Trachs, Vents, and Passy-Muir Valves

Charles Williams, RRT

Hillary Beck, SLP

Types of Tubes(Most commonly seen here)

• Cuffed Shiley

• Uncuffed Shiley

• Fenesrated Trachs

• Fome Trach– Cuff inflates with negative pressure– Cuff cannot be deflated– Contraindication for PMV

Tube Parts

• Outer Cannula• Inner Cannula (disposable and non)• Cuff (cuffed trachs only)• Pilot Balloon (cuffed trachs only)• Flange: Size and type found here• Obturator (At bedside in case of need to reinsert

the trach)• Cap (AKA Button, plug, cork)• Trach ties

Tube Sizes• Dependent on size of patient, vent/support needs

and surgeon’s selection• Hard to ventilate patients will have larger tubes

and size will be decreased with weaning away from the tube

• Smaller people may have smaller tracheas and vice versa

• Average size is a 6• #8 or larger may contraindicate PMV placement

due to limited space around the tube through which to move air into the upper airway

Fenestrated Tubes

• Primarily for patients without respiratory failure

• A fenestration is a hole in the outer cannula of the tube

• The fenestration allows air to go into the trach that will be directed up through the vocal cords

Cuffed versus Uncuffed TrachsNote: Patients can sometimes voice around their trachs (if cuffless or if

the cuffed trach tube is deflated).

• Seals trachea off from vocal cords, mouth, and nose

• Allows delivery of support without resistance

• Mostly seen in vent dependent patients

• Allows airflow through vocal cords, mouth, and nose

• Mostly seen once patients are weaned off the vent and beginning the downsizing process

• Used for sleep apnea, trauma patients, etc (Patients without respiratory failure)

Trach Cuffs

• A syringe is used to inflate and deflate the cuff via the pilot balloon.

• A cuff is fully deflated when the pilot balloon is flat and no more air comes out into the syringe

• A cuff should be re-inflated using minimal leak technique (by trained clinicians only), when no more air can be heard in the upper airway. This can also be done using a manometer.

• Over-inflation of a cuff can cause tracheal trauma and/or stenosis

Mechanical Ventilation

Indications:

• Apnea or impending respiratory failure(ARDS, CHF, Status Asthmaticus, Neuromuscular disease)

• Acute Respiratory Failure:– Hypoxemic respiratory failure (Type I failure)

– Hypercapnic respiratory failure (Type II failure)

• Prophylactic Support:(Post-op, Post MI, Brain injury, etc.)

• Hyperventilation Therapy (Acute head injury)

Mechanical Ventilation

Minimum required settings:– Mode (Pressure Control, SIMV, etc.)

– Respiratory rate (# breaths per minute)

– Tidal Volume (volume delivered per breath in ml’s)

– FIO2 (inspired oxygen percentage)

Additional settings: Pressure Support, PEEP

Mechanical Ventilation

– Considerations

Pressure mode vs. Volume mode

Control mode vs. Support mode

Modes of Ventilation

Spontaneous breathing

– Sinusoidal waveform– No ventilator support

CPAPContinuous Positive Airway Pressure

PEEPPositive End Expiratory Pressure

Modes of VentilationCPAP/PEEP

5 5

– Applied during spontaneous breathing– Used to treat OSA

– Applied during ventilator breaths

Improves oxygenation by “holding” the alveoli open.

Modes of VentilationPressure Support/CPAP

– Adds a set amount of pressure to spontaneous breaths to enhance tidal volume

– All breaths are patient triggered– Used alone or with other modes such as SIMV

5

Modes of VentilationSIMV/PS

Synchronized Intermittent Mandatory Ventilation

– Weaning mode

– Allows for combined ventilator timed breaths patient triggered breaths

– Pressure support is usually added to spontaneous breaths

5

Volume Control Pressure Control

Modes of VentilationControl Modes

5 5

– All breaths are delivered at a preset volume

– All breaths are delivered at a preset amount of pressure.– Used for stiff, non-compliant lungs, i.e. ARDS

– Control modes are not used for weaning. – Breaths that are triggered by the patient are identical to ventilator breaths.

