Weaning from Prolonged Mechanical Ventilation: Use of Speaking Valve Trials
CCCF ePoster library. Kowalski S. Oct 27, 2015; 114753; P101 Disclosure(s): This study was supported by a grant from the Department of Anesthesia and Perioperative Medicine, University of Mantoba
Stephen Kowalski
Stephen Kowalski
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Abstract
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P101


Topic: Case Report


Weaning from Prolonged Mechanical Ventilation: Use of Speaking Valve Trials



Stephen Kowalski, K. Macaulay, R. Thorkelsson, A. Robertson, L. Girling, Z. Bshouty

Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada | Deaprtment of Respiratory Therapy, Health Sciences Centre, Winnipeg, Canada | Deaprtment of Critical Care, Health Sciences Centre, Winnipeg, Canada | Department of Medicine, University of Manitoba, Winnipeg, Canada | Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, Canada | Department of Medicine, University of Manitoba, Winnipeg, Canada

Introduction:

Patients who require prolonged weaning from mechanical ventilation (MV) have failed 3 or more spontaneous breathing trials (SBT) or require more than 7 days of MV after the first SBT.

The Intermediate Intensive Care Unit (IICU) is a dedicated 6-bed unit for patients who require prolonged weaning. All patients have tracheostomies. Traditional weaning strategies have involved either reduction of pressure support ventilation or gradual increase of T-piece breathing (1-3).

Successful weaning is defined as liberation from MV for > 48 hrs.

.



Objectives:

This report describes the successful use of a variation of T-piece weaning entitled a speaking valve trial (SVT).

T-piece weaning occurs when the patient is disconnected from all ventilator support and allowed to breathe spontaneously for gradually extended periods of time. Traditionally, the tracheostomy cuff is kept inflated and supplemental oxygen is delivered with a T-piece connection or a mask.

In an SVT, the patient is disconnected from the ventilator and a specific type of tracheostomy tube, the Bivona Tight-To-Shaft (TTS) is used. The TTS has an elastic cuff, which when deflated, is adherent to the shaft of the tracheostomy tube. This gives the tube a “low profile” which minimizes the resistive work of breathing around the tube.

The tracheostomy cuff is deflated and a one-way valve is attached to the tracheostomy tube.

Inspiration occurs through the valve or through the pharynx around the tracheostomy tube.

Expiration can only occur around the tracheostomy tube, through the glottis, hence enabling the patient to vocalize.

Supplemental oxygen can be delivered via nasal prongs, facemask or tracheostomy mask.

The time off the ventilator is gradually increased until the patient is liberated



Methods:

After local ethics board approval, all patients admitted to IICU in 2013 and 2014, were identified. This list was cross-referenced with the Respiratory Therapy Department, which kept a log of patients who had a TTS. The charts were then reviewed and data extracted concerning the use of SVTs.



Results:

In 2013-14, there were 48 patients admitted to the IICU. The average length of stay in IICU was 110 days (range 15 to 375).

Twenty one patients had Bivona TTS. Five patients did not have SVTs.

Data on the 16 (9 males, 5 females) patients with SVTs are included in Supplementary Materials.

None of the 16 patients died in IICU but 3 subsequently died in hospital.

Two patients relapsed after being weaned and had to be re-ventilated.

No other patients had pneumonia after SVT initiation.

Two patients were transitioned to long-term ventilator support, at night only, with permanent tracheostomies.

Eleven patients were discharged.



Conclusion:

SVTs were successfully used in a diverse group of patients requiring prolonged weaning. All patients had evidence of respiratory muscle weakness as shown by the first recorded VC and MIP. There was no formal protocol regarding the initiation of SVTs.

The major barrier to deflation of the tracheostomy cuff is the aspiration risk to the patient, which has to be assessed on an individual basis (4).

The over-riding observation of the IICU care team was that the ability and opportunity to speak, was of enormous psychological benefit to patients. The patient felt empowered and in control.

As the care team gained more experience with SVT, it has been initiated progressively earlier in the weaning process, starting with 5 minute trials. The patients appreciate the ability to speak, even for these short periods and are eager to participate and progress.

We plan to initiate a protocol for patients requiring prolonged ventilation involving the use of SVT.



References:

1. Martin AD, Smith BK, Gabrielli A. Mechanical Ventilation, Diaphragm Weakness and Weaning: A Rehabilitation Perspective. Respiratory Physiology & Neurobiology 2013;189, 377- 383

2. Frutos-Vivar F, Esteban A. Our Paper 20 years later: How has withdrawl from mechanical ventilation changed? Intensive Care Med 2014;40, 1449 – 1459
3. Ladeira MT, Vital FM, Andriolo RB, Andriolo BN, Atallah AN, Peccin MS. Pressure Support versus T-tube weaning in Adults Cochrane Database Sys Rev. 2014 May 27;5​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​ 4

​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​ 4. Hernandez G, Pedrosa A, Ortiz R, et al. The effects of increasing airway diameter on weaning from mechanical ventilation in tracheostomized patients: a randomized trial. Intensive Care Med 2013;39, 1063 - 1070
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