Vol. 17 •Issue 8 • Page 31
Passy-Muir Valve Helps Ventilator Patients Speak
Ask any ventilator-dependent patients what the most difficult aspect of their condition is and often they will answer, “Not being able to speak.” Family members respond with, “Not being able to understand what the patient is trying to say.” This inability to communicate can create frustration and friction between the patient, family and staff.
The ventilator-dependent patient is unable to speak because the tracheal tube is positioned below the larynx, resulting in no airflow passing through the vocal folds to create speech. However, the use of a small plastic device called the Passy-Muir Speaking Valve can eliminate this problem.
The Passy-Muir Valve (PMV) is a one-way closed position “no leak” valve that alters the direction of tracheal airflow, allowing patients to use their own vocal folds to speak. The valve is open during the inspiratory cycle, allowing ventilation through the tracheostomy tube, and closes automatically at the beginning of the expiratory cycle, directing air up through the vocal folds.
AN IDEAL CANDIDATE
Recently, a 74-year-old male diagnosed with progressive muscular dystrophy and COPD was admitted to Vencor Hospital in Ontario, Calif. He and his wife were frustrated by his inability to communicate while on the ventilator. Ventilator settings were SIMV 6, PEEP 5, tidal volume 750cc and 30 percent FiO2. The patient was alert and cooperative, and clinical evaluation showed he was a good candidate for the PMV.
Clinicians placed the valve, and the patient was able to speak immediately with clear but breathy phonation. He was highly intelligible at the one- to two-word level but only about 40 percent at sentence level because of decreased breath support related to his muscular dystrophy. With training, he was able to improve breath support and speech intelligibility. Now 100 percent intelligible with normal vocal volume, he wears the PMV during all waking hours. The patient and his family are thrilled with his ability to communicate.
To use the PMV, the patient must be able to tolerate cuff deflation, if only for a short time. We usually use a fenestrated, cuffed tracheostomy tube (although neither fenestration nor cuff are required) with the inner cannula removed and cuff deflated prior to valve placement. This allows maximum airflow through vocal folds with the least amount of airway resistance during the expiration phase. We place the valve on the side of the inline suction catheter with a 15 mm by 22 mm step-down adapter, allowing for suctioning without removing the valve.
Adequate supervision is essential because harm can result from patient fatigue or the clinician’s failure to remove the inner cannula (with fenestrated tubes) and deflate the cuff. This potential is limited through appropriate staff education and mechanical monitoring.
The physiologic benefits of positive airway pressure promote a louder voice and the ability to speak in multiple word phrases or sentences. The patient is not limited to one or two words, as when they use “leak speech,” which occurs when the patient increases intrathoracic pressure, forcing air around the inflated cuff and through the vocal folds. This greatly increases the patients’ work of breathing, limits speaking and may increase mean airway pressure as these patients often try to talk forcefully against the inspiratory cycle.
Other advantages include return of physiologic PEEP, return of the patient’s ability to smell and taste, and a decreased risk of aspiration during eating. Tidal volume and O2 saturation are not only maintained, but are enhanced as glottic function improves through increased phonation and speech therapy.
Being able to verbally express oneself, participate in decision-making, and communicate with family, friends and staff members are important for all patients, especially those who depend on mechanical ventilation. The Passy-Muir Speaking valve restores the patient’s ability to vocalize and reinstates confidence. It is a valuable asset in improving quality of life and in giving back some control to patients.
Eyglo Gudsteinsdottir is senior speech pathologist and Curtis Powell is manager of respiratory care services, both at Vencor Hospital in Ontario, Calif.