OVERCOMINGBARRIERS TO SPEAKING VALVE USE Success Through Teamwork 12/12/13. Passy Muir Inc. Clinical Consultant 1

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1 If you have not registered for this event, go to the Education Portal to complete your registration. ep.passy-muir.com o You will also have an opportunity to do this after the meeting ends. This is an Audio Broadcast meeting, which means that the audio signal will be sent out through your computer. A toll telephone number will also be available. Use the Audio section of the file menu for audio options. o Call-in toll number (US) o Access code: The audio for this meeting is one-way, so the presenter will not be able to hear the attendees, nor will the attendees be able to hear each other. If you have a question for the presenter, please use the Q and A (not the chat box), in the lower right of meeting window After the webinar ends, you will have an opportunity to fill in your evaluation on the Passy-Muir Education Portal Katy Peck, M.A., CCC-SLP, CBIS, CLE, BRS-S If you have a technical issue, please call Passy-Muir at , or Daniel at dcarrillo@passy-muir.com Katy Peck, M.A., CCC-SLP, CBIS, CLE, BRS-S o Disclosure: Financial -Received a speaking fee from Passy- Muir Inc. for this presentation. Nonfinancial -No relevant nonfinancial relationship exists. Passy-Muir, Inc. has developed and patented a licensed technology trademarked as the Passy-Muir Tracheostomy and Ventilator Swallowing and Speaking Valve. This presentation will focus primarily on the biasedclosed position Passy-Muir Valve and will include little to no information on other speaking valves. 16 year old Neuromuscular 16 year old Neuromuscular 6 year old Facial Mass Goldenhar 6 year old Facial Mass Goldenhar Expremie 5 month old Unknown Dx Expremie 5 month old Unknown Dx Passy Muir Inc. Clinical Consultant 1

2 Medical History Respiratory Dysphagia History Worsening neuromuscular weakness Unknown diagnosis, central hypotonia Scoliosis Chronic respiratory failure 1 years of age Admitted for PNA GT removed due to pain associated Full oral feeds prior to admission Unable to self feed Regular-for-age diet Did not like the feeling Refused to use it DTE MBSS Therapy MBSS Discharge Clinical s/s of aspiration, presumed PNA Frank aspiration, delayed swallow, and maximum residue Assessment: 55 minutes and Safe with dysphagia inline therapy to rehearse compensatory Full oral strategies feeds No Mild oral phase dysphagia Severe pharyngeal phase dysphagia o Maximum residue after swallow o Frank silent aspiration before 1 st swallow puree texture and honey thick liquids o Recommended Assessment Wear-time (hours) 3.5 Diagnostic Therapy MBSS review 3 o o Position 2.5 o Mode 2 o Sensory compensations Rehearsed practice o Mendelsohn Maneuver o Supraglottic swallows MBSS readiness/timing o ABX course complete o Independent with strategies o tolerance 5/1/13 5/1/13 Passy Muir Inc. Clinical Consultant 2

3 Initial MBSS MBSS #2 in-line in-line Puree & Soft Chewable Chilled Honey- Thick: Spoon Chilled Honey Thick: Med Cup Chilled Thin: Spoon Chilled Thin: Med Cup Chilled Thin: Single Sips with Straw Bolus formation and containment Mild residue Mild residue Premature spillage Premature spillage Premature spillage Residue Retrograde movement Mild residue UES- cued supraglottic Oral intake only Age Prognosis QOL Ventilator Dependency Cognition Voice o Marginal improvement in intensity Enteral feeds Secretion Management o Reduced endotracheal suction PNA Surgery Pain/QOL Respiratory sequalae Readmissions Controlled volume oral feeds with supplementation Cough o Productive Passy Muir Inc. Clinical Consultant 3

4 16 year old Neuromuscular 6 year old Facial Mass Goldenhar Expremie 5 month old Genetic Disorder Medical History Respiratory Dysphagia History Cleft palate and lip Severe HL (microtia and anotia) Low tone 3.5 month NICCU course Chronic respiratory failure Laryngomalacia OSA- supplemental oxygen (1.5lpm at night) Trach at 9 months of age GT Reflux Mouthing objects Assessed at 9 months- recommendation to wait 6 months to allow growth of the tracheal lumen Primarily nonverbal, audible cry, use of ASL signs Age appropriate cognitive functioning 9 mo. 14 mo. 16 mo. Assessment #1 Assessment #2 Therapy Initiated Trial 1 (Dx-1) Trial 2 (Dx-1) Baseline HR (bpm) Baseline SpO2 Duration (min) Trial 3 (Dx-2) Trial 4 (Tx 1) Trial 5 (Tx 2) Max Trial HR (bpm) Low Trial SpO2 Anat tomical Physio ological Anxiety an nd Fear Learned Be ehavior Passy Muir Inc. Clinical Consultant 4

