If you are interested in speech-language pathology, the American Speech and Hearing Website (asha.org) is a wonderful resource to start.  You can search for different masters programs based on location.  Then, go to the school’s website to learn more about requirements.  Many schools require Speech-Language Pathology or Communication Disorders as an undergraduate degree.  Other schools only require a certain number of classes in speech pathology.

If your undergraduate school does not have Speech-Language Pathology or Communication Disorders as a degree, look into similar courses.  Linguistics courses frequently contain similar courses to the SLP or CD major.  Such courses may include Language Disorders or Phonetics.  Get a good background in sciences such as biology and anatomy as a foundation for your SLP degree.  You may need to acquire more speech pathology classes after graduation depending on the graduate school’s requirements.

Related posts:

1. Top Speech Pathology Schools
2. Speech Pathology
3. Supervising Speech Pathology Students

Why don’t PEG tubes improve nutrition/hydration in advanced dementia patients?

Nutritional parameters have not shown to improve with PEG tubes even with adequate formula. Patients with advanced dementia have cachexia due largely from inflammatory cytokines that are unimproved by nurition. 

Why don’t PEG tubes improve survival in advanced dementia patients?

Feeding tube placement is a surgical procedure.  Although it is a simple procedure, all procedures come with risks.  Mortality during PEG placement ranges from 0-2%.  Mortality rates (not restricted to patients with dementia only) were 2-27% at 30 days and 50% or more at 1 year.  Median survival rate was 7.5 months (Finucane T, Christmas C, &Travis, K., 1999).

Complications of PEG tubes include tube migration, gastric prolapse, prolonged ileus, necrotizing fascitis, diarrhea, nausea, tube malfunction, aspiration, peritonitis, abdominal abscess, bowel obstruction, vomiting, death, pneumonia.

Why don’t PEG tubes improve pressure ulcers?

Retrospective studies found an increased risk or no benefit associated with tube feeding and pressure ulcers.  Another study with a 6-month follow up reported that tube feeding was not associated with healing of preexisting pressure sores or protection of new pressure sores. 

This may be due to increased restraint use with patients with PEG tubes causing limited movement to be off the pressure sore.

Why don’t PEG tubes reduce aspiration risk or pneumonia rates in advanced dementia patients?

 
PEG tubes actually increase the risk of aspiration pneumonia. It is one of the most common causes of death after PEG placement. This may be due to increased gastroesophageal reflux or from oropharyngeal colonization. (Finucane TE, Bynum JPW, 1996).  PEGs may reduce lower esophageal sphincter pressure and increase the risk of gastroesophageal reflux.  A nonrandomized, prospective study showed that orally fed patients with oropharyngeal dysphagia had significantly fewer major aspiration events than those fed by tube.

Why don’t PEG tubes improve quality of life in advanced dementia patients?

Patients with advanced dementia are likely unable to communicate his or her wants/needs. Therefore comfort can only be based on inference.  Terminally ill patients with anorexia with cancer/stroke, few experienced hunger or thirst.  Of those who did, relief was achieved with small amounts of food and fluids. 

Tube fed patients would be denied the pleasure of eating or made uncomfortable to the tube and frequent repositioning.  Increased restraint use occurs with advanced dementia patients with PEG tubes.

Are we starving the patient if we do not provide artificial nutrition/hydration?

The majority of patients who stop eating do not experience hunger or are only hungry initially.  Terminal anorexia and dehydration may actually benefit the patient by inducing ketosis, uremia, and endorphin release. 

Speech-language pathologists are important in helping families make decisions concerning PEG placement. When a patient begins having difficulty with eating or dirnking, make them aware and let them know their decisions for the future. The patient can then be prepared and have their wishes written down.

Patient education form: to help families decide if a PEG tube would benefit their loved one:

Tube Feeding Decisions for People with Advanced Dementia

_______________________________________________________________________________

References:
Finucane, T., Christmas, C. & ravis, K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA, 1999;282:1365-1370.

