THE IMPACT OF THE SPEAKING VALVE IN THE
TREATMENT OF DYSPHAGIA
Fleurette K. Davis, SLP.D., CCC-SLP
DISCLOSURES
Dr. Fleurette K. Davis
Financial relationships:
- I am receiving a speaking fee from Passy-Muir, Inc.
Nonfinancial relationships:
- Full-time employee of Amedisys Home Health
- ASHA member
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Course Objectives
• Describe how the Passy-Muir® Valve operates
• Identify up to five clinical complications of the
tracheostomy tube.
• Identify up to five techniques to increase
vocalizations in the tracheostomized patient
• List up to five techniques to improve swallow safety
in the tracheostomized patient.
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Course Outline
• Normal and Disordered Breathing and Swallowing
• Facts, Figures, Complications of Tracheostomy
Tubes & Cuffs
• Benefits of cuff deflation and Passy-Muir Speaking
Valve use
• Team Approach to Treatment
• Speech therapy techniques
• Practical swallow therapies
• Resources, Web links, Patient Video/Testimonial
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
David Muir
INVENTOR OF THE
PASSY-MUIR® VALVE
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Normal Process of Breathing
• Inhalation and Exhalation
occurs through the
mouth and nose
• Airflow movement
enables smell and taste
• Normal oral sensation
• Speech is possible as air
passes through vocal
folds
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Normal Process of Swallowing
• Larynx elevates, moves
food and acts as a
mechanical lever
• Epiglottis flaps over
trachea to protect the
airway
• VF closes and breathing
temporarily stops
• Allows food/liquid to
bypass the airway and
enter the esophagus
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Risk Factors and Co-Morbidities
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Head and neck cancer
MD
CVA
COPD
Trauma
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Sarcopenia
TBI
ALS
SCI
CP
MS
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Endotracheal Tube
• Prior placement of the
endotracheal tube
contributes to aspiration
risk
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Bacterial colonization
and aspiration to lower
airways
Microaspiration of oralpharyngeal secretions
into the upper airway
Blunting of the glottic
reflex, and reduced
airway protection
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Tracheal edema,
ulceration and stenosis
Injury to the vocal folds
which may be transient or
permanent
Mucosal injury to the
oral pharynx and larynx
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Disordered Breathing and Swallowing
• Occurs when inability to properly ventilate
• Tracheostomy Tube and/or Mechanical
Ventilation is needed
• Absent function of the aerodigestive track
• Increased aspiration risk
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Complications of Tracheostomy
• Inflated Cuff
– Trauma
– Laryngeal anchoring
– Reduced airway closure
• No Airflow to upper airway
– reduced sensation
– reduced taste/smell
– loss of voice
• Loss of positive airway pressures
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–
–
–
peep
cough
swallow
trunk stability, postural control
• Anatomical Complications/Risk
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Aspiration Risk
• Incidence of aspiration in
patients with
tracheostomy is
estimated to be in the
range of 50-83%, and
includes “silent
aspiration”
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Effects of an Open System
• Aphonia
• Disrupted laryngeal and
pharyngeal sensation
• Loss of subglottic airflow
and pressure
• Reduced smell and taste
• Inability to expectorate
secretions
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Muscle Disuse Atrophy
• Patients lose about 2-4%
of muscle mass a day
during their illness
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Complications of the Cuff
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Cuff Status
• Clinicians often have a
misconception that the
tracheostomy cuff
prevents aspiration
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Cuffs and Aspiration
• Occurs at the level of
the vocal folds
• Aspiration around the
tracheostomy tube cuff
has been well
documented
• Cuffs do not form a
complete seal against
the tracheal wall
• Secretions pool above
the cuff
• Create a reservoir for
aspirated and pooled
secretions to colonize
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Cuffs and Aspiration Risk
• Aspiration 2.7 times greater for cuff inflated condition
• Silent Aspiration
-22.6% inflated
-7.2 deflated
• Respiratory Infections
-36% inflated
-20% deflated
• Higher Cuff Pressures
-reduced laryngeal elevation
-swallow latency is increased
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Benefits of Cuff Deflation
• Airflow is redirected
through the upper airway
• Improved swallow
physiology
• Decreased rates of
aspiration and respiratory
infections
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Benefits of PMV use
• No leak patented feature
• Restores the system to it’s
most “normal” and ideal
condition
• Improved voice/speech
• Improved
swallow/reduced
aspiration
• Restores positive airway
pressure
• Improved olfaction
• Facilitates secretion
management
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Reduced Aspiration with Passy-Muir Valve
Video Fluoroscopy without Passy-Muir®
Valve: Aspiration
Video Fluoroscopy with Passy-Muir®
Valve: No Aspiration
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Team Approach to Evaluation & Treatment
• Create a “Dream Team” that
includes key clinical staff
• Identify a champion to lead
the team
• Establish roles/responsibilities
• Complete online
educational webinars from
Passy-Muir
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Enlist the Team
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Physician
SLP
RT
Nursing
Dietary
PT
OT
Social Worker
ENT
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Best Approach to Evaluation
• Cuff Deflation
• Downsizing
• PMV assessment and
trials
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Blue Dye Test
• Sensitivity 50%
• False negatives
• Screening tool
