Tracheostomy patients Are we really their voice Tracheostomy

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Tracheostomy patients: Are we really their voice? Tracheostomy Discussion Group EBP Extravaganza December 18

Tracheostomy patients: Are we really their voice? Tracheostomy Discussion Group EBP Extravaganza December 18 th 2007 Amy Nelms & Beth King

Highlights 2007 l Completed 2 CATs. . . almost! l Changing practice on the

Highlights 2007 l Completed 2 CATs. . . almost! l Changing practice on the shop floor l Planning for 2008

Beginnings of clinical questions!

Beginnings of clinical questions!

Passy Muir Valves

Passy Muir Valves

Beginnings of clinical questions! l Company claims ‘ Passy Muir Valves aid in the

Beginnings of clinical questions! l 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 l In ventilated tracheostomy patients, do Passy Muir valves reduce the

Evidence: Clinical question l In ventilated tracheostomy patients, do Passy Muir valves reduce the time of mechanical ventilation?

Passy Muir Valve

Passy Muir Valve

PMV’s reduce time MV? l Frey, JA et al. 1991 Level IV evidence (below)

PMV’s reduce time MV? l Frey, JA et al. 1991 Level IV evidence (below) Clinical bottom line: Placement of PMV may assist weaning of some respiratory patients to independently GREAT…but what does tolerate CPAP mode. it mean?

Evidence: Clinical questions l Does an inflated cuff exacerbate/increase aspiration at the level of

Evidence: Clinical questions l Does an inflated cuff exacerbate/increase aspiration at the level of the vocal folds?

Inflated cuff exacerbate/increase aspiration? l Davis et al 2002 Level IV evidence l Clinical

Inflated cuff exacerbate/increase aspiration? l Davis et al 2002 Level IV evidence l 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 l ASHA conference 2007 Skoretz. S & Coyle. J –

New evidence to critique l ASHA conference 2007 Skoretz. 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 = EBP + Discussion + clinical experience + time! What are

Changes in Practice = EBP + Discussion + clinical experience + time! What are TDG doing?

Changes in Practice l Do you use blue dye in your assessment? ¡ 63%

Changes in Practice l 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 l Do you use Modified Barium Swallow (MBS) or Flexible Endoscopic

Changes in Practice l 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 l Do you use a cap or speaking valve during oral

Changes in Practice l 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 l Are you involved with ventilated patients? ¡ ¡ l 75%

Changes in Practice l Are you involved with ventilated patients? ¡ ¡ l 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?

Tracheostomy patients: Are we really their voice?

Future directions l Critical care and tracheostomy discussion & EBP group Amy. nelms@email. cs.

Future directions l Critical care and tracheostomy discussion & EBP group Amy. nelms@email. cs. nsw. gov. au Beth. king@sswahs. nsw. gov. au