1/22/2014. Disclosure. Course Outline. Course Objectives EARLY INTERVENTION IN PERSONS WITH MINIMALLY CONSCIOUS STATE & TRACHEOSTOMY

Transcription

1 Welcome to Passy-Muir s Event Webinar: Pediatric Candidacy for Speaking Valve Use: Journeys to Success If you have not registered for this event, go to the Education Portal to complete your registration. ep.passy-muir.com 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. Call-in toll number (US) Access code: EARLY INTERVENTION IN PERSONS WITH MINIMALLY CONSCIOUS STATE & TRACHEOSTOMY 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 Leigh Anne Baker and Kelly Abry Promise Hospital of Baton Rouge If you have a technical issue, please call Passy-Muir at , or Daniel at dcarrillo@passy-muir.com Presenters Leigh Anne Baker, MS, CCC-SLP, BCS-S Speech-Language Pathologist at Promise Hospital in Baton Rouge, LA Clinical Consultant for Passy-Muir leighannebaker@hotmail.com Kelly Abry, BA, AS, CRT Respiratory Therapist at Promise Hospital, Baton Rouge, LA kellyabry@bellsouth.net Disclosure 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 biased-closed position Passy-Muir Valve and will include little to no information on other speaking valves. Financial Disclosure Both speakers receive a wage from Promise Hospital of Baton Rouge and have received a speaking fee from Passy-Muir, Inc. for this presentation. Non-Financial Disclosure - none Course Objectives State the benefits of the Passy-Muir Valve for minimally conscious patients Describe valve tolerance criteria and therapeutic interventions Discuss team member roles Course Outline Define traumatic brain injury & minimally conscious state Conventional vs. minimally-conscious patient evaluations Tracheostomy tube effects on respiration Benefits of closed-position one-way speaking valve Early placement benefits for the minimally-conscious patient Examples of standardized assessments Therapeutic interventions 1

2 Introducing Case 1: CB Five General Categories of TBI 1 Medical History Motor vehicle accident Sustained traumatic brain injury Coma Good Recovery Main Goal Passy-Muir Valve/Capping Decannulation Death Partial Recovery Stable Criteria Medically stable Trach collar Managing secretions Marked Vegetative State with Minimal Recovery Vegetative State with Modest Recovery Introducing Case 1: CB How did we conduct this assessment? Medical History Main Goal Motor vehicle accident Sustained traumatic brain injury Coma Passy-Muir Valve/Capping Decannulation Confirm Stable Criteria Oxygen saturation Secretion management Slow Cuff Deflation Suction as needed Provide verbal cues Stable Criteria Medically stable Trach collar Managing secretions Confirm Airway Patency and Place Valve Monitor vitals Utilize a team approach Where is CB now? Went to inpatient rehabilitation when discharged from Promise Decannulated Oral diet Discharged home with parents after inpatient t rehabilitation Conventional Evaluation Awake, Alert and Attempting to Communicate Medically Stable Mouthing words Making clicking sounds Utilizing written communication Not sedated, sleeping or in a comatose State Engaging in conversation Able to answer questions and follow commands Team Approach MD order received Patient in stable condition Speech Therapy and Respiratory Therapy 2

3 Minimally Conscious Patient Evaluation Minimally Conscious Patient Evaluation Awake, Alert and Attempting to Communicate Awake/alert eyes open Attempting to communicate low level of responsiveness Tolerate Cuff Deflation Medically Stable As defined by MD Not sedated or sleeping May be in a comatose state Have a Patent Airway Team Approach Respiratory Therapist present for placement RN as needed Secretion Management Introducing Case Study 2: Mr. C How did we conduct this assessment? Medical History Respiratory Status Speech Therapy Traumatic Brain Injury (Subarachnoid Hemorrhage/Subdural Hematoma) Discharge plans for hospice services Very weak; Functional maintenance program History: Intubation, failed extubation, tracheostomy tube, trach collar #8 Shiley with cuff inflated Treated 9/19/12-10/3/12 by PRN SLP My first session 10/5/12 Criteria for Placement Stable Criteria: F i O 2 < , SpO 2 >0.90 Medically Stable Awake, alternating attention from wife to SLP Placement of the valve Slow cuff deflation and management of secretions Assess for airway patency with digital occlusion Place valve and confirm patient meets stable criteria Cuff Deflation Benefits Cuff Deflation Benefits: Improves swallow 2 Decreases risk of aspiration 7 Decreases risk of silent aspiration and decreases risk of reduced laryngeal elevation 4 Improves secretion management Improves cough Shortens weaning time, reduces respiratory infections and improves swallow 8 How did we know he was tolerating Passy-Muir Valve? Cheeks expanded on exhalation and air was felt flowing through the oral cavity Engaged in imitative speech Main goals: Communication, motivation, participation in PT/OT, inpatient rehabilitation Question: Why was the cuff still inflated after so many weeks? Staff education 3

