, O2
  saturation, heart rate, respiratory rate, and
  patient comfort should be carefully monitored.
• Most weaning protocols dictate downsizing the
  tracheostomy cannula in conjunction with
  plugging.
• Successful use of finger occlusion may be an
  endpoint, or an initial step in the process of
  assessing other communication options.

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Tracheostomy Ventilator-Dependent Patients2.
Communication Options Talking Tracheotomy Tube

• If trials of successful finger occlusion lead to
  decannulation, the patient may use a tracheostomy
  button or plug to occlude the stoma.
• If decannulation is not possible, as in the case
  of some individuals with ALS, a talking
  tracheotomy tube may be considered.
• Talking tracheotomy tubes are devices designed to
  allow a patient with adequate cognitive skills
  who is tracheotomized but may or may not be
  ventilator-dependent to communicate orally.

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Tracheostomy Ventilator-Dependent Patients2.
Communication Options Talking Tracheotomy Tube

• Talking tracheotomy tubes are single-cuffed
  (unfenestrated) tubes designed to allow air or O2
  to travel through an external airflow line, exit
  by way of openings superior to the cuff, and
  continue up through the glottis and vocal tract
  allowing an appropriate power source for voice
  speech production.
• Because the extra channel is attached to a
  standard air or O2 flow meter by a supply tube,
  talking tracheotomy tubes can be used without
  interrupting mechanical ventilation.

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Tracheostomy Ventilator-Dependent Patients2.
Communication Options Talking Tracheotomy Tube

• Several types of "talking tracheostomy tubes" are
  available.
• Bivona Fome-Cuf tracheostomy tubes with talk
  attachment
• Bivona mid-range aire-cuf tracheostomy tubes with
  talk attachment and
• Portex Vocalaid.

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Tracheostomy Ventilator-Dependent Patients2.
Communication Options One-way Speaking Valve

• Unidirectional (one-way) speaking valves are
  considered communication options for individuals
  who are medically stable but who are not expected
  to have the tracheostomy plugged immediately or
  for permanently tracheostomized cognitive intact
  individuals.
• Contraindications to valving are unconscious
  and/or comatose patients, inflated tracheostomy
  tube cuff, severe airway obstruction (e.g.,
  tracheal stenosis and bilateral abductor vocal
  fold paralysis), thick and copious secretions,
  and severely reduced lung elasticity.

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Tracheostomy Ventilator-Dependent Patients2.
Communication Options One-Way Speaking Valve

• The one-way valve couples to the hub of the trach
  cannula and accomplishes the results of finger
  occlusion, while leaving the hands free.
• Such valves open during inspiration and close
  during expiration forcing air through the larynx.
• Both ventilated and unventilated patients can use
  the one-way speaking valve for uninterrupted
  speech.

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Tracheostomy Ventilator-Dependent Patients2.
Communication Options One-Way Speaking Valve

• Although frequently used in adults, one-way
  speaking valves have also been found to be
  extremely successful with babies as young as two
  months.
• Even before they start talking, these valves help
  with pre-speech development in terms of cooing
  and vocalizing, bonding between mother and child,
  and establishing for the child that when she
  cries, she can get her needs met.

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Tracheostomy Ventilator-Dependent Patients2.
Communication Options One-Way Speaking Valve

• For the initial valve trial, the patient is
  seated upright and suctioned thoroughly for oral
  and tracheal secretions.
• Baseline measurements of pulse oximetry are made
  prior to applying the valve.
• The trach cuff is deflated, and the patient is
  observed for increased respiratory rate,
  shortness of breath, inspiratory stridor, or
  effortful exhalation.
• If respiratory status remains unchanged and
  patient seems comfortable, finger occlusion
  procedures are begun.

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Tracheostomy Ventilator-Dependent Patients2.
Communication Options One-Way Speaking Valve

• If the individual is on a ventilator, the
  respiratory therapist will place the valve with
  the flex tube in-line the ventilator.
• We will discuss ventilator assessment
  requirements in later slides.

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Tracheostomy Ventilator-Dependent Patients2.
Communication Options One-Way Speaking Valve

• If the individual is not on a ventilator, the
  valve is attached to the tracheostomy hub.
• Once the valve is in place, wait five minutes so
  that the individual can adjust to a normal closed
  respiratory system.

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Tracheostomy Ventilator-Dependent Patients2.
Communication Options One-Way Speaking Valve

• Patients may initially experience increased
  coughing due to restoration of a closed
  respiratory system, which re-establishes
  subglottic pressure and normal exhaled airflow in
  the oral/nasal chambers.
• Observe the patient to ensure that the diaphragm
  of the speaking valve opens during the patients
  inspiration and remains closed during exhalation.
• If the patient exhibits signs of respiratory
  distress, remove the speaking valve and reassess
  for airway patency (e.g., make sure cuff is fully
  deflated).

