Application of the Passy-Muir® Swallowing and Speaking Valves for

Application of the Passy‐Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients 3/7/2013
APPLICATION OF THE PASSY-MUIR® SWALLOWING AND SPEAKING
VALVES FOR TRACHEOSTOMIZED AND VENTILATED PATIENTS
Leigh Anne Baker, M.S., CCC-SLP, BRS-S
Passy-Muir Inc. Consultant
UTAH SPEECH AND HEARING
ASSOCIATION
[email protected]
Disclosure: Financial — Received a speaking fee from Passy-Muir, Inc. for this presentation.
Nonfinancial — No relevant nonfinancial relationship exists.
Course Outline
David A. Muir
INVENTOR OF THE
PASSY-MUIR® VALVE
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Physiology of Swallow
Aspiration Risk
Trach Tubes: Clinical Complications and Swallow
PMV Design
PMV Benefits
Types of PMV
Patient Assessment
Application of PMV
Troubleshooting/Treatment Planning
Respiratory Failure
Types of ventilation
Modes of ventilation
RT terminology
Optimal vent settings for PMV placement
Vent Connections
The Aerodigestive Tract Is a Shared System
Physiology of Swallow
Leigh Anne Baker, M.S., CCC‐SLP, BRS‐S
Passy‐Muir Inc. Consultant
• Respiratory system shares
a common functional
space with the digestive
tract and the vocal tract.
• We never fully exhale (i.e.
(i e
physiological PEEP)
1
Application of the Passy‐Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients The Upper-Aerodigestive Tract Is a Valving System
• Beginning at the lips and
ending at the UES, the
valves are always
permitting or preventing
airflow food,
airflow,
food or liquids
from going one
direction to another.
Pharyngeal Stage of Swallowing
• Hyo-laryngeal anterior
motion provides some
airway protection and
opens UES sphincter
• Bolus pressure widens
opening of UES
• Closure of the laryngeal
valving system.
3/7/2013
Oral Preparatory & Oral Stage of Swallowing
• Readiness to accept the
bolus, including level of
alertness.
• Positioning, dentition,
and medications may
affect this stage.
• Valving system: lip
closure, lingual
propulsion,
velopharyngeal closure.
Respiratory Pause
• In healthy adults there is a
respiratory “pause” during
the swallow, with
swallowing occurring most
often in mid-expiration
• There is evidence that
swallows occurring at
lower lung volumes such as
exhalation to inhalation
transition are more likely to
result in aspiration
Esophageal Phase of Swallowing
• Reflexive phase
transports the bolus via
peristaltic wave through
the esophagus to the
stomach.
stomach
Leigh Anne Baker, M.S., CCC‐SLP, BRS‐S
Passy‐Muir Inc. Consultant
Aspiration Risks
2
Application of the Passy‐Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients Effects of Tracheostomy on Normal
Swallowing Function
• A Tracheostomy is often
preceded by an
endotracheal tube
intubation (oral or nasal)
Aspiration Pneumonia Is an Opportunistic
Infection
• Something must be aspirated.
• Aspirate must contain a respiratory pathogen.
• Must be able to overwhelm patient’s normal
defense/immune system.
Tracheostomy and Aspiration
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•
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Does a cuff prevent
aspiration?
Definition
Incidence of aspiration
– 50% - 87% rate for trach
and vent patients
3/7/2013
Well Documented Complications Associated
with Endotracheal Tubes:
• Mucosal injury
• Blunting of glottic
reflexes
• Free passage
(
(aspiration)
i ti ) off orall
pharyngeal secretions
into the upper airway
with a heightened risk
for Ventilator Associated
Pneumonia (VAP)
Additional Identified Risk Factors
Predisposing Patients to Aspiration Include:
• Witnessed aspiration
secondary to emesis or
reflux.
• Supine position and
coma.
coma
• Enteral nutrition (i.e.,
presence of a
nasogastric tube).
• Multiple intubations or
self-extubation.
