We are pleased to welcome Lisa Y. Torres, M.A., CCC-SLP, and
Lori Burkhead Fitsimones, M.S., CCC-SLP as our guest hosts for
the SLP chat tonight, Monday, November 8, 2004. They will be
addressing the topic of Tracheostomy and Ventilator Speaking Valves.

Lisa Y. Torres, M.A., CCC-SLP, has been a clinical specialist at
Passy-Muir, Inc. for over nine years.  She is a speech-language
pathologist who has worked with tracheostomized and ventilator
dependant individuals in adult and pediatric settings including
Pre-School / Early-intervention, rehabilitation and acute care.
She has coordinated speech therapy services for tracheostomized
and ventilator dependent patients at University of California,
Irvine Medical Center. She has extensive speech and respiratory
knowledge about the application of the Passy-Muir Values. She has
presented nationally at one day seminars and state and national
conventions.  She is an internationally recognized speaker and has
guest lectured at several hospitals and medical facilities abroad.

Lori Burkhead Fitsimones, CCC-SLP, has worked as a speech-language
pathologist for ten years in a variety of healthcare settings including
inpatient & outpatient rehabilitation, subacute, and an acute care
hospital with level-one trauma center designation.  She has developed
an expertise in working with medically complex patients with particular
emphasis on respiratory issues.  She has provided numerous seminars to
both domestic and international audiences on respiratory issues in
voice production and swallowing in tracheostomized and ventilator-
dependent populations.  She continues her clinical practice while
pursuing a Ph.D. in Rehabilitation Science through the Department of
Communicative Disorders at the University of Florida.  Her current
research interests include the application of exercise physiology
principles to the rehabilitation of oropharyngeal musculature for motor
speech production and swallowing.

<Robin> Welcome!  Tonight we are chatting with Lisa Y. Torres, M.A., CCC-SLP, and Lori Burkhead
          Fitsimones, M.S., CCC-SLP about the topic of Tracheostomy and Ventilator Speaking Valves.
<Robin> Glad you could all be here!  Lisa and Lori, please give us some background about this topic...
          ie, what populations you serve and why there is a need for tracheostomy and ventilator
          speaking valves.
<Lisa Y. Torres> The Passy-Muir Valves (PMV) are for all ages from neonatal to geriatric.
<Lisa Y. Torres> They can be used across the continuum from ICU to home care on tracheostomized and/or
          ventilator dependent pediatric and adult patients.
<jennifer> I am practicing at a hospital in the NICU, pediatrics, and adults....kind of do it all.
<Lori Fitsimones> When patients have a trach, the air does not pass over the vocal folds for speech.
<Lori Fitsimones> The valve redirects the air upon exhalation so that patients may phonate.
<Lori Fitsimones> This would be for babbling, cooing, crying, in babies or speaking/vocalizing in adults.
<Lori Fitsimones> Recent research has also shown that the airflow disturbance (and other mitigating factors
          due to trach) can also negatively affect swallowing.
<Lori Fitsimones> These studies have shown that occluding the trach with either capping or for those who
          cannot tolerate capping, using the PMV (specifically a closed positon speaking valve) can change
          swallow physiology as well.
<Lisa Y. Torres> In addition, many of these patients have been significantly medically compromised.
          While the PMV cannot be used by every tracheostomized patient, often patients who were initially
          considered unable to use the valve have ultimately been able to tolerate it very well.
<Lisa Y. Torres> For example, successful use of the PMV has occurred following a downsizing of the
          tracheostomy tube to allow for more air leak around the tube or after removal of granulation
          tissue from the upper airway, and/or with effective management of patient transitioning issues.
<Lisa Y. Torres> Therefore, it is extremely important that the assessment process utilized to identify
          candidates for use of the PMV is thorough and that reassessments are performed as a patient's status
<AdrienneFSU> Please tell us about assessing patients for tracheostomy and ventilator valves.
<Lori Fitsimones> First, the airway patency should be assessed.
