Anna-Liisa Sutt

The use of tracheostomy speaking valves in mechanically ventilated patients results in improved communication and does not prolong ventilation time in cardiothoracic intensive care unit patients

PURPOSE The aim of this study was to assess the effect of the introduction of in-line tracheostomy speaking valves (SVs) on duration of mechanical ventilation and time to verbal communication in patients requiring tracheostomy for prolonged mechanical ventilation in a predominantly cardiothoracic intensive care unit (ICU). MATERIALS AND METHODS We performed a retrospective preobservational-postobservational study using data from the ICU clinical information system and medical record. Extracted data included demographics, diagnoses and disease severity, mechanical ventilation requirements, and details on verbal communication and oral intake. RESULTS Data were collected on 129 patients. Mean age was 59 ± 16 years, with 75% male. Demographics, case mix, and median time from intubation to tracheostomy (6 days preimplementation-postimplementation) were unchanged between timepoints. A significant decrease in time from tracheostomy to establishing verbal communication was observed (18 days preimplementation and 9 days postimplementation, P <.05). There was no difference in length of mechanical ventilation (20 days preimplementation-post) or time to decannulation (14 days preimplementation-postimplementation). No adverse events were documented in relation to the introduction of in-line SVs. CONCLUSIONS In-line SVs were successfully implemented in mechanically ventilated tracheostomized patient population. This resulted in earlier verbal communication, no detrimental effect on ventilator weaning times, and no change in decannulation times. PURPOSE The purpose of the study was to compare tracheostomy outcomes in mechanically ventilated patients in a cardiothoracic ICU preintroduction and postintroduction of in-line SVs. It was hypothesized that in-line SVs would improve communication and swallowing specific outcomes with no increase in average time to decannulation or the number of adverse events.

Speaking valves in tracheostomised ICU patients weaning off mechanical ventilation - do they facilitate lung recruitment?

BackgroundPatients who require positive pressure ventilation through a tracheostomy are unable to phonate due to the inflated tracheostomy cuff. Whilst a speaking valve (SV) can be used on a tracheostomy tube, its use in ventilated ICU patients has been inhibited by concerns regarding potential deleterious effects to recovering lungs. The objective of this study was to assess end expiratory lung impedance (EELI) and standard bedside respiratory parameters before, during and after SV use in tracheostomised patients weaning from mechanical ventilation.MethodsA prospective observational study was conducted in a cardio-thoracic adult ICU. 20 consecutive tracheostomised patients weaning from mechanical ventilation and using a SV were recruited. Electrical Impedance Tomography (EIT) was used to monitor patients’ EELI. Changes in lung impedance and standard bedside respiratory data were analysed pre, during and post SV use.ResultsUse of in-line SVs resulted in significant increase of EELI. This effect grew and was maintained for at least 15 minutes after removal of the SV (p < 0.001). EtCO2 showed a significant drop during SV use (p = 0.01) whilst SpO2 remained unchanged. Respiratory rate (RR (breaths per minute)) decreased whilst the SV was in situ (p <0.001), and heart rate (HR (beats per minute)) was unchanged. All results were similar regardless of the patients’ respiratory requirements at time of recruitment.ConclusionsIn this cohort of critically ill ventilated patients, SVs did not cause derecruitment of the lungs when used in the ventilator weaning period. Deflating the tracheostomy cuff and restoring the airflow via the upper airway with a one-way valve may facilitate lung recruitment during and after SV use, as indicated by increased EELI.Trial registrationAnna-Liisa Sutt, Australian New Zealand Clinical Trials Registry (ANZCTR). ACTRN: ACTRN12615000589583. 4/6/2015.

Speaking valves as part of standard care with tracheostomized mechanically ventilated patients in intensive care unit

We recently reported on tracheostomy-related outcomes comparing 2 consecutive years before (2011) and after (2012) the introduction of an inline tracheostomy speaking valve (SV) into practice in a primarily cardiothoracic intensive care unit (ICU) [1]. Our results indicated a significantly earlier return to verbal communication for tracheostomized patients after the introduction of an inline SVwithout effecting ventilator weaning or decannulation time. The practice of using SVs in our ICU has continued to increase and is now part of standard care with tracheostomized mechanically ventilated patients. After ethics approval, we collated and analyzed similar outcomes of all tracheostomized patients in ICU for the following 2 years (2013 and 2014). Our aim was to assess whether clinical uptake had continued after the initial “honeymoon” phase associated with the original research. Equally, as our process matured, how tracheostomy outcomes had changed.

