PMV ON OR OFF WITH SWALLOWING DOES IT MAKE A DIFFERENCE? 1 Tedd Masiongale, MA, CCC-SLP Lorry Lewis, MS, CCC-SLP
REASON FOR STUDY After several years of working with trach and ventilator dependent patients, we continue to hear and read that the Passy-Muir Valve (PMV) is necessary to feed a patient. In our practice, however, we have observed that a PMV is not always necessary and waiting until a patient is able to tolerate a PMV delays PO intake. We often admit patients to our facility with a trach but no PMV; swallowing was not attempted at the referring facility. This delay decreases patients nutritional status, therefore delaying their weaning ability and contributes to the patient s medical and physical decline. 2
PMV SURVEY RESULTS Because the perception exists that a PMV must be placed prior to PO trials, we conducted an informal survey of our staff in a Long Term Acute Care Hospital and two Acute Care hospitals. We asked this question: Should a PMV always be placed when a patient is eating? The results below indicate the percent of staff who answered yes : Respiratory Therapy 75% Physicians 100% Speech Language Pathologist 100% 3
ARTICLE REVIEW Most studies reviewed offered small sample sizes several with just one subject Replicability of some studies would be difficult Inconsistency in incidence of reported aspiration PMV use with known aspirators may be of benefit Evidence with cuff inflation and deflation supports use of PMV for swallowing If, as reported, the presence of a trach may inhibit swallowing, can we conclude that this may be another factor in the presence of dysphagia? 4
PMV DURING SWALLOWING According to Literature, the following are reasons the PMV should be placed during swallowing: Reduced laryngeal elevation and anterior movement Reduced airway closure Reduced positive subglottic air pressure Reduced pharyngeal/laryngeal sensation Inefficient/Ineffective Cough Reduced sensory awareness and Coordination of Respiration with swallowing Loss of sense of smell and taste 5
METHOD OF STUDY One SLP and two Radiology Physician Assistants completed all studies Two SLPs and two PAs were in 100% agreement on all observations of aspiration and penetration All studies occurred in one hospital MBS studies were completed in an upright, lateral position Digital C-Arm machine was used in all MBS studies All MBS studies were recorded on DVD Cuff was deflated for all PO presentations 6
SUBJECTS All subjects in the study: Patients that were admitted to Dekalb Medical LTAC with a trach some on the vent/some off the vent On t-collar when the MBS was performed PMV trials prior to the MBS Shiley Trach Tubes in place Trachs were in place >10 days prior to MBS Appropriate to move toward PO intake Bedside swallow evaluations were completed prior to MBS Over 18 7
PATIENT DEMOGRAPHICS Age Sex Dx Category Race BMI Days PMV prior to study Day off vent prior to study Feeding Type Trach size Did PMV make a difference? 42 M Infectious B 41.6 3 1 NGT 6 No 32 M Trauma W 13.1 3 PTA PEG 8 No 48 F Respiratory B 21.4 2 PTA NGT 8 No 60 M Infectious W 26.9 2 2 PEG 8 No 57 M Trauma W 18 3 4 NGT 8 No 46 F GI sx B 42.5 3 4 PEJ 6 No 72 F Cardiac W 23 3 4 NGT 6 No 39 M Infectious W 20.1 4 5 PEG 8 No 70 M Infectious W 21.2 1 1 NGT 8 Yes 62 M Infectious W 27.5 1 2 PEG 6 Yes 8
PATIENT DEMOGRAPHICS Ages from 32-72, with mean age of 52 and median age of 46 Gender 7 males, 3 females Race 3 African American, 7 Caucasian Diagnosis (reason for respiratory failure) 5 infectious 2 trauma 1 cardiac 1 surgical 1 respiratory disease All patients had multiple co-morbidities BMI range from 13.1-42.4, mean BMI 25.3 9
RESULTS Two out of ten patients showed that PMV improved swallowing function. Both patients displayed penetration after the swallow without the PMV, however no penetration was noted when PMV was on One patient displayed penetration only with thin liquids and one patient displayed penetration with thin and nectar thick liquids All 10 patients were started on a PO diet after the MBS 10
RECOMMENDATIONS Following review of the patients, we recommend: If patient is able to tolerate PMV patient should wear for PMV for PO intake to improve: Patient s ability to cough Sense of smell and taste Improve subglottic pressure If patient is unable to tolerate PMV, PO trials should be attempted without PMV. When patient is medically and neurologically stable, PO trials should be attempted as soon as possible. 11
PLAN Increase number of subjects to 30-50 Run statistics on data Publish findings Other potential studies: Look at aspiration in vent dependent patients Look at FEES and PMV use 12
DEKALB MEDICAL LONG TERM ACUTE CARE UNIT Located in Decatur, Georgia Licensed for 76 beds Average length of stay 30 days Average Case Mix Index 1.38 Average APACHE Score - 62 Ventilator Wean Rate 54% Discharge to Home/Acute Rehab 48% Patient satisfaction 77 th percentile nationally Infection Rates CABSI 3.1 VAP 1.0 CAUTI 1.9 13
BIBLIOGRAPHY Suiter, DM, McCullough, GH, Powell, PW. Effects of Cuff Deflation and One-Way Tracheostomy Speaking Valve Placement on Swallowing Physiology. Dysphagia 18:284-292 (2003). Bonanno, PC. Swallowing Dysfunction after Tracheosomy. Annuals of Surgery. 174:1 (1971). Elpern, EH, Borkgren, M, Bacon, M, Gerstung, C, Skrzynski, M. Effect of the Passy- Muir tracheosotomy speaking valve on pulmonary aspiration in adults. Heart and Lung: The Journal of Acute and Critical Care. 29:4:287-293 (2000). Dettelbach, MA, Gross, RD, Mahlmann, J, Eibling, DE. Effect of the Passy-Muir Valve on Aspiration in Patients with Tracheostomy. Head and Neck. July/August 1995. Dysphagia and Improving Swallow with the Passy-Muir Valve (February 2000). Passy-Muir, Inc., CEU Course. Retrieved and completed April 7, 2010 from www.passy-muir.com Tansley, Cheryl and Ieronimo (September 29, 2010). Swallowing Management of the Tracheostomized Adult Patient [Passy-Muir Special Event Webinar, Swallowing Series]. Retrieved September 28, 2010 from www.passy-muir.com 14
BIBLIOGRAPHY Leder SB, Ross DA, Burrell MI, Sasaki CT. Tracheotomy tube occlusion status and aspiration in early postsurgical head and neck cancer patients. Dysphagia. 1998;13:167 171. Carmin, Bartow (September 29, 2010). Swallowing managemnt of the Tracheostomized Adult Patient [Passy-Muir Special Event Webinar, Swallowing Series]. Retrieved September 28, 2010 from www.passy-muir.com Leder S, Tarro J, Burrell M: Effect of occlusion of a tracheostomy tube on aspiration. Dysphagia 11:254 258, 1996 Stachler, R. J., Hamlet, S. L., Choi, J. and Fleming, S. (1996), Scintigraphic Quantification of Aspiration Reduction With the Passy-Muir Valve. The Laryngoscope, 106: 231 234. doi: 10.1097/00005537-199602000-00024 15