EBP Tracheostomy JUST DO ing IT NSW Speech

EBP & Tracheostomy: JUST DO ing IT NSW Speech Pathology EBP Network EBP Extravaganza 6 December 2006 Emma Clifton Senior Speech Pathologist Blacktown & Mt Druitt Hospitals (02) 9881 8612 Emma. Clifton@swahs. health. nsw. gov. au

Session Outline p Tracheostomy CATs & CAPs … what’s new? p Tracheostomy EBP & clinical practice … an emerging relationship p Tracheostomy EBP & the workplace … JUST DO ing IT

Tracheostomy CATs & CAPs … What’s new? p Clinical Question n In non-ventilated patients with tracheostomy tubes, does occlusion with a Passy Muir Speaking Valve (PMSV) or a one-way valve reduce aspiration? p CAPs n Dettelbach et al 1995 n Elpern et al 2000 n Gross et al 2003 n Stachler et al 1996 n Suiter et al 2003 p Clinical Bottom Line n Occlusion will not always eliminate aspiration, but it can reduce aspiration with thin fluids n Modified Barium Swallow (MBS) recommended due to high silent aspiration risk p Changing TDG Clinical Practice n It is not assumed that if aspiration is occurring that it will be eliminated by use of a PMSV/one-way speaking valve, but highlights that more objective assessment is frequently indicated

Tracheostomy CATs & CAPs … What’s new? p Clinical Question n In non-ventilated patients with head/neck cancer and tracheostomy tubes, does occlusion reduce aspiration? p CAPs n Leder et al 1998 n Logemann et al 1998 n Muz et al 1989 n Stachler et al 1996 p Clinical Bottom Line n Occlusion can reduce aspiration with some of these patients, possibly due to changes in swallowing bio-mechanics n Occlusion immediately post-surgery ineffective in reducing aspiration n MBS recommended

Tracheostomy CATs & CAPs … What’s new? p Clinical Question n In non-ventilated patients with tracheostomy tubes, does digital occlusion reduce aspiration? p CAPs n Leder et al 1996 n Leder et al 2001 n Logemann et al 1998 p Clinical Bottom Line n Occlusion does not appear to not make a significant difference in eliminating aspiration n MBS recommended

Tracheostomy CATs & CAPs … What’s new? p Clinical Question n In patients with tracheostomy tubes, is the Modified Evans Blue Dye Test (MEBDT) an effective clinical indicator in determining aspiration? p CAPs n O’Neill-Pirozzi et al 2003 n Belafsky et al 1999 n Belafsky et al 2003 n Brady et al 1999 n Donzelli et al 2001 n Thompson-Henry & Braddock 1995 n Peruzzi et al 2001 p Clinical Bottom Line n MEBDT may not be sensitive enough to detect trace aspiration, both p p high false -ve rates - when suctioned, up to ~ 46% of the time no blue dyed material will be returned when aspiration has occurred under FEES and MBS high false +ve rates - when suctioned, up to ~ 20% of the time return of blue dyed material does not actually represent aspiration of item tested eg. was it puree? OR was it saliva? Note also that food/fluid/saliva can be suctioned from the supraglottis rather than aspirated material Changing TDG Clinical Practice n Clinical Pathways for RPA and Liverpool Hospital no longer state that the MEBDT is essential in the Speech Pathologist’s toolbag

Tracheostomy CATs & CAPs … What’s new? p Clinical Question n In non-ventilated patients with tracheostomy tubes, is capping indicated for safe and effective decannulation? p CAP n Thompson-Ward et al 1999 p Clinical Bottom Line n Down-sizing + capping and 24 -48 hrs cuff deflation both effective n < 3% re-cannulation with both protocols n 24 -48 hrs cuff deflation more efficient in facilitating earlier decannulation and reducing medical costs p Changing TDG Clinical Practice n Capping not being a ‘must-do’ before safe and effective decannulation

Tracheostomy CATs & CAPs … What’s new? p Clinical Question n Is it safe to feed patients with the tracheostomy cuff inflated? p CAPs n Pinkus 1973 p Clinical Bottom Line n Patients with tracheostomy tubes should be fed non-orally due to aspiration risk … TDG currently re-visiting. . .

Tracheostomy EBP & clinical practice … An emerging relationship Other considerations: p The time factor … n to have discussions n to ‘let go’ of tools and beliefs n to apply the evidence p Some clinical questions where you would expect many papers, to be out there are not p Robustness of studies in existence

Tracheostomy EBP & the workplace … JUST DO ing IT p Having CAPs and CATs with us when seeing patients p Utilising the tracheostomy listserve p Liaising with Librarians for automatic notification of new articles for our CIAP search p Time managing for EBP p Being aware of what exactly is out there, so as to be able to assert view from a position of strength

References p NSW Speech Pathology EBP Network: Tracheostomy Education for NSW Speech Pathologists