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.
Therefore, the authors recommend deﬂation of the cuff or removal of the tracheostomy tube as a therapeutic measure to improve swallow function based on “improved sensitivity under reestablished Ask the Clinical Specialist By Mike Harrell, RRT, Director of Clinical Education - Respiratory, Passy-Muir, Inc. physiologic expiration.” For patients not ready for decannulation, cuff deﬂation and early use of the Passy-Muir® Valve can signiﬁcantly contribute to the improvement of swallow safety and efﬁcacy by not only restoring expiratory airﬂow physiology, but also reestablishing the beneﬁts of subglottic pressure (5).
Mike Harrell was formerly Director of Respiratory Care with Charlotte Regional Medical Center (CRMC) in Punta Gorda, FL for several years prior to joining the Passy-Muir Educational Team as a Passy-Muir Clinical Specialist in 2005. Mike also presided as president of the Florida Society of Respiratory Care in where he brought his clinical knowledge and strong advocacy for patient care together to improve respiratory care in the state of Florida.
1. Rappaport, M. (2005). The Disability Rating Scale and Coma/Near Coma Scales in evaluating severe head injury. Neuropsychological Rehabilitation, 15(3/4): 442-443.
2. Rappaport, M., Dogherty, A., & Kelting, D. (1992). Evaluation of coma and vegetative states. Archives of Physical Medicine and Rehabilitation, 73:628-634.
3. Talbot, L., & Whitaker, H. (1994). Brain injured persons in an altered state of consciousness: Measures and intervention strategies. Brain Injury, 8:689-699.
4. Seidl, R., et. al. (2005). The inﬂ uence of tracheostomy tubes on the swallowing frequency in neurogenic dysphagia. Otolaryngology Head Neck Surgery, 132:484-486.
5. Eibling, D., & Gross, R. (1996). Subglottic air pressure: A key component of swallowing efﬁ ciency. Annals of Otology Rhinology Laryngology, 105:253-258.
6. Dettelbach, M., Gross, R., Mahlmann, J., et. al. (1995). The effect of the Passy-Muir valve on aspiration in patients with tracheostomy. Head & Neck, 17:297-302.