Helping the Chronically Critically Ill To Communicate: Speaking Valve Pilot Trial.

Abstract

Prolonged mechanical ventilation (MV) is a hallmark of chronic critical illness (CCI) and a major source of distress for patients, who struggle to communicate even after tracheotomy. In this pilot study, we evaluated the use of a Passy−Muir (PM) speaking valve to assist communication by CCI patients during weaning from the ventilator. Methods: We studied consecutive, consenting, ventilator −dependent, tracheotomized patients admitted from adult ICUs to our Respiratory Care Unit (RCU) for protocol−based weaning. Participation required ability to respond to English−language evaluative tools, tolerance of cuff deflation, no vocal cord dysfunction, and expected RCU stay ³10 days. The PM valve was placed for up to 60 minutes, as tolerated. Before and after valve placement, research staff recorded physiologic parameters (blood pressure, pulse, respiratory rate, SaO2), and patients rated communication (none to maximum ability) and dyspnea (none to maximum shortness of breath) on 0−10 scales. Results: We enrolled 10 of 13 (77%) eligible patients (5 men; mean±SD age = 68±17.1 yrs; MV duration = 22.4±11.2 days). The 60−minute trial was completed by 5 patients without subjective or objective distress. PM valve removal was requested by 5 patients at a median of 2 minutes (range 1−30) after placement due to dyspnea. Staff noted accessory muscle use in 3 of these 5, but none had any physiologic deterioration. Mean communication ratings improved from 3.7±3.8 to 6.7± 3.2 with valve use. Patients who tolerated the 60−minute trial reported better communication and less dyspnea than those who did not (communication, 10±0 vs. 4.4±2.2; dyspnea, 4.3±2.9 vs. 6.6±3.9). Conclusions: The PM speaking valve is tolerated by some CCI patients and may facilitate communication as perceived by patients and caregivers during weaning from MV. In a larger sample, factors predicting tolerance and effectiveness of the valve in enabling communication may be identified.

Integration of Palliative Care in Chronic Critical Illness Management

“…33 Although many chronically critically ill patients may be too debilitated or delirious to make use of any of these methods, clinicians should make every effort to facilitate communication, given its importance to patients and their caregivers. When successful, as has been reported in case series, 33,34 such efforts not only address one of the most important sources of symptom distress during CCI, but may enable patients to provide self-reports of their experience to clinicians, express their emotions and thoughts to loved ones, and participate in discussions of treatment goals and preferences.…”

“…33 Some chronically critically ill patients tolerate placement of a tracheostomy speaking valve, allowing them to speak intelligibly with staff and family. 34 To supplement speech (or provide a sole avenue of communication for those who cannot vocalize through a speaking valve), patients may be offered an alphabet board or a communication board, to which either they or a caregiver (with affirmation from the patient through nodding or other signaling) can point. 33 Other options to enhance communication include touch screens and specialized key pads that can translate minimal physical pressure into synthesized speech, but the cost of such devices may limit their availability.…”