Passy-Muir Speaking Valve (PMV) Protocol

Posted by | December 5, 2010 | Protocols, Trach and Vent Articles

 STANDARDS OF CARE/PRACTICE ONE WAY SPEAKING VALVE

PASSY-MUIR VALVE

 ISSUE DATE:NO.:   RCS- 605
REVISION DATE(S):Page  1  of 4
JCAHO STANDARDS/DHS REGULATION:REVIEW DATE(S):
CROSS REFERENCES:

DESCRIPTION

The Passy-Muir Valve is a specialized one way speaking vavle that attaches to the hub of the tracheostomy tube or swivel adapter.

STANDARD OF CARE

The patient or significant other can expect to receive assistance in communication through use of the one-way speaking valve safely without complication.  The patient/caregiver can expect to be educated in the proper use of the device.

PATIENT POPULATION

  1. 1. Adult and geriatric inpatient who are tracheotomized
  2. 2. Alert, responsive and able to make basic attempts at communication (e.g. mouthing, efforts at voicing around tracheostomy).
  3. 3. Ability to generate at least minimal phonation upon brief treacheal occlusion or upon cuff deflation, and/or ability to utilize the upper airway via expiratory attempts.
  4. 4. Ability to tolerate cuff deflation without risk of gross aspiration of pt’s secretions.
  5. 5. Generally stable medical status and vital signs; no current infections, i.e. pneumonia or sepsis

Patient Exclusion Criteria

1. Poor responsiveness/persistent lethargy.

2. Unstable respiratory/cardiac status, including presence of any current respiratory infections.

3. History of tracheal stenosis, obstructing lesions or anatomical abnormalities, which may impact upon airway patency. Obtain consult with otolaryngology for these individuals.

STANDARD OF PRACTICE

A physician order is required for placement of the one way speaking valve.  These services are provided jointly by Respiratory Care Practitioner, Speech Language Pathologist and Licensed Nurse.  The Speech Language Pathologist and Respiratory Care Practitioner will set up, provide safe assessment, application and instruction in the use of the device.

LEVEL OF PRACTITIONER

Physician (MD)                                           Respiratory Care Practitioner

Speech Language Pathologist (SLP)           Licensed Vocational Nurse (LVN)

Registered Nurse (RN)

EQUIPMENT

One Way speaking valve                             Suction equipment

Syringe, 10cc or 20cc                                   Personal Protective Equipment

