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Tracheostomy patients: Are we really their voice?

Tracheostomy patients: Are we really their voice?. Tracheostomy Discussion Group EBP Extravaganza December 18 th 2007 Amy Nelms & Beth King. Highlights 2007. Completed 2 CATs...almost! Changing practice on the shop floor Planning for 2008. Beginnings of clinical questions!.

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Tracheostomy patients: Are we really their voice?

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

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

  3. Beginnings of clinical questions!

  4. Passy Muir Valves

  5. Beginnings of clinical questions! • 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?

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

  7. Passy Muir Valve

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

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

  10. NEWS FLASH – EVIDENCE GROWS DAILY!!!! Inflated cuff exacerbate/increase aspiration? • Davis et al 2002Level IV evidence • Clinical bottom line: Cuff inflation may exacerbate/increase aspiration at the level of the vocal folds and an MBS should be pursued.

  11. New evidence to critique • ASHA conference 2007Skoretz. 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

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

  13. Changes in Practice • 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

  14. Changes in Practice • 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).

  15. Changes in Practice • 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

  16. Changes in Practice • Are you involved with ventilated patients? • 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

  17. Tracheostomy patients: Are we really their voice?

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

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