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To maximize the benefits of speaking valve use in patients receiving mechanical ventilation, proper usage of a speaking valve involves deflating the cuff to optimize respiratory function and patient safety. The reasons behind deflating the cuff while using the Passy Muir® Valve (PMV) and its impact on respiratory function are related to how the Valve functions. The PMV is a device that allows patients with tracheostomies to communicate and breathe more naturally. When used in conjunction with mechanical ventilation, the PMV offers several advantages, such as improved speech and swallowing, reduced respiratory complications, and enhanced patient comfort. Having a comprehensive understanding of cuff deflation and its effect on improving speech, swallowing, and respiratory efficiency in patients with tracheostomies is critical to improve care with mechanical ventilation and during the weaning process. The Passy Muir Valve is a no-leak, bias-closed position Valve which opens during inspiration and closes at the end of inspiration, redirecting airflow up and out the mouth and nose during exhalation. It is this change in direction of airflow that restores a more typical respiratory process by re-engaging the upper airway. This reengagement has been shown in the literature to improve lung recruitment and function1-3; psychological well-being 4-5; and multiple benefits related to restoring sensation, communication, swallowing, and secretion management.6-7
Cuff Deflation for Valve Use
Enhanced Speech and Communication
Deflating the cuff while using the PMV is essential for speech production. The PMV enables exhaled air to pass through the vocal cords, resulting in voice production. This restoration of speech ability not only enhances communication but also improves the overall quality of life for patients with tracheostomies.4 When considering restoration of speech and communication, one should also consider that doing so allows them to participate in their care and be engaged in the decision-making process. A study published in 2016 reported that medical errors are the third leading cause of death in the United States and that communication barriers and breakdowns are the leading cause of medical errors and adverse events.8 So while restoring communication enhances quality of life, handoff communication and patient’s ability to communicate potentially have a significant impact on patient safety. Deflating the cuff and using a Valve provides the opportunity for a patient to access their voice. It also has been shown to improve both diagnostic and treatment interventions because of the patient’s improved ability to participate.
Reduction of Aspiration Risk and Improved Swallow Function
A primary consideration for healthcare professionals is the impact of cuff management on swallowing and airway protection. Deflating the cuff during PMV use has been shown to help to reduce the risk of aspiration.9 While trachloreTM (information spread by word of mouth, not supported by research, but commonly thought or done) would present that keeping the cuff inflated prevents aspiration, this is not accurate. Aspiration occurs when foreign substances, such as liquids or food particles, pass the vocal folds and enter the airway and lungs. As the cuff is located below the vocal folds, it cannot prevent aspiration. A cuff also cannot stop aspirated material from moving into the lung fields as the airway is dynamic with the walls of the trachea moving during respiration and allowing micro-aspiration even with an inflated cuff. Additionally, an inflated cuff, if not properly managed, has actually been shown to impair swallowing and airway protection.10 By deflating the cuff and using the Passy Muir Valve, swallowing pressures that assist with airway protection are restored and assist with preventing substances from entering the airway and mitigating aspiration risk in patients with tracheostomies. Cuff deflation also contributes to improved swallowing function. The presence of a fully inflated cuff can interfere with the natural swallowing mechanism. By deflating the cuff, patients can restore sensation, improve swallowing function, and restore the more normal pressurized system. Pressure assists with driving a bolus through the oral cavity, pharyngeal area, and esophageal sphincter. A tracheostomy tube with an inflated cuff reduces pressures throughout the swallowing system, including having a reduction in subglottic pressure.11 By deflating the cuff and using a Valve, the swallowing reflex and improved pressure allow for better control over the swallowing process, reducing the risk of complications.
Impact on Respiratory Function
Cuff deflation during PMV use decreases airway resistance, allowing for more efficient airflow to the upper airway. A fully inflated cuff may create an obstruction in the airway, leading to increased work of breathing and is a contraindication for Valve use. By deflating the cuff, patients experience less resistance to airflow, resulting in improved respiratory function by reengaging the upper airway. When the cuff is deflated and a Valve is used while on mechanical ventilation, research has shown that there is improved lung recruitment, increased diaphragmatic function, and overall improved respiratory mechanics as compared to mechanical ventilation with an inflated cuff.3 Improved lung recruitment was described as occurring because with the Valve in-line with mechanical ventilation, more normal respiratory pressures occurred which allowed improved ventilation of the alveoli. The research by Sutt et al. (2016) also demonstrated that there were increased lung volumes in the patients with a Passy Muir Valve as compared to those patients with an inflated cuff. Cuff deflation facilitates better lung volume and ventilation.3 When the cuff is deflated, patients can achieve a more natural breathing pattern, allowing for deeper inhalations and more effective exhalations. This enhanced ventilation helps prevent atelectasis and promotes lung expansion. They also found that these positive effects of improved lung recruitment and pressures continued for a period of time after removal of the Valve. By improving respiratory pressures and reengaging the upper airway, use of the PMV with the cuff deflated encourages the engagement of respiratory muscles. Breathing through an open airway, restoring pressures, and producing speech with the PMV requires increased respiratory effort, leading to improved strength and endurance of respiratory muscles.
