Multidisciplinary quality improvement plan: Introduction of use of Passy Muir speaking valve in line with mechanical ventilation in patients with tracheostomy in ICU setting in MUH

Abstract

Background / Problem Identified: What is a tracheostomy tube? A tracheostomy tube is an artificial airway inserted through the neck into the trachea to allow a more direct access for ventilation. What is a Passy Muir speaking valve? A Passy Muir speaking valve is a one-way valve which can be placed over the end of tracheostomy hub to redirect airflow into the upper airways when the tracheostomy cuff is deflated, allowing air to flow through vocal folds and facilitating verbal communication in patients with tracheostomy. What is mechanical ventilation? Mechanical ventilation is the technique through which gas is moved towards and from the lungs through an external device connected directly to a patient. What is involved in using a speaking valve in line with mechanical ventilation? Speaking valves can be used in line with ventilators but requires deflation of tracheostomy cuff to allow leaked expiratory air to travel through the vocal folds to facilitate speech. This has implications in measuring expired tidal volume and potential loss of lung volume. Project Background: Increased numbers of patients requiring tracheostomy in last 2 years in MUH. More complex cohort of patients requiring tracheostomy with prolonged length of weaning from mechanical ventilation and protracted ICU stay. Implications of protracted ICU admission: - significant impact to patient with increased risk of ICU delirium - psychological impacts to patient including frustration, anxiety, low mood, poor engagement with rehabilitation. - increased morbidity. - impacts negatively on patient flow and bed management. - high financial cost to MUH - impacts on staff morale. Current practice in MUH: Speaking valves are utilised in patients with tracheostomy who have weaned from mechanical ventilation but have not yet been decannulated (tracheostomy tube removal). This results in a period when patients are conscious, alert and unable to communicate verbally. Practices in larger critical care facilities have progressed to use of speaking valves in line with ventilators (SVILV). Benefits of speaking valve: Benefits of speaking valve (on ventilated/non-ventilated patients) are well recognised. These include restoration of speech, improved swallow function and reduced aspiration risk. Benefits of SVILV: Benefits include primarily earlier restoration of verbal communication. In addition, it can expedite weaning from mechanical ventilation by re-establishing physiological PEEP (Positive End Expiratory Pressure) which improves arterial oxygenation, improved secretion management by enabling a stronger, more effective cough and increased end expiratory lung impedance.