Misconception: “We need to wait until the patient is off the ventilator”

Many clinicians believe it is necessary to wait until the patient is weaned from mechanical ventilation to place the Passy-Muir® Valve. However, evidence indicates that:
  • A delay in treatment may do more harm than good. Up to 50% of intensive care unit patients who require mechanical ventilation present with Systemic Inflammatory Response Syndrome (SIRS). 50-70% of those patients with SIRS go on to develop diffuse pathological muscle weakness (myopathy) and peripheral nerve disorders.1
  • Muscle weakness is an independent predictor of pharyngeal dysfunction as well as symptomatic aspiration. Pneumonia caused by aspiration causes acute lung injury, which translates to weaning failure, delayed hospital discharge, and mortality.2
  • The inability to communicate causes the most anxiety for patients on mechanical ventilation. Fear-induced anxiety markedly compromises respiratory function and contributes to subsequent weaning failures.3

     

    Clinical research demonstrates early use of the Passy-Muir® Valve, including ventilator application, can expedite ventilator weaning:

    • The use of the Passy-Muir Valve in mechanically ventilated patients facilitates independent vocalization, allowing them to become active participants in their healthcare. Improving communication between the patient and the healthcare team reduces patients’ anxiety and improves their sense of well-being, dignity, and motivation to wean.4-6
    • The Passy-Muir Valve re-establishes a closed respiratory system which restores physiologic PEEP, resulting in improved oxygen saturations and reduced ventilator support. There is greater tolerance of weaning attempts leading to independent breathing. Patients have reported that breathing is easier and have been able to tolerate trials of CPAP longer with the valve in place.7
    • Multidisciplinary teams that incorporate the valve as a routine strategy in ventilator weaning have improved outcomes.
      • In one critical care study, University College London Hospital found a reduction in ICU and hospital mortality, as well as duration of mechanical ventilation (average reduction of 11 days) following a team approach with speaking valve use.8
      • Southport and Ormskirk Hospital successfully weaned patients with cervical spinal cord injury who had failed all other weaning attempts by using a progressive ventilator-free breathing method in conjunction with the speaking valve.9
      • Following incorporation of the Passy-Muir Valve into their weaning protocol, Madonna Rehabilitation Hospital was able to wean 62% of their ventilator patients in an average of 12.5 days. This is well above the benchmark of 50% in an average of 20 days set by the National Association of Long Term Hospitals.10,11
      • Early intervention by a multidisciplinary team at Kindred Hospital Wyoming Valley, PA incorporated ambulation therapy in conjunction with the Passy-Muir Valve in their weaning protocols. This resulted in an increase in ventilator weaning rates by 13% over a 1.5 year period.12
    View the recorded webinar: Early Intervention for the Ventilated ICU patient in our Education Portal for more information on this topic.

    Next Barrier

    "The ventilator will alarm"

    Clinicians are often uncertain of how to make appropriate ventilator adjustments for cuff deflation and placement of the valve in-line... Read more.

     

    1. Burkhead, L. (2011). Swallowing evaluation and ventilator dependency—Considerations and contemporary approaches. Perspectives. 22(2):18-22.

    2. Mirzakhani, H., Williams, J.N., Mello, J., Joseph, S., Meyer, M., Waak, K., Schmidt, U., Kelly, E., Eikermann, M. (2012). Muscle Weakness Predicts Pharyngeal Dysfunction in Symptomatic Aspiration in Long-term Ventilated Patients. Anesthesiology. Aug;119(2):389-397.

    3. Chen, Y.J. et al (2011). Psychophysiological determinants of repeated ventilator weaning failure: an explanatory model. American Association of Critical Care Nurses. Jul;20(4):292-302.

    4. Desai, A. et al. (2009) Helping the chronically critically ill to communicate: speaking valve pilot trial. American Journal Respiuratory Care Medicine. 179:A3083.

    5.Bell, S.(1996). Use of the Passy-Muir Tracheostomy Speaking Valve in mechanically ventilated neurological patients. Neurology. 16(1):63-68.

    6. Manzano, J. et al. (1993). Verbal communication of ventilator-dependent patients. Critical Care Medicine. 21(4):512-517.

    7. Frey, J. & Wood, S. Weaning from Mechanical Ventilation Augmented by the Passy-Muir Speaking Valve (1991). Abstract at the International Conference of American Lung Association and American Thoracic Society

    8. Black, C. et al. (2012). A Multidisciplinary team approach to weaning from prolonged mechanical ventilation. British Journal of Hospital Medicine. Aug;, 73(8): 462-466.

    9. Atito-Narh, E. et al (2008). Slow ventilator weaning after cervical spinal cord injury. British Journal of Intensive Care. 95-102.

    10. Kobak, J. & Dean, L. (2011). Use of the Passy-Muir Valve for weaning in long term acute care hospital. Respiratory Therapy. 6 (4):44, 57.

    11. Windhorst, C., et al (2009). Patients requiring tracheostomy and mechanical ventilation: a model for interdisciplinary decision making. The ASHA Leader, 14 (1), 10-13.

    12. Gurnari, D. & Martin, C. (October, 2011). Early collaboration of respiratory and rehabilitation department improves ventilator weaning rates. Poster presented at the Conference of the National Association of Long Term Hospitals, New Orleans, LA.

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