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INTERDISCIPLINARY CLINICAL MANUAL
Policy and Procedure
TITLE:
Tracheostomy Speaking Valve
(Care of the Patient )
NUMBER:
CC 45-092
Effective Date:
July 2014
Page
1 of 9
Applies To:
Holders of Interdisciplinary Manual - ICU and IMCU; Medical /Surgical
Nursing Units
POLICY
1. While this policy specifically addresses the Passy Muir Speaking Valve (PMSV), the
principles for safe usage are transferable to other types of speaking valves (e.g.: Shiley
and Orator). Use of another type of speaking valve will be based on those individual
clinical unit’s policies and physician practices.
DEFINITIONS
Passy-Muir tracheostomy
Speaking Valve (PMSV)
A one way valve designed for patients with a tracheostomy.
This valve has a flexible diaphragm that allows for inspiration
through the tracheostomy tube and expiration through the
larynx, thus allowing for vocalization. The PMSV allows the
patient to experience more normal respiratory sensations
such as airflow in the oral and nasal cavities.
GUIDING PRINCIPLES
1. Benefits from use of the PMSV include:
1.1. Improves patient communication
1.2. Improves swallowing
1.3. May decreased risk for aspiration
1.4. Improves secretion management
1.5. Improves smell and taste
1.6. Decreases risk for respiratory infection
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not
controlled and should be checked against the electronic file version prior to use.
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1.7. Facilitates weaning
1.8. Facilitates timely decannulation
1.9. Restores Physiologic positive end expiratory pressure (PEEP)
PRACTICE GUIDELINES
1. In ICU/IMCU the speaking valve may be used in conjunction with a plan to wean the
patient from a ventilator.
1.1. A patient who has a cuffed tracheostomy tube requires that the cuff be inflated for
ventilation and deflated in order to use a speaking valve.
1.2. The weaning plan is patient specific and includes a plan to change this cuffed
tracheostomy to a smaller size and or insertion of a fenestrated tracheostomy tube.
2. Patients with a cuffed tracheostomy who are unable to care for the speaking valve on
their own need to be in an ICU/IMCU environment.
2.1. Patients who are able to provide self-care for PMSV may be on any nursing unit.
2.2. Upon transfer from the IMCU/ICU, if the patient is unable to provide self-care,
discontinue the PMSV.
3. Patients who are alert and awake may care for these valves on any floor.
4. Ensure that the patient has a patent upper airway.
5. Avoid using speaking valves with foamed cuffed tracheostomy tubes.
6. Registered Respiratory Therapists or Registered Nurses (RRTs/RNs) caring for patients
with speaking valves are to be familiar with the specific speaking valve in use.
6.1. RRT provides basic education to the RN caring for the patient.
6.2. The Clinical Nurse Educator arranges for inservices/teaching of RNs on specific
units as required.
7. Assess for the following criteria when considering using a speaking valve:
Patient Selection
Awake and alert
Medically stable
Able to tolerate cuff deflation
Able to manage secretions
Tracheostomy tube must be small enough to allow air to pass
Ventilation Criteria
Patient on less than 60% FiO2
PEEP less than 10 cmH₂O
Peak inspired pressure(PIP) less than 40 cmH₂O
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not
controlled and should be checked against the electronic file version prior to use.
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PROCEDURE
Equipment
Passy-Muir tracheostomy Speaking Valve (PMTSV) kit (purple for non ventilated
patients and aqua for ventilated patients) or Shiley or Orator
PMSV labels for health record, head of bed and cuff (found in the PMSV kit--small
purple or aqua labels are provided for cuff)
Ambu bag
Pulse oximetry
Suction equipment
Extra tracheostomy tube
Syringe
PRE-TRIAL AND GENERAL
1. Obtain a physician order for a PMSV (purple) Passy Muir Speaking Valve trial.
Note #1: Based on patient assessment - including Glasgow Coma Scale (GCS), trials
can be done around the clock if staffing is adequate to ensure patient safety.
Note #2: Types of PMSVs are distinguished by color. Capital Health only stocks purple
PMSV. However, patients who already have a valve may have a different type.
