The Role of the Passy-Muir® Valve in Physical Therapy

Mary Massery PT, DPT, DSc

Dr. Massery received her BS in Physical Therapy from Northwestern University in 1977, her DPT from the University of the Pacific in 2004, and her DSc from Rocky Mountain University in 2011. Mary’s publications and interests focus on linking motor behaviors to breathing and/or postural mechanics for both pediatric and adult patient populations.
Dr. Massery has been invited to give over 750 professional presentations in the United States and 13 other countries. Mary has received national awards from the American Physical Therapy Association, including its highest clinical award, The Florence Kendall Practice Award, and the honorary Linda Crane Memorial Lecture. She continues to maintain a private practice in Chicago, specializing in ventilation and postural dysfunction.

Dr. Massery, we often get asked the question, “Should I remove the Passy-Muir® Valve while the patient is in physical therapy?” From your experience, how would you answer this question?

If the tracheostomy tube is sized appropriately and the Passy-Muir® Valve is well tolerated, the patient should do better with their exercises during physical therapy with the valve on. The Passy-Muir Valve restores the pressure support in the trunk, allowing for natural increases in intra-thoracic pressure (ITP) and intra-abdominal pressures (IAP) in response to increased postural demands. Without the valve, thoracic pressures cannot be increased as the air will “fall” out of the trach. For example, if a patient needs to push on a chair armrest to stand up, he would typically engage the glottis (vocal folds) to restrict the expiratory lung volume in order to stabilize the chest. If he has a trach, but no valve, air will fall out of the trach causing lower ITP, presenting as decreased arm strength. It may mean the difference between a successful independent transfer and an assisted transfer.

For example, my young patient, Nick, needed his Passy-Muir® Valve to weight bear through his left arm while reaching with his right arm. Without the valve, he would sink down into his trunk which impaired his biomechanical support for reaching. Bouncing balls and pushing activities were used while the Passy-Muir Valve was on in order to strengthen his vocal folds and trunk muscles as we worked toward decannulation. In addition, the valve provided Nick a stronger voice and improved the spontaneous interaction and play between us, which likely improved his willingness to participate in some harder physical activities.

You have recently published an article in the Journal of Applied Physiology about the effect of airway control by glottal structures on postural stability. Does this research have implications for the patients with tracheostomy?

Yes, our findings indicate that the glottis (vocal folds and surrounding airway constrictors) are involved in
dynamic postural stabilization even with a very low level of balance disturbance. In simple terms, it means that people naturally use their airway for balance. This indicated that glottal engagement should be considered for balance training. Although our research was on normal subjects, the extrapolation would be that patients with tracheostomies should consider a Passy-Muir Valve for balance training. A follow up study is needed to confirm our findings in this population.

A simple way to visualize the role of the vocal folds in postural stability is to think of the trunk of a patient as soda-pop can. The pressure inside a closed can is greater than the pressure outside, and this pressure “stabilizes” the can. Without pressure, the aluminum can is easily crushed.

The Passy-Muir® Valve allows the vocal folds to act as the top pressure valve of the trunk (can) adding to the stabilizing forces of ITP and IAP. Without the valve, the air, and therefore the internal pressures, fall out of the trach tube.

There is a lot of evidence that supports an interdisciplinary approach to the care of the tracheostomized patient. What role does the physical therapist have on the trach team?

This topic is near and dear to my heart. Everyone breathes, so pulmonary issues can not belong to a single discipline. If we all work together, like the Olympic Rings, overlapping rather than gapping, it should improve outcomes: greater physical rehabilitation gains and greater health. Engaging in resistive exercises increases ITP and IAP, which in turn can help to open the distal airways and drive the equal pressure point deeper into the lungs. This may contribute to better airway clearance as well as improved physical health.

As a clinical researcher and expert on the link between breathing and postural control, what will be the focus of your future work and research?

The logical progression of my research would include patient populations with tracheostomies who are Passy-Muir® Valve candidates. In particular, I would like to look at patients with spinal cord injuries; testing their sitting balance with and without the PMV. My clinical experience as a neuro PT and my recent research on
normal populations would suggest that I will find sitting balance is improved with a Passy-Muir Valve compared
to an open trach. Similarly, I would like to look at the same patients’ limb force production (arm strength) with and without the PMV on their trach tubes. If it is true that we need increased ITP and IAP in order to produce force (strength) through our limbs, then wearing the Passy-Muir Valve should demonstrate increased upper extremity force.

Visit the following website to watch Dr. Massery explain her “soda pop can model” and other concepts from her
course “If You Can’t Breathe, You Can’t Function.”

Watch a physical therapist from Madonna Rehabilitation Hospital perform techniques developed by Dr. Massery to facilitate postural support, control of breathing and vocalization with the PMV.
Physical Therapy for Patients with Tracheostomy Using a Passy-Muir Valve

References

  1. Davis PR, Troup JDG. (1964). Pressures in the trunk cavities when pulling, pushing and lifting. Ergonomics: 7(4):465 - 474.
  2. Gandevia SC, Butler JE, Hodges PW, Taylor JL. (2002). Balancing acts: respiratory sensations, motor control and human posture. Clin Exp Pharmacol Physiol: 29(1-2):118-121.
  3. Hagins M, Lamberg E. (2006). Natural breath control during lifting tasks:effect of load. Eur J Appl Physiol; 96(4):453-458.
  4. Hagins M, Pietrek M, Sheikhzadeh A, Nordin M, Axen K. (2004). The effects of breath control on intra-abdominal pressure during lifting tasks.
    Spine; 4, 29(4):464-469.
  5. Hamaoui A, Gonneau E, Le Bozec S. (2010). Respiratory disturbance to posture varies according to the respiratory mode. Neurosci Lett; 475(3):
    141-144.
  6. Hodges PW, Gandevia SC. (2000). Changes in intra-abdominal pressure during postural and respiratory activation of the human diaphragm. J Appl Physiol; 89(3):967-976.
  7. Lamberg EM, Hagins M. (2013). Breath control during a tiptoe task. Physiother Theory Pract. Epub Sept 11.
  8. Massery M. (2006). Multisystem Consequences of Impaired Breathing Mechanics and/or Postural Control. In Cardiovascular and Pulmonary Physical Therapy Evidence and Practice, ed 4. 4 edition. Edited by
    Frownfelter D, Dean E. St. Louis, MO.: Elsevier Health Sciences:695-717.
  9. Massery M, Hagins M, Stafford R, Moerchen V, Hodges PW. (2013). Effect of airway control by glottal structures on postural stability. J Appl Physiol; 3, 115(4):483-490.
  10. Orlikoff RF. (2008). Voice production during a weightlifting and support task. Folia Phoniatr Logop; 8, 60(4):188-194.

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