If the PEEP is set to zero, most of the exhaled gas escapes out the tracheostomy tube, with little airflow through the upper airway for speech on exhalation. Providing set PEEP when the cuff is deflated can increase the amount of utterances per breath.
Lengthening the set inspiratory time iTime can also provide longer speech as well as improve patient comfort. The set rate may also be a setting that can be increased during leak speech to improve speech output. For example, if the ventilator is set at 8 breaths with an inspiratory time of 1 second, this will result in approximately 8 seconds of speaking time per minute. If the set rate is 14 breaths per minute, with an inspiratory time of 2 seconds, this will allow for 28 seconds of speaking time per minute.
Although changing the ventilator settings may improve speech output, it is important to make sure the patient is achieving adequate ventilation. The higher respiratory rates require smaller tidal volumes to achieve PaCO2. Prior to re-inflating the cuff, additional PEEP should be turned off to prevent hyperinflation. All vent settings should return to settings prior to cuff deflation. Low minute volume alarms are expected to alarm with full cuff deflation due to the escape of gas through the upper airway during cuff deflation.
Do not turn alarms off if the individual is not directly monitored by staff. Since exhaled volumes are not fully returned to the ventilator with cuff deflation some air passes through the upper airway , some alarms can be adjusted or silenced to stop unnecessary alarming.
The high and low pressure alarms should remain intact and adjusted appropriately to detect and alert caregivers to disconnects, patient fatigue, or changes in peak airway pressures. An external low pressure alarm can be put into place if the ventilator does not have a low pressure alarm setting.
Tracheal occlusion using a finger is a technique to produce voicing for patients with tracheostomy who are spontaneously breathing only. The cuff must be completely deflated or a cuffless tracheostomy tube must be used. When the cuff is inflated, air flows in and out of the tracheostomy tube and air is prevented from escaping through the upper airway by the cuff.
If the cuff is inflated and the tube is occluded, air will not be able to escape out of the tracheostomy tube since it is occluded or through the upper airway due to the cuff, and therefore the individual would be unable to breathe.
Speaking valves are one way valves that are designed to allow patients with tracheostomy the ability to produce natural voice. Some speaking valves Shiley, Shikani, Tracoe can only be used for patients who are spontaneously breathing.
The only speaking valves approved for patients on mechanical ventilation are manufactured by Passy-Muir and Montgomery. All speaking valves are considered open-position valves except the Passy-Muir Speaking Valve, which is designed as a bias-closed position valve. The bias-closed position means that the valve remains in a closed position at all times, opening only when the patient inhales. At the end of inspiration, the Passy-Muir Valve returns to the closed position, creating a column of air inside the tracheostomy tube so that secretions do not build inside the tube.
All expired air passes around the tracheostomy tube and deflated cuff if present , through the vocal folds and upper airway for speech. The Passy-Muir Valve thus provides benefits other than speech by restoring a closed respiratory system including: restores positive airway pressure, improved swallowing and may reduce aspiration, reduced secretions, facilitates weaning and decannulation.
An open position speaking valve has a diaphragm in an open position, meaning that expiratory flow is needed to close the diaphragm. As a consequence the first part of expiratory air has to travel through the tracheostomy tube and close the diaphragm of the speaking valve, leaving the rest of expiratory air to flow through the upper airway.
This can result in patients coughing secretions into the tracheostomy tube and partially blocking the open-position speaking valve. Since there is a leak with open position valves, the system is not closed and positive pressure is unable to sustain. To find out more about the differences of speaking valves and more in-depth descriptions, please go to the section- Speaking Valves.
The basic way the valves work is by opening on inspiration to allow air to move into the lungs. A one way speaking valve does not permit expired air to flow back out through the tracheostomy tube. Instead, expired air passes around the tracheostomy tube, through the vocal folds and upper airway to allow for speech.
If a cuff is present, the cuff must be completely deflated prior to placing a speaking valve. A speaking valve can be placed on a tracheostomy tube with the cuff deflated, a cuffless tracheostomy tube, a fenestrated or non-fenestrated tracheostomy tube. All valves fit on the the universal 15mm hub of the tracheostomy tube. Heated humidification is an alternative if the patient requires more humidification during prolonged use of a speaking valve. Check out Ventilation Application of Speaking Valves for information on in-line use of a speaking valve, trouble shooting and ventilator changes.
An occlusion cap is placed on the tracheostomy tube in order to allow air from inspiration to be delivered from the nose and mouth, around the tracheostomy tube and into the lungs and exhaled air to also flow up around the tracheostomy tube, through the vocal folds and out the oral cavity.
