On September 21, 2019, I attended Strategies for Assessment and Treatment Following Tracheostomy: An Interactive Seminar in Fort Worth, Texas produced by Passy Muir. This seminar covered tracheostomies, trachs, trach management, and speaking valves. The speakers Gail Sudderth, RRT and Kristin King, PhD, CCC-SLP were both very knowledgeable and held my attention – as in, not boring. The workshop was a mix of lectures, patient videos, case studies, and hands-on break-out sessions. This course was well attended by not only respiratory therapists, but by speech pathologists, nurses, and several other disciplines. If you ever get a chance to attend one, I highly recommend it. 

Being a respiratory therapist, I know quite a bit about tracheotomies, but I can always learn more.  Here are a few details they covered:

1. Best practice is to have an airway team to assess tracheostomies.
2. Place the correct size trach. Not everyone should get an 8.
3. Having the cuff inflated does not protect against aspiration, it may cause it.
4. Evaluate correctly the tolerance of a speaking valve, search for reasons of failure.
5. A speaking valve not only helps with speaking, but also with swallowing and secretion management.
6. Communication with a patient is key to success, and lip-reading has been shown to be a terrible solution and is virtually completely unreliable. Research has shown that lip reading is only about 10% correct. Although they did play a silent video of a young lady speaking and asked the audience what she said.  Amazingly, someone shouted out the correct answer. He was a respiratory therapist! For the record, I am terrible at lip-reading.
7. The blame for many medical errors can be pinned on failure to communicate. For example, the failure to communicate properly with the patient, during report, or between departments. Early placement of a speaking valve can prevent many of these.

Clear communication with patients and other staff is key to avoid medical errors.

Just because a patient is in the ICU on a vent does not preclude them from wanting to communicate. Consider placing a speaking valve in-line as soon as you can. Here are suggested guidelines to in-line placement:

Patient:

• Awake and alert
• Medically stable
• Able to manage cuff deflation
• Low risk for gross aspiration
• Patent upper airway
• Manageable secretions

Ventilator:

• FiO2 ≤ 50%
• PEEP ≤ 10 cmH20
• PIP ≤ 40

Imagine the impact on a patient’s psychological well-being when allowing them to speak again. 

At my hospital we don’t currently use speaking valves inline. I hope to change that. I’ll post updates as they become available.

Image Credit: Passy Muir

Learn More

To learn more about trach management and enabling communications for patients with artificial airways, take our class Tracheostomy Devices and Management for 1.5 AARC approved live CRCE hours. (Use discount code trach for 15% off!).