Ventilation distribution and lung recruitment with speaking valve use in tracheostomised patient weaning from mechanical ventilation in intensive care

Purpose Speaking valves (SV) are used infrequently in tracheostomised ICU patients due to concerns regarding their putative effect on lung recruitment. A recent study in cardio‐thoracic population demonstrated increased end‐expiratory lung volumes during and post SV use without examining if the increase in end‐expiratory lung impedance (EELI) resulted in alveolar recruitment or potential hyperinflation in discrete loci. Materials and methods A secondary analysis of Electrical Impedance Tomography (EIT) data from a previous study was conducted. EELI distribution and tidal variation (TV) were assessed with a previously validated tool. A new tool was used to investigate ventilated surface area (VSA) and regional ventilation delay (RVD) as indicators of alveolar recruitment. Results The increase in EELI was found to be uniform with significant increase across all lung sections (p < 0.001). TV showed an initial non‐significant decrease (p = 0.94) with subsequent increase significantly above baseline (p < 0.001). VSA and RVD showed non‐significant changes during and post SV use. Conclusions These findings indicate that hyperinflation did not occur with SV use, which is supported by previously published data on respiratory parameters. These data along with obvious psychological benefits to patients are encouraging towards safe use of SVs in this critically ill cardio‐thoracic patient population. Trial registration: Anna‐Liisa Sutt, Australian New Zealand Clinical Trials Registry (ANZCTR). ACTRN: ACTRN12615000589583. 4/6/2015. HighlightsUniform increase of end‐expiratory lung volume across ventral‐dorsal and R‐L lung sections with speaking valve use.Data suggests no alveolar hyperinflation associated with speaking valve use.Data are encouraging towards wide use of speaking valves in intensive care.

Patients want to be heard-loud and clear!

We congratulate ten Hoorn et al. [1] on their systematic review of communication with ICU patients. Their work in defining an algorithm to assist improving communication options for these patients addresses a clear gap in patient-centred care in the ICU. Despite the article giving a good overview of possible communication options for the ventilated ICU patient, we respectfully suggest that the most important communication option is the restoration of the patient’s own voice by enabling airflow through their larynx. This is particularly in the conscious patient cohort—the focus of the review article. We are supported by patient data indicating that verbal communication is the most successful form of communication [2]. Once tracheostomised, a speaking valve (SV) should be considered as the first option for communication as it restores our natural way of communication. Beliefs that cuff deflation required for the restoration of laryngeal function with SV causes atelectasis or would be deleterious in the weaning process have been proven to be unfounded [3]. We currently lack published data on the safe ventilatory parameters for SV use; however, patients in our studies using a SV whilst mechanically ventilated had substantial levels of pressure support and PEEP requirements and were able to communicate using a SV in-line with their mechanical ventilation circuit successfully without any discernible harm to their respiratory function or weaning from the ventilator [3]. Using SVs is common in our cardio-thoracic ICU [4] and may commence on the day of tracheostomy insertion, with patients spending hours, sometimes all their awake hours, being able to talk with the treating teams and loved ones. Following the success of this work, we now use SVs successfully with patients on veno-arterial extracorporeal membrane oxygenation (VA ECMO), ventricular assist devices and open chest. The difference it makes for the patients to have their own voice, and therefore be active participants in their care, is immeasurable with current tools. Studies elsewhere have also demonstrated benefits of early SV use in the ventilated tracheostomised ICU patient [5]. Alternative communication options should be used only if natural communication is not able to be achieved or as complementary devices when verbal communication is not fully successful. In the most critically ill, weakness frequently limits the use of augmentative and alternative communication boards and teaching complex new skills (i.e. electrolarynx) is fraught with difficulty. We concur with the importance of communication but suggest that before moving to more complex interventions, the larynx must always be considered.

Corrigendum to “Ventilation distribution and lung recruitment with speaking valve use in tracheostomised patient weaning from mechanical ventilation in intensive care” [Journal of Critical Care 40 (2017) 164–170]

The authors regret to inform that Graphs 2 and 3 on page 168 are swapped in the article. The graph headings and written information about the results are all accurate, however graph 3 is in fact graph 2 and vice versa. The authors would like to apologise for any inconvenience caused.

e-Screening revolution: a novel approach to developing a delirium screening tool in the intensive care unit

Delirium is common in the intensive care unit (ICU), often affecting older patients. A bedside electronic tool has the potential to revolutionise delirium screening. Our group describe a novel approach to the design and development of delirium screening questions for the express purpose of use within an electronic device. Preliminary results are presented.