Codi 531 - Lecture 6
Tracheostomized and Ventilator-Dependent Clients:  Management of Communication and Swallowing

1. Types of Artificial Airways

 a. Endotracheal tube - intubation
 b. Tracheostomy tube
2. Indications for Artificial Airways
 a. Upper airway obstruction
 b. Loss or impairment of airway protective reflexes
 c. Inability to maintain clearance of bronchial secretions
 d. Need for mechanical ventilatory support
3. Common Medical Complications : Pharyngeal, laryngeal, tracheal
 a. Sore throat and/or hoarse voice
 b. Glottic or subglottic edema
 c. Ulceration of tracheal mucosa
 d. Ulceration of vocal folds (granuloma, polyps)
 e. Vocal cord paralysis
 f. Laryngotracheal web
 g. Tracheal stenosis
 h. Tracheomalacia
4. Types of Tracheostomy Tubes
 a. Cuffed

 b. Cuffless

 c. Fenestrated

 d. Communication tubes

5. Communication Options: Cuffed tubes
 a. Non-ventilated pt can speak with cuff deflation & occlusion of the tube manually if able to tolerate deflation medically
 b. Ventilated pts in stable condition may also be able to speak with cuff deflation
  i. Will require adjustments to ventilator
  ii. Speech will occur on inspiration
6. Communication Options: Cuffless tubes
 a. This is the tube of choice for speech if airway protection is not needed
 b. Air flows around the tube allowing speech production
 c. Vocal intensity is reduced - may require greater effort
 d. Manual occlusion or use of cork will improve airflow for speech
 e. Can be used for stable pt on ventilator - speech on inspiration
7. Communication Options: Fenestrated tubes
 a. Not appropriate for those on continuous mechanical ventilation
 b. Occlusion allows pt to speak & breathe through upper airway
 c. Minimizes the work of breathing around the tube
 d. Available on both cuffed and cuffless tubes
8. Communication Tubes: Speaking Trach
 a. Used for pts who canít tolerate cuff deflation
 b. Provides a separate airflow to upper airway for speech
 c. Drawbacks
  i. Manual manipulation of gas (air) flow when speech is desired
  ii. Coordination of speech is difficult due to steady airflow past vocal cords
  iii. Secretions may collect above cuff and block airflow to upper airway
9. One-Way Tracheostomy Speaking Valves
 a. Allows for inspiration through the trach tube and exhalation through the upper airway to produce speech
 b. Requires a deflated cuff
 c. May require oxygen through both upper and lower airway
 d. Best used with cuffless, fenestrated or tracheal buttons
 e. Various types available with specific recommendations for use
10. One-Way Tracheostomy Speaking Valves: Types of Valves
 a. Brands include Passy-Muir, Montgomery, Olympic, Kistner & Hood
 b. Most important difference is in the valve bias
 c. Bias closed valves are normally closed - open with inspiration and close as inspiratory cycle ends (Passy-Muir, Hood)
 d. Bias open valves are open and close with forceful exhalation(Olympic, Kistner, Montgomery)
11. One-Way Tracheostomy Speaking Valves: General Criteria for Use
 a. Normal mental/cognitive status
 b. Medical stability
 c. Lung compliance
 d. Upper airway patency
 e. Able to tolerate cuff deflation
 f. Showing some receptive and expressive communication attempts
12. One-Way Tracheostomy Speaking Valves: Benefits
 a. Improved vocalization
 b. Less potential for infection when compared to finger occlusion
 c. Possible improved oxygenation and pulmonary function
 d. Possible effects on swallow and secretion management
13. One-Way Tracheostomy Speaking Valves: Contraindications
 a. Bivona Fome Cuff tubes
 b. Upper airway obstruction/tracheal edema or stenosis
 c. Medical instability including end-stage pulmonary disease
 d. Severe aspiration/copious secretions
 e. Anarthria/severe dysarthria
 f. Unconscious/comatose patients
14. One-Way Tracheostomy Speaking Valves: Monitoring/Assessment During Valve Use
 a. Vital signs (HR, RR, BP)

 b. Oxygenation and ventilation status
 c. Respiratory pattern and work of breathing
 d. Breath sounds & I:E ratio
 e. Monitoring devices include pulse oximetry, capnography, transcutaneous monitoring & arterial blood gases

15. One-Way Tracheostomy Speaking Valves: Role of Speech Pathologist
 a. Screen pt. to determine if candidate for valve placement
 b. Obtain physicianís orders to evaluate patient - often done in conjunction with RT
 c. Includes brief cognitive/linguistic eval plus oral/motor and articulatory assessment
 d. Cuff deflation and trial phonation
 e. Trial valve placement - MBS for swallowing eval with valve
16. One-Way Tracheostomy Speaking Valves: Role of Speech Pathologist
 a. Usually responsible for establishing phonation, evaluate voice quality and institute steps to improve voice
 b. RT usually responsible for suctioning, deflating cuff, placing valve, manipulation of ventilatory settings, monitor oxygen saturation
 c. Obtain physicianís orders to treat pt - specify if for communication, swallowing or both
 d. Educate staff, patient and family regarding valve use
17. Effects of Tracheostomy on Swallowing
 a. Scar tissue may cause fixation of trachea to overlying tissue resulting in restrictions in laryngeal movement

 b. Cuff inflation with tight contact with tracheal walls - same as above plus esophagus may not expand normally

 c. Unoccluded tube does not allow normal increase of subglottic pressure during swallow

 d. Tracheostomy tube placement for 6 months or more may result in subglottic sensory receptors becoming desensitized

18. Adjustments to Assessment for Patients with Trachs
 a. If cuff inflated, check with physician and if possible deflate prior to exam
 b. Lightly cover the trach and say /a/ at comfortable pitch, then on falsetto to observe laryngeal elevation
 c. If tube is not corked or does not have one-way valve, teach pt to cover lightly during speech and swallow
 d. Blue dye exam
19. Swallowing Therapy
 a. For reduced laryngeal elevation use Mendelsohn maneuver and falsetto as exercise
 b. For reduced laryngeal closure use super-supraglottic, effortful breath hold & adduction exercises
 c. Adduction exercised include phonation on vowels with hard glottal attack, phonation while pushing & lifting