Co-Author: Gabriela Ortiz, BSRT, RCP

This case study is the third and final installment of a three-part series that has reviewed Sam’s recovery from COVID-19 with an associated pneumonia and subsequent bilateral lung transplant. This case study report picks up after his discharge from a long-term acute care hospital (LTACH) and his subsequent return home with admission to services through a home health agency (to read part one of this series, go here; for part two of this series, please go here).  

Admission and Evaluation

During the workday, the home health agency office contacted the speech-language pathologist (SLP) to report that a new patient with a tracheostomy was being admitted by nursing and would need an evaluation visit later in the afternoon. The SLP asked about any pertinent health history, but the office reported that not all the paperwork from the discharging facility had been uploaded yet. 

The first step taken by the SLP was to contact the patient to schedule a time for the evaluation. The wife answered and reported that since the nurse was currently in the home performing the admission visit, it would be agreeable to have an evaluation visit in the late afternoon, following the respiratory care company’s visit.

Prior to traveling to the patient’s home for the visit, the SLP communicated with the admitting nurse to discuss the patient’s history. The nurse reported a history of COVID-19, which led to a bilateral lung transplant. Upon arrival at the home, the SLP noted that the patient was not wearing a speaking Valve and was using finger occlusion to introduce himself. The SLP asked both the patient, Sam, and his wife if he had a speaking Valve. The wife reported he used a Passy-Muir® Valve (PMV®) during all waking hours but that it had been dropped on the floor. She reported they cleaned it according to discharge training and manufacturer recommendations, and it currently was air-drying. The SLP used this opportunity to instruct Sam and his wife that a PMV can be used after cleaning and before it completely dries. If they store it in the storage container, then it should be completely dry prior to closing the container’s lid. 

The next step was for the SLP to look at the tracheostomy that Sam had. The SLP viewed the neck flange of the tracheostomy tube to confirm its size (size 8) and type (cuffless).  Sam’s wife was able to provide her copy of the therapy notes and discharge instructions from the LTACH. The SLP then reviewed the notes for information pertinent to the treatment plan.

During the session, Sam demonstrated independent placement of his PMV®007 (Aqua Color™) and produced functional voicing for conversation throughout the evaluation visit but exhibited some breathlessness toward the end of the assessment. During the evaluation visit, the SLP:

  • Reviewed his medical history (including diagnosis, treatment, recovery, and extensive rehabilitation) to confirm with Sam’s primary care physician (PCP). 
  • Reviewed and instructed on the discharge goals from the LTACH for continued dysphagia management.
  • Confirmed independent use of mealtime compensatory strategies and compliance with the recommended plan for six small meals a day.
  • Educated him on the increased risk of swallowing issues, including aspiration, with the tracheostomy and his need for good oral care (Amthieu et al., 2021; Bergl et al., 2018; Jung et al., 2012).
  • Observed Sam demonstrate home exercises provided by his respiratory therapist (RT) during an earlier visit. 
  • Retrieved contact information for the RT from Sam’s wife and the respiratory company’s admission booklet (an information and communication booklet required to be provided to patients who are receiving in-home care) to coordinate treatment plans.
  • Provided Sam and his wife with the contact information for the SLP.
  • Discussed goals for dysphagia management with end goal being a return to normal diet, treatment plan, visit frequency, and scheduling, following discussion with Sam and his wife as to what goals they wanted to pursue.

Even though the SLP had been maintaining competencies through continuing education, experience with patients with tracheotomies was limited. To ensure competency and comfort with the tracheostomy, the SLP sought online resources, education, and research from reputable sources to ensure delivery of best practice and to support other clinicians working with Sam. 

Troubleshooting

During the first therapy visit, following the evaluation, the SLP noticed a honking sound with Valve use. Sam reported that it had just started within the last day or two. To investigate why the Valve may be honking, the SLP considered the following:

  1. How and how often was the Valve being cleaned? If a Valve is not cleaned properly, then it may honk. 
  2. How old was the Valve?
  3. How was Sam breathing? Turbulent airflow may cause the honking sound – this may occur during laughter, coughing, pursed lip breathing, or some other breathing difficulties, such as those seen with patients with COPD. With Sam’s history of a bilateral lung transplant, assessing his breathing pattern was important.

