Co-author: Gail Sudderth, RRT
This case study is the second in a three-part series that continues the review of Sam’s recovery from COVID-19 with an associated pneumonia and subsequent bilateral lung transplant. This case study picks up after his discharge from acute care for his subsequent admission to an LTACH (Click Here for part one).
The rehabilitation department within the LTACH received notification of Sam’s admission, a patient with a tracheostomy and mechanical ventilation who was to be evaluated by all disciplines (for details on medical history and his acute stay, see Bartow & Hereford, 2021). He had no significant medical history prior to his acute hospital admission and subsequent diagnosis of COVID-19 with pneumonia and subsequent bilateral lung transplant. The speech-language pathologist (SLP) reviewed notes from the acute care speech department. It was reported that Sam demonstrated intact cognitive function and had been assessed and treated for communication deficits and dysphagia. His primary nutrition and hydration were delivered via percutaneous endoscopic gastrostomy (PEG) tube.
After admission to the LTACH, the respiratory therapist (RT) and SLP planned to conduct their assessments of Sam together and during visitation hours while his wife could be present. Upon entering the room, Sam was upright, awake, and alert. He was communicating with his wife using an AAC app on an iPad (for details, see Bartow & Hereford, 2021). After introductions, the RT and SLP initiated re-assessment with the Passy-Muir® Valve (PMV), to ascertain that no changes had occurred during his transition to the LTACH. During their evaluation, the RT and SLP worked together to assess baseline measures and ensure medical stability. The RT provided suctioning as needed. While the RT managed ventilator settings and alarms, the SLP slowly deflated the cuff of the tracheostomy tube. Both disciplines assessed airway patency. During the slow cuff deflation, the SLP cued the patient to breath in with the inspiratory cycle of the ventilator and to attempt voicing during exhalation. Following complete cuff deflation, the RT noted a significant change in the PIP and tidal volume as measured with return to the ventilator on exhalation. This change indicated a leak had been created with cuff deflation, allowing airflow around the tracheostomy tube and out through the upper airway. The SLP placed the Valve in-line. Sam adjusted well to the change in sensation and pressure and began speaking to his wife and the clinicians without cueing.
Even though Sam had no apparent difficulty wearing the Valve, he reported feeling tired after a couple hours. Sam’s goals were to eat again, regain strength, come off the ventilator, and go home. His wife reported she had the same goals.
The SLP performed a bedside evaluation of his voice. Sam demonstrated low amplitude and a breathy vocal quality with voicing, with his vocal quality diminishing at the end of long utterances. These observations indicated decreased breath support and possible decreased vocal fold closure was suspected, both of which may have been related to prolonged endotracheal intubation and disuse atrophy.
The SLP provided oral care, then initiated a clinical evaluation of swallowing, during which Sam demonstrated throat clearing with his secretions prior to oral intake and multiple swallows to clear a bolus from the oral cavity. Sam verbalized and demonstrated the compensatory strategies previously instructed in acute care and consumed small bites of modified solids and small sips of thin water with no overt signs of aspiration. The SLP instructed Sam and his wife on the risk and prevalence of silent aspiration in patients with tracheostomy and recommended an objective assessment using fiberoptic endoscopic evaluation of swallowing (FEES).
Tracheostomy Team Meeting
This LTACH’s tracheostomy team included representatives from respiratory therapy, occupational therapy (OT), physical therapy (PT), speech-language pathology, and nursing. There was also a physician assistant (PA) present for weekly meetings when available. Additionally, the RT, SLP, nurse manager, and PA performed team rounding on patients with tracheostomy once weekly. This team was SLP-driven with regular communication with the PA.
Each discipline reviewed their evaluation findings and proposed plans of care. The SLP reported goals and treatment approaches for addressing communication and swallowing, including the use of respiratory muscle training (RMT), in conjunction with the RT’s plan for weaning. Both disciplines initiated goals to address secretion management and cough strengthening. PT and OT reported their plans to address transfer, ambulation, and self-care needs to meet Sam’s and his wife’s goals for discharge home. During PT and OT therapies, use of the Valve was incorporated to restore thorasic and abdominal pressure and core stability (Ceron et al., 2020). The tracheostomy team agreed a multidisciplinary approach was key to achieving these goals for COVID-19 recovery (Bovento et al., 2017; Mooney, et Al., 2021).