Aspiration
• Is this a causal relationship? Some researchers think
so; However…
• Other factors cited to contribute to aspiration
include intubation and underlying critical illness
(Elpern et al., 1987, 1994, 2000; Tolep et
al., 1996)
– 75% silent aspiration
(Davis & Stanton, 2004; Elpern et aI.,
1994).
– Aspiration around the cuff
(Bone, Davis, Zuidema, & Cameron,
1974; Elpem et al.,1987; Nash, 1988;
Pavlin, VanNimwegan, & Hombein,
1975; Ross & White, 2003)
Leigh Anne Baker, M.S., CCC‐SLP, BRS‐S
Passy‐Muir Inc. Consultant
3
Application of the Passy‐Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients Additional Identified Risk Factors
Predisposing Patients to Aspiration Include:
• COPD, age > 60 years, and acute respiratory
distress syndrome
• Prior exposure to antibiotics which predispose the
patient to colonization of the upper aerodigestive
tract.
• Infection control lapses, including hand washing
and non-sterile tracheal suctioning
3/7/2013
Ventilator Associated Pneumonia (VAP)
• VAP is defined as
nosocomial (hospital
acquired) pneumonia
occurring in patients after
48 hours of mechanical
ventilation via
endotracheal tube or
tracheostomy tube
• Oral-pharyngeal secretions
colonized with bacteria
bypass the cuff on the ET
tube or tracheostotmy
tube and pass into the
lower respiratory tract.
Factors Related to Dysphagia Which May Influence
Cost of Care for Tracheostomized Patients:
• Pulmonary complications from aspiration, use of
antibiotics, reduced weaning, and prolonged
ICU/hospital stay.
• Late onset aspiration due to undiagnosed laryngeal
injury or impairment.
impairment
• Depression and reduced patient participation in care,
reduced quality of life and impaired communication
and loss of control over decision making.
Tracheostomy Basics
•
What is a tracheotomy?
•
What is a tracheostomy?
•
What is a tracheostomy
tube?
– “the making of an incision
into the trachea through
the neck below the larynx
allowing access to the
airway1”
– “an artificial airway created
by a surgical opening
through the neck for
insertion of a tube”
Tracheostomy Tubes and Swallow
Indications for Tracheostomy
• Prolonged mechanical ventilation
• Inability to perform trans-laryngeal intubation
(trauma, max/fax deformity)
• Upper airway obstruction (temporary or permanent)
• Secretion management (neuromuscular disease)
– “a tube placed in the
trachea to keep the airway
to the lungs open following
a tracheotomy surgery”
1Singh,
S. and Kent, R. Singular’s Pocket Dictionary of Speech-Language Pathology (2000). Singular Publishing Group.
Leigh Anne Baker, M.S., CCC‐SLP, BRS‐S
Passy‐Muir Inc. Consultant
4
Application of the Passy‐Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients HOW: TRACHEOTOMY PROCEDURES
3/7/2013
Percutaneous Tracheotomy
Open or Surgical Tracheotomy
Tried and True Method
Percutaneous Dilatation or Balloon Dilatation
Tracheotomy
L
Less
costly
tl and
d more convenient
i t
Cricothyoidotomy
As seen on ER Shows
Does the method of tracheotomy affect outcomes ?
Permission for use granted by Cook Medical Incorporated, Bloomington, Indiana Parts of a tracheostomy tube - ISO STANDARDS
• Single Lumen/Cannula
Neck flange
Tube shaft
Cuff
Tracheostomy Tubes
• Double Lumen/Cannula
15 mm connector
Inflation line
Pilot balloon
Pilot port with one way valve
Types of Tubes
• MATERIALS
– PVC, Silicone, Metal
– Metal Reinforced
• SHAPE
– Curved, Angular, Non
Nonpre formed
• LENGTH
– Standard
– Extra length
• Proximal
• Distal
• Adjustable Flange
Calculating Tube Size
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SINGLE LUMEN
DOUBLE LUMEN
FENESTRATED
MRI COMPATIBLE
S b l tti SSuction
Subglottic
ti
Trach Talk
CUFFS
– Air, water, or foam
– Double cuffed
– Un-cuffed
• Custom Made
Leigh Anne Baker, M.S., CCC‐SLP, BRS‐S
Passy‐Muir Inc. Consultant
• ATS Consensus: The
tracheostomy tube
should take up no more
than 2/3 the ID of the
trachea
trachea.
