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Candidacy for Passy Muir® Valve Placement in Infants and Young Children: The Airway Assessment
Suzanne Abraham, PhD, CCC-SLP
Assessment of the upper airway is a critical component for a comprehensive evaluation of any infant or very young child who has a tracheostomy. It is the analysis and interpretation of the data collected during the airway assessment that guides the decision-making regarding two critical quality of life issues for very young patients with tracheostomies and their families: (1) the route for nutritional intake and (2) candidacy for Passy Muir® Valve placement and wear time. Use of the Passy Muir Valve not only addresses neurodevelopment but also health-related quality of life.
When we examine the airway of a baby with a tracheostomy, the primary goals are to determine the baby’s baseline respiratory status and upper airway patency. To meet the goals, these two variables must be examined under two different clinical conditions: (1) the tracheostomy tube in the open mode and (2) the tracheostomy tube in the closed mode. The data collected under condition 1 and condition 2 are subsequently subjected to comparative analysis in the decision-making process of candidacy for Passy Muir Valve placement.
Airway Assessment
I. Clinical Condition 1: Tracheostomy Tube in the Open Mode
I. a. Respiratory Criterion in the Open Mode
- No evidence of respiratory distress (RD) in the open mode
- No evidence of increased work of breathing (WOB) in the open mode
- No retractions in the region of the chest wall or chest cavity: suprasternal, substernal, intercostal, subcostal, or clavicular
- No nasal flaring
- No head bobbing
- No aberrant respiratory cycling
I. b. Airway Patency Criterion in the Open Mode
- No evidence of airway obstruction in the open mode
- No noisy breathing
- No obstructive sounds associated with inspiration or expiration through the open tube
- Precaution: baseline breathing that produces an audible, dry sound can be a red flag
I. c. Secretion Criterion in the Open Mode
- No evidence of copious secretions in the open mode
- Check at the level of the oral cavity, larynx, or trachea
II. Clinical Condition 2: Tracheostomy Tube in the Closed Mode
II. a. Transtracheal Pressures (TTP)
- Used to Measure
- End expiratory pressures (in centimeters of water pressure) during quiet breathing
- An indicator of airway patency at the level of the cannula
- Equipment
- Closed system, coupling the Passy Muir® Valve to a manometer
- Patient Requirements for TTP Procedure
- Quiet breathing only
- No audible tracheal secretions
- No crying
- No vocal behaviors
- No forced expiratory airflow, e.g., a reflexive or volitional cough
- What to Monitor During TTP: Data & Analysis
- Complete 3 to 4 trials while maintaining quiet breathing
- With TTP in place, monitor the pressure that is registering on the manometer
- Each trial = 2 to 3 respiratory cycles as tolerated
- Calculate the average & range of TTPs across trials
- TTP Criterion in the Closed Mode
- Average TTP in quiet breathing should be 6 cmH2O or less
II. b. Tracheostomy Occlusion Trials
- What It Measures
- An indicator of airway patency above the cannula
- Equipment
- Gloved index finger
- How to Measure
- Finger occlude the hub of the tracheostomy tube completely and consistently by a gloved finger for the inspiratory and the expiratory phases throughout consecutive respiratory cycles
- Patient Requirements for Tracheostomy Occlusion Procedure
- Compliant for complete occlusion of the hub of the tracheostomy tube
- What to Monitor During Tracheostomy Occlusion Trials: Data & Analysis
- Tolerance for the number of respiratory cycles of consistent and complete occlusions of the tracheostomy tube
- Observe for respiratory distress signs and increased WOB across respiratory cycles in closed mode
- Listen for any obstructive sounds, which can be wet or dry
- Determine the presence or absence of airflow from mouth and nose in the closed mode
- Trach Occlusion Criteria in the Closed Mode
- Tolerance for a minimum of 10 consecutive respiratory cycles in the closed mode
- During consistent, complete occlusion of the tube:
- Confirm inspired & expired airflow from the mouth or nasal passage(s)
- Observe no evidence of respiratory distress or WOB
- Hear no audible obstructive sounds
- Observe no build-up of secretions at the oral, nasal, or laryngotracheal level
The data collected under condition 1 and condition 2 are subsequently subjected to comparative analysis in the decision-making process of candidacy for Passy Muir® Valve placement. If the infant or very young child with a tracheostomy meets respiratory, airway patency, and secretion criteria in the open mode (condition 1) and meets criteria for TTPs, trach occlusion trials, and associated respiratory, airway patency, and secretion criteria in the closed mode (condition 2), then advancing the tracheostomized baby to initial wear time trial of Passy Muir Valve placement is indicated. If the baby does not meet criteria for condition 1 or 2, then candidacy for PMV placement should continue, albeit with the addition of appropriate medical and clinical collaborative problem-solving.
This article is from the Fall 2017 Pediatric Issue of Aerodigestive Health. Click here to view Candidacy for Passy Muir® Valve Placement in Infants and Young Children: The Airway Assessment.
References:
Abraham, S. (1997). Little tikes with trachs + Passy Muir: Airway safety, secretions, swallow. [Abstract]. ASHA, 39(10), 179.
Abraham, S. and Gereau, S. (1995). Tracheostomized pediatric patients + Passy Muir: Protocol for candidacy. [Abstract] ASHA, 37(10), 7.