Finucane TE, Bynum JPW. Use of tube feeding ot prevent aspiration pneumonia. Lancet, 1996; 348:1421-1424.

Related posts:

1. Does Thickening Liquids Work to Prevent Aspiration in Patients with Dementia?
2. SLP role in Decannulation of Tracheostomy Tubes
3. Blom Tracheostomy Tube

What is VitalStim?

VitalStim Therapy is a dysphagia treatment that uses Neuromuscular Electrical Stimulation to the swallowing muscles.  Current is applied to the neck region, with the expectation that muscle function during swallowing will be enhanced.  The use of VitalStim is FDA approved and must be used in conjunction with convetional swallow exercises.  You must pass a certification program in order to perform VitalStim therapy.  Certification includes an online course, written exam, 2-day conference where participants demonstrate the ability to use VitalStim effectively, and ability to correctly apply electrodes and operate the equiment appropriately.

Even if you do not ever use VitalStim, the conference reviews the anatomy and phsyiology of the swallow very effectively.  There is a review of the cranial nerves used for swallowing such as the Trigeminal (CN V), Facial (CN VII), Glossopharyngeal (CN IX), Vagus (CN X) and Hypoglossal (CN XII).

Protocol for VitalStim

The protocol for VitalStim involves placing electrodes on the laryngeal and submental regions, depending on where the patient’s swallowing problems are.  The intensity of the stimulation is increased until the patient reports feeling the “muscles grabbing.”  Therapy is an hour long and patients are encouraged to perform swallow exercises while having the muscles stimulated.  For example, patients may be asked to “swallow hard” with their saliva and then work up to ice chips, purees and solid foods.

VitalStim is not covered by insurance due to the paucity of evidence at this time.

Indications/Contraindications for VitalSim

According to the conference, candidates for VitalStim are thoses on a modified diet, at risk for aspiration, or patients demonstrating penetration or aspiration.  Contraindications are those with an active cancerous tumor, severed/compromised nerve, Guillian Barre.

Although the conference teaches that VitalStim can be used on all individuals (except thet few contraindications), it seems that electrical stimulation should be considered only for persons with healthy sensory and motor nerves. Individuals who have injuries to the CNS may be candidates such as patients with a stroke, traumatic brain injury or excision of a brain tumor. After injury to cortical and/or subcortical pathways, cortical control may be lost or cortical inputs may be blocked, interfering with voluntary or automatic firing of the motor neurons in the brain stem for the craniofacial, laryngeal, and pharyngeal musculature during swallowing.  Electrical stimulation bypasses that block by stimulating the axons from the motor neurons to fire the muscles, bypassing the central control abnormalities.

Conversely, if the client has intact sensory inputs to the brain stem, but the transmission of the sensory inputs from the brain stem to the thalamus and/or cortex is disrupted because of brain injury, then the client can no longer perceive the sensory information being relayed to the brain stem. In this case, electrical stimulation of the sensory nerves may augment the person’s sensation if there is some sensory relay to the thalamus and cortex so that the client can perceive the stimulus.

The presenters reported that VitalStim was beneficial on patients with ALS and Myasthenia Gravis.  However, in electrical stimulation of muscles, the axons innervating muscle fibers—not the muscle fibers—are stimulated. Clients with motor neuron diseases such as ALS have motor neuron death resulting in axonal die back and loss of muscle fiber innervation, blocking the effects of electrical stimulation. Similarly, in persons with peripheral injury or neuropathies, such as spinal muscular atrophy, the axons die back and the muscle fibers are no longer innervated and can’t be accessed by electrical stimulation. Persons with myasthenia gravis have antibodies that block acetylcholine receptors on muscle fibers, preventing muscle fiber activation. Further, in sensory peripheral neuropathies, the sensory nerve endings are lost and can’t be stimulated. Therefore, TES is not an appropriate option to use with individuals with peripheral sensory and/or motor impairments.