(for pediatrics, no adult standard)
trachea
O.D. I.D.
• AP Diameter of trachea
– Male:
18 +/- 5mm
– Female: 12 +/- 3 mm
tube
5
Application of the Passy‐Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients Cuff Choices
3/7/2013
Air Filled Cuffs
• AIR FILLED – minimal
leak
• Cuff Inflated
• Cuff Deflated
• TTS™ : WATER FILLED –
minimal
i i
l occlusion
l i
((can
be air filled)
• FOME-Cuf® – self
sealing
Water Filled Cuffs TTS
• Cuff Up
Early Tracheostomy (7-10 days) May:
• Cuff Deflated
A Tracheostomy Alters Physiological
Function of Upper AeroDigestive Tract
• Aphonia
• Reduced ability to
expectorate secretions
• Reduced sense of taste
and
d smellll
Leigh Anne Baker, M.S., CCC‐SLP, BRS‐S
Passy‐Muir Inc. Consultant
• Reduce incidence of VAP
and further injury to the
larynx caused by the ET
tube.
p
p
patient comfort
• Improve
including possibility for oral
communication and oral
diet and requirement for
less sedation
• Improve oral hygiene
• Improve secretion
management
Decreased Physiologic PEEP
• Decreased gas
exchange due to
reduced surface area of
alveoli
• Poor oxygenation
• Possible atelectasis
6
Application of the Passy‐Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients Tracheostomy Effect on Swallowing:
• Scar tissue formation from
the tracheotomy
procedure may affix the
trachea to overlying tissues
and the larynx may not
move freely
• If the tube is too large for
the patient’s trachea,
patient may feel
discomfort and may
compensate with reduced
laryngeal excursion
Tracheostomy Tube Effect on Swallowing
• Impaired oralpharyngeal pressure
• Impaired hyolaryngeal
elevation/excursion
• Impaired
I
i d glottic
l tti closure
l
• Reduced subglottic
pressures and reduced
sensation
• Muscle disuse atrophy
3/7/2013
Tracheostomy Effect on Swallowing:
“Many physicians conceive of a tracheostomy as
a solution to long term aspiration, but in reality, it
may increase the problem rather than solve it.”
Nash, 1998
Swallowing Complications
• Laryngeal Tethering
(Bonanno, 1971; Cameron et aI., 1973;
Ding & Logemann, 2005; Nash, 1988)
• Decreased Sensation in
the Oropharynx
2
(Siebens, Tippet, Kirby, & French, 1993)
• Reduced Airway Closure
3
4
(Sasaki and Buckwalter,1984)
• Reduced Subglottic Air
Pressure
1
(Eibling & Gross,1996; Gross, Atwood,
Grayhack, & Shaiman ,2003)
Effect of Mechanical Ventilation on Swallowing:
• Ventilator modes with a
pre-set breath may push
air at a time the patient
is trying to maintain
airway closure for a
swallow.
ll
• If the cuff is deflated,
without a Passy-Muir®
valve, a translaryngeal
leak may occur on
inspiration and
expiration.
Leigh Anne Baker, M.S., CCC‐SLP, BRS‐S
Passy‐Muir Inc. Consultant
The Cuff on the Tracheostomy Tube Is
Indicated During Mechanical Ventilation
• The cuff is designed to
create a “closed”
system, so the volume of
air delivered to the lungs
is not lost due to an
upper airway
i
lleak.
k
• The cuff may reduce the
impact of aspiration, but
cannot prevent
aspiration because it sits
below the level of the
true vocal folds.
