Clinical Assessment and Outcome
The use of tracheostomy speaking valves in mechanically ventilated patients results in improved communication and does not prolong ventilation time in cardiothoracic intensive care unit patients,☆☆,

https://doi.org/10.1016/j.jcrc.2014.12.017Get rights and content

Abstract

Purpose

The aim of this study was to assess the effect of the introduction of in-line tracheostomy speaking valves (SVs) on duration of mechanical ventilation and time to verbal communication in patients requiring tracheostomy for prolonged mechanical ventilation in a predominantly cardiothoracic intensive care unit (ICU).

Materials and methods

We performed a retrospective preobservational-postobservational study using data from the ICU clinical information system and medical record. Extracted data included demographics, diagnoses and disease severity, mechanical ventilation requirements, and details on verbal communication and oral intake.

Results

Data were collected on 129 patients. Mean age was 59 ± 16 years, with 75% male. Demographics, case mix, and median time from intubation to tracheostomy (6 days preimplementation-postimplementation) were unchanged between timepoints. A significant decrease in time from tracheostomy to establishing verbal communication was observed (18 days preimplementation and 9 days postimplementation, P < .05). There was no difference in length of mechanical ventilation (20 days preimplementation-post) or time to decannulation (14 days preimplementation-postimplementation). No adverse events were documented in relation to the introduction of in-line SVs.

Conclusions

In-line SVs were successfully implemented in mechanically ventilated tracheostomized patient population. This resulted in earlier verbal communication, no detrimental effect on ventilator weaning times, and no change in decannulation times.

Purpose

The purpose of the study was to compare tracheostomy outcomes in mechanically ventilated patients in a cardiothoracic ICU preintroduction and postintroduction of in-line SVs. It was hypothesized that in-line SVs would improve communication and swallowing specific outcomes with no increase in average time to decannulation or the number of adverse events.

Introduction

An in-line speaking valve (SV) is a 1-way valve that blocks airflow from returning to the ventilatory circuit and redirects it through to the upper airway enabling functional use of the glottis [1] in a tracheostomized patient. The valve is designed to be inserted in line with the ventilator tubing and requires the tracheostomy cuff to be deflated allowing air to bypass the tracheostomy cannula and be exhaled through the larynx. In-line SVs have the potential to improve the quality of life of tracheostomized mechanically ventilated patients by enabling verbal communication and improved swallowing. However, the impact of the valve on respiratory mechanics remains unclear. Cuff deflation alongside placement of the SV in line creates a leak in the ventilatory system. This has led to concerns that lung derecruitment could occur reducing end-expiratory lung volumes leading to alveolar collapse and atelectasis. This may be deleterious to liberating patients from the ventilator and prolong their length of stay in intensive care. There is currently no published research documenting the effect of talking with a deflated cuff (leak speech) or SV on end-expiratory lung volume and limited research documenting the effect of leak speech or SVs on weaning from mechanical ventilation.

Communication in mechanically ventilated patients is extremely restricted and in many cases is reliant on nonverbal modes (eg, mouthing, gesture, and communication boards). The inability to use verbal communication results in decreased exchange of diagnostic information between staff and patient leading to decreased adherence to recommendations and poor patient satisfaction with the health care service [2]. Patients report a preference for verbal communication [3] and have associated the inability to verbally communicate with depression, social withdrawal, and reduced motivation to participate in care [4], [5], [6], [7]. In addition, poor sleep and increased anxiety and stress levels have been associated with the mechanically ventilated patients' inability to effectively communicate [8].

There are inconsistencies reported as to the effect a tracheostomy tube (TT) has on swallowing physiology [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19]. By restoring the airflow through the upper airway, return of subglottic pressure during swallowing is facilitated [20]. Improved taste and smell have also been reported [1], [21]. However, it is unclear if this is necessary for a successful swallow. Practice in some intensive care units (ICUs) for tracheostomized patients is for them to be nil by mouth, until they are able to tolerate cuff deflation with or without an SV. This might unnecessarily delay return to activities of daily living and could also lead to increased costs with enteral feeds. Furthermore, tracheostomized patients often report extreme dryness of mouth, thirst, and discomfort, when left nil by mouth [22], [23], [24].