Evidence for VitalStim:

There has been much debate regarding the benefits of Vital Stim. Whether or not VitalStim works is a tough questions since there is limited data. Empirical data regarding the effect of electrical stimulation specific to swallowing function primarily in adults are beginning to appear in peer-reviewed publications. Some of the results are conflicting, and there appears to be mixed evidence in regard to electrical stimulation’s rehabilitative effects on swallowing recovery. Evidence is needed for different types of diseases and disorders.

The limited research on this topic includes two reports of treatment outcomes before and after the introduction of TES (Blumenfeld, Hahn, Lepage, Leonard, & Belafsky, 2006; Kiger, Brown, & Watkins, 2006). One report was a retrospective unblinded chart review comparing changes in swallow severity, and found a greater benefit in a TES group compared with the traditional dysphagia treatment (TDT) group (Blumenfeld et al., 2006). The other report compared unblinded ratings of videofluoroscopic and fiberoptic endoscopic evaluations of oral and pharyngeal swallowing (FEES) before and after either TES or TDT treatment. The TDT group experienced greater improvements in both the oral and pharyngeal phases than did the TES group (Kiger et al., 2006). As changes in dietary consistency advancement did not differ between the two groups, the authors concluded that there was no difference in outcome between the two groups (Kiger et al., 2006). Thus, these two investigations yielded inconsistent results, but because neither study included random assignment of participants to different treatment conditions, their validity is questionable.

A more recent study (Permsirivanich W, Tipchatyotin S, Wongchai M, et al., 2009), also compared the use of NMES (VitalStim) with traditional treatment techniques. They randomized 23 subacute stroke patients with severe dysphagia into a rehabilitation group receiving traditional interventions or an NMES group receiving NMES with swallowing exercise. They found that the NMES group made significantly greater gains in their swallow function.

A meta-analysis combining some of the TES studies found a modest effect size of 0.6 (Carnaby-Mann & Crary, 2007); however, the effect sizes for TES with TDT versus TDT alone is unknown. Two uncontrolled reports on a series of patients, one retrospective (Shaw et al., 2007) and the other prospective (Leelamanit, Limsakul, & Geater, 2002), provide some information regarding severity of dysphagia and response to TES. The prospective study found that the more severely involved participants with post-stroke dysphagia did not improve to the same degree as the participants whose swallowing problem was idiopathic or due to aging. The retrospective case series found a relationship between participants’ initial severity and subsequent improvement with TES. Mildly to moderately impaired participants showed some improvement, while participants with the most severe dysphaga did not improve with TES treatment (Shaw et al., 2007). Without a control group, it cannot be determined whether or not recovery in the mildly to moderately impaired persons was due to TES, dysphagia therapy, or spontaneous recovery.

However, the results of these two case series are in agreement with the physiological findings on the effects of TES (Humbert et al., 2006; Ludlow et al., 2007). Ludlow and colleagues (2007) concluded that participants with severe dysphagia who are unable to overcome the TES induced hyo-laryngeal descent during swallowing may not benefit from TES. That is, the risk of aspiration or penetration may be increased because the application of TES can reduce hyo-laryngeal elevation even in healthy persons with normal swallowing (Humbert et al., 2006). Therefore, it is recommended that clinicians evaluate whether or not a patient has increased risk of aspiration or penetration during swallowing when the device is turned on at an effective level during videofluoroscopy before considering using TES in therapy.

The result of a systematic review of the literature by Clark in 2009: “Promising results are reported in the reviewed literature on the use of surface NMES as a motor facilitation tool (VitalStim). The useof NMES as a sensory facilitation tool is also reported as a promising modality. Studies on both these application methods generally have methodological limitations, making it difficult to estimate effect size.”

Surface NMES to the neck has been most extensively studied with promising findings, yet high-quality controlled trials are needed to provide evidence of efficacy.  Even if we are certified in VitalStim, we should continue to use the available research to evaluate outcomes.  As speech-language pathologists, we can personally acquire new clinical data to the existing research for specific populations.

