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Tracheostomy and a Passy-Muir Valve
The Passy-Muir speaking valve is commonly used to help patients speak more normally. This one-way valve attaches to the outside opening of the tracheostomy tube and allows air to pass into the tracheostomy, but not out through it. The valve opens when the patient breathes in. When the patient breathes out, the valve closes and air flows around the tracheostomy tube, up through the vocal cords allowing sounds to be made. The patient breathes out through the mouth and nose instead of the tracheostomy.
Some patients may immediately adjust to breathing with the valve in place. Others may need to gradually increase the time the valve is worn. Breathing out with the valve (around the tracheostomy tube) is harder work than breathing out through the tracheostomy tube. Patients may need to build up the strength and ability to use the valve, but most children will be able to use the speaking valve all day after a period of adjustment.
How to use the Passy-Muir Speaking Valve:
- Suction the tracheostomy tube as needed before placing the valve. It may not be possible to use the valve if the patient has a lot of secretions or very thick secretions.
- If the tracheostomy tube has a cuff, deflate it (remove the air from it) before placing the valve. Suction the patient’s mouth and nose as needed before deflating the cuff so that secretions do not trickle into the trachea (windpipe) and bronchi.
- Attach the valve to the top of the tracheostomy tube with a twisting motion to the right (clockwise) approximately ¼ turn. This will prevent it from popping off with coughing.
- To remove the valve, twist off to the left (counter clockwise).
- Humidity can be used with the valve in place.
- Oxygen can be given with the valve in place.
- Remove the valve during aerosol treatments. If it is left on, remove it and rinse it to remove any medications that could cause the valve to stick or not work well.
Care of the Valve:
- Clean the valve daily with mild soapy water. (Ivory is suggested.)
- Rinse thoroughly with cool to warm water. Do not use hot water as it may damage the valve.
- Let the valve air dry completely before using it again.
- Do not use a brush, vinegar, peroxide, bleach or alcohol on the valve.
- Replace the valve when it becomes sticky, noisy or vibrates.
- Patients must not use the valve while sleeping.
- The valve should only be used under direct supervision of caregivers who know how it works and how to correctly use it.
- Remove the valve immediately if the patient has difficulty breathing. Suction and/or change the tracheostomy tube if needed.
- The entire manufacturer’s instruction booklet must be read prior to using the Passy-Muir Valve.
- The valve must not be used on tracheas that have the cuff inflated.
For some patients, a tracheostomy tube alone may not be enough. The tube may need to be connected to a breathing machine (ventilator) that provides a mixture of gases for life support. Patients on ventilators can speak as long as the tracheostomy tube allows flow through the larynx and vocal cords. However, the speech patterns of ventilator users present particular problems.
Because of the design of the ventilator, speech occurs during the expiratory cycle of the ventilator. Then there is a long silence until the next cycle of the ventilator. During this silence, the patient may lose his or her turn to talk as conversation partners fill the silence with their own speech. Listeners may also find it hard to follow the patient's speech because the normal rhythm of conversational give-and-take is disrupted.
Spoken phrases may have sudden bursts of loudness, reduced loudness at the end of phrases, and changes in voice quality because pressure in the trachea from the ventilator gases is not as stable as in typical speech production. Recent research has indicated that the speech of patients on ventilators may be improved by making simple adjustments to ventilator settings, particularly if no other problems exist besides breathing insufficiency. There is also at least one speaking valve available that can be used with a ventilator.
Speech-Language Pathologist and the Rehabilition Team
The multiple and interconnected decisions that need to be made for patients with tracheostomies or ventilators cannot be made by one professional. Physicians, nurses, respiratory therapists, dietitians, speech-language pathologists, and others must all work together to choose the options that best meet the patient's total health needs. The speech-language pathologist assesses the patient's cognitive and language abilities to determine communication potential, evaluates oral-motor and swallowing functions, and assesses the patient's ability to produce voice in different situations that may include using a speaking valve. Whatever mode of communication is recommended for the patient in the context of his or her other needs, the speech-language pathologist plays a central role in ensuring that patients and caretakers know how maximum communication can be achieved. Speech-language pathologists also treat problems of swallowing when indicated.
Make an extra effort to talk with the patient, even if he/she cannot vocalize. If the patient is not able to vocalize, plan for alternative methods of communication. Alternative methods include sign language, picture cards, and communication boards.
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