2. Do not use the speaking valve with:
2.1. Inflated tracheostomy tube cuff
2.2. during administration of aerosolized medications,
2.3. patients who have signs of respiratory distress
2.4. patient exhibiting signs of inadequate air flow
2.5. severe upper airway obstruction as it may prevent sufficient exhalation
2.6. unresponsive and/or comatose patients
2.7. thick and copious secretions
2.8. a foam cuffed tracheotomy tube
3. The PMSV may be used with a tracheostomy mask for O₂ and humidification.
4. Use with a heat moisture exchanger (HME) is ineffective.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not
controlled and should be checked against the electronic file version prior to use.
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5. If a speaking valve is used for speech initiate a speech pathology consult.
6. Clean the speaking valve between uses to minimize potential safety issues with a
malfunctioning valve. (Refer to Removal of PMSV – Procedure Statement #1)
7. The RRT/RN/Physician assesses the patient for the following:
7.1. awake and alert to begin the trial
7.2. not deemed at high risk to aspirate
7.3. able to tolerate cuff deflation
7.4. secretions will be manageable to ensure safety
Note: 100% cuff deflation is mandatory.
8. Provide the patient and family with information regarding the benefits (refer to Guiding
Principles) of the speaking valve and the procedure that will be followed
9. Place the warning stickers (included with the PMSV) at the head of the bed (HOB), on
the health record, and the tracheostomy tube pilot line.
10. Monitor (RT/RN) heart rate, respirations, blood pressure and SPO2 continuously
and document every five minutes for the first 30 minutes during the first trial.
11. Adhere to Routine Practices (Refer to IC 04-002 Routine Practices).
12. Position the patient’s HOB at least at a 45 degree angle if possible.
13. Suction orally and via tracheostomy tube as required.
TRIAL Non Ventilated Patient
1. Deflate the cuff using a 10 mL syringe and remove the syringe.
1.1. Ensure that the cuff is completely deflated is otherwise the patient will be unable to
breathe.
1.2. Suction at the same time as cuff is deflated.
2. Determine the patient’s capacity to tolerate cuff deflation.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not
controlled and should be checked against the electronic file version prior to use.
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Note: Patients may initially experience coughing due to a restoration of a closed
respiratory system which re-establishes sub-glottic pressure and normal airflow in the
oral/nasal cavities. The patient should not experience prolonged excessive coughing.
2.1. Target an O2 saturation (SpO₂) of greater than 92% unless otherwise ordered.
2.2. To ensure adequate airflow past the tracheostomy tube and into the oral cavity, the
RRT/RN occludes the airway with the index finger before placing the speaking
valve; if no signs of respiratory distress place the speaking valve on the
tracheostomy tube.
2.3. Allow patient to become accustomed to the change in breathing sensations and
observe for signs of respiratory distress. (Patients may experience anxiety with
initial placement.)
2.3.1. Monitor closely for changes in HR, RR, SpO₂, work/effort of breathing, color,
responsiveness, effectiveness of cough, and ability to clear secretions,
adequacy of airflow through the tracheostomy tube and into the oral cavity.
2.3.2. Discontinue immediately if there are any significant changes.
2.3.3. The RRT stays with the patient for at least 20 minutes the first time the
speaking valve is used.
Note: As per physician orders, the patient may have a smaller tracheostomy
tube, a cuffless tracheostomy, or a fenestrated tracheostomy tube inserted
prior to PMSV usage or after assessment with valve in place.
2.4. Assess for the patient’s ability to adjust to the PMSV and adjust usage to the
individual patient’s need.
2.5. As required, provide re-education of breathing and speaking if the patient has not
done either in a prolonged period
Trial with Ventilated Patients- To be done by RRT
1. Assess using the following criteria:
1.1 Patient on less than 60% FiO₂
1.2 PEEP of less than 10 cmH₂O
1.3 Peak Inspiratory Pressure (PIP) less than 40cmH₂O
1.4 Observe pre-cuff deflation PIP
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not
controlled and should be checked against the electronic file version prior to use.