<Lori Fitsimones> This can be done by deflating the cuff and determining if the patient can exhale
          adequately around the tube and through the upper airway.
<Lisa Y. Torres> Therefore, it is extremely important that the assessment process utilized to identify
          candidates for use of the PMV is thorough and that reassessments are performed as a patient's
                    status changes.
<AdrienneFSU> Is everyone here familiar with vents and cuffs, etc?
<Lori Fitsimones> The cuff is a balloon-like device that is attached to the trach tube.  When this is
          inflated, it prevents any air from passing up through the upper airway.  The purpose of the cuff
          is to separate the upper and lower airway and prevent air from leaking out through the upper
          airway when patients are on the ventilator.  We want this FULLY DEFLATED when using a Passy-Muir
          Valve, or else the patient will not be able to exhale.  With a Passy-Muir Valve in place, the
          patient inhales through the valve.  This valve then closes off when the patient stops actively
          inhaling.  Upon exhalation, the valve is closed, and the air is redirected up around the trach
          tube, and around the deflated cuff, out the upper airway.  It is important to remember that even
          when a trach cuff is deflated, though, the deflated cuff does take up some space in the airway. 
          Most patients can use the Passy-Muir Valve with the cuff deflated, but some may need to be switched
          to a cuffless tube.
<Lisa Y. Torres> A deflated cuff on a tracheostomy tube can cause a significant obstruction of the airway,
          as it continues to take up some space in the trachea.
<Lisa Y. Torres> If the patient displays signs of not tolerating the valve with the cuff completely deflated,
          replacement with a cuffless tracheostomy tube should be considered or have the cuffed tracheostomy
          tube downsized to allow a sufficient amount of airflow past the deflated cuff.  
<Lori Fitsimones> Are you all using the PMV in line with the vent?
<djspeech> I have in the past, but now I am working in the home environment with trach patients.
<Lisa Y. Torres> While using the closed-position valve, the patient should be monitored for any changes in
          vital signs, oxygen saturation levels, breath sounds, color, work of breathing, and airway patency.
<Lisa Y. Torres> If significant adverse changes are observed, the valve should be removed immediately.
          Some patients can tolerate use of the valve for 5 to 10 minutes or longer on the first trial.
<Lisa Y. Torres> Other patients need to increase the time that the valve is worn by a few minutes at a time.
          Ideally, patients will gradually reach a point where they can tolerate the closed-position valve for
          all waking hours.
<Lisa Y. Torres> Patients can be evaluated for use of the closed-position speaking valve as early as 48 to
          72 hours after tracheotomy.
<Lisa Y. Torres> Valve placement can occur with a physician's order as soon as the patient's condition has
          stabilized, depending on the degree of tracheal edema and the amount of secretions present.
<ekspino> Question, is 'closed position valve' interchangeable with 'one-way valve?
<Lori Fitsimones> No
<Lisa Y. Torres> No, a closed position valve specifically only refers the Passy-Muir Valve.
<djspeech> Are there other closed position valves other than the PMV?
<Lisa Y. Torres> No, all other one-way speaking valves available have an open position design that require
          expiratory pressure to close them.
<Lori Fitsimones> The research has focused only on the closed position valve (which is the PMV).  This is the
          only closed position valve on the market but..there are other one-way speaking valves.
<Lisa Y. Torres> There is always some air leakage through these valves during expiration which precludes the
          benefit of a "closed system" that is obtained with the closed position "no leak" design of the PMVs.
<Lisa Y. Torres> Increased work of breathing can also occur with open position speaking valves because the
          patient must both open and close these valves while the biased-closed PMV closes automatically.
<Lisa Y. Torres> In addition, while the closed position "no leak" design of the PMV creates a buffer against
          secretions and resists occlusion, the open position design of other one-way speaking valves allows
          secretions to travel up the tracheostomy tube and potentially occlude these valves.
<djspeech> PMV seem to be much easier for patients to transition easily with.
<jennifer> What is the earliest age you implement the PMV with NICU babies?