4 Striving for Success What is the end goal? Decannulation Communication Swallowing What do families have to say I firmly believe that hearing her own voice as she breathed through the valve is what pulled her out of the state she was in. Where is Mr. C now? Discharged to inpatient rehabilitation from Promise Decannulated within one week at inpatient rehabilitation Oral diet Discharged home with wife Introducing Case Study 3: Kristie Trach Tube & Vegetative Patient Medical History Respiratory Status Passy-Muir Valve Placement 39 year old Traumatic Brain Injury (Subarachnoid Hemorrhage/Subdural Hematoma) Coma Trach collar #8 Shiley tracheostomy tube Minimal secretions Deflated cuff, checked for patency Met stable criteria, tolerated cuff deflation and digital occlusion Placed valve as tolerated; always checking patency Siedl and colleagues found that the swallowing frequency increased after removal of the trach tube Patients unable to be decannulated often benefit from cuff deflation and early use of the Passy-Muir Valve 4

5 Swallowing Benefits for Minimally Conscious Patient Closed respiratory system: Improved swallow2, 3, 4 Better airway protection during the swallow 4 Secretion management 5 and reduced aspiration 6 Restored physiologic Positive end-expiratory expiratory pressure 2 Cost-effective, quicker weaning and decannulation 7 Improved quality of life! Early Valve Placement and Swallowing Burkhead (2011) 11 In the earliest phases of intervention, the SLP may simply use a Passy-Muir Valve to facilitate reflexive airway protection and swallowing function without necessarily requiring focused attention or active participation from the patient. Restoring airflow through the larynx can improve basic swallowing safety and airway clearance. FEES Video Cuff up: No spontaneous swallows Unable to visualize structures Cuff down & Passy-Muir Valve: Spontaneous swallows Visualize structures Early Valve Placement for Minimally Conscious Patient Evaluation for Passy-Muir Valve can occur hours post tracheotomy In a minimally conscious patient being considered for the valve, the patient should be: Medically stable Have a low level of responsiveness Able to tolerate cuff deflation Have a patent airway Have manageable secretions Promise Hospital Valve Placement Criteria: Trach Collar Patient 10 Stable Criteria: F i O 2 <.60 SpO 2 >.90 Cuff deflation Patent airway Stop Criteria: Heart Rate: >20 beats per minute from baseline Respiratory Rate: >35 Oxygen: F i O 2 >.60, SpO 2 <.90 Why was the valve appropriate? We felt the valve was appropriate for Kristie because we wanted to give her a chance to: restore physiologic PEEP improve her cough perform better on the Coma/Near Coma Scale 5

6 Where is Kristie now? Touro Rehabilitation Center brain injury program Decannulated within a few weeks of arriving at Touro Eating ice chips, opening and tracking with both eyes and is aware of her surroundings. Smiling, frowning and pouting Still in a near coma and hasn t had the ah-ha! moment but the doctors are hopeful that it will happen soon. Standardized Assessments 1 The Disability Rating Scale (DRS) Coma/Near-Coma Scale (C/NC) Scores are correlated with a patient s physical and mental condition Monitor progress or lack of progress over time Predict outcome even when evaluations take place many months after initial injury. 1 ( Disability Rating Scale 1 Disability Rating Scale 1 Rate patients on four categories 10 disability categories ranging from no disability to death Psychosocial Adaptability Arousability, Awareness and Responsivity Cognitive Ability for Self Care Scores 0-30 with higher scores reflecting greater disability Dependence on Others Early Placement for Minimally Conscious Patient More complete and meaningful assessment C/NC Scale categories that require upper airway use: Olfactory and Vocalization Hasten recovery to the highest possible function Improve swallowing and verbal communication Coma/Near-Coma Scale Categories 1 The C/NC Scale is used when DRS score is greater than 21 (extremely severe disability). No Coma consistently and readily responsive to at least 3 sensory stimulation tests plus consistent responsitivity to simple commands. Near Coma consistently responsive to stimulation presented to 2 sensory modalities and/or inconsistently or partially responsive to simple commands. 6

