2000 OPEN FORUM Abstracts
PEEP ENHANCED UTILIZATION OF THE PASSY-MUIR SPEAKING VALVE
Susan Regg, RRT, RCP, Drake Center, Cincinnati, Ohio, Brad Carr, MA, CCC-SLP, Drake Center, Cincinnati, Ohio, Mark Rinaldi, RRT, RCP, Drake Center Cincinnati, Ohio, Melanie Bradle, MA, CCC-SLP, Drake Center Cincinnati, Ohio
BACKGROUND: There has been limited use of the Passy-Muir Speaking Valve (PMV) by patients with ventilator dependence. This study was performed to determine if utilization of Positive End Expiratory Pressure (PEEP) with cuff deflation increased airflow through the glottis sufficiently to enhance phonation with the PMV.
METHOD: The data for this study was collected from a group of patients that were evaluated by a Respiratory and Speech Therapist to determine qualifications. The study requirements included: Patient must be awake and alert with stable vital signs, have functional oropharyngeal muscles, have a tracheostomy tube with an outer diameter not greater than 11.3 mm, have a respiratory rate less than 32 breaths per minute, an FIO2 not exceeding 50% with associated oxygen saturation not less than 90%, a PEEP of 0, Peak Inspiratory Pressures (PIP) less than 40 cmH20 pressure, and patient must be free of excessive secretions, wheezing, or stridor. Patients were then placed on the following standardized ventilator settings using the Siemens Servo 300: Volume Control mode with tidal volume adjusted to 10cc per kilogram Ideal Body Weight (if the patient was previously in a "weaning mode", the adjusted respiratory rate was determined by taking the patient's minute volume ventilation and dividing it by the adjusted tidal volume) and I:E ratio not less than 1:2. Once the patient was placed on these standardized ventilator settings, they were monitored for changes in oxygen saturation and PIPs. The patients were then asked to perform speech tasks, which included sustained phonation, loudness in decibels during sustained phonation and syllables per breath during a standardized reading (The Grandfather Passage). For the decibel reading, a baseline level near the patient's mouth was recorded, then factored into loudness level during phonation. During the same session the above protocol was repeated with incremental adjustments of PEEP levels at 5 cm H20 and 10 cm H20 pressure.
Results: The information gathered in this study revealed that standardization of ventilator settings optimized use of the Passy-Muir Valve, especially with patients utilizing weaning modes of ventilation. There were minimal changes in oxygen saturation with cuff deflation, PMV placement and with the addition of incremental levels of PEEP using both 5 cmH20 and 10 cm H20 pressure. The results indicate that there is minimal enhancement with the use of 5 cmH20 PEEP. However, phonation was significantly enhanced by the use of 10 cmH20 PEEP by an average of more than 100%, often from less than 2 seconds to over 10 seconds. Decibel levels on sustained phonation also increased significantly, often from an inaudible to an audible level, and this increased intelligibility. Syllables per breath measurements increased an average of 50%, often from a nonfunctional to a functional level. The increased syllables per breath enabled patients to participate in conversation and express wants and needs without difficulty.
CONCLUSION: The standardization of clinical pathways and utilization of 10 cmH20 PEEP appears to enhance patient tolerance and efficacy. While this study indicates that the use of PEEP may enhance, or in some cases enable, phonation and functional communication, there is a need for further investigation into methods to improve tolerance and usage of the Passy-Muir Speaking Valve.