tracheostomy patients: are we really their voice? tracheostomy discussion group ebp extravaganza...
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Tracheostomy patients:Are we really their voice?
Tracheostomy Discussion GroupEBP Extravaganza
December 18th 2007Amy Nelms & Beth King
Highlights 2007
Completed 2 CATs...almost!Changing practice on the shop floorPlanning for 2008
Beginnings of clinical questions!
Passy Muir Valves
Beginnings of clinical questions!
Company claims
‘ Passy Muir Valves aid in the weaning process’…It is considered negligent not to provide a valve…denying the right of communication.
What does the literature say?
Evidence: Clinical question
In ventilated tracheostomy patients, do Passy Muir valves reduce the time of mechanical ventilation?
Passy Muir Valve
PMV’s reduce time MV?
Frey, JA et al. 1991
Level IV evidence (below)
Clinical bottom line:Placement of PMV may assist weaning of some respiratory patients to independently tolerate CPAP mode.GREAT…but what does
it mean?
Evidence: Clinical questions
Does an inflated cuff exacerbate/increase aspiration at the level of the vocal folds?
Inflated cuff exacerbate/increase aspiration?
Davis et al 2002Level IV evidence
Clinical bottom line:
Cuff inflation may exacerbate/increase aspiration at the level of the vocal folds and an MBS should be pursued.
NEWS FLASH – EVIDENCE GROWS DAILY!!!!
New evidence to critique
ASHA conference 2007Skoretz. S & Coyle. J – Assessment of patients with tracheostomy: Dispelling the myths.
Ding & Logemann (2005): Inflated cuff status leads to significant increased frequency of silent aspiration and less hyolaryngeal elevation
Changes in Practice
Changes in Practice = EBP + Discussion + clinical experience + time!
What are TDG doing?
Changes in Practice
Do you use blue dye in your assessment? 63% No 37% Yes, as an adjunct to bedside swallowing
assessment This is a big change in our clinical practice,
because of a CAT completed by the TDG
Changes in Practice
Do you use Modified Barium Swallow (MBS) or Flexible Endoscopic Evaluation of Swallowing (FEES)? Varies FEES appears to be used with more acute patients,
MBS down the track Many CAP’s/CAT’s indicate MBS or FEES is necessary
for accurate assessment of a patient with a tracheostomy. There are practical issues with adopting this EBP (eg very unwell patients in ICU can’t always be transported to x-ray for an MBS).
Changes in Practice
Do you use a cap or speaking valve during oral intake? 88% Yes, usually a Passy Muir Speaking Valve Majority of the group adopting EBP based on a
CAT
Changes in Practice
Are you involved with ventilated patients? 75% Yes: for feeding, weaning and communication Earlier intervention by SP’s
Do you use a Passy Muir Speaking Valve to assist weaning from the ventilator? Of those SP’s involved with ventilated with patients, ALL
are trialling PMSV to assist with weaning Based on most recent CAP done by the TDG
Tracheostomy patients:
Are we really their voice?
Future directions
Critical care and tracheostomy discussion & EBP group