Passy-Muir Valve (PMV) in-line Ventilator Protocol

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

  

PASSY-MUIR

VALVE USED WITH MECHANICAL VENTILATOR

 

 ISSUE DATE;08/09 No.:  
REVISIONDATE(S):5/11, 11/12 Page 1 of  4
 JC STANDARD/CDPH REGULATION:PC, RC, NPSG REVIEW DATE(S):  4/10, 5/11
 CROSS REFERENCES:

DESCRIPTION

The usage of the one-way speaking valve/Passy-Muir valve that attaches to the hub of the tracheostomy tube and may be used in conjunction with a ventilator.

 

SATELLITE UNITS

Same policy applies.

 

STANDARD OF CARE

One way speaking valves/Passy-Muir valves improve the quality of life of patients by allowing them to verbally communicate their wants/needs.  The patient/caregiver can expect to be educated in the proper use of the device.

 

PATIENT POPULATION

  1. All adult and geriatric inpatients who are tracheostomized and ventilator dependent
  2. Alert, responsive and able to make basic attempts at communication
  3. Able to tolerate cuff deflation without risk of gross aspiration of secretions (per Speech Pathologist)
  4. Generally medically stable; no current infections ie. Pneumonia or sepsis

 

Patient Exclusion Criteria

  1. Poor responsiveness
  2. Unstable respiratory/cardiac status
  3. History of tracheal stenosis, obstructing lesions or anatomical abnormalities, which may impact upon airway patency. May need to consult otolaryngology for these individuals.
  4. Inability to tolerate cuff deflation.  Full cuff deflation is mandatory.
  5. DO NOT USE PMV WITH BIVONA FOAM FILLED CUFF (red pilot balloon)

 

 

 

 

LEVEL OF PRACTITIONER

Respiratory Care Practitioner (RCP)

Speech Pathologist (SP)

 

EQUIPMENT

· Personal Protective Equipment

. One way speaking valve/Passy-Muir valve

. Oximeter

. Manual resuscitator – oxygen delivery device

. Syringe, 10 or 20 cc

  . Suction equipment

 

PROCEDURE

 

 

STEPS

 

RATIONALE

 

SPECIAL CONSIDERATIONS

 I.             Verify order and assess patient for indications or contraindications in the use of the One way speaking valve/Passy-Muir valve    
 II.           Request a physician order for a speech evaluation to assess oral-motor integrity and rule out upper airway obstruction (e.g. tumors, stenosis, granulation tissue).  Continue only if speech evaluation is satisfactory.  If not, inform ordering physician.   
 III         Verify patient using two identifiers. Patients rightsEnsure proper treatment correct patientUniversal ProtocolIdentification of patient per Hospital policy.
     IV.            Wash hands, don gloves, identify patient, and explain procedure to the patient, family, and RN   Wash hands.Infection ControlReduces transmission of microorganisms
       V.            Suction patient’s oral cavity and trachea to remove accumulated secretions    
     VI.            Reposition patient for optimal breathing mechanics    
  VII.            Ensure that the inner cannula is in place and adaptable to one way speaking valve/Passy-Muir valve.    
 

  1. VIII.            Place patient on pulse oximeter. 
    
    IX.            For 840: Change to NIV mode.  Once the 840 is placed in NIV mode, the “D”-sense automatically shuts off and exhaled volume alarms default off. 

1. Zero out the PEEP

2. Note the Peak Inspiratory Pressure (PIP) with the tracheal cuff up (pre-cuff PIP).

3. Slowly deflate the cuff. Additional oral and tracheal suctioning may be required once cuff is fully deflated.  For patients, with increased secretions, consider suctioning while deflating the cuff.