<Robin> Good question jennifer
<Lisa Y. Torres> The PMV has been used in the NICU on vent dependent babies as young as five days old.
<Sue> That is amazing
<Lisa Y. Torres> Engleman and Turnage-Carrier found that of 29 children tested with the closed-position
          speaking valve at Texas Children's Hospital in Houston, 24 (83%) tolerated the closed-position speaking
          valve and 75% of those children produced vocalization on the first trail. The closed-position "no leak"
          design of the PMV is unique in that it closes spontaneously at the end of inhalation and does not allow
          any air to flow back out through the valve.
<Lisa Y. Torres> This reintroduction of airflow and pressure when the closed-position speaking valve is used
          restores the patient's natural physiology and reduces complications that may arise from the placement
          of the tracheostomy tube.
<jennifer> Are you talking about as young as a 28 week gestation and on the vent would tolerate it?
<Lori Fitsimones> I think it is hard to put an exact age/timeframe on when PMV placement would be appropriate. 
          It is most important to assess airway patency, and individual tolerance on a case-by-case basis.
<Lisa Y. Torres> It would depend upon the respiratory status and other medical complications for the individual
<Lori Fitsimones> I think the point is that we shouldn't NOT try a PMV trial simply based on age.
<Lisa Y. Torres> Careful assessment and monitoring is required for the NICU population.
<Robin> Tell us what happens after you fit the patient with the PMV.
<Lori Fitsimones> Watch for signs of tolerance
<Lori Fitsimones> Encourage vocalization
<Lori Fitsimones> Monitor vitals
<Lisa Y. Torres> The restoration of airflow through the upper airway restores the senses of smell and taste,
          which can lead to an improved appetite.
<Lisa Y. Torres> Overall nutritional intake is imperative, especially for ventilator-dependent patients.
          The restoration of airflow restores sensation to the oropharynx, allowing the patient to sense any
          pooled secretions or material that would otherwise be aspirated.
<Lori Fitsimones> Essentially, once you re-couple the upper airway, you resume speech/language and swallowing
          therapy as you normally would.
<jennifer> I understand the the benefits of the PMV with the adults, but to encourage use in the NICU,
          what benefits have you found with this population?
<Lisa Y. Torres> The restoration of speech is essential for normal language development in tracheostomized
<Lisa Y. Torres> The tracheostomized child is now able to request a desired activity or object, obtain
          information from the social surroundings, display displeasure, gain relief from an undesirable
          situation, and acknowledge the presence of others.
<Lisa Y. Torres> Restoration of communication for tracheostomized infants can diminish exposure to other
          developmental impediments to language development such as repeated and extended periods of
          hospitalization, neurological injuries, prematurity, inconsistent primary caregivers, poor growth and
          muscle strength, lack of normal feeding experiences, and a high incidence of otitis media and ambient
          noise exposure that can affect hearing.
<Lisa Y. Torres> The communicating infant is now capable of bonding with parents and siblings through crying,
          cooing and babbling.
<Lori Fitsimones> I have spoken to a mother who indicated that she has her infant perform non-nutritive
          sucking on a nipple while she gets tube feeds, all while wearing her PMV.  This is because with the 
          upper airway airflow...
<Lori Fitsimones> The baby has increased sensation and the sucking during the time her tube feedings are going
       provides her the cues to pair sucking with a full tummy.
<Lori Fitsimones> As you can see this not only benefits her oral motor development, but also pairs oral
          activity with feeding.
<Lisa Y. Torres> Lichtman et al verified results of previous studies indicating that use of the PMV decreased
          the amount of secretions by restoring airflow in the nasal passages and that, with a more forceful cough,
          the secretions may be elevated to the oropharynx and subsequently expectorated or swallowed.
<Lisa Y. Torres> They report that the continued clearing of secretions from the lower airway while wearing the
          speaking valve would reduce the requirement for suctioning through the tracheal lumen.