5 12 Duration (minutes) tomical Anat ological Physio nd Fear Anxiety an ehavior Learned Be Trial 1 Trial 2 Trial 3 Trial 4 Trial 5 Trial 6 Trial 7 Trial 1 Trial 2 Trial 3 Trial 4 Trial 5 Trial 6 Trial 7 Increased HR and diaphoretic Fear and crying Increased secretions and WOB Anat tomical Physio ological Anxiety an nd Fear Learned Be ehavior Gloves Hospital setting Poor tolerance Setting o Garden, FRC, and hallway Medical play o Vibrating frog inside gloves o Cleanup routine o Caregiver/child placement tolerance o Lower expectations o Family education Physiologic Changes? Behavior? Passy Muir Inc. Clinical Consultant 5

6 tomical Anat ological Physio nd Fear Anxiety an ehavior Learned Be Minimal tolerance Isolated 7 minute trial No expectations 6 month therapy hold recommended Refusal Group Fake and functional communication ENT workup o Wait for MORE tracheal lumen growth o Downsize trach tube Diagnostic therapy to determine cause o Use fake o Place when in a light sleep Anxiety Airway patency Learned behavior 6 year old Facial Mass 16 year old Neuromuscular Goldenhar Expremie 5 month old Unknown Dx Medical History Respiratory Dysphagia History Retrognathia, microglossia, & hypotonia NICCU stay for stridor & increased WOB Genetic and neurology w/u negative No significant upper obstruction Epiglottis somewhat retroflexed Normal VFs and subglottis Suction 5-7x/day Enteral feeds (GT) Receiving feeding/swallowing therapy without use of ENT from OSH said pt was too young Patients mother continued to research and requested assessment Nonverbal 5 months 1 months ENT declined referral HRI follow and OT at CHLA Dx: 1 st sounds Therapy and Dysphagia Assessment MBSS Early communication & enteral feed wean Passy Muir Inc. Clinical Consultant 6

7 Oral Motor Swallowing Speech/Voice Cognition Physiology Tolerance Hypotonic Open mouth posture Mouthing toys Reduced R d d oral secretion management Enteral feeds only- learned caregivers provided tastes Aphonic- no audible cry - Effortful vocalizations and cry Typical for developmental age Reddish cheeks: consistent with baseline Excellent Cried without voice once removed Appeared upset Wear-time (hours) 5 months 6 months 7 months 8 months Wear-time (hours) Familiar o Faces o Utensils o Tastes o Feeder seat Sensory o Preferred cold o Homemade options Presentation o Distractions o Positive feedback Passy Muir Inc. Clinical Consultant 7

8 in-line Chilled Puree (Thick and Thin) Delayed bolus formation and transfer Reduced oral containment and pooling Mild residue Chilled Nectar- Thick Premature spillage Moderate residue Chilled ½ Nectar Thick Mild residue Mild to moderate residue Chilled Thin Liquid Increased premature spillage Laryngeal penetration before the swallow Micro-aspiration before the swallow Suzanne Abraham 1 (29) 9 5 children with trach 8 Age Range: 2 month- 7 4:9 6 24/5 candidates 5 o Wear-time success 4 achieved 3 All waking hours 2 Daily/consistently 1 o Secretion management Established within 2 weeks on average 49% candidates 98% Secretion Management 16 year old Neuromuscular Clinical Findings Prematurity: 28 week expremie Neuro: Grade III IVH (left) and Grade II (right) Cardiac: VSD and PDA Adrenal suppression 6 year old Facial Mass Goldenhar Respiratory Respiratory insufficiency Chronic lung disease Supraglottic and arytenoid edema (GERD) Tracheotomy and mechanical ventilation dependency Suction every 1-2 hours Expremie 5 month old Genetic Disorder GI Delayed gastric emptying GERD GT and JT 1 months OT recommended Nonnutritive Stimulation & no sound play Assessment and dysphagia therapy Scant tastes Early communication & outpatient referrals Wear-time Across 1 Sessions Wear-time (minutes) Passy Muir Inc. Clinical Consultant 8