References:

Blumenfeld, L., Hahn, Y., Lepage, A., Leonard, R., & Belafsky, P. C. (2006). Transcutaneous electrical stimulation versus traditional dysphagia therapy: a nonconcurrent cohort study. Otolaryngology—Head and Neck Surgery, 135(5), 754-757.

Carnaby-Mann, G. D., & Crary, M. A. (2007). Examining the evidence on neuromuscular electrical stimulation for swallowing: a meta-analysis. Archives of Otolaryngology—Head & Neck Surgery, 133(6), 564-571.

Humbert, I. A., Poletto, C. J., Saxon, K. G., Kearney, P. R., Crujido, L., Wright-Harp, W., et al. (2006). The effect of surface electrical stimulation on hyo-laryngeal movement in normal individuals at rest and during swallowing. Journal of Applied Physiology, 101, 1657-1663.

Kiger, M., Brown, C. S., & Watkins, L. (2006). Dysphagia management: an analysis of patient outcomes using VitalStim therapy compared to traditional swallow therapy. Dysphagia, 21(4), 243-253.

Leelamanit, V., Limsakul, C., & Geater, A. (2002). Synchronized electrical stimulation in treating pharyngeal dysphagia. Laryngoscope, 112(12), 2204-2210.

Ludlow, C. L., Humbert, I., Saxon, K., Poletto, C., Sonies, B., & rujido, L. (2007). Effects of surface electrical stimulation both at rest and during swallowing in chronic pharyngeal dysphagia. Dysphagia, 22, 1-10.

Permsirivanich W, Tipchatyotin S, Wongchai M, et al (2009). Comparing the effects of rehabilitation swallowing therapy vs. neuromuscular electrical stimulation therapy among stroke patients with persistent pharyngeal dysphagia: a randomized controlledstudy. J Med Assoc Thai. 92(2):259-265.

Related posts:

1. American Woman Wakes from Surgery with British Accent
2. Does Thickening Liquids Work to Prevent Aspiration in Patients with Dementia?
3. Dysphagia Treatment

Goals for Targeting Increased Knowledge of Stuttering

•  Johnny will increase his knowledge about stuttering by passing 3 quizzes on basic stuttering facts.

• Johnny will educate 2 friends about his stuttering treatment techniques.

•  Johnny will give a presentation to his family members, peers, or teachers on stuttering.

•  Johnny will participate in periodic stuttering trivia contests that are held with other children who stutter.

• Johnny will be able to identify and explain the process of producing speech and the anatomical structures involved in this process through use of drawings and other illustrations.

Goals for Targeting “Quality” of Stuttering

• Johnny will demonstrate the ability to reduce physical tension during stuttering using the “easing out” technique, for 50% of disfluencies during various tasks.

•  Johnny will use cancellation and pull-out techniques for 75% of disfluencies in a structured conversational task.

• Johnny will be able to correctly identify location of physical tension during 80% of stuttering episodes in a structured task.

• Johnny will decrease the use of any secondary behaviors associated with his stuttering to less than 10% of disfluencies.

Goals for Targeting the “Quantity” of Stuttering

•  Johnny will demonstrate the ability to reduce the number of disfluencies in his speech by using easy starts 85% of the time in a structured conversation.

• Johnny will decrease the number of disfluencies in a structured conversational task by 15%.

•  Johnny will demonstrate the ability to reduce the number of disfluencies in his speech by reducing rate of communication by 20%.

Goals for Targeting Overall Communication

•  Johnny will decrease avoidance behaviors associated with his stuttering by entering 3 specific situations where he previously avoided stuttering.

•  Johnny will demonstrate desensitization to stuttering by using 5 pseudostutters during a conversation in the classroom.

•  Johnny will increase participation in educational and social situations, as noted on a weekly basis by his parents and teachers.

•  Johnny will use correct posture and eye contact 85% of the time in conversational speech with the clinician.

Related posts:

1. Sample Articulation Goals
2. Dysarthria Treatment
3. Articulation Treatment

Here is a list of articulation games to help improve your therapy!