<djspeech> Could you touch on using the PMV in home health swallowing therapy in regards to swallow safety and
          caregiver education of signs of aspiration? I have had patients' caregivers use blue dye followed by
          suction so that they begin to feel safe with independent feeding (paired with a sat monitor) however a
          recent article did not recommend any dye
<Lori Fitsimones> Blue dye has a high false negative rate.
<Lori Fitsimones> I do use it, but with caution.
<Lori Fitsimones> Having the PMV on with swallowing, as we mentioned earlier, has physiologic benefits.
<Lori Fitsimones> Not to mention that the family can assess vocal quality for "wetness", which cannot be done
          with an open trach.
<Lisa Y. Torres> In conjunction with placement of the Passy-Muir Valve (PMV) on the tracheostomy tube, restoration
          of subglottic pressure has been reported by Gross and Eibling to significantly improve swallowing
          efficiency and decrease the risk of aspiration for patients using the valve.
<Lisa Y. Torres> Similarly, Dettelbach et al used the PMV to occlude the tracheostomy tubes of 11 patients who
          were known to aspirate and unable to tolerate capping or decannulation.
<Lisa Y. Torres> They concluded that aspiration was reduced or eliminated in all cases with at least 1 food
          consistency provided.
<Lori Fitsimones> Here are some recent studies that discuss the physiologic benefits of PMV use with swallowing:
<Lori Fitsimones> Suiter DM, McCullough GH, Powell PW.  Effects of cuff deflation and one-way tracheostomy speaking
          valve placement on swallow physiology.  Dysphagia. 2003 Fall;18(4):284-92.
<Lori Fitsimones> Gross RD, Mahlmann J, Grayhack JP.  Physiologic effects of open and closed tracheostomy tubes on
          the pharyngeal swallow.  Ann Otol Rhinol Laryngol. 2003 Feb;112(2):143-52.
<Lisa Y. Torres> Stachler et al completed a similar investigation using a thin liquid. Scintigraphic evidence
          quantified that occlusion of the tracheostomy tube during swallowing with a PMV significantly reduced the
          frequency of aspiration as compared with the open condition in the same patient.
<Lisa Y. Torres> Elpern et al used videofluoroscopy to examine swallowing in a mixed group of tracheostomy
          patients to compare occurrences of aspiration with and without use of the PMV.
<Lisa Y. Torres> They found that aspiration was significantly less frequent in patients using the PMV than in the
          same patients when not using the PMV.
<wendy> Great!  Thank you for all of those references.
<djspeech> I find that because their family member can verbalize that they are okay after a swallow this increases
          confidence quickly which increases feedings independently and thus increases progress.
<Lori Fitsimones> absolutely
<Lori Fitsimones> We can't forget that sometimes what is so beneficial is using the PMV with swallowing is that
          they can TELL us how the swallow felt and what they think.
<Lisa Y. Torres> I think we often forget how important the psychological enhancement empowers the patient.
<Robin> exactly!
<Lisa Y. Torres> Decreased risk of aspiration may prevent further surgical intervention for swallowing
          complications such as placement of a gastrostomy tube or a jejunostomy tube.
<Robin> Lisa and Lori, could you walk us through a case study?
<AdrienneFSU> great idea
<Lori Fitsimones> I have had many patients that I have used this on that were low-level brain injuries.
<Lori Fitsimones> I have used it on someone as low-level as Ranchos III.
<Lori Fitsimones> Having the PMV on during therapies provided more opportunities for the patient to hear their
          own efforts at phonation.
<Robin> Tell us about what you do with this type of patient.
<Lori Fitsimones> With this population in particular, it seems to encourage them to attempt to speak when they
          begin to hear thier own attempts.
<Lisa Y. Torres> There are clinicians who are using the PMVs on comatose patients for sensory stimulation.
<Lori Fitsimones> Oftentimes, on low level patients we think they are much lower that they really are simply
          because they do not attempt to communicate
<Lori Fitsimones> I have a video of a patient that looks like a classic level III, but about 30 minutes after
          wearing the PMV he communicates quite a bit, giving better insight into his cognitive level.