The first consideration was that the Valve may need to be cleaned. Following proper cleaning, the Valve continued to honk. However, the SLP reviewed the cleaning process with Sam and his wife just to ensure appropriate cleaning. When the SLP asked how long Sam had had the Valve, his wife reported that it was the same Valve he started using in acute care. The SLP educated them that the guaranteed lifespan of the Valve is 60 days and if longer, it may need replacing. Sam was well past that timeframe. Since it was not functioning properly, the Valve would need to be replaced.  An order was obtained from his physician for a PMV 2000 (clear) instead of his previous PMV 007 (Aqua colorTM) Valve. The PMV 2000 was sought because it has a lower profile and had a PMV Secure-It® to prevent accidental drops. The clear color would make it more discrete for use at home and out in public. 

Following downsizing of the tracheostomy tube to a size 6, Sam complained he felt like air was leaking out around the tracheostomy tube when using the Valve. The SLP assessed the air leak and noted that the stoma site was still enlarged from the #8 tracheostomy tube. The SLP contacted the RT to discuss options for using a silicone stoma pad or hydrophilic dressing to assist with occluding the opening around the outer edges of the tracheostomy tube. The RT provided a silicone stoma pad which diminished the leak and assisted with healing of the stoma.

Respiratory

Sam’s respiratory services were provided by a different home-based company than his nursing and allied therapy services. To ensure consistency, following the evaluation visit, the SLP contacted the RT by phone to discuss Sam’s plans of care and to coordinate treatment to reach Sam’s discharge goal of decannulation and to return to baseline function. The RT reported that education, instruction, and troubleshooting techniques on all equipment and supplies had been provided, as well as additional instructions for recognizing signs and symptoms of increased work of breathing (WOB), respiratory distress, and appropriate responses.  

The initial respiratory plan of care included:

  • Initiation of cool mist aerosol therapy via trach mask to provide pulmonary humidification and hydration.
  • Use of supplemental oxygen via bedside concentrator and cylinders when outside of the home to maintain SpO2 ≤91%.
  • Review of suctioning with #14 Fr suction catheters. Conducted every 2 – 4 hours and as needed with lavage as needed (3-5 ml of 0.9% normal saline solution), to help provide pulmonary hygiene and prevent respiratory infections.
  • Initiation of handheld nebulizer (HHN) breathing treatments with Albuterol 0.083% Inhalation Solution (2.5 mg) every 4-6 hours as needed to aid in the thinning and mobilization of retained secretions that may cause respiratory distress. 
  • Continuation of the size 8, uncuffed tracheostomy tube with disposable inner cannula (DIC). The tracheostomy tube was to be changed by the doctor, nurse, or RT every 30-45 days to prevent respiratory infections. The DIC was to be exchanged for a new one and the old one discarded daily. 
  • Continuation of the tracheostomy tube and stoma care daily to prevent skin breakdown and infection. 
  • Continuation of Passy-Muir Valve use while awake but to be removed during sleeping hours. 
  • Cleaning the Valve daily and as needed. 
  • Continuation of respiratory muscle training (RMT) and lung expansion exercises to maintain good lung function and promote adequate ventilation and oxygenation (Crouch & Kulkarni, 2016). 

When the RT received the PCP’s orders to downsize to a size 6 tracheostomy tube, treatment focused primarily on respiratory strengthening to work towards capping trials.  Sam progressed well, and the RT received orders to begin capping. The RT re-assessed airway patency and provided instruction on monitoring vital signs (including oximetry while sleeping).  With the prescribed decannulation orders, the cuffless size 6 tracheostomy tube was capped while in the home, and after a successful 72-hour capping trial, the tracheostomy tube was removed (Hernandez Martinez et al., 2020). Sam was decannulated within 3 weeks of the initiation of home care. The RT continued to provide monitoring, stoma care, and education to Sam and his wife. 

Dysphagia

Another area of consideration for the SLP was to re-evaluate Sam’s swallowing. With the scheduling and availability challenges that exist for coordinating outpatient services for home-based patients, the SLP contacted the PCP for an order for a follow-up fiberoptic endoscopic evaluation of swallowing (FEES). FEES was selected, rather than videofluoroscopy, to best compare results to the previous FEES evaluations and to assess for signs of fatigue with a meal, with such indicators as multiple swallows per bolus and increased = penetration or residue toward the end of a meal (Hiramatsu et al., 2015; Brates & Molfenter, 2021). The SLP scheduled the evaluation for the first available appointment, which was nearly three weeks from admission to home health services, allowing time for further strengthening and possible decannulation.

