Transcript SPEAKING VALVES AND VOICE PROSTHESIS: PRESENTATION

TRACHEOESOPHAGEAL
PUNCTURE VOICE
PROSTHESIS (TEP VP) AND
SPEAKING VALVES
An introduction to the Speech Language
Pathologist’s role in working with patients
who have either a voice prosthesis or who
are appropriate for wearing a speaking
valve
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Tracheoesophageal Voice Prosthesis
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For patients that
have had
laryngectomies
Trachea is
redirected through
the neck
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Stoma to lungs
Mouth to
esophagus
Before and After Laryngectomy
Low pressure Voice Prosthesis
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A small surgical passage is created just inside the
stoma (from the back wall of the trachea into the
esophageal wall)
A voice prosthesis can then be placed into this
passage to enable tracheoesophageal speech.
Voice is produced by temporarily blocking the
stoma, either with a finger or an adjustable
tracheostoma valve, so that exhaled air from the
lungs can be directed from the trachea through
the prosthesis into the esophagus (where
vibrations are produced) and then out through the
mouth.
In-Dwelling Voice Prosthesis
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clinician-placed voice
prosthesis.
This variant is
designed for patients
who have had a
laryngectomy and are
unable or unwilling to
routinely remove,
clean, and reinsert a
patient-changeable
voice prosthesis.
TEP VP Trouble shooting
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When to call:
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The TEP VP has become dislodged.
The pt is having difficulty talking or is unable
to talk and flushing the prosthesis does not
improve voice quality.
The TEP VP is leaking either through or around
the device.
The TEP VP is fitting too long or too short
(flange is not fitting flush against the TEP).
Cont.
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Who to call?
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Call SMH TEP pager 604-571-5031 to schedule appointment
date & time with Reena/Celia.
Call SMH Ambulatory Day Care Booking (604-585-5666 ext
772445) to advise them re: TEP change appointment with
SMH Speech-Language Pathologist for patient.
If the patient is medically stable and transportation to SMH
for TEP VP management will not interfere with patient’s
hospital treatment plan or increase length of stay, please
arrange for appointment to SMH by non-ambulance
transport. If patient would require ambulance transfer to
SMH, please call Celia/Reena and they will arrange to come
to your site instead.
Ensure a Care Aide accompanies patient to appointment and
back.
Return to check on patient once back at on unit (ensure
correct diet ordered, patient tolerating everything well,
patient voicing adequately, liquids not leaking from
prosthesis, etc).
Special Considerations with TEP VP
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Do not remove the TEP VP.
Always ensure the white tab of the TEP VP
is securely taped above the patient’s
stoma.
If the TEP VP falls out, as soon as possible
ask the patient’s RN to insert a red rubber
14 or 16 French catheter ¾ of the way into
patient’s TEP and tie off the proximal end
before taping it to patient’s chest to secure
in place. This will ensure that the TEP
doesn’t begin to close (which can occur in
as little as one hour). With the catheter in
place, patient may eat and drink after 1
hour as they normally would.
Cont.
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An SLP without an Advanced Competency
in Voice Restoration - Voice Prostheses
may not place any device or instrument
beyond the patient’s stoma opening, rather
should advise/instruct nursing on TEP VP
care/cleaning/flushing per SMH SLP
direction.
Ensure that over-bed signage is in place –
Alert notice re: neck breathing. If you
don’t have copies of this sign, contact the
SLP department.
CONTACT INFORMATION
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SMH FVCC SLPs: Celia Moore and
Reena Parhar
Phone: 604-585-5666 ext 778318
Pager: 604-571-5031
On-call Mon-Fri 0800 – 1800
On-call Weekends and Holidays 1000 1800
Speaking Valves - PMV
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Main RSLP objectives:
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Improve quality of life and communication for ICU patients who fail
corking;
Work collaboratively within interdisciplinary team to identify and manage
pts with the potential to use a PMV (RTs have a large role in identification
since RSLP are not regularly on ICU);
Use of PMV is a step towards a safer swallow (p.o. intake) for those ICU
pts who fail corking;
PMV consideration for pts with vents.
Role of RSLP
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Voice (quality, pitch, volume, breath support):
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If voice poor post-PMV, risks for continued PMV use?
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WOB;
Maladaptive voicing/breathing behaviours;
Damage to vocal folds.
Communication (speech, expr/recep language, AAC)
Swallowing  PMV creates a positive closure “no leak” system which helps
to:
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Improve swallowing function;
Reduce aspiration;
Increase pharyngeal/laryngeal sensation;
Strengthen airway clearance mechanisms (e.g. cough, throat-clear) and secretion
management;
Improve olfaction.
Speaking Valves - PMV
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Procedure
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RSLP to be paged in the morning when
speaking valve trial is considered
No formal order is needed
RT and RSLP to screen for speaking
valve candidacy and if passes, educate
pt re: PMV
Trial valve
Post head of bed sign, provide
education to pt/RN re: care/cleaning
Speaking Valve (PMV) Candidacy
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IMPORTANT: All criteria below MUST be met before considering
speaking valve placement. If criteria are met, proceed to the
Interdisciplinary Speaking Valve Assessment
Criteria
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Does not tolerate corking
48 hours post tracheostomy placement
Tolerates cuff deflation
No upper airway obstruction
Richmond Agitation and Sedation Scale score (-1 to +1)
Attempts communication (via writing, mouthing words, gesturing, etc.)
Vitals signs are stable
Hemodynamically stable
Patient does NOT have thick secretions
Patient can voice when tracheostomy is occluded with the finger (cuff must
be deflated while assessing this)
Able to sit up
Fi02 < 40
Tolerate PEEP 0
For palliative patients: Consider above however, exceptions may
be made to allow for brief monitored periods of communication.
Interdisciplinary Assessment (SMH
form used as guide)
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Before PMV:
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Put PMV on, observe:
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Deflate cuff, check tolerance, suction as needed (RT);
Oral Motor and Cogn-Comm Status (RSLP).
Resps (O2 sats, RR, HR, breath sounds, cough);
Voice (quality, pitch, volume, breath support);
Speech/Language (automs, rep, convo, rdg).
Monitor for ~30mins, checking resps/voice.
After initial PMV trial:
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Monitor resps and PMV tolerance longer-term (RT).
RSLP F/U 1-2 days post- to check PMV tolerance wrt
voice and breath support:
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Setup PMV wearing schedule if needed;
Setup voice/speech therapy if needed.
Head of Bed Signage
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The Passy-Muir Valve (PMV) Information
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WEARING SCHEDULE:______________________________
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Swish PMV in mild soap and warm water. Rinse thoroughly with warm water. Allow
PMV to air dry thoroughly. Do not apply heat to dry the PMV. Do not use hot water,
peroxide, bleach, vinegar, alcohol, brushes or Q-tips to clean the PMV. Do not
autoclave.
WARNINGS:
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Deflate cuff prior to PMV placement.
Remove PMV if patient is in respiratory distress
May be worn when eating or drinking.
CARE OF VALVE:
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_______________________________________has a Passy Muir Valve (PMV)
attached to the trache tube to allow for speech. Please refer to the PMV pamphlet for
details.
DO
DO
DO
DO
NOT
NOT
NOT
NOT
use
use
use
use
when sleeping
with inflated cuff
with thick and copious secretions
during chest physiotherapy
For further information contact Respiratory Therapy at pager_____________
or Speech-Language Pathology at local ________
References
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http://www.inhealth.com/featuredpr
dvppage1new.htm
SMH Speech-Language Pathology
Department