<Lisa Y. Torres> There are several case studies examples in the transitioning and troubleshooting CEU course on
<Lisa Y. Torres> Early intervention with use of the closed-position speaking valve allows patients to use their
          expiratory muscles while receiving mechanical ventilation by breathing past the tracheostomy tube past
          their own natural anatomy, and out the mouth and nose. This process strengthens the respiratory
          musculature, which promotes the decannulation and weaning process.
<Lisa Y. Torres> Light et al found that tracheostomized patients who used the PMV were able to be decannulated 
          5 days sooner than patients in the control group who were not using the valve.
<Lisa Y. Torres> Frey and Wood reported an overall improvement in oxygen saturation levels, a 56% greater
          tolerance for weaning attempts, which eventually led to independent breathing for 33% of the patients
          included in that study. Expedited weaning from the ventilator with the closed-position speaking valve
          promotes shorter stays in the intensive care unit for patients; shorter stays in an acute care facility
          and ultimately, transfer of patients from the hospital to home.
<Lisa Y. Torres> These differences translate into significant cost savings for the healthcare facility and the
          patient's family.
<Robin> All excellent points.
<Lori Fitsimones> Many people don't realize that the PMV was originally intended to be used ON the vent.
<Lori Fitsimones> The inventor, David Muir, was a vent user.
<Lisa Y. Torres> He was a 23 year old quad who had muscular dystrophy.
<Robin> I encourage everyone to visit the Passy-Muir website and read the story about David Muir.  It is inspiring.
<Lori Fitsimones> It is ironic that practitioners are sometimes reluctant to use it in line (while the patient
          is on the ventilator).
<thatlagirl> Why is that?
<Lori Fitsimones> Some hold the belief that you cannot compensate for the air leak past the deflated cuff.
<Lori Fitsimones> Again, there is research to indicate that you can adequately ventilate with a deflated or even
          cuffless tube.
<Lisa Y. Torres> You can however, compensate for the leak past a deflated cuff by making minor changes to the vent.
<thatlagirl> Generally, how long do patients take to gain confidence and a comfort level on the PMV?
<Lisa Y. Torres> It depends
<Lori Fitsimones> Sometimes a minute or less...sometimes much longer.
<Lisa Y. Torres> Some tolerate it all day on the first trial.
<Lisa Y. Torres> It depends entirely on the individual patient.
<Lori Fitsimones> I think it is important to not set up the patient to feel like if they do not tolerate the PMV
          immediately, that they have "failed" in some way.
<thatlagirl> I agree, since everyone's anxiety level varies.
<jennifer> With the vent are you working directly with respiratory therapy to make those changes or initial trials?
<Lori Fitsimones> Yes, we are always working, conjunctively with the Respiratory Therapists.  They assess and monitor
          breathing and ventilation, and make adjustments to ventilator settings, as appropriate.  There is constant
          communication between the RT and SLP in order to trouble-shoot any adjustments that may need to be made to
          the ventilator.  Of course, we do this all with the MD order to do so.
<Lori Fitsimones> Vent adjustments are usually made on initial trials in order to compensate for leak and enhance
          tolerance of the PMV.
<Lori Fitsimones> Fine-tuning may occur along the continuum.
<Robin> Lisa and Lori, you have been chatting for almost an hour...is there anything else that you would like to add,
          or are there any more questions for our hosts?
<Lisa Y. Torres> Please feel free to email me at info@passy-muir.com or call me toll free at 800-634-5397 for any
          clinical questions or to request a free clinical video/DVD and research literature packet.
<thatlagirl> I will order info. Thanks!
<AdrienneFSU> Thanks for all the info!
<ekspino> Thank you!
<djspeech> This was my first time chatting here, great topic. I will definately be joining future chats.
<Robin> Thank you for sharing your expertise.
<Lori Fitsimones> Thank you for having us.
<Lisa Y. Torres> Thank you for this wonderful opportunity.
<AdrienneFSU> goodnight everyone!