4. Note Peak Inspiratory Pressure (PIP) with cuff deflated (post-cuff deflation PIP). 

5. Compare pre-cuff deflation PIP and post-cuff deflation PIP.

6. Place speaking valve between suction T and flex connector.

7. Decrease Ti spont to 1.0, not available with A/C.

8. May need to increase sensitivity setting to avoid autocycling. 

9. Increase Vt incrementally to equal pre PIP. If patient is on CPAP or SIMV, pressure support may need to be adjusted to maintain adequate spontaneous tidal volume or for patient comfort. 

10. Set Low Pressure alarm to 5-10cmH20 below the peak airway pressure (at least 10cmH20)

11. Set Apnea Ventilation settings equal to above parameters.

 

 

 A leak results from cuff deflation and adjustments in ventilator setting are required to compensate. There should be a 40-50% loss of VT and significant drop in the PIP after cuff deflation. This indicates a patent airway.  If not consider the size of the tracheostomy tube, downsizing may be necessary.   

 

It is not recommended to add more than 400cc of Vt.

                X.            Once the valve is in place, evaluate the patient for at least 15 minutes by direct observation for the following:

  1. Respirations, HR, and BP.
  2.  Respiratory distress/adequate airflow/obstructed airway.
  3. Vocal quality.
  4. Oxygen saturation.
  5. Breath Sounds
  6. Overall comfort.  May need to coach and re-educate patients to breathe through their upper airway.
  7. Signs/symptoms of Hypercarbia.
  8. After trial period remove speaking valve and return ventilator settings to pre-trial settings.
 Patient safety Patients must be supervised/monitored by direct observation during trial period.Criteria to remove speaking valve:-HR change by 20bpm-RR greater than 35

-SpO2 less than 90%

-FiO2 greater than or equal to 60%

Pt reports difficulty breathing greater than 6/10

   XI.     If the patient tolerates the initial trial, a wear schedule will be developed. The RCP will be informed of the patient’s status so that valve use may be incorporated into daily respiratory care.  The MD will be alerted as to results of the evaluation and may generate an order indicating “cuff deflation as tolerated”, “PMV with direct supervision” or “PMV PRN”  
   XII.     SLP will educate patient/family how to place, remove and  clean PMV if appropriate.To Clean: Swish PMV in pure, fragrance free soap and warm water.  Rinse PMV thoroughly in warm running water and allow to air dry. Do not apply heat to dry PMV.

 

SPECIAL CONSIDERATIONS:

  • One way speaking valve/PMV may be trialed 48-72 hours after insertion of a tracheostomy tube providing tracheal secretions are minimal and a speech evaluation has been completed.
  • Valve can be used in some patients up to 18-20 hours.  DO NOT USE VALVE WHEN THE PATIENT IS SLEEPING OVERNIGHT.  Pt may use during the day when napping if there is an order.
  • Humidification and oxygen can be supplied through a mask or trach collar.
  • Take valve off before aerosolization of medication.
  • With proper training, patients and family members can apply and remove the valve independently.  All training must be documented in the EMR under education.

 

DOCUMENTATION:     

The Respiratory Care Practitioner should monitor the patient and be aware that the valve can increase the work of breathing.  Thus, document the valve being in use, the patient’s ability to talk, that the cuff is fully deflated, and a statement that the work of breathing is appropriate.

 

HAZARDS/CONSIDERATIONS:

  • Initial use of valve may be associated with some increased work of breathing, this is normal, and an attempt to work through this phase is recommended.
  • Other causes of increased work of breathing associated with valve use may include tracheal stenosis or malacia, or vocal cord dysfunction, or trach tube being too big. Additional possibility; temporary edema after trach change.  If any difficulty in breathing develops, valve should be removed.
  • Do not use HME with the valve.  HME requires exhaled gas humidity for appropriate use.
  • Large volume/thick secretions may limit successful use of valve.
  • “Honking” through valve indicates that the valve needs to be replaced if >2monts old;  if <2 months old, clean in water, rinse and thoroughly air dry.
  • DO NOT USE FOAM CUFFED TRACH TUBES (i.e. Bivona)

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