Prior to the scheduled assessment, the SLP treated dysphagia by:

  • Instructing in laryngeal strengthening tasks based on FEES results from LTACH (Oakes & Sudderth, 2021).
  • Instruction for use of RMT with the Valve in place to assist with both respiratory and swallow functions.
  • Establishing a home exercise program for strengthening tasks.
  • Training on preparation of a modified meal plan in the home environment.
  • Reinforcing compensatory strategies.
  • Providing education on changes that may occur to swallow function which are related to tracheostomy and decannulation (Jung et al., 2012).

Sam was decannulated prior to his outpatient FEES. The report from the assessing SLP revealed that Sam demonstrated a functional swallow with all consistencies and had no penetration or aspiration. Sam demonstrated improved endurance with no signs of fatigue while eating and drinking regular consistencies, without use of super-supraglottic swallow maneuver, over the course of a 20-minute assessment. The assessing SLP recommended a return to his normal, baseline diet. 

The SLP educated Sam and his wife on the findings and discharged him from SLP services following education on how to monitor for signs and symptoms of dysphagia and after contacting the PCP if there are any changes.  

Discharge

Sam progressed quickly with all disciplines and was discharged from home health services. He was referred to an outpatient pulmonary rehabilitation program to continue exercise endurance and to promote continued improvement (Crouch & Kulkarni, 2016). Sam was able to return to work seven months after his initial hospitalization.

References

Amathieu, R., Sauvat, S., Reynaud, P., Slavov, V., Luis, D., Dinca, A., … Dhonneur, G. (2012). Influence of the cuff pressure on the swallowing reflex in tracheostomized intensive care unit patients. British Journal of Anaesthesia, 109(4), 578-583. https://doi.org/10.1093/bja/aes210

Bergl, P., Kumar, G., Zane, A., Shah, K., Zellner, S., Taneja, A.,… Nanchal, R. (2018). 517: Acquired dysphagia after mechanical ventilation an underrecognized and undercoded phenomenon? Critical Care Medicine, 46(1): 243. https://doi.org/10.1097/01.ccm.0000528535.80915.5b

Brates, D. & Molfenter, S. (2021). The influence of age, eating a meal, and systematic fatigue on swallowing and mealtime parameters. Dysphagia. Epub ahead of print. https://doi.org/10.1007/s00455-020-10242-8. 

Crouch, R., & Kulkarni, H. S., (2016). Pulmonary exercise training before and after lung transplantation. Journal of Respiratory Critical Care Medicine, 194, 9-10. American Thoracic Society. Patient Education Series. Retrieved from: https://54.209.11.195/patients/patient-resources/resources/pulmonary-exercise-training-transplantation.pdf

Hernadez Martinez, G., Rodriguez, M. L., Vaquero, M. C., Ortiz, R., Masclans, J. R., Roca, O., Colinas, L., De Pablo, R., Espinosa, M. C., Garcia de Acilu, M., Climent, C., & Cuena-Boy, R. (2020). High-flow oxygen with capping or suctioning for tracheostomy cannulation. The New England Journal of Medicine383, 1009-1017. https://doi.org/10.1056/NEJMoa2010834

Hiramatsu, T., Kataoka, H., Osaki, M., & Hagino, H. (2015). Effect of aging on oral and swallowing function after meal consumption. Clinical Interventions in Aging, 10, 229-235.
https://doi.org/10.2147/CIA.S75211

Jung, S., Kim, D., Kim, Y., Koh, Y., Joo, S., & Kim, E. (2012). Effect of decannulation on pharyngeal and laryngeal movement in post-stroke tracheostomized patients. Annals of Rehabilitation Medicine36(3), 356-364. https://doi.org/10.5535/arm.2012.36.3.356

Oakes, T. & Sudderth, G., (2021). COVID-19 complications and the role of the SLP: An LTACH case study. Dysphagia Café. Retrieved from https://dysphagiacafe.com/2021/06/01/covid-19-complications-and-the-role-of-the-slp-an-ltach-case-study/#comments

Co-Author Bio:

Gabriela has been in the field of respiratory care since 2006. She lives in Southern California and has worked in clinical education and sales roles, where she has used the knowledge gained about ventilation products for the ICU, PICU within acute and subacute hospitals during her clinical experiences in critical care. Gabriela is an invited guest speaker for schools, Better Breather’s Group meetings, and ALS support groups. She currently is a full-time clinical specialist with Passy-Muir, Inc.

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