Voicing is able to occur since air flows through the vocal folds on exhalation. A cap provides more resistance to airflow on inspiration than a speaking valve, and therefore capping is typically performed after an individual has used a speaking valve comfortably. It is typically used as a final assessment to determine if the tracheostomy tube is still required, or if decannulation removal of the tube is possible.
A cap may be placed only after the cuff of the tracheostomy tube is deflated if present or on a cuffless tracheostomy tube. A cap can be placed on both a fenestrated or nonfenestrated tracheostomy tube. If the cuff is not deflated and a cap is placed, the individual will be unable to breathe. The cuff of the tracheostomy tube can cause an increase in resistance due to the obstruction from the plastic of the cuff. For this reason, c apping is typically performed with a cuffless tracheostomy tube or a Tight to Shaft TTS.
The tracheostomy tube itself may require to be downsized to a smaller tube to allow for improved breathing with the cap in place. The cap is typically placed on universal 15mm hub of the tracheostomy tube. Shiley dual cannula tracheostomy tubes have a packaged cap which requires removal of the inner cannula to place the cap. Leak speech, finger occlusion, speaking valves and capping all require the cuff of the tracheostomy tube to be completely deflated if present or cuffless.
Individuals who are unable to tolerate cuff deflation may benefit from other means of communication such as a talking tracheostomy tube. Talking tracheostomy tubes are designed to allow speech with an inflated cuff of the tracheostomy tube, for either patients on or off mechanical ventilation. After the initial tracheostomy tube is placed, a waiting period of days is recommended prior to placing a talking tracheostomy tube to allow the tract to heal. The airflow port is connected to oxygen tubing, which is connected to an external air or oxygen source.
Higher flows may dry the mucosa and cause discomfort. When the port is manually occluded, air goes through the airflow line, out the lumen above the cuff, and is directed through the vocal cords to allow speech with the cuff fully inflated. If the patient is unable to manually occlude the port, staff or trained family members can occlude the port to enable speech. Advantages of talking tracheostomy tubes are that ventilator settings do not need to be adjusted because the air for speech is separate from the ventilator.
Disadvantages are that the vocal quality is frequently a soft whisper, the patient or caregiver must occlude the line for speech, the air supply line can become occluded with secretions, discomfort and drying of the trachea from high airflow.
The patient also does not get the benefits from cuff deflation or restoring a closed system such as with a Passy-Muir Valve. Home health may not provide medical air needed to use a talking tracheostomy tube and oxygen can be used instead Pandian, V et al, The Portex Trach-Talk Blue line Tracheostomy Tubes have the additional lumen above the cuff that can be used for speech.
There is no ability to suction above the cuff or to clean the port and therefore, the lumen often clogs. Another disadvantage is that the inner cannulas are corrugated, potentially increasing the risk of mucus plugging and difficulty in clearing secretions. Pandian, V et al, When the cuff is deflated and air can pass around your trach, you should try to talk and make sounds. Speaking will be harder than before you had your trach. You may need to use more force to push the air out through your mouth.
To speak:. In order to speak, it is important that you place a clean finger over the trach to prevent air from exiting through the trach. This will help the air go out through your mouth to make voice.
If it is hard to speak with a trach in place, special devices can help you learn to create sounds. One-way valves, called speaking valves, are placed onto your tracheostomy.
Speaking valves allow air to enter through the tube and exit through your mouth and nose. This will allow you to make noises and speak more easily without needing to use your finger to block your trach each time you talk. Some patients may not be able to use these valves. The speech therapist will work with you to ensure you are a good candidate. If a speaking valve is placed on your trach, and you have trouble breathing, the valve may not be allowing enough air to pass around your trach.
The width of the tracheostomy tube may play a role. If the tube takes up too much space in your throat, there may not be enough room for the air to pass around the tube. Non-verbal communication aids can be used by staff and families, but usually require some dexterity and strength from the patient. There are also a number of techniques that can be used to promote airflow through the larynx and lead to speech.
Techniques and success will vary from patient to patient and over time, depending on the underlying problem and other medical needs.
I still don't know what to do next. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions.
Patient Education. Your Tracheostomy Tube: Learning How to Communicate Having a tracheostomy can affect your ability to talk and communicate with others. Agree on the meanings of hand gestures with friends and family members. Learn and use sign language. Use facial expressions, such as a smile.
0コメント