Speaking Valve Assessment in Medically Complex Patients

Educational Objectives

The goal of this program is to improve patient tolerance to speaking valves. After hearing and assimilating this program, the clinician will be better able to:

1. Identify optimal leak pressure during exhalation for a pediatric patient with tracheostomy considering a speaking valve.

Summary

Introduction: medically complex patients require tracheostomies; acquired etiologies include traumatic brain injury, spinal cord injury, airway stenosis, eg, chemical ingestion; congenital etiologies include bronchopulmonary dysplasia, airway abnormalities, and craniofacial anomalies; the presence of the tracheostomy may impact the development of verbal speech, and language skills; communication begins with crying, and cooing; vocal exploration is essential for language development, and social interaction, eg, bonding with caregivers; various other medical diagnoses may contribute to these challenges; swallowing, taste, and smell are affected; the tracheostomy tube redirects the airflow, thereby limiting the stimulation of sensory receptors responsible for smell; tracheostomy may lead to decreased stability, and loss of intrathoracic pressure affecting gross motor skills, and bowel function

Speaking valves: restore the ability to voice and communicate, enhancing social interaction and bonding; by directing airflow through the upper airway, they improve the sense of smell, and taste; speaking valves assist in secretion management by facilitating the feeling and swallowing of secretions, improving swallow safety; they contribute to overall development and quality of life, and for some patients, represent the initial step toward decannulation

Indications: speaker’s institution — for new tracheostomy patients, speaking valve consideration occurs 7 days after the first tracheostomy tube change; patients must be medically stable, have a patent upper airway, and tolerate cuff deflation; they should have minimal oral secretions, and be able to manage secretions effectively; ventilator dependent patients may require specific criteria to be met before considering a speaking valve

Team members: physician or a provider who understands the benefits of early use and can advocate for speaking valves is important; ancillary team members include respiratory therapist, occupational therapist, physical therapist, and speech pathologist; educating parents about the benefits of speaking valve is important; they can ensure that their child benefits from this therapy when they are ready; the assessment team varies depending on patient needs

Chart review and assessment: prior to assessment, a thorough chart review is performed, which includes review of medical history, airway history, and recent direct laryngoscopy and bronchoscopy findings; a key question for caregivers is whether the patient voices around the tracheostomy tube; this information, along with any history of vocal cord mobility issues, helps determine the potential for a successful speaking valve trial

Assessment: an ear, nose, and throat nurse practitioner measures the air leak around the tracheostomy tube using a manometer; the goal at speaker’s institution is a leak pressure of 20 cm of water pressure or lower during exhalation, indicating sufficient air leakage for speech; other factors must be considered; the progression of speaking valve therapy varies from patient to patient; inpatient trials start with speech therapy, and gradually involve other staff and family members after thorough education; outpatient therapy begins with short durations and gradually increases daily; the goal for many patients with speaking valves is to wear them during all waking hours under direct supervision; for some, this may lead to capping and eventual decannulation of the tracheostomy tube; specific goals vary depending on the individual patient’s needs and capabilities

Troubleshooting: consider adjusting the tracheostomy tube size; for infants, downsizing may not be an option because of their small size; in such cases, waiting for growth might be necessary; for older patients, downsizing the tube or switching to a cuff less tracheostomy tube might be beneficial; these adjustments may create a larger air leak, making the speaking valve more tolerable; if a patient coughs when a speaking valve is applied, it might be because of increased secretions in the upper airway; suctioning the patient beforehand may help reduce this; for infants, if the valve consistently triggers negative reactions, it might be necessary to pause the trial and try again later; if a patient experiences new difficulties tolerating the speaking valve, it could be because of potential airway issues, eg, granulation tissue; a team approach is important

Hospital strategies: increasing documentation, discussing speaking valves in rounds, and establishing clear inpatient orders may help raise awareness among health care providers; educating staff empowers them to advocate for patients and guide them towards speaking valve therapy; the development of guidelines for referrals and reassessments may streamline the process and reduce barriers to access

Evidence: speaker’s group (Althubaiti et al [2022]) examined 89 ventilator-dependent patients with tracheostomy who had various medical diagnoses; 85% of assessed patients successfully completed a speaking valve trial; 46% were successful on their first attempt; patients with airway obstructions were more likely to fail the assessment

Readings

Althubaiti A, Worobetz N, Inacio J, et al. Tolerance of one-way in-line speaking valve trials in ventilator dependent children. Int J Pediatr Otorhinolaryngol. 2022;157:111131. doi:10.1016/j.ijporl.2022.111131; Lian S, Teng L, Mao Z, et al. Clinical utility and future direction of speaking valve: A review. Front Surg. 2022;9:913147. Published 2022 Sep 8. doi:10.3389/fsurg.2022.913147; Martin KA, Cole TDK, Percha CM, et al. Standard versus accelerated speaking valve placement after percutaneous tracheostomy: A randomized controlled feasibility study. Ann Am Thorac Soc. 2021;18(10):1693-1701. doi:10.1513/AnnalsATS.202010-1282OC; Watters KF. Tracheostomy in infants and children. Respir Care. 2017;62(6):799-825. doi:10.4187/respcare.05366.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Ms. Stevens was recorded at the SENTAC 52nd Annual Meeting, held November 7-9, 2024, in Denver, CO, and presented by the Society for Ears Nose and Throat Advancement in Children. For information on upcoming CME activities from this presenter, please visit www.sentac.org. Audio Digest thanks the speakers and the Society for Ears Nose and Throat Advancement in Children for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

OT580303

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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