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Instrumental Swallowing Assessment
MBSS
FEES
The only way to document aspiration/silent aspiration
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Diagnostic use of the No-Leak Valve
May help in assessment of
airway patency, laryngeal
sensitivity and function
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Conditions of Evaluation
• With and without PMV
• Cuff inflated/cuff deflated
• On and off the ventilator
• Any positional or postural considerations
• Any facilitating or compensatory strategies
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Treatment
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Therapeutic Use of No-Leak Valve
• Decreases need for
tracheal suctioning
• Improves sense of smell
and taste
• Enables participation in
swallowing evaluation
• Studies since early 1990’s
- improved swallowing
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Therapeutic Use of No-Leak Valve
• Improves sensation
• Improves subglottic air
pressure
• Normalizes cough
response
• Minimizes
aspiration/silent
aspiration
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Expiration Through Upper Airway
A no-leak valve increases
the expired volume
through the upper airway
after swallowing
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Swallowing during expiration
• Facilitates vocal cord
adduction affording a
protective mechanism
• Positive pressure keeps
glottis closed
• Expiratory flow towards
the upper airway after
swallowing expels
misdirected liquid
and/or food particles
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Lung Volumes and Subglottic Pressure
• Lung volume at the time
of the swallow could be a
variable that may
influence the motor
characteristics of
deglutition
• Swallows occurring at
lower lung volumes or at
the exhalation-inspiration
transition may result in
aspiration
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Compensatory Strategies and Techniques
• Generally same as nontrach/non vent
dependent patients
-reduce bolus size
-multiple swallows
-alternate food/liquid
-diet modification
-positioning strategies
-respiratory strengthening
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Speech Techniques
• Deflate cuff
• Finger occlude or use
PMV for voicing
• Speak or cough on
exhalation
• VF adduction /ah ah ah/
• VF abduction (in-nose
and out-mouth)
• Visual and tactile sensory
feedback to elicit voice
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Swallow Techniques and Exercises
• Use of PMV during
swallowing
• Base of tongue weakness
• Laryngeal excursion
• Vocal fold adduction
• Coordination of
swallowing and breathing
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Respiratory Muscle Strength Training
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Respiratory Muscle Strength Training
• Suprahyoid complex
activation (similar to
swallow)
• Provides resistive
strength training to
intercostals as well as
suprahyoids
• May also increase
strength of protective
cough
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Clinical Scenario #1
• Our pulmonologist directs the nurses to feed the
patient with the cuff up
• How do we educate them about the
risks/benefits to cuff deflation?
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Clinical Scenario #1-cont.
• Review the role of the cuff during
mechanical ventilation
• Request a trial of cuff deflation and noleak valve use to restore more than
normal physiology
• Perform as instrumental exam, and
document findings under both
conditions
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Short-term Goals for Scenario #1
• Utilize no-leak valve
during supervised trials
with speech pathology
for 30 mins twice daily
• Expectorate pulmonary
secretions when using
valve with reduced need
for tracheal suctioning
80% of the time
• Have functional voice,
laryngeal responses
(cough/throat clear)
when using valve 75% of
time
• Participate in bedside
bolus trials with valve,
demonstrating prompt
and efficient swallow,
and without s/s of
aspiration 80% of the time
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Clinical Scenario #2
• Our pulmonologist will not let us use the
valve with our patients during weaning
from mechanical ventilation, stating, “the
valve will increase the work of breathing”
• How do I convince him/her otherwise?
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Clinical Scenario #2-cont.
• Work of breathing is multi-factorial
• Patients may actually benefit from
“exercising” the respiratory and upper
airway musculature
• Careful monitoring of the patient by
respiratory and speech
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Short-term Goals for Scenario #2
• With cuff deflation, use
valve during t-piece
trials for 30 mins, twice a
day, with maintenance
of baseline vital signs
• Participate in respiratory
muscle training at a
threshold of 10 while
using the valve
• Participate in bedside
swallow exam while
using the valve
• Swallow ice chip x5 trials,
while wearing the valve,
without s/s of aspiration
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
PMV user testimonial
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Key Points
• Instrumental evaluation provides the most valuable
diagnostic information
• The no-leak valve is useful for both evaluation and
treatment
• If patient cannot use the valve, they may still be able to
eat orally
• Even with the valve, additional intervention may be
necessary
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Key Points
• The management of tracheostomy patients is not
a cook-book approach
• Early intervention is essential
• Swallowing evaluations are not pass/fail
• Interaction of pulmonary physiology and
deglutition is complex- it requires a multidisciplinary team
THE IMPACT OF THE SPEAKING VALVE IN THE TX OF DYSPHAGIA
Additional Educational Opportunities
• Self-study webinars available on demand
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Getting Started
Ventilator Application
Swallowing
Pediatric
Special Populations
• Live group webinars
• www.passy-muir.com
• Passy-Muir Inc. is an approved provider of
continuing education through ASHA , AARC and
California Board of Nursing Credit