Wear Time and Weaning
Sam arrived to the LTACH with a size 8 cuffed tracheostomy tube, receiving pressure control synchronized intermittent mandatory ventilation (PC-SIMV) and pressure support (PS) of 15cm H2O and a set rate of 10. The RT followed the facility’s weaning protocol to gradually decrease his rate from ten to two. By day six, Sam was on continuous positive airway pressure (CPAP) with PS weaned down to 6. During this time, Sam continued to wear the Valve for two – three hours at a time. Per the weaning protocol, upon reaching a PS of six, trach collar (TC) trials were initiated. By the fifth day, he was on TC with periods of rest on PS throughout the day, while gradually increasing Valve wear time and participating in RMT. By day seven, his TC and Valve use was up to 8 hours per day. Sam benefited from Valve use to achieve quicker weaning times and improved lung recruitment (Sutt et al., 2015; Sutt et al., 2016; Sutt et al., 2017). RMT therapy and Valve use continued during his weaning trial and transition to TC. By day ten, Sam was wearing the Valve during all waking hours while on room air (FiO2 .21).
|Day||Mode||Trach Collar (TC)||Pressure Support(cmH2O)||Oxygen (FiO2)||Set Rate||Valve Wear Time(hours)|
|5||CPAP||TC with periods of rest on PS||6||.40||4-6 hrs with rest|
|7||Weaned to TC||.21||8 hrs without rest|
|10||TC, room air||.21||All waking hrs|
While Sam was still on mechanical ventilation and using the Valve, the SLP treated Sam’s dysphagia with techniques to improve laryngeal elevation, compensatory strategies to increase airway protection, and cough training. These treatment areas were determined according to the findings reported from the FEES completed just prior to Sam’s discharge from acute care.
After Sam was weaned to trach collar, another FEES evaluation was conducted. The results of this evaluation confirmed he had decreased laryngeal elevation and decreased vocal fold closure. There also was a mild delay in swallow timing. The SLP noted increased secretions that cleared with consecutive effortful swallows. The assessment was conducted during a meal of regular consistencies and thin liquids. During the assessment, Sam exhibited increasing residue and was asked to alternate small bites and sips with a super-supraglottic swallow. While no aspiration was visualized, the increased residue required multiple swallows to clear. He also exhibited transient penetration toward the end of the meal.
The SLP discussed findings the with tracheostomy team, PA, and dietician. Together, a plan was developed to transition Sam from PEG feedings and to primary oral feedings with six small meals a day. The dietician followed Sam closely to ascertain he would achieve and maintain adequate nutrition through his oral diet.The SLP trained Sam in the use of the super-supraglottic swallow during meals. The super-supraglottic swallow maneuver was continued as both a strengthening treatment and compensatory strategy, utilizing his restored subglottic pressure and cough function provided by the Valve (Gross et al, 2006; Suiter et al., 2003).
With the Valve in place, the SLP targeted vocal fold adduction and breath support, with timing tasks to improve voice quality and stamina. While the RT targeted RMT for weaning and wear time, the SLP also utilized expiratory muscle training (EMT) strategies to increase respiratory support for speech. Through his stay, he demonstrated improved loudness and length of utterance, without breathiness.
The SLP provided training to both Sam and his wife for placing and removing the Valve and for cleaning the Valve. Sam reported improved mood and motivation with his communication improved, including calls to friends and family whenever he wanted, and his restored sense of autonomy in communicating with the medical staff. (Freeman-Sanderson et al., 2018).
Sam was a patient at this LTACH for two weeks. Prior to discharge, the tracheostomy team determined that Sam no longer required a cuffed tracheostomy tube and changed him to a size 8 cuffless tube. Sam was wearing the Valve during all waking hours and communicating well with good voicing. He required further treatment for respiratory strengthening and secretion management and to work toward his decannulation goal. Sam still required a modified meal plan (six small meals as compared to the more typical three meal plan) with use of compensatory strategies. He was discharged to home, with health services to continue treatment by PT, OT, nursing, RT, and speech-language pathology.
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