7
Application of the Passy‐Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients Aspiration of Liquid or Food Around the
Tracheostomy Tube Cuff Has Been Well Documented
• The tracheal lumen is not
static during respiration.
• Aspiration around the
tracheal cuff may be due to
the leak caused by tracheal
dilation during inspiration,
and/or
d/ d
due to
t secretions
ti
which pool above the cuff.
• The cuff may create a
reservoir for pooled or
stagnate secretions to
colonize and eventually
enter the lower respiratory
tract.
Mismanagement of Cuff Pressures
• Distention caused
by the cuffed
tracheostomy tube
against the
esophagus may
cause liquids to
overflow the UES
and fall into the
trachea.
• Refluxed tube
feedings or gastric
contents may also
enter the airway via
the same
mechanism
3/7/2013
Cuff Mismanagement Has Been Associated with:
• Damage to the tracheal
mucosa
• Tracheal stenosis
• Granulation tissue
f
formation
ti
• Tracheal erosion
• Tracheoesophageal
fistula
• Tracheal dilation
Evaluation and Rehabilitation of Swallowing
in the Tracheostomized Patient
“All tracheostomy patients should be referred for speech
therapy prior to surgical placement of the tracheostomy or
soon thereafter. “
Respiratory Care, April 2005.
Passy-Muir® Valve and Swallowing
•
Placing the Passy-Muir
valve before your
swallowing assessment
may enhance your
patient’ss swallowing
patient
performance
Leigh Anne Baker, M.S., CCC‐SLP, BRS‐S
Passy‐Muir Inc. Consultant
Passy-Muir® Valve Design
8
Application of the Passy‐Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients Open Position Speaking Valve
3/7/2013
Biased Closed Position-No Leak Design
Clinical Benefits
Benefits of Passy-Muir® Valve
Improved Swallowing
• Restoration of voice
• 100% airflow through
vocal tract on
exhalation
• Improved
I
d sense off smellll
and taste
Improved Swallowing
• Decreased Laryngeal
Tethering
• Increased Sensation in
the Oropharynx1
• Improved
I
d Ai
Airway
Closure2
• Restored Subglottic Air
Pressure3
2
3
4
1
1.
2.
3.
Synderman & Eibling, 1994; Baker et al., 1994; Detelbach, et al., 1995; Lichtman and colleagues,1995
Sasaki et al., 1977
Gross et al., 2003, 2006
Leigh Anne Baker, M.S., CCC‐SLP, BRS‐S
Passy‐Muir Inc. Consultant
9
Application of the Passy‐Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients Improved Swallowing
3/7/2013
Restored physiological PEEP
• Improved gas exchange
• Improved oxygen
saturation levels
• Decreased risk of
atelectasis
t l t i
• Laryngeal Elevation
Reduced Aspiration
• Improved Sensation
• Vocal Cord Closure
• Restored Subglottic Pressure
Dettelbach et al., 1995; Stachler et al., 1996; Elpern et al., 2000; Suiter et al., 2003; Gross et al., 2003
Frey and Wood, 1995
Improved Secretion Management
Expedites Weaning and Decannulation
• Improved sensation and cough
• Decreased suctioning needs
• Decreased risk of tracheal damage
• Restoration of normal
physiology
• Utilization of expiratory
muscles
• Accustomed
A
t
d to
t a more
normal breathing
pattern
• Able to communicate
• Develops confidence
and motivation
Lichtman et al., 1995
Frey & Wood, 1991; Sierros, et. al. 2007; Light et al., 1989
Cost Savings
$9,155/day
Quality of Life…
About $1 a day
1. Tube Feeding
2. Antibiotics/ ICU stay
3. Vent days/LOS
• Passy‐Muir Valve
4. Suctioning Supplies
PRICELESS!!!