7 Coma/Near-Coma Scale Categories 1 Coma/Near-Coma Scale Stimulation 1 Moderate Coma inconsistently responsive to stimulation presented to 2 or 3 sensory modalities but not responsive to simple commands. May vocalize (in absence of tracheostomy) with moans, groans and grunts but no recognizable words. (Patient with open trach tube would not get points in this category because that t patient t is unable to vocalize) Marked Coma inconsistently responsive to stimulation presented to 1 sensory modality and not responsive to simple commands. Extreme Coma no responsitivity to any sensory stimulation. Vocalization Pain Tactile Auditory Command Responsitivity (with priming) Visual (with priming must be able to open eyes) Threat Olfactory Therapeutic Interventions Coma stimulation techniques 1 Touch - pinching Movement shoulder tap Position bed, chair Smell ammonia, perfume, spices Taste oral stimulation Management of secretions Voicing Dysphagia treatment Coma/Near-Coma Scale Introducing Case Study 4: Duston Why was the valve appropriate? Medical History Respiratory Status Passy-Muir Valve Placement 22 years old Unrestrained driver motor vehicle accident Traumatic brain injury #8 Shiley Trach Collar Minimal secretions Deflated cuff, checked for patency Met stable criteria, tolerated cuff deflation and digital occlusion Placed valve as tolerated; always checking patency Duston benefited from: Restored PEEP Improved cough/swallow reflex Improved status on the C/NC scale 7

8 C/NC Scale- Progress Made Kristie and Dustin Kristi Duston Functional goals Increased responsiveness Intervention Inpatient rehabilitation Decannulation Summary The Passy-Muir Swallowing and Speaking Valves significantly changed the course of treatment for the patients presented today. For all, it was the difference between a skilled nursing facility and inpatient rehabilitation. By successfully placing the valve and utilizing a standardized assessment to document progress, we were able to reach the patients goals. for videos THANK YOU! Receiving CEUs for this Course You will have 5 days from the time this courses ends to complete the evaluation, which is required to receive credit. 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: k2726p402 If you are already registered, you do not need to use this code References: See Online Handout 8

9 Webinar References: 1. Rappaport, M. (2005). The Disability Rating Scale and Coma/Near Coma Scales in evaluating severe head injury. Neuropsychological Rehabilitation, 15(3/4): Amathieu, R. et al. (2012). Influence of the cuff pressure on the swallowing reflex in tracheostomized intensive care unit patients. British Journal of Anaesthesia. Oct;109(4): Lichtman, S.W., Birnbaum, I.L., Sanfilippo, M.R, Pellicone, J.T., Damon, W.J., King, M.L. (1995). Effect of a tracheostomy speaking valve on secretions, arterial oxygenation, and olfaction: a quantitative evaluation. Journal of Speech and Hearing Research, June; 38(3): Ding, R. & Logeman, J. (2005). Swallow physiology in patients with trach cuff inflated or deflated: A retrospective study. Head & Neck. Sep;27(9): Dettelbach, M., Gross, R., Mahlmann, J., et. Al. (1995). The effect of the Passy-Muir valve on aspiration in patients with tracheostomy. Head & Neck, 17: Christopher, K. (2005) Tracheostomy Decannulation. Respiratory Care 50(4): Davis, D., Bears, S., Barone, J., Corvo, P., Tucker, J. (2002). Swallowing With a Tracheostomy Tube in Place: Does Cuff Inflation Matter? Journal of Intensive Care Medicine 17(3). 8. Hernandez, G., Pedrosa, A., Ortiz, R., Accuaroni, M., Cuena, R., Collado, C., Plaza, S., Arenas, P., Fernandez, R. (2013) The effects of increasing effective airway diameter on weaning from mechanical ventilation in tracheostomized patients: a randomized controlled trial. Intensive Care Med Jun; 39(6): Seidl, R. et. Al. (2005). The influence of tracheostomy tubes on the swallowing frequency in neurogenic dysphagia. Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, Orlando, FL, September 21 24, Otolaryngology Head Neck Surgery, 132: Baker, L., Pirzadah, Z., Bridges, S. (2013) Promise Hospital Speaking Valve In-Line with Ventilator Hospital Policy and Procedure. Promise Hospital of Baton Rouge, 5130 Mancuso Lane, Baton Rouge, Louisiana, Burkhead, L. (2011). Swallowing Evaluation and Ventilator Dependency Considerations and Contemporary Approaches. Perspectives on Swallowing and Swallowing Disorders (Dysphagia) March 2011,20:18-22