Weaning Indicators

– Resolution of acute phase of disease– FIO2 of 40% or less, Peep 5-10– Stable vital signs– Stable ABG’s (minimal acidosis)– No continuous IV sedation– Adequate cough– RSBI less than 100

Weaning Indicators RSBI (Rapid Shallow Breathing Index)

– Reliable predictor of weaning outcomes– Pt is allowed to breath without vent support for 1

minute, RR is then divided by exhaled tidal volume– Normal value is < 100– Performed on all vent patients every a.m. in

conjunction RN sedation vacation– Not performed on patients in Pressure Control mode

Ventilator WeaningControl mode Combined Support mode

Pressure ControlVolume Control

PRVC

SIMV/PS Pressure Support/CPAP

Approaches to Weaning

– Spontaneous Breathing Trials

– Decreasing levels of Pressure Support

– Decreasing SIMV rate

Approaches to Weaning

Spontaneous Breathing Trials:

The patient is removed from the vent and placed on T-Bar or left attached to the ventilator and placed on Flow-By mode.

The patient’s vitals are monitored during the trial, usually for 30-120mins

Example order: May attempt SBT on T-Bar x 30 min as tolerated, BID

Approaches to Weaning

Decreasing Levels of Pressure Support:

Pressure Support level is slowly decreased over time

When the patient has tolerated a pressure support level of 5 -7cm H2O for 2-4 hours, the patient is considered weaned

Example order: Wean pressure support by 2 every 6-8 as tolerated. Maintain RSBI < 100. Lowest pressure 5cm H2O.

*PS of 5 maintained to overcome airway resistance from breathing tube

Approaches to Weaning

Decreasing SIMV rate:

The SIMV rate is decreased by 2 breaths/min every 4-6 hours as tolerated

When the SIMV rate is down to 4, and is tolerated for 2-4 hours , the patient is then considered for extubation or changing to pressure support mode

Example order: Wean IMV rate by 2, every 4-6 hours as tolerated. Maintain RR < 30 w/ no respiratory distress

Passy Muir Valves (PMV)

• When is the patient ready?– The patient is alert and attempting to

communicate AND/OR– The patient is weaning OR

• Usually (at a minimum) to SIMV, if rate is low enough

– The patient has weaned to T-bar and would benefit from the stimulation of hearing their own phonation

PMV

• One way valve– Allows air/support in through trach tube– Prevents air/support out through trach tube– Redirects expiration through cords, mouth, nose (upper

airway)– Restores positive airway pressure for swallowing– Reduces aspiration – Reduces tracheal secretions– Allows phonation– Reduces vent weaning and decannulation time

PMV Contraindications

• Inflated cuff or fome cuff

• Unconscious/comatose patients

• Severely medically unstable patients

• Airway obstruction/stenosis

• Unmanageable secretions

• Severe aspiration risk

• Severely reduced lung compliance

PMV Placement

• Select appropriate valve (Aqua or purple)– We try to fit those who will wean with purple

• Suction as needed• Deflate cuff fully• Suction as needed• Try finger occlusion phonation trials• Place PMV with or without adaptor with a quarter,

clockwise turn– Replace tubing or collar

PMV Trial

• Closely monitor patient and vitals– O2 Sats– Respiratory rate– Effort of breathing– Heart rate– Color of patient– Signs of distress– Negative changes

Reasons for Failure with/Intolerance to PMV

• Trach tube is too large• Stenosis, granulation tissue, or vocal fold paralysis• Patient needs more training to relearn phonation

with the PMV• Thick and/or copious secretions• Inability to tolerate cuff deflation• Vent requirements/support needs too high for

PMV placment

PMV and PT/OT/Nursing• Once a patient has been cleared by SLP to wear

the valve without supervision, it should be worn during all waking hours (unless otherwise indicated)

• Ask nursing to place the PMV if you are not comfortable doing so yourself

• Benefits– Improves communication– Builds confidence– Reduces anxiety– Facilitates independence and improves locus of control

What if the PMV pops off?• The valve can come off due to hard coughing or

the weight of the T-bar• If there are visible secretions, have the patient

suctioned or the trach wiped clean before replacing the valve

• Reattach the valve using a ¼ clockwise turn. Do Not force it on.

• If you are not comfortable ask nursing/SLP to replace the valve

• Feel free to arrange cotreatments with speech anytime