Patients with respiratory failure and distress are now surviving with the help of medical advances including tracheostomy tubes and mechanical ventilation. At the Madonna Rehabilitation Hospital in Lincoln, Neb., we accept patients with tracheostomy tubes; in this 185-bed inpatient hospital, the number of patients who require a tracheostomy tube or mechanical ventilation has increased 19% over the last five years. Between July 2007 and June 2008, 188 patients were admitted with tracheostomy tubes, 116 of whom required mechanical ventilation during part or all of their stay. While some acute rehabilitation hospitals do not accept vents, our hospital has a unique program in which we work on trach and vent weaning.
These patients often are medically fragile with a complex variety of diagnoses including respiratory failure, spinal cord injury, cardiac complications, cerebrovascular accident, and neurological disorders. Ages vary but the majority of patients are adults. Speech-language pathologists help these patients regain verbal communication and return to oral intake of food—both quality-of-life issues.
Few SLPs enter the field confident in their knowledge and skills related to working with ventilators and tracheostomy tubes. ASHA has developed position statements and practice guidelines stating that "not all SLPs are equally experienced in the advanced technologies pertinent to these devices during their academic and clinical fellowship years...a significant portion of professional training must be conducted in settings that allow the SLP to gain appropriate background and experience" (Asha, 1993, p. 18). ASHA's Code of Ethics requires that SLPs "provide all services competently" (Principle of Ethics I, Rule A, ASHA, 2003). Therefore, SLPs working with individuals with trachs and vents must have appropriate training and experience. Based on our experiences with admissions from other rehabilitation facilities, there is variance in clinical practices for the assessment and treatment of patients with tracheostomy tubes and mechanical ventilation.
Co-evaluation and Treatment
Our communication disorders and pulmonary departments collaborated to develop an interdisciplinary flow chart (Figure 1 [PDF]) that outlines a protocol for assessment and treatment planning for patients who require a tracheostomy tube or mechanical ventilation. The protocol does not include patients with oral or nasal endotracheal tubes.
The protocol provides objective criteria for patient tolerance of a one-way speaking valve, a critical step in the process of safe, efficient tracheostomy tube weaning. With the placement of a one-way valve, the SLP and licensed respiratory care practitioner (LRCP) can accurately assess the patient's speech, voice, and swallowing, and begin to wean the patient. By following the protocol and "stop" criteria outlined in the flow chart, the SLP and LCRP can determine whether or not the patient safely tolerates the valve and if not, what other steps to take.
The chart is designed to guide the process for tracheostomy tube weaning, and allows for completion of critical assessment by SLPs in evaluating speech, voice, and swallowing. During the past fiscal year, we have used the protocol to wean successfully 58% of patients requiring a tracheostomy tube and 57% of patients requiring mechanical ventilation.
Depending on a patient's specific diagnosis, initial evaluation consists of an assessment of speech, language, cognitive communication, voice, and swallowing. Evaluation of patients with a ventilator and/or tracheostomy tube requires additional steps and more equipment but is otherwise the same as for any other patient.
Standing admission orders call for completion of an initial one-way speaking valve assessment by both an SLP and LRCP within 48 hours. An SLP must complete a one-way speaking valve assessment prior to evaluating speech, voice, and swallowing. The flow chart provides a step-by-step decision-making process, with measurable criteria for documenting a patient's outcome in using the valve. The chart also guides the subsequent treatment plan for documenting a patient's outcome using a one-way speaking valve; these outcomes guide the subsequent treatment plan with the establishment of goals to address noted deficits in speech, voice, and swallow.
The one-way speaking valve assessment is the same for patients who are on a ventilator or have a tracheostomy tube. The SLP should be knowledgeable about ventilator modes, oxygen needs, type and size of the tracheostomy tube, the patient's vital signs—respiratory rate, heart rate, and saturation percentage of oxygen (see glossary [PDF]), and the basic anatomy for speech and swallowing and how it relates to a tracheostomy tube placement.
When a tracheostomy tube is in place, the upper airway is eliminated and patients inhale and exhale through the tracheostomy tube. When the tracheostomy cuff is deflated for placement of a one-way speaking valve, the upper airway is restored, allowing a patient to inhale through the tracheostomy tube and exhale through the mouth and nose. An SLP can then assess secretions, sensation of secretions with the presence or absence of a reflexive throat clear and cough, reflexive swallow response, and ability to phonate. Without a one-way speaking valve, this critical portion of the assessment cannot be completed.