Games with Articulation Cards:

• HIDE & SEEK: Clinician hides the articulation cards around the therapy room.  When the client finds them, he says the word on the card using good sounds.
• GO FISH!: Each player gets 5 cards.  The goal is to make a match with each of the cards.  Player 1 asks player 2 for a card they need to make a match.  If player 2 has the card, he hands it over to player 1.  If not, player 2 says “GO FISH” and player one chooses a card from the deck. Use articulation cards that the client needs to work on!
• MYSTERY PICK: Clinician chooses a winning card, places the card back in the deck, shuffles and fans the cards out. Clients take turns selecting cards, saying the word on the card. The one who picks the winning card gets a sticker.
• BEAN BAG TOSS: Place the cards in a row on the floor. Select a winning card. Have the client stand a few feet back and try to toss the bag on the winning card. The client must say the word on the card that the bag lands on.
• FISHING FOR WORDS OR NUMBERS: Use a fishing pole with a magnet to pick up cards with paper clips attached, or use the pole to pick up fish with numbers on them. The number indicates how many words the clients have to say.
• RACE FOR CANDIES: Turn articulation cards upside down in 1 row per player. The clients have to turn over a card, say the word correctly and move to the next card. If they misarticulate they have to stop and repeat the word until they get it right. At the end of the rows of cards is a prize, such as candy or a sticker.
• GUESS WHAT!: Cover an articulation card with a plain index card and slowly unveil it. The client has to guess (and correctly articulate the word) before the picture is totally revealed.
• PICK 2: The client selects 2 cards from the deck at random and has to put both in 1 sentence that makes sense and with correct articulation.
• ARTICU-BOWL: Attach cards to bowling pins and have the client bowl over the pins. As he picks the pins up, he must correctly articulate each word attached to the pins.
• MEMORY LINE-UP: Place 3, 4, 5 cards in a row, have the client say the words, then close his/her eyes while you switch the order. He must put them back in order and say them again.
• ARTIC AIM: Use a gun that shoots spinners (plastic ones are about a dollar at major discount stores) to try and hit a card. The client has to correctly articulate the one s/he is aiming for and then hits.
• PICTURE GUESS: Two teams take turns selecting a card from the deck and then drawing the picture. The other team must try to guess what the target word is and correctly articulate it.
• PSYCHIC ARTIC: Show clients 2 or 3 cards, shuffle these and pass them out. They each must each take turns trying to guess which card you or the other players have. (this can be a good language-naming game too)

OTHER GAMES FOR ARTICULATION:

Related posts:

1. Articulation Treatment
2. Sample Articulation Assessment
3. Sample Articulation Goals

Supervising speech pathology students can be more work.  However, there are some positives to having a student.  Students are learning new information and research in their classes and can bring additional information to the clinical practicum.  They also frequently ask questions that make us think about our evaluation and therapy options.

Being a mentor is important to give back to our field.  Speech pathology is expanding and supervising helps to bring new professionals into our field.  Professional growth and career development are also benefits of supervision.  It can provide a leadership opportunity to provide knowledge to another person.

There are a few requirements if you are thinking of supervising a graduate student.

• Hold a certificate of clinical competence from the American Speech and Hearing Association
• Supervisors must have competency in the area that they are supervising the student
• Supervisors do not need a certain number of years, but one must have sufficient knowledge to educate a student
• According to Standard IV-E of the SLP Certification Handbook: ”Direct supervision must be in real time and must never be less than 25% of the student’s total contact with each client/patient and must take place periodically throughout the practicum. These are minimum requirements that should be adjusted upward if the student’s level of knowledge, experience, and competence warrants.”
• “The amount of supervision must be appropriate to the student’s level of knowledge, experience, and competence. Supervision must be sufficient to ensure the welfare of the client/patient.”
• Supervisors must have clinical competency in supervision.  This can be done through classes, continuing education courses, etc.

Asha has more information on requirements and frequently asked questions concerning the supervision of students.

