Speaking valves in tracheostomised ICU patients weaning off mechanical ventilation--do they facilitate lung recruitment?

Abstract

Background: Patients who require positive pressure ventilation through a tracheostomy are unable to phonate due to the inflated tracheostomy cuff. Whilst a speaking valve (SV) can be used on a tracheostomy tube, its use in ventilated ICU patients has been inhibited by concerns regarding potential deleterious effects to recovering lungs. The objective of this study was to assess end expiratory lung impedance (EELI) and standard bedside respiratory parameters before, during and after SV use in tracheostomised patients weaning from mechanical ventilation.

Methods: A prospective observational study was conducted in a cardio-thoracic adult ICU. 20 consecutive tracheostomised patients weaning from mechanical ventilation and using a SV were recruited. Electrical Impedance Tomography (EIT) was used to monitor patients' EELI. Changes in lung impedance and standard bedside respiratory data were analysed pre, during and post SV use.

Results: Use of in-line SVs resulted in significant increase of EELI. This effect grew and was maintained for at least 15 minutes after removal of the SV (p < 0.001). EtCO2 showed a significant drop during SV use (p = 0.01) whilst SpO2 remained unchanged. Respiratory rate (RR (breaths per minute)) decreased whilst the SV was in situ (p <0.001), and heart rate (HR (beats per minute)) was unchanged. All results were similar regardless of the patients' respiratory requirements at time of recruitment.

Conclusions: In this cohort of critically ill ventilated patients, SVs did not cause derecruitment of the lungs when used in the ventilator weaning period. Deflating the tracheostomy cuff and restoring the airflow via the upper airway with a one-way valve may facilitate lung recruitment during and after SV use, as indicated by increased EELI.

Trial registration: Anna-Liisa Sutt, Australian New Zealand Clinical Trials Registry (ANZCTR).

Actrn: ACTRN12615000589583. 4/6/2015.

Keywords: Communication; FRC; Lung recruitment; Mechanical ventilation; Speaking valve; Tracheostomy.

Fig. 1

Participant selection chart. SV speaking valve, BiVAD biventricular assist device, EIT electrical impedance tomography, LVAD left ventricular assist device, PMSV Passy-Muir speaking valve, PPM permanent pace maker

Fig. 2

Mean end-expiratory lung impedance (EELI) vs time with average EELI trend for non-vent and pressure support ventilation (PSV). Mean EELI is plotted on the y-axis against a nominal time base. A lowess smoothing line has been added to clarify the overall trend. non-vent patient off mechanical ventilation during recruitment, SV speaking valve