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Tracheostomy Ventilator-Dependent Patients2.
Communication Options One-Way Speaking Valve

• If respiratory status is acceptable, ask the
  patient to phonate /a/.
• Have the patient repeat words and phrases, answer
  simple questions, and engage in conversational
  speech.
• Tolerance of the speaking valve is determined by
  monitoring respiration (see ventilator
  requirements), voice quality, and the patients
  subject assessment of comfort.
• If a patient exhibits prolonged excessive
  coughing, the one-way valve should be removed and
  airway patency should be reassessed.

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Tracheostomy Ventilator-Dependent Patients2.
Communication Options One-Way Speaking Valve

• Many patients adjust immediately and easily to
  the one-way speaking valves.
• However, some may require a gradual transition to
  wearing it.
• Some patients can tolerate a one-way speaking
  valve during all waking hours.
• Others may experience anxiety with initial
  speaking valve placement.

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Tracheostomy Ventilator-Dependent Patients2.
Communication Options One-Way Speaking Valve

• Educate the patient prior to placement of the
  valve about the airflow sensations he will
  experience and the movement of secretions through
  the airway and out the mouth.
• Re-educate breathing pattern and voice/speech
  production patterns if the patient has not
  vocalized for a prolonged period of time.
• With ventilator-dependent patients, ventilator
  settings should be assessed before, during, and
  after speaking valve placement.

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Tracheostomy Ventilator-Dependent Patients2.
Communication Options One-Way Speaking Valve

• Settings to be assessed include mode, tidal
  volume (VT), rate, faction of inspired O2 content
  (FI02), positive end expiratory pressure (PEEP),
  peak inspiratory pressure (PIP), sensitivity, and
  alarm settings.
• If the patient has a cuffed trach tube,
  ventilator adjustments (requiring a physicians
  order) may be required to compensate for leakage
  around the trach tube after cuff deflation in
  order to meet the patients comfort and
  ventilatory requirements.

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Tracheostomy Ventilator-Dependent Patients2.
Communication Options One-Way Speaking Valve

• If the PIP decreases significantly following cuff
  deflation, inspired air may be escaping through
  the upper airway and not entering the lungs.
• To compensate, adjustments to VT may be
  necessary, but in small increments to avoid
  overcompensation.
• When adjusting VT for cuff deflation, VT
  increases may result in an increase in PIP.
• DO NOT EXCEED PRE-CUFF DEFLATION PIP.

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Tracheostomy Ventilator-Dependent Patients2.
Communication Options One-Way Speaking Valve

• When the speaking valve is placed in-line with
  the ventilator, the patient will no longer be
  exhaling into the ventilator circuit.
• Therefore, the high and low tidal volume, the
  high and low minute volume and the apnea alarms
  must be reassessed.
• Once the speaking valve is removed, the patients
  ventilator should be returned to previous levels
  prior to re-inflating the trach tube cuff.

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Tracheostomy Ventilator-Dependent Patients3.
Types of One-Way Speaking Valves

• There are several speaking valves commonly used
  for children.
• Those made to fit on the 15 mm hub of a tracheal
  tube include the Passy-Muir Tracheostomy Valve,
  the Passy-Muir Ventilator Valve, the Montgomery
  Tracheostomy Speaking Valve, the Shiley Phonate
  Speaking Valve, and the Hood Speaking Valve.
• Both the Montgomery and Shiley speaking valves
  come with cough release mechanisms to prevent the
  valve from coming off when the child coughs.
• The Passy-Muir, Montgomery, and Hood speaking
  valves come with models that fit onto ventilators
  as well.

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Tracheostomy Ventilator-Dependent Patients3.
Types of One-Way Speaking Valves

• For adults, common one-way speaking valves
  include Passy-Muir, Eurocare, Montgomery, Tracoe,
  Portex, and Shiley
• These are available through
• http//www.passy-muir.com/valves.htm
• http//www.bosmed.com/products/tracheostomy/montgo
  mery_trachspeak.htm
• http//www.bosmed.com/products/tracheostomy/tracoe
  _twisttrach.htm
• http//www.nellcor.com/products/index.asp

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Tracheostomy Ventilator-Dependent Patients4.
Advantages

• In addition to speaking, patients with one-way
  speaking valves will experience more normal
  respiratory sensations such as airflow in the
  oral/nasal chambers, and the effects of increased
  respiratory muscle activity.
• Secretion management is also facilitated,
  creating movement and clearance of tracheal
  secretions.
• The safety and efficiency of swallowing is also
  improved by the establishment of a normal closed
  system, increased laryngeal/pharyngeal sensation,
  and increased subglottic air pressure.