1. EBP & Tracheostomy: JUST DO ing IT NSW Speech Pathology EBP Network EBP Extravaganza 6 December 2006 Emma Clifton Senior Speech Pathologist Blacktown & Mt Druitt Hospitals (02) 9881 8612 Emma.Clifton@swahs.health.nsw.gov.au

2. Session Outline  Tracheostomy CATs & CAPs … what’s new?  Tracheostomy EBP & clinical practice … an emerging relationship  Tracheostomy EBP & the workplace … JUST DO ing IT

3. Tracheostomy CATs & CAPs … What’s new?  Clinical Question In non-ventilated patients with tracheostomy tubes, does occlusion with a Passy Muir Speaking Valve (PMSV) or a one-way valve reduce aspiration?  CAPs Dettelbach et al 1995 Elpern et al 2000 Gross et al 2003 Stachler et al 1996 Suiter et al 2003  Clinical Bottom Line Occlusion will not always eliminate aspiration, but it can reduce aspiration with thin fluids Modified Barium Swallow (MBS) recommended due to high silent aspiration risk  Changing TDG Clinical Practice It is not assumed that if aspiration is occurring that it will be eliminated by use of a PMSV/one-way speaking valve, but highlights that more objective assessment is frequently indicated

4. Tracheostomy CATs & CAPs … What’s new?  Clinical Question In non-ventilated patients with head/neck cancer and tracheostomy tubes, does occlusion reduce aspiration?  CAPs Leder et al 1998 Logemann et al 1998 Muz et al 1989 Stachler et al 1996  Clinical Bottom Line Occlusion can reduce aspiration with some of these patients, possibly due to changes in swallowing bio-mechanics Occlusion immediately post-surgery ineffective in reducing aspiration MBS recommended

5. Tracheostomy CATs & CAPs … What’s new?  Clinical Question In non-ventilated patients with tracheostomy tubes, does digital occlusion reduce aspiration?  CAPs Leder et al 1996 Leder et al 2001 Logemann et al 1998  Clinical Bottom Line Occlusion does not appear to not make a significant difference in eliminating aspiration MBS recommended

6. Tracheostomy CATs & CAPs … What’s new?  Clinical Question In patients with tracheostomy tubes, is the Modified Evans Blue Dye Test (MEBDT) an effective clinical indicator in determining aspiration?  CAPs O’Neill-Pirozzi et al 2003 Belafsky et al 1999 Belafsky et al 2003 Brady et al 1999 Donzelli et al 2001 Thompson-Henry & Braddock 1995 Peruzzi et al 2001  Clinical Bottom Line MEBDT may not be sensitive enough to detect trace aspiration, both  high false -ve rates - when suctioned, up to ~ 46% of the time no blue dyed material will be returned when aspiration has occurred under FEES and MBS  high false +ve rates - when suctioned, up to ~ 20% of the time return of blue dyed material does not actually represent aspiration of item tested eg. was it puree? OR was it saliva?  Note also that food/fluid/saliva can be suctioned from the supraglottis rather than aspirated material  Changing TDG Clinical Practice Clinical Pathways for RPA and Liverpool Hospital no longer state that the MEBDT is essential in the Speech Pathologist’s toolbag

7. Tracheostomy CATs & CAPs … What’s new?  Clinical Question In non-ventilated patients with tracheostomy tubes, is capping indicated for safe and effective decannulation?  CAP Thompson-Ward et al 1999  Clinical Bottom Line Down-sizing + capping and 24-48 hrs cuff deflation both effective < 3% re-cannulation with both protocols 24-48 hrs cuff deflation more efficient in facilitating earlier decannulation and reducing medical costs  Changing TDG Clinical Practice Capping not being a ‘must-do’ before safe and effective decannulation

8. Tracheostomy CATs & CAPs … What’s new?  Clinical Question Is it safe to feed patients with the tracheostomy cuff inflated?  CAPs Pinkus 1973  Clinical Bottom Line Patients with tracheostomy tubes should be fed non-orally due to aspiration risk … TDG currently re-visiting...

9. Tracheostomy EBP & clinical practice … An emerging relationship Other considerations:  The time factor … to have discussions to ‘let go’ of tools and beliefs to apply the evidence  Some clinical questions where you would expect many papers, to be out there are not  Robustness of studies in existence

10. Tracheostomy EBP & the workplace … JUST DO ing IT  Having CAPs and CATs with us when seeing patients  Utilising the tracheostomy listserve  Liaising with Librarians for automatic notification of new articles for our CIAP search  Time managing for EBP  Being aware of what exactly is out there, so as to be able to assert view from a position of strength

11. References  NSW Speech Pathology EBP Network: Tracheostomy Education for NSW Speech Pathologists