9 Wear-time Narcotic wean o Unpredictable transitions in neurobehavioral regulation o Physiologic i parameters o Diaphoretic Variable secretions Caregiver involvement Not a candidate for MBSS Acute Vs. Outpatient Status 1. Staff availability 2. Frequency and consistency of trials 3. Build confidence 4. Initiate speech and swallow therapy 1. Underlying diagnosis 2. Generalized weakness 3. Pharmaceutical intervention(s) 4. Reduced activity Oral Feeding/Swallowing Sensory responses o Gag o Shaking head New oral feeder o GI concerns o Immature oral motor skills Safety of swallow concerns o MBSS candidacy Caregiver involvement o Passive stimulation/massage o Scant tastes o Food play and exploration Baseline Skill Set Hand to mouth Oral exploration Massage and stretches Smell and taste Massage Smell Hand exploration epoao Toys and tubes Spoon Passive Participant => Orofacial massage and intraoral stretches. Peek-a-boo and sound play. Guided Participation => Facilitate hand to mouth. Tactile, thermal, and gustatory t stimulation. Encourage voicing! Overwhelmed => Monitor stress signs and facial expression Disinterest or uncertainty => Balance opportunities 16 year old Neuromuscular Medical History Large facial mass Closure of right eye Disfiguring right side mouth, ear, and nose 6 year old Facial Mass Goldenhar Respiratory OSA & hypoventilation Failure to extubate s/p biopsy Trach placed with ventilation dependency Mechanical ventilation (<1 week) Dysphagia Full oral feeds prior to admission Enteral feeds (NGT) s/p trach MBSS before and after trach placement Expremie 5 month old Genetic Disorder Communication Tracheotomy POD #1 Agitation- unable to communicate Mandarin and English Passy Muir Inc. Clinical Consultant 9

10 Pre-Tracheotomy 6 years old Clinical Bedside Assessment 9/23/13 MBSS 9/24/13 Clinical Swallow, Bedside and SLP Assessment Assessment and MBSS (s/p trach) 1/8/13 1/1/13 Discharge 1/14/13 All nutrition by mouth and 8% intelligible Speech and Communication Oral Motor Ventilation Sensation Safety Recommendations Pre-tracheostomy Thin Liquid Anterior spillage Premature spillage Mild Residue Esophageal phase unremarkable Puree Labored, delayed oral transit Reduced oral containment, premature spillage No residue Soft Chew Timely and labored Pocketing Inconsistent pooling Delayed pharyngeal swallow Mild residue Pre-tracheotomy Functional Communication Trach/Vent Education o GWN videos o Anatomy/physiology o Communication vulnerability o Voice o Speech Wear-time (hours) Initial Assessment MBSS (before tracheotomy) MBSS ( in place) MBSS readiness/timing o Wanted to eat o No alternative mode o Caregiver support Passy Muir Inc. Clinical Consultant 1

11 After 1 st Trach Change in-line Speech and Communication Oral Motor Ventilation Sensation Safety Recommendations Puree Labored, delayed oral transit Reduced oral containment, premature spillage No residue Thin Liquid Anterior spillage Reduced oral containment/ swallow timing Mild Residue Laryngeal penetration prior to swallow Retrograde movement Soft Chew Timely and labored Pocketing Delayed pharyngeal swallow Minimal residue Talk Muir- Pediatric Issue (Spring 211). Passy-Muir News, Events and Education, Passy-Muir, Inc. Pg 1-3. Reason for tracheotomy Discuss placement Changes in sensation Describe voicing Describe secretion care Define diet progression Socialization Children with Trachs: Facilitating Speech and Swallowing (December, 21). Advance Magazine for Speech-Language Pathologists and Audiologists [Vol. 2, Issue 25, Pg. 5]. Passy Muir Inc. Clinical Consultant 11

12 Abraham, SS. Clinical and fluoroscopic issues in the management of swallowing disorders in infants and young children with tracheostomies. Perspectives on Swallowing and Swallowing Disorders. 25;4: Abraham, S and Wolf, E. Swallowing Physiology of Toddlers with Long-Term Tracheostomies: A Preliminary Study. Dysphagia. 2;15: Bailey, R. Tracheostomy and Dysphagia: A complex Association. Swallowing and Swallowing Disorders (Dysphagia). 25;14: 2-7. Carron JD, Derkay CS, Strope GL, Nosonchuk JE, and Darrow DH. Pediatric Tracheotomies: Changing Indications and Outcomes. Laryngoscope. 2;11: Suiter, D.M. and Easterling, C.S. (27). Update on current treatment practice patterns for dysphagia. Topics in Geriatric Rehabilitation, 23(3): You will have 5 days from the time this courses ends to complete the evaluation, which is required to receive credit. o Look in your for a reminder link, or type this into your Internet browser s address bar: ep.passy-muir.com If you are a late registrant, the meeting code is: k2727p664 o If you are already registered, you do not need to use this code passy-muir.com/ped_candidacy Passy Muir Inc. Clinical Consultant 12