How Early in Recovery from Traumatic Brain Injury Can a Passy Muir® Valve Be Used?

Assessment of cognitive function begins very early in patients with severe traumatic brain injury, often as soon as patients begin emerging from a deep coma (1-3). The Rappaport Coma/Near Coma Scale is a standardized assessment tool that scores a patient’s responses to various stimuli across all sensory domains (1). A patient’s ability to vocalize or verbalize is a significant factor in this assessment. Responses to strong odors, visual, tactile and painful stimuli are also rated. An open tracheostomy tube does not allow airflow through the oral and nasal tract for olfaction nor does it allow the patient the ability to vocalize or verbalize a response. Therefore, for some tracheostomy patients, the total score of this scale can be altered, and therapeutic plans based on the assessment can be misguided. Use of the Passy Muir® Valve can begin as soon as 48 hours after the original placement of the tracheotomy tube. Early placement of the Passy Muir® Valve can restore airflow to the upper airway allowing increased vocalizations and awareness of sensory stimulation, thus providing more complete and meaningful assessment and ultimately hastening recovery to the highest possible function.

The presence of a tracheostomy tube with an inflated cuff has significant effects on swallowing frequency and effectiveness due to decreased laryngeal excursion, subglottic pressure and oropharyngeal sensitivity (4-6) . In a study by Dr. Seidl and colleagues (4), tracheostomy tubes were determined to decisively influence the swallowing behavior of vegetative patients. For patients with a Glasgow Coma Scale score below 8 points, the presence of the tracheotomy tube decreased the swallowing frequency. Removal of the tracheostomy tube significantly improved swallowing frequency for this group of patients.

Therefore, the authors recommend deflation of the cuff or removal of the tracheostomy tube as a therapeutic measure to improve swallow function based on “improved sensitivity under reestablished Ask the Clinical Specialist By Mike Harrell, RRT, Director of Clinical Education - Respiratory, Passy-Muir, Inc. physiologic expiration.” For patients not ready for decannulation, cuff deflation and early use of the Passy Muir® Valve can significantly contribute to the improvement of swallow safety and efficacy by not only restoring expiratory airflow physiology, but also reestablishing the benefits of subglottic pressure (5).

Bio:

Mike Harrell was formerly Director of Respiratory Care with Charlotte Regional Medical Center (CRMC) in Punta Gorda, FL for several years prior to joining the Passy Muir Educational Team as a Passy Muir Clinical Specialist in 2005. Mike also presided as president of the Florida Society of Respiratory Care in where he brought his clinical knowledge and strong advocacy for patient care together to improve respiratory care in the state of Florida.

 

1. Rappaport, M. (2005). The Disability Rating Scale and Coma/Near Coma Scales in evaluating severe head injury. Neuropsychological Rehabilitation, 15(3/4): 442-443.

2. Rappaport, M., Dogherty, A., & Kelting, D. (1992). Evaluation of coma and vegetative states. Archives of Physical Medicine and Rehabilitation, 73:628-634.

3. Talbot, L., & Whitaker, H. (1994). Brain injured persons in an altered state of consciousness: Measures and intervention strategies. Brain Injury, 8:689-699.

4. Seidl, R., et. al. (2005). The infl uence of tracheostomy tubes on the swallowing frequency in neurogenic dysphagia. Otolaryngology Head Neck Surgery, 132:484-486.

5. Eibling, D., & Gross, R. (1996). Subglottic air pressure: A key component of swallowing effi ciency. Annals of Otology Rhinology Laryngology, 105:253-258.

6. Dettelbach, M., Gross, R., Mahlmann, J., et. al. (1995). The effect of the Passy Muir® Valve on aspiration in patients with tracheostomy. Head & Neck, 17:297-302.




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