Leigh Anne Baker, M.S., CCC‐SLP, BRS‐S
Passy‐Muir Inc. Consultant
10
Application of the Passy‐Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients 3/7/2013
PMV ® 2000 (clear) &
PMV ® 2001 (Purple Color™)
Types of Passy-Muir® Valves
PMV® Secure It®
PMA® 2000 Oxygen Adapter
PMV® 007 (Aqua Color™)
Metal Tubes
Original Jackson
Original with 15mm hub and PMV®2000
Improved Jackson with PMV®2020
Leigh Anne Baker, M.S., CCC‐SLP, BRS‐S
Passy‐Muir Inc. Consultant
11
Application of the Passy‐Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients 3/7/2013
Patient Care Kit
Patient Assessment
Team Approach
Speech
Therapist
Occupational
Therapist
Patient Selection
• Awake, responsive, attempting to communicate
• Medically stable
• Able to tolerate cuff deflation
Physician
Nurse
Patient
Physical
Therapist
– Vent
e status
s a us
– Aspiration status
• Able to manage secretions
• Have a patent upper airway
Dietician
Respiratory Therapist
Factors Affecting Upper Airway Patency
• Size of Tracheostomy
Tube
• Presence and Degree of
Obstruction
• Edema
Ed
• Secretions
• Foam-Filled Cuff
Leigh Anne Baker, M.S., CCC‐SLP, BRS‐S
Passy‐Muir Inc. Consultant
To Assess for Upper Airway Patency
• Deflate cuff
• Ask patient to inhale
• Apply digital occlusion to trach and ask patient to
g on exhalation
voice or cough
• Use mirrors, cotton, whistles or bubbles to assist with
the oral exhalation process.
12
Application of the Passy‐Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients 3/7/2013
Placement Guidelines
Application
Baseline Measurements
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Oxygenation
Vital Signs
Breath Sounds
Color
Work of Breathing (WOB)
Patient Responsiveness
Patient education
Peer education
Patient position
Suctioning
Achieve complete cuff
deflation
• Use the warning label
provided with
packaging
•
•
•
•
•
Placement of Passy-Muir® Valve
• Gentle quarter turn twist while stabilizing the flange of
tracheostomy tube
Transitioning and Troubleshooting
Swallowing and Passy-Muir®
Troubleshooting and Treatment Planning
Leigh Anne Baker, M.S., CCC‐SLP, BRS‐S
Passy‐Muir Inc. Consultant
•
•
•
•
Anxiety
Airway patency
Depression
Breathing pattern changes
13
Application of the Passy‐Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients Cuff Up or Down?
Treatment Short Term Goals:
• Our pulmonologist directs the nurses to feed the
patient with the cuff up.
• A clinician asks:
Q: How do we educate them about the risks/benefits
Q
/
of cuff deflation?
– Review the role of the cuff during mechanical ventilation.
– Request a trial of cuff deflation and Passy-Muir® Valve use
to restore more normal physiology.
– Perform an instrumental exam, and document findings
under both conditions.
Work of Breathing
• Our pulmonologist will not let us use the
Valve with our patients during weaning from
mechanical ventilation, stating that: “the valve will
increase the work of breathing”
• A clinician asks:
Q: How do I convince him otherwise?
– Work of breathing is multifactoral.
– Patients may actually benefit from “exercising” the
respiratory and upper airway musculature.
– There should be careful monitoring of the patient by
respiratory and speech.
Dysphonia–Dysphagia Despite
Passy-Muir® Valve Use
• I have placed the Passy-Muir Valve on my patient,
and she tolerates it well, but she only has
whispered voice, and we still document aspiration
of thin liquids on a VFSS.
• A clinician asks:
Q: Should I continue to use the Passy-Muir Valve?
– What do you observe?
• s/s of dysphonia and reduced airway protection.
– What do you request?
• Intubation history.
• ENT consult .
• Vocal function/laryngeal strengthening exercises.
Leigh Anne Baker, M.S., CCC‐SLP, BRS‐S
Passy‐Muir Inc. Consultant
• Patient will tolerate cuff deflation and Passy-Muir® Valve
placement during supervised trials with speech therapy(30
min), twice daily, to enhance communication.
