Vol. 16 •Issue 1 • Page 22
Speaking Valves Aren’t for Everyone, But They Offer Better Lifestyles for Many
In Walt Disney’s movie The Little Mermaid, Ariel trades her voice for the opportunity to walk on land and woo a handsome prince. But her hopes are soon dashed. Without the ability to speak, she is unable to let her handsome beaux know she is the girl of his dreams. Luckily, Ariel’s friend Sebastian, a small Bahamian crab with a penchant for Reggae, comes to her rescue and steers the handsome prince to his awaiting bride.
In true fairy tale fashion, they wed and live happily ever after. It is a charming story, but the reality of not being able to speak and effectively communicate is frustrating, a feeling well known by pulmonary patients.
One such patient who acutely knows the pain of not being able to express himself is David Muir, a muscular dystrophy patient who experienced a respiratory arrest in February 1984.
He decided to sleep in one morning and awakened two days later in an ICU and intubated. David fought back; he noticed a one-way valve in his ventilator circuit and envisioned using it to assist him in channeling air through his vocal cords. His concept resulted in the development of Passy-Muir speaking valves widely used throughout the U.S. today.
Basically, the Passy-Muir Tracheotomy and Ventilator Speaking Valves (PMVs) are one-way valves which can connect to the universal 15mm hub of most tracheotomy tubes. The patient breathes in through the valve and exhales around the tube. As the air flows past their vocal cords, the patient is able to vocalize. In addition to giving patients a voice, PMVs restore positive subglottic pressure, enhancing the patient’s ability to swallow.
Recent studies have suggested the PMV can also facilitate weaning and tracheal decannulation.
INDICATIONS FOR USE
So who exactly should use a PMV? Actually the user group is fairly large because PMVs are approved for adult, pediatric and neonatal populations both on and off a ventilator. Specifically, PMVs are used for patients with neuromuscular diseases, quadriplegia, COPD, vocal cord paralysis and tracheomalacia and for ventilator-dependent patients. It is almost easier to say who should not use them as to define who should. Patients with copious amounts of secretions are at risk for plugging or at risk of severe air trapping and would not be good candidates. Nor are comatose or unresponsive patients who are unable to communicate anyway.
Cuff deflation is mandatory for the proper functioning of the PMV. The valves may be used with either fenestrated or nonfenestrated tubes. And while it may sound silly to mention it, patients with foam-filled cuffs on their tubes would be poor candidates because foam in the cuff would prevent their exhalation. This is an easy point to overlook, particularly if you don’t use the PMV device often.
To determine whether a patient is a good candidate for a PMV, caregivers must make a good comprehensive clinical assessment. The ideal PMV patient should be awake, alert and responsive. In essence, they should be cognitive enough to want to communicate. This is also a good safety precaution because patients utilizing PMVs should be attentive enough to either assist themselves or alert a caregiver in the event the valve becomes plugged or malfunctions.
The valve is contraindicated for sleeping patients. From a medical perspective, the patient should be clinically stable, have good vital signs, good breath sounds, a demonstrated ability to ventilate and oxygenate with the valve in place and normal work of breathing.
Patients with an increased risk of aspiration should be evaluated carefully because proper utilization of the device necessitates cuff deflation. For patient safety, it is a good idea to place a sign or warning to care providers not to inflate the cuff of the trach tube while the patient is using the device.
By design, the PMV creates a degree of airway resistance and the patient must exhale around the trach tube. Alert patients may notice the resistance and should be given reassurance that, in fact, they can breathe. Patients should be carefully monitored while they are using the device. Monitoring should include, but not be limited to, patient comfort, pulse oximetry, vital signs, work of breathing, respiratory rate, minute volume and respiratory mechanics. If the patient tires, demonstrates an increased work of breathing or any type of respiratory distress during the trials, the PMV should be removed. Short trials with the PMV may be necessary until the individual’s endurance develops. Caregivers can withdraw direct supervision of patients who have successfully mastered the technique of speaking and are deemed medically appropriate and safe to use it. For patients who need oxygen, there is a version of the valve that permits O2 deliveries.
While there are other speaking devices on the market, the Passy-Muir brand has perhaps the highest name recognition among RCPs and speech pathologists.
Unlike Ariel, the little mermaid, trach patients may not live happily ever after, but at least if they have access to a PMV, they will be able to express themselves.
Margaret Clark is a Georgia practitioner.