Tracheostomy patients: Are we really their voice? Tracheostomy Discussion Group EBP Extravaganza December 18th 2007 Amy Nelms & Beth King Title – advocacy for best care Recommending the best clinical Mx?

Highlights 2007 Completed 2 CATs...almost! Changing practice on the shop floor Planning for 2008

Beginnings of clinical questions!

Passy Muir Valves

Beginnings of clinical questions! Company claims ‘ Passy Muir Valves aid in the weaning process’…It is considered negligent not to provide a valve…denying the right of communication. What does the literature say?

Evidence: Clinical question In ventilated tracheostomy patients, do Passy Muir valves reduce the time of mechanical ventilation?

Passy Muir Valve

GREAT…but what does it mean? PMV’s reduce time MV? Frey, JA et al. 1991 Level IV evidence (below) Clinical bottom line: Placement of PMV may assist weaning of some respiratory patients to independently tolerate CPAP mode. GREAT…but what does it mean? Different levels of ventilation – weaning to last ‘mechanical mode’, power to discuss with consultants, early SP involvment, start on communication and swallowing earlier! Able to use at RPA to wean pt Ideas for research

Evidence: Clinical questions Does an inflated cuff exacerbate/increase aspiration at the level of the vocal folds?

Inflated cuff exacerbate/increase aspiration? Davis et al 2002 Level IV evidence Clinical bottom line: Cuff inflation may exacerbate/increase aspiration at the level of the vocal folds and an MBS should be pursued. Pts weaned from ventilation, stable. N=12 Completed 8 mbs per pt; 4 consistencies trialled (thin, thick, puree, solids) cuff inflated and deflated Radiologist blind to cuff status NEWS FLASH – EVIDENCE GROWS DAILY!!!!

New evidence to critique ASHA conference 2007 Skoretz. S & Coyle. J – Assessment of patients with tracheostomy: Dispelling the myths. Ding & Logemann (2005): Inflated cuff status leads to significant increased frequency of silent aspiration and less hyolaryngeal elevation

Changes in Practice Changes in Practice = EBP + Discussion + clinical experience + time! What are TDG doing?

Changes in Practice Do you use blue dye in your assessment? 63% No 37% Yes, as an adjunct to bedside swallowing assessment This is a big change in our clinical practice, because of a CAT completed by the TDG

Changes in Practice Do you use Modified Barium Swallow (MBS) or Flexible Endoscopic Evaluation of Swallowing (FEES)? Varies FEES appears to be used with more acute patients, MBS down the track Many CAP’s/CAT’s indicate MBS or FEES is necessary for accurate assessment of a patient with a tracheostomy. There are practical issues with adopting this EBP (eg very unwell patients in ICU can’t always be transported to x-ray for an MBS).

Changes in Practice Do you use a cap or speaking valve during oral intake? 88% Yes, usually a Passy Muir Speaking Valve Majority of the group adopting EBP based on a CAT

Changes in Practice Are you involved with ventilated patients? 75% Yes: for feeding, weaning and communication Earlier intervention by SP’s Do you use a Passy Muir Speaking Valve to assist weaning from the ventilator? Of those SP’s involved with ventilated with patients, ALL are trialling PMSV to assist with weaning Based on most recent CAP done by the TDG

Tracheostomy patients: Are we really their voice?

Future directions Critical care and tracheostomy discussion & EBP group Amy.nelms@email.cs.nsw.gov.au Beth.king@sswahs.nsw.gov.au