• Patient will have functional voice and laryngeal responses
(cough, throat clear) when using Passy-Muir Valve, 75% of
the time to enhance communication.
communication
• Patient will expectorate pulmonary secretions when using the
Passy-Muir Valve with reduced need for tracheal suctioning,
80% of the time to improve secretion management.
• Patient will participate in bedside bolus trials, demonstrating
prompt and efficient swallow, without signs/symptoms of
aspiration, 80% of the time to promote oral feedings.
Treatment Short Term Goals:
Passy-Muir®
– What do you do?
3/7/2013
• Patient will tolerate cuff deflation and Passy-Muir® Valve
placement during t-piece trials, 30 minutes, twice per day,
with maintenance of baseline vital signs, 80% of the time to
restore upper airflow/sensation.
• Patient will participate in respiratory support exercises
(diaphragmatic breathing),
breathing) 10-15
10 15 min
min. per day while using
the Passy-Muir Valve to strengthen respiratory muscles.
• Patient will participate in bedside swallow exam while using
Passy-Muir Valve without signs/symptoms of aspiration to
determine po readiness.
• Patient will tolerate ice chip trials, while wearing the PassyMuir Valve , without signs/symptoms of aspiration, 80% of the
time to promote oral feedings.
Treatment Short Term Goals:
• Patient will tolerate Passy-Muir® Valve placement 30-90
minutes daily with no decline in baseline vital signs, 80% of
the time to promote oral communication.
• Patient will utilize Passy-Muir Valve and participate in vocal
function exercises to increase vocal fold adduction for voice
as measured by audible phonation attempts , 45% of the
time to enhance communication.
• Patient will utilize Passy-Muir Valve while participating in
laryngeal strengthening exercises 90% of the time for
improved airway protection during swallowing.
• Patient will utilize Passy-Muir Valve to maximize benefit of
using compensatory swallowing strategies, with reduced
episodes of aspiration for liquid trials, 80% of the time.
14
Application of the Passy‐Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients Educate and Document
3/7/2013
Care, Cleaning, and Lifetime of the Passy-Muir Speaking Valves
• If you didn’t document it, you didn’t do it.
• Utilize the instructions and labels that come
® Valve.
packaged
p
g
with the Passy-Muir
y
• Develop multidisciplinary policies and procedures
for best outcomes.
Average lifetime of 2 months
Ventilation and Respiration
VENTILATOR BASICS FOR THE NON-RT
•
Ventilation
– The act or process of inhaling and exhaling
– Breathing
– Inhale O2, exhale CO2
• Respiration
– Gas exchange at the cellular level
Structures
Respiratory Failure
• Defined as inability to maintain adequate
ventilation to maintain:
– normal oxygenation
– carbon dioxide elimination
– or a combination of both
Leigh Anne Baker, M.S., CCC‐SLP, BRS‐S
Passy‐Muir Inc. Consultant
15
Application of the Passy‐Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients Indications for Mechanical Ventilation
3/7/2013
Non-Invasive Ventilation
• Respiratory failure / impending respiratory failure
–
–
–
–
–
Post operative – whatever the duration
C-spine injuries – quadriplegia
Neuromuscular disease – progressing
Central sleep apnea – nocturnal ventilation only
Trauma – multiple reasons
Invasive Ventilation
Ventilator Settings:
Just What Does The Doctor Order?
•
•
•
•
•
•
Ventilator Settings
Things The Doctor Does Not Order
•
•
•
•
•
Flow Rate – L/min
Alarms Settings
Trigger Sensitivity
Exp % Sensitivity (time limits PS breaths)
PIP – Peak Inspiratory Pressure
Mode of Ventilation = AC, SIMV, CPAP, etc.
Vt = tidal volume (cc or ml)
RR = respiratory rate
FiO2 = % oxygen
PEEP = positive end expiratory pressure
Pressure Support/Pressure Control
Types of Ventilation
• Volume ventilation = ventilator delivers the pre-set Vt
regardless of the peak pressure required. Volume is a
constant.