Following the protocol, the one-way speaking valve assessment involves four major steps:
1. Initial cuff deflation. The result often is a significant amount of pooled secretions being cleared from the pharynx, which frequently requires additional tracheal and/or oral suction for adequate management. The excess secretions are a natural response to the tracheostomy tube and may be present for several trials with the one-way speaking valve. Patients without tracheostomy tubes typically manage secretions by swallowing or through the evaporation process by breathing. The more time that passes without cuff deflation, the more secretions will pool in the pharynx. The resulting fear of aspiration often leads to recommendations that a patient cannot use a one-way speaking valve. Aspiration—the passage of food or liquid below the level of the vocal folds—can occur if the tracheostomy cuff is inflated or deflated. The SLP's goal is to decrease aspiration risk for patients with tracheostomy tubes by improving secretion management through increased one-way speaking valve use. If no indications lead to a "stop" on the flow chart, the evaluation continues.
2. Placement of the one-way speaking valve inline with the ventilator or on the tracheostomy tube itself after suctioning if needed. The SLP and LRCP again evaluate tolerance of the one-way speaking valve by referring to the "stop" criteria. The SLP next evaluates speech, voice, and swallowing and provides recommendations and referrals for oral/pharyngeal exercises, therapeutic trials, further instrumental swallow study, or ENT consultations as appropriate.
3. Valve toleration. The SLP and LRCP obtain a physician order for the patient to wear the one-way speaking valve as tolerated. The patient wears the valve for increasing amounts of time.
4. Tracheostomy cap trials. The LRCP begins these trials after the patient successfully wears the one-way speaking valve with the ultimate goal of decannulation.
A one-way speaking valve provides numerous clinical benefits. It restores positive airway pressure, creating a more normal respiratory system that allows for louder voice, stronger cough, improved secretion management, and increased oxygenation. It can improve swallowing function and reduce aspiration.
When a tracheostomy tube is in place, the upper airway is bypassed. The patient has decreased airflow through the upper airway with a loss of sensation in the pharynx. With sensation in the pharynx eliminated, so is the need to swallow, resulting in increased secretions and decreased swallowing, often leading to dysphagia. When the tracheostomy cuff is deflated and the one-way speaking valve is placed in line with the ventilator or on the tracheostomy tube, the patient's closed respiratory system is restored, increasing sensation and subglottic air pressure, and allowing the patient more strength in coughing to clear pooled secretions from the pharynx.
A 49-year-old male admitted eight weeks after a motorcycle accident had a C1-C2 fracture with tetraplegia. The patient required a tracheostomy tube and mechanical ventilation. He was on a puree diet with thin liquids and communicated by mouthing words, with increased repetition needed for accuracy. The SLP at the transferring hospital found that an eye-gaze computer system allowed him to communicate and had ordered one at an estimated cost of $8,000. Transfer records indicated a one-way speaking valve had never been used to assess his swallowing, speech, and voice.
The LRCP assisted with the initial speech evaluation, deflating the tracheostomy cuff and placing the one-way speaking valve in line with the ventilator tubing. Initially the patient could produce minimal voicing with the one-way speaking valve. The SLP completed a fiberoptic endoscopic evaluation of swallowing (FEES). Results showed the patient was aspirating thin and nectar liquids due to premature transfer and decreased airway protection. We changed his diet to puree solids with honey-thickened liquids.
After several days of using the one-way speaking valve, the patient could communicate independently with adequate voicing. After two weeks of a swallowing exercise program, a second FEES detected no aspiration; his diet was upgraded to thin liquids and mechanical soft solids, as he was edentulous. The patient continued to require long-term mechanical ventilation because of his spinal cord injury.
An 18-year-old female admitted four weeks after a car accident had a C6-C7 fracture. The patient required a tracheostomy tube and mechanical ventilation. She was admitted on a thin liquid diet and communicated by mouthing words. Medical records indicated a one-way speaking valve had not been tried.
The LRCP assisted with the initial speech evaluation, deflating the tracheostomy cuff and placing the one-way speaking valve in line with the ventilator tubing. The patient then was able to vocalize adequately at the sentence level. She had decreased vocal intensity due to weak respiratory muscles. A FEES observed no aspiration, indicating a normal swallow with no pharyngeal or laryngeal impairments. We recommended that she start on a regular diet with thin liquids. The patient was successfully weaned off the ventilator and decannulated within four weeks after admission.
Improving Quality of Life
SLPs are in a pivotal role to advocate for ventilator and/or tracheostomy patients to wear their one-way speaking valves. Our protocol provides us the ability to advocate for patients with tracheostomy tubes and mechanical ventilation by providing a consistent decision-making process with objective criteria for patient tolerance of a one-way speaking valve. The goal is for the patient to wear a one-way speaking valve throughout the day and evening hours, as tolerated by the "stop" criteria outlined in the flow chart. If it is not tolerated, the SLP must work with the patient and other team members to move the process forward.
Problem-solving to increase patient tolerance of the one-way speaking valve may include tracheostomy tube downsizing or continued therapeutic trials with implementation of strengthening programs to address respiration, voice, and swallowing.
Support and education are also critical for the patient, family, and/or caregivers as the patient works through the adjustment period and strives to attain identified treatment goals. By restoring verbal communication and safe oral intake, SLPs play a vital role in the patient's recovery and quality of life.