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1.5 Observe pre-cuff deflation tidal volume (VT)
1.6 Deflate cuff- slowly
1.7 Look for 40-50% loss of exhaled tidal volume
1.8 Look for approximately 50% drop in PIP
1.9 Assess for adequate air flow
2. Place PMSV in line.
3. Assess Ventilator and make adjustments accordingly.
3.1. Consider Non Invasive Ventilation mode, if available
3.2. If PEEP is 5cm H₂O turn PEEP off. If PEEP between 5-10cm H₂O, may need to
add PEEP.
3.3. Increase VT in small increments to achieve pre-cuff deflation PIP-this compensates
for the volume lost during cuff deflation.
3.4. Use low pressure alarm as disconnect/indirect low exhaled volume VT alarm. Set it
10 cm H₂O above.
3.5. Set high pressure limit appropriately(10-15cm H₂O above PIP)
3.6. Use pressure trigger, if possible. Adjust sensitivity as appropriate.
3.7. If patient is on Pressure Support (PS), use E-Sense (PB840), inspiratory cycle off
(Servo i) or set I-time to time limit PS breath.
3.8. If patient is on Pressure Control- Set I-time
4. Allow the patient to become accustomed to the change in breathing sensations and
observe for signs of respiratory distress. (Patients may experience anxiety with initial
placement.)
4.1. Monitor closely for changes in HR, RR, SpO₂, work/effort of breathing, color,
responsiveness, effectiveness of cough, and ability to clear secretions, adequacy of
airflow through the tracheostomy tube and into the oral cavity.
5. Document on the CD2361MR Passy Muir Speaking Valve Log. Document all ventilator
changes on CD0279MR Respiratory Monitoring Record.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not
controlled and should be checked against the electronic file version prior to use.
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REMOVAL OF PMSV
1. At the end of the trial remove the valve and clean as follows:
1.1. Remove any hardened secretions by soaking in sterile water, swirling gently.
1.2. Do not use Q tips.
1.3. Do not use hot water or tap water.
1.4. Allow to air dry before placing in storage container.
1.5. Do not apply heat.
2. Place in the container designated for the valve. Ensure the container is labeled with the
patient’s encounter visit information label.
3. If the valve is used as an adjunct to weaning, inflate the cuff and remove signage.
4. Reassess vital signs
5. Document vital signs and progress/problems on the log record.
SUBSEQUENT TRIALS - TREATMENT PLAN
1. Perform subsequent trials as determined by RRT/RN and physician and as tolerated by
the patient.
1.1. Use the log sheet to track progress.
Note: Time of usage may increase depending on patient tolerance. With success, the
RRT/RN can emphasize increasing length of time valve is in place
2. Monitor BP, pulse, respiratory rate and O2 saturation at least q1h and prn or with
any deterioration of patient condition while the patient is in an acute care setting.
3. With continued usage the RN takes primary responsibility for placing the valve and
monitoring the patient status.
4. Consider a speech language pathologist consult if the patient has difficulty with
phonation once easy and relaxed breathing is established.
5. Keep the cleaned valve in its container at the bedside. (Refer to Removal of PMSV–
Procedure # 1 for cleaning instructions)
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not
controlled and should be checked against the electronic file version prior to use.
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6. Each time a valve is reused, check for proper functioning. (Each valve is guaranteed to
last a minimum of two months.)
PATIENT /FAMILY EDUCATION
1
RNs/RRTs/Physicians/Speech Therapists continually assess the need for on-going
education and provide as necessary.
PATIENTS ADMITTED FROM HOME WITH A PMSV
1. If a patient is admitted from home with a PMSV:
1.1. Check for a physician’s order indicating that the patient may continue to use the
PMSV.
Note: The patient may have a fenestrated tracheostomy, or a very small
tracheostomy tube.