• Pressure Ventilation = ventilator
til t d
delivers
li
a pre-sett
pressure and volume can vary depending on lung
compliance/resistance. Pressure is a constant, volume may
be variable.
• The higher the pressure, the sicker the lung…
Leigh Anne Baker, M.S., CCC‐SLP, BRS‐S
Passy‐Muir Inc. Consultant
16
Application of the Passy‐Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients Ventilation Terminology
Modes of Ventilation – Alphabet Soup!
•
SIMV, IMV, with/without PS – synchronized intermittent
mechanical ventilation (pressure support is an option)
•
A/C and/or PC– assist control ventilation/pressure control
•
PRVC – pressure regulated volume control
•
APRV, Biphasic, BiLevel – airway pressure release ventilation
•
CPAP/PS – continuous positive airway pressure/pressure support
•
BIPAP – bi-level positive airway pressure --- to name a few!
– this patient is typically too sick for PMV on this mode.
– this is a spontaneous breathing mode.
Ventilation Terminology
• Ventilators that are Passy-Muir®
Valve compatible:
3/7/2013
Ventilation Terminology
“Must Knows” for Passy-Muir® Valve Use!
• FiO2 = oxygen % (<50%)
• PEEP = positive end expiratory pressure
(<10cmH2O)
– Pressure in our lungs at end exhalation (the air we can
never exhale that maintains lung inflation)
• Vt = volume of delivered vent breath (cc’s)
• PIP/PAP = peak airway pressure (<40)
– How much driving pressure from the machine is required
to deliver the set Vt
Ventilation Terminology
• Double limb circuit
– Most acute care, sub-acute
and homecare vents
Ventilation Terminology
Cuff Inflated-Closed Circuit
• Single Limb Circuit
5 cm
H20
.30
FiO2
PEEP
PIP
25cm
H2O
Leigh Anne Baker, M.S., CCC‐SLP, BRS‐S
Passy‐Muir Inc. Consultant
Vt
500cc
500cc
17
Application of the Passy‐Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients Cuff Deflated-Open Circuit
3/7/2013
Passy-Muir® Valve In-line
250cc
0 cm
H20
500cc
.30
0 cm
H20
FiO2
PEEP
.30
FiO2
PEEP
PIP
Vt
10cm
H2O
PIP
500cc
250cc
10cm
H2O
Vt
500cc
0cc
Ventilator Alarms for
Passy-Muir® Valve Applications
Ventilator Adjustments
• Low exhaled Vt
• Low pressure alarm – MUST be set 5 to 10 cm below
PIP
700cc
0 cm
H20
• High pressure alarm – Should be set 10cm above
PIP
.30
FiO2
PEEP
15cm H20
30cm H20
Vt
PIP
20cm
H2O
700cc
0cc
Ventilator Connections
Dual‐Axis Swivel
Omni‐Flex™
15mmx22mm Step Down Adapter
22/22mm Silicone Adaptor
Leigh Anne Baker, M.S., CCC‐SLP, BRS‐S
Passy‐Muir Inc. Consultant
18
Application of the Passy‐Muir® Swallowing and Speaking Valves for Tracheostomized and Ventilated Patients TEAM APPROACH
• TRACH TEAM
• CO-TREATMENT STRATEGIES
• What are the goals?
• HOW DO I GET THE RT TO HELP ME?
3/7/2013
Additional Educational Opportunities
• Self-study webinars available on demand
–
–
–
–
–
Getting Started
Ventilator Application
Swallowing
Pediatric
Special Populations
• Live group webinars
• www.passy-muir.com
• Passy-Muir Inc. is an approved provider of
continuing education through ASHA, AARC, CMSA
and California Board of Nursing Credit
Leigh Anne Baker, M.S., CCC-SLP
Passy-Muir Inc. Consultant
[email protected]
Disclosure: Financial — Received a speaking fee from Passy-Muir, Inc. for this presentation.
Nonfinancial — No relevant nonfinancial relationship exists.
Leigh Anne Baker, M.S., CCC‐SLP, BRS‐S
Passy‐Muir Inc. Consultant
19