A challenge for many speech pathologists who choose to supervisor students may be meeting productivity standards.  Some work environments may demand  75% productivity.  There must be a balance between providing high quality service to our clients while also providing efficient supervision.  The most difficult may be with a novice clinician.

The first few days, the student would need the most supervision. The supervisor would demonstrate how to perform the evaluation and effective goal setting and treatment plans.  Then the supervisor can expect the student to perform more of the evaluations and therapy independently as they gain competence.  A supervisor meeting can be held to review cases and questions.  Determine the feedback that is preferred and the students learning style.  Student strengths, areas that require improvement, and suggestions to make the improvement can be reviewed. Constant feedback is important and also having the student provide feedback on his or her own session would be beneficial.  Try to have an agenda for each meeting and review goals and objectives for the client cases.

Evaluate  yourself during supervision:

Ask yourself, “Did I…..

• Make clear the expected behaviors/desired results
• Provide instructions in a clear, understandable manner
• Invite dialog/discussion
• Provide specific/appropriate feedback
• Answer supervisee’s questions
• Demonstrate a supportive, encouraging attitude rather than being judgmental or punitive.
• Make time for planning on a weekly basis
• Schedule regular supervisory conferences

Resources:

McCrea, Elizabeth S. andBrasseur, Judith A., The Supervisory Process inSpeech-Language Pathology and Audiology, Allyn& Bacon, 2003, p. 8

Related posts:

1. Speech Pathology
2. Request for Speech Consultation- Teacher Form
3. Articulation Treatment

The first applications for speech therapy became available on Itunes in 2009.  Now there are new apps added daily.  They can  be fun and engaging for clients.  Apps can be used for a variety of disorders.  Applications for articulation include Articulate It, Smarty Ears, /r/ intensive, All About Sounds, and ArticPix.  Other applications are for improving language such as helping with answering WH- questions, sentence building apps, and sequencing.  There are even apps for fluency/stuttering and voice as well as text-to-speech generators.  Apps can be used to collect data, record conversations, or for motivation.

These applications can be more affordable than the traditional paper-based materials.  Some apps are free, while others can cost a few hundred dollars. Proloquo2Go^™, a popular app for augmentative and alternative communication (AAC), currently costs $189.99.

However, this is a text-to-speech generating devices.  Devices such as this can  go for thousands of dollars.  Text-to-speech mobile applications are thus more affordable. Families don’t have to wait for funding through their insurance companies for augmentative communication (AAC).  Also, people may be more accepting of using applications on devices such as the Ipad or Iphone.  Individuals may have felt traditional AAC technology was too large, too heavy, too costly, and too difficult to learn.  However, one should be cautious about the use of mobile devices as a means of AAC, unless an assistive technology assessment has been conducted and the device and app(s) are found to be the most appropriate means of communication for the individual.

These apps are not for everyone, and the speech-language pathologist is needed to decide which application is best, if any.  Apps do not replace therapy.  Instead they should be used to complement treatment.

There is a great link listing applications for the Iphone and Ipad here.   It includes a description of many of the available applications.

Related posts:

1. Augmentative and Alternative Communication
2. Augmentative Communication for ALS Patients
3. Autism

Related posts:

1. Speech Pathology

The Blom Tracheostomy Tube is a revolutionary tracheostomy tube that allows adult ventilator dependent patients the ability to speak, regardless of cuff status.  Patients are able to speak with a clear voice, with the cuff inflated.  This is different from the Passy-Muir Speaking Valve (PMV).  The PMV requires full cuff deflation and is not to be used with an inflated cuff.  The patient would not be able to breath if the PMV was used with an inflated cuff.  The Blom Tracheostomy would be most beneficial for patients who are not able to tolerate cuff deflation due to aspiration risk, medical status, etc.

How does the Blom Tracheostomy Tube work?

The Blom Tracheostomy Tube is a fenestrated tracheostomy tube.  This means that there is an opening in the tube that permits airflow through the upper airway.  The fenestration is located 1mm above the cuff, to help prevent the fenestration from touching the tracheal mucosa.  The placement of