1.2. Ensure that the patient admitted to a general inpatient unit is able to provide selfcare for the PMSV.
1.3. If unfamiliar with PSMVs, the RNs on the unit seek education as to what the valve is
and why it is being used. (Refer to Policy Statement # 4)
DOCUMENTATION
1. Document the following on the nurses notes/process notes/RRT documentation record
(as per the specific unit’s protocol):
1.1. Vital signs (BP, pulse, respiratory rate and O2 saturation)
1.2. Patient’s tolerance using the PMSV
1.3. Length of time PMSV is used
1.4. Stability of the patient
2. Maintain a log sheet of the PMSV usage to track trends, time, stability of patient, and to
monitor patient assessments and progress
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not
controlled and should be checked against the electronic file version prior to use.
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REFERENCES
Passy-Muir Tracheostomy & Ventilator swallowing and speaking valves instruction booklet,
Hallmark International Management Consultants, Tadcaster, England, 2012.
Fitsimones, L., (2003) Tracheostomy and ventilator speaking valves, Vital Signs. April ,6-8.
Tracheostomy and a Passy-muir Valve retrieved August 2, 2010 from
http://www.hopkinsmedicine.org/tracheostomy/living/passey-muir_valve.html
www.passy-muir.com
RELATED DOCUMENTS
Policies
CC 45-090
IC 04-002
Care and Management of Patients with Tracheostomy
Routine Practices
Forms
CD2361MR Passy Muir Speaking Valve Log
CD0279MR Respiratory Monitoring Record
Appendices
Appendix A - One Pager on Passy Muir Speaking Valve Usage
Other
Bed signage
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not
controlled and should be checked against the electronic file version prior to use.
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Appendix A
ONE PAGER ON PASSY MUIR SPEAKING VALVE USAGE (for the Health Record)
This is a quick reference only for non ventilated patients and does not replace review of the policy
and procedure CC 45-092)
All tracheostomy speaking valve orders must be written by a physician.
Warning stickers are placed at the patient head of bed (HOB), on the health record and the
tracheostomy tube balloon
The following are guidelines for safe care.
1. RRT, RN and physician to complete an assessment of patients’ medical stability, awareness
and readiness for capping using this valve. The patient secretions will be manageable
2. Position the patient for maximum tracheal airway exchange at least HOB 45 degrees.
3. Baseline assessment of vital signs HR, BP, RR, skin color, work of breathing O2
concentration must be documented. Patient must be an O2 sat monitor and have HR, RR
and BP checked frequently during the initial assessment stage.
4. Use Passy Muir Speaking Valve Log (CD 2361 MR) to record the initial trials.
5. Target O2 sat of greater than 92% unless otherwise ordered.
6. Suction orally prior to starting.
7. Deflate cuff if cuffed tube is in place. Suction at same time as cuff is deflated. Patient cannot
breathe unless cuff is deflated entirely.
8. First Time - RRT occludes airway with index finger before placing cap to ensure adequate
airflow past the tracheostomy tube and into the oral cavity. If no signs of respiratory distress
then place the speaking valve on the tracheostomy tube.
9. Allow patient to become accustomed to the change in breathing sensations and observe the
patient for signs of respiratory distress. Monitor closely for changes in HR, BP,RR, Oxygen
saturation, work/effort of breathing, effectiveness of cough, and ability to clear secretions,
adequacy of airflow thru the tracheostomy and into the oral cavity.
Discontinue immediately if there are any significant changes
10. Start therapy as per treatment plan. The first time document RR, HR, O2 sats and BP every 5
minutes for the first 30 minutes. For subsequent trials document q1 and PRN or with any
deterioration in pt status.
11. The first time the speaking valve is used the RRT stays with the patient for at least 20
minutes.
12. At the end of the trial remove the valve and rinse with sterile water and replace in the
container specifically for the valve.
13. Reassess vital signs
14. Document vital signs and progress/problems
15. The RN may take primary responsibility for placement of the valve with subsequent trials.
The speaking valve must not be used, during administration of aerosolized medications, if the patient
has signs of respiratory distress, or the patient exhibits signs of inadequate air flow.
It may be used with a tracheostomy mask for O2 and humidification
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not
controlled and should be checked against the electronic file version prior to use.