In-line SVs have the potential to improve the quality of life of tracheostomized mechanically ventilated patients through restoration of communication and eating/drinking capacity. However, it is important to ensure that this benefit is not lost through worsening of respiratory function. A team decision was made to trial implementation of in-line SVs for 1 year with a view to assess patient outcomes with tracheostomies and adverse events with the introduction of the in-line SVs. The aim of this study was to compare tracheostomy outcomes preimplementation and postimplementation of in-line SVs over 2 consecutive 1-year periods.

Section snippets

Sample

The sample is composed of tracheostomized patients in a cardiothoracic ICU.

Setting

The study was conducted in a university-affiliated teaching hospital with 630 acute care beds. The ICU is a 27 bed mixed medical surgical adult ICU with a predominantly cardiothoracic case mix including thoracic organ transplantation and extracorporeal life support. Neurosurgical and trauma patients are not managed at the facility. The ICU is staffed by a multidisciplinary team (medical, nursing, and allied health) with

Demographics and clinical characteristics

One hundred twenty-nine patients were included, 56 preimplementation and 73 postimplementation of in-line SVs. The demographic and clinical characteristics of both groups are summarized in Table 1. There were no statistically significant differences between the group in terms of age, sex, diagnoses on admission, or surgical intervention during ICU admission (P > .05). Acute Physiology and Chronic Health Evaluation III and SOFA (days 2, 3, and 4) scores were significantly higher (P > .05) in the

Discussion

There has been an increase in the number of tracheostomized patients [25] in ICUs due to the improved safety and training for percutaneous tracheotomies and some evidence for benefits of early tracheostomy [26]. This means that there is an increasing number of patients potentially able to verbally communicate while mechanically ventilated and awake. Despite clinical concerns that SVs may affect patient outcomes such as ventilation duration and time to decannulation, the current study found that

Conclusion

The use of in-line SVs in tracheostomized patients provides return to verbal communication sooner, accompanied by improved oral intake. However, more research is needed to determine the efficacy of SVs in the weaning process of tracheostomized mechanically ventilated ICU patients. These data demonstrate that the ability of the patient to communicate can be improved substantially, with no adverse effect on ventilation times. If our data on SVs are replicated in other centers, it would suggest

Limitations of the study

The limitations of this study include that it is an observational before and after study at a single center. The results in cardiothoracic patients in this sample may not be generalizable to other settings such as those with neurologic diagnoses. Because of small patient sample, we were unable to compare the outcomes of similar patients across the 2 groups, to get more accurate data on the potential impact of in-line SVs on time to decannulation. The fact that there was a different type of SV

Acknowledgments for research support

Prof John Fraser thanks Queensland Health Medical Research Fellowship. The funding sources had no involvement in designing of the study protocol, data collection, analysis and interpretation, or the decision in how and where to publish the findings.

The authors thank Stephanie Yerkovich for helping out with statistical analyses; SP students Kerri Latvanen and Georgia Nelson for their contributions in data collection; SP Department, Critical Care Research Group and Adult Intensive Care Unit staff

References (31)

  • J.E. Heffner

    Management of the chronically ventilated patient with a tracheostomy

    Chron Respir Dis

    (2005)
  • G. Hernandez et al.

    The effects of increasing effective airway diameter on weaning from mechanical ventilation in tracheostomized patients: a randomized controlled trial

    Intensive Care Med

    (2013)
  • D.M. Suiter et al.

    Effects of cuff deflation and one-way tracheostomy speaking valve placement on swallow physiology

    Dysphagia

    (2003)
  • D.H. Conway et al.

    The effects of tracheostomy cuff deflation during continuous positive airway pressure

    Anaesthesia

    (2004)
  • R. Ding et al.

    Swallow physiology in patients with trach cuff inflated or deflated: a retrospective study

    Head Neck

    (2005)
  • Cited by (0)

    The authors' COI: There are no conflicts of interest.

    ☆☆

    The Prince Charles Hospital Foundation for financial support.

    The authors declare that they have no conflict of interest.

    1

    Postal address: The Prince Charles Hospital, Rode Road, Chermside, QLD 4032, Australia.

    2

    Postal address: Mayne Medical School, 288 Herston Road, Herston, Brisbane, QLD 4006, Australia.

    3

    Postal address: Griffith University, 170 Kessels Road, Nathan, QLD 4111, Australia.

    View full text