Oximeter                    Manual Resuscitator- oxygen delivery device

PROCEDURE

STEPSRATIONALESPECIAL CONSIDERATIONS
Patient assessed for readiness by health care team.Patient SafetyAppropriateness of therapySee patient exclusion criteria
Review chartVerify physician’s order and identify therapeutic objectives 
SLP acknolwledges order and notifies patient’s RCP of order and schedule time to initiate PMV trails.To coordinate procedure. 
SLP gathers equipmentFor preparedness 
Identify patient (check wristband) and introduce yourself.Patient RightsUse of two identifiers
Explain therapy including the purpose and therapeutic goals.Patient Rights 
SLP and RCP to wash hands and put on appropriate protective gear.Infection controlStaff Safety 
RCP and SLP position patient, sitting upright in bed or in chairPatient Safety 
RCP determines need for preoxygenation or bagging  
Suction pt using established suctioning procedures.  
Allow patient to rest.Patient safetyUpon initial assessment if patient’s tracheostomy tube cuff is inflated, a blue dye test can be performed to rule out gross aspiration of oral secretions.  If the blue dye test is negative and the resident does not have copious secretions, the possibility of cuff deflation during all waking hours will be discussed with the primary care MD, consulting pulmonologist, and RCP.  An order can then be generated tomaintain cuff deflation at all ties.
Take baseline measures of patient’s oxygen saturations, heart rate, and respiratory rate.Observe patient for any signs of respiratory distressBaseline oximetry must be 93% or greater to initiate
Reinsert suction catheter into tracheostomy tube. Insert syringe into cuff valve.  
SLP or RCP will slowly deflate cuff completely while suctioning using established cuff deflation procedure.  Oral suction if needed Copious secretions especially when paired with an inability to elevate the head of he resident’s bed, may restrict an ability to tolerate prolonged cuff deflation and/or valve placement.  These individuals would require further consultation with respirator therapy and pulmonologist.PMV may not be used with inflated cu
Observe patient for signs of distress and monitor O2.  Allow rest time.Patient safetyDried, retained secretions may block airway
Insert syringe into cuff and slowly withdraw air until cuff completely deflated PMV may not be used with inflated cuff or Bivona foam filled cuff.
Briefly occlude tracheostomy tube with a gloved fingerPatient SafetyTo determine if the patient is able to produce voice and generate airflow through the upper airway.Inability to voice with tracheal occlusion. In this case, to facilitate upper airway use, downsizing of the tracheostomytube may be requested by the speech pathologist and ordered by the MD. If downsizing is not an option due to anatomical problems (i.e., tracheal stenosis), airway issues or aspiration risk, placement of a fenestrated tube (with a fenestrated inner cannula) may be recommended and attempted for short periods. If resident is still not able to phonate after downsizing and/or with the fenestrated tube, speech pathologist and ordered by the MD.
If patient is able to phonate, place the PMV #007 valve on the patient’s tracheostomy tube hub (RCP will place the valve on the initial session and SLP/RCP/Nurse will do placement on subsequent sessions). The device fits all Shiley tracheostomy tubes.  Shiley tubes with disposable inner cannula must have inner cannula in place.  The device fits Portex tracheostomy tubes with or without inner cannula in place.  The inner cannula may need to be removed if it interferes with the operation of the device.
Assess response via monitoring tools (oxygen saturations, heart rate, respiratory rate).  Assess presence of additional secretions and need for repeated suctioning.Patient Safety 
SLP encourages patient to begin using the upper airway by phonating and blowing.  SLP will provide voice evaluation and speech/breathing treatment techniques.Encourage use of upper airway 
The length of the initial trial is dependent upon patient tolerance.  The patient should be closely monitored during the initial trial by speech pathology so that the valve can be removed before significant changed from baseline status occur Drop in O2 saturation, consistent increase in pulse rate, increased work of breathing, shortness of breath, or patient complaint of discomfort would necessitate immediate removal of the valve.A slow decrease in SpO2 can be addressed by an increase in FiO2, if the resident’s clinical signs are stable and if deemed appropriate by the RCP
Valve is removed by RCP or SLP following initial evaluation.  Cuff is inflated if indicated.  
If the patient tolerates the initial trial, a wear schedule will be developed.  The RCP will be informed of the resident’s status so that valve use may be incorporated into daily respiratory care. If the patient can only tolerate the valve for a few moments, the SLP will remove the valve and the patient will not wear the device until further diagnostic assessment.
Patient with PMV in place must be routinely assessed for suction needs.To remove secretions and prevent aspirationThe valve must be removed prior to attempts at tracheal suctioning
The MD will be alerted as to results of the evaluation and will generate an order indicating “cuff deflation, PMV with direct observation” or “PMV as tolerated.”  
SLP/RCP will educate family how to place, remove and clean PMV  
Clean PMV with fragrance free soap and warm waterInfection ControlPMV should be removed during aerosol therapy since some medication may affect the valve and cause it to stick.Do Not use hot water, peroxide, bleach, vinegar, alcohol, brushes or Q-tips to clean PMV

MONITORING

The extent of patient monitoring should be determined on the basis of the stability and severity of the patient’s condition.

  • • Patient subjective response- pain, discomfort, dyspnea, restlessness
  • • Heat rate
  • • Respiratory rate, pattern, mechanics, accessory muscle use
  • • Skin color
  • • Breath sounds
  • • Pulse oximetry

EVALUATION

Expected outcome:

ASSESSMENT OF NEED

  • • Patient will be able to verbalize needs and concerns, without compromising oxygenation
  • • Patient will tolerate one-way speaking valve maintaining stable vital signs and adequate saturation
  • • Patient will have functional voice to communicate needs, desires, and emotions

Unexpected Outcomes:

Patient does not tolerate one-way speaking valve

Patient does not achieve phonation

DOCUMENTATION

The procedure will be documented in RCP and CSD Department Progress Notes.

  • • Respiratory will document on appropriate form
  • • Baseline vitals signs
  • • Vital signs during procedure
  • • Cuff pressure after procedure
  • • O2 saturation
  • • Tolerance of procedure

PATIENT /FAMILY EDUCATION

Patient and/or family will be trained how to place/remove one-way speaking valve when appropriate

SATELLITE UNIT

Same procedures and regulations apply.

REFERENCES

ASHA-Supplement #10 3/93 Volume 35, #3

www.passymuir.com

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2 Responses to “Passy-Muir Speaking Valve (PMV) Protocol”

  1. Comment made by Janice Salcedo on Jul 11th 2012 at 19:23: Reply

    Thank you for this protocol!!

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