Assessment of cognitive function begins very early in patients with severe traumatic brain injury, often as soon as patients begin emerging from a deep coma (1-3). The Rappaport Coma/Near Coma Scale is a standardized assessment tool that scores a patient’s responses to various stimuli across all sensory domains (1). A patient’s ability to vocalize or verbalize is a signiﬁcant factor in this assessment. Responses to strong odors, visual, tactile and painful stimuli are also rated. An open tracheostomy tube does not allow airﬂow through the oral and nasal tract for olfaction nor does it allow the patient the ability to vocalize or verbalize a response. Therefore, for some tracheostomy patients, the total score of this scale can be altered, and therapeutic plans based on the assessment can be misguided. Use of the Passy-Muir® Valve can begin as soon as 48 hours after the original placement of the tracheotomy tube. Early placement of the Passy-Muir Valve can restore airﬂow to the upper airway allowing increased vocalizations and awareness of sensory stimulation, thus providing more complete and meaningful assessment and ultimately hastening recovery to the highest possible function.
The presence of a tracheostomy tube with an inﬂated cuff has signiﬁcant effects on swallowing frequency and effectiveness due to decreased laryngeal excursion, subglottic pressure and oropharyngeal sensitivity (4-6) . In a study by Dr. Seidl and colleagues (4), tracheostomy tubes were determined to decisively inﬂuence the swallowing behavior of vegetative patients. For patients with a Glasgow Coma Scale score below 8 points, the presence of the tracheotomy tube decreased the swallowing frequency. Removal of the tracheostomy tube signiﬁcantly improved swallowing frequency for this group of patients.