Deflating the cuff for Valve use is crucial for restoring speech, reducing aspiration risk, and improving respiratory function in patients with tracheostomies. Numerous research studies have investigated the benefits of cuff deflation for Passy Muir Valve use and its impact on respiratory function.1-11 A study by Suiter et al. (2003) found that cuff deflation with PMV resulted in significant improvements in the penetration-aspiration scaled score during swallow studies. Even improved speech clarity and respiratory function in patients with tracheostomies have been indicated in numerous studies. The use of the PMV with cuff deflation leads to enhanced speech and communication, decreased airway resistance, improved respiratory muscle function, and better lung volume and ventilation.1-7 Clinical evidence supports the positive impact of cuff deflation, emphasizing the importance of incorporating this practice into the management of patients with tracheostomies with use of the PMV. Healthcare professionals should be aware of these benefits and encourage proper cuff deflation to optimize the respiratory function and overall well-being of their patients.
- Sutt, A.L., Antsey, C., Caruana, L.R., Cornwell, P.L., & Fraser, J. (2017). Ventilation distribution and lung recruitment with speaking value use in tracheostomised patient weaning from mechanical ventilation in intensive care. Journal of Critical Care, 40, 164-170. https://doi.org/10.1016/j.jcrc.2017.04.001
- Sutt, A., Caruana, L. R., Dunster, K. R., Cornwell, P. L., Anstey, C. M., & Fraser, J. F. (2016). Speaking valves in tracheostomised ICU patients weaning off mechanical ventilation – Do they facilitate lung recruitment? Critical Care, 20(1), 91. https://doi.org/10.1186/s13054-016-1249-x
- Sutt, A., Caruana, L. R., Dunster, K. R., Cornwell, P. L., & Fraser, J. F. (2015). Improved lung recruitment and diaphragm mobility with an in-line speaking valve in tracheostomised mechanically ventilated patients – An observational study. Australian Critical Care, 28(1), 45. https://doi.org/10.1016/j.aucc.2014.10.021
- Freeman-Sanderson, A. L., Togher, L., Elkins, M. R., & Phipps, P. R. (2016). Quality of life improves with return of voice in tracheostomy patients in intensive care: An observational study. Journal of Critical Care, 33, 186-191. https://doi.org/10.1016/j.jcrc.2016.01.012
- Freeman-Sanderson, A. L., Togher, L., Elkins, M. R., & Phipps, P. R. (2016). Return of voice for ventilated tracheostomy patients in ICU: A randomized, controlled trial of early-targeted intervention. Critical Care Medicine, 44(6), 1075-1081. https://doi.org/10.1097/ccm.0000000000001610
- Skoretz, S. A., Anger, N., Wellman, L., Takai, O., & Empey, A. (2020). A systematic review of tracheostomy modifications and swallowing in adults. Dysphagia, 35(6), 935-947. https://doi.org/10.1007/s00455-020-10115-0
- O’Connor, L. R., Morris, N. R., & Paratz, J. (2019). Physiological and clinical outcomes associated with use of one-way speaking valves on tracheostomised patients: A systematic review. Heart & Lung, 48(4), 356-364. https://doi.org/10.1016/j.hrtlng.2018.11.006
- Makary, M. A. & Daniel, M. (2016). Medical error – third leading cause of death in the US. British Medical Journal, 353, i2139. https://doi.org/10.1136/bmj.i2139
- Suiter, D. M., Mccullough, G. H., & Powell, P. W. (2003). Effects of cuff deflation and one-way tracheostomy speaking valve placement on swallow physiology. Dysphagia, 18(4), 284-292. https://doi.org/10.1007/s00455-003-0022-x
- Amathieu, R., Sauvat, S., Reynaud, P., Slavov, V., Luis, D., Dinca, A., Tual, L., Bloc, S., & 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
- Gross, R. D., Steinhauer, K. M., Zajac, D. J., & Weissler, M. C. (2006). Direct measurement of subglottic air pressure while swallowing. The Laryngoscope, 116(5), 753-761. https://doi.org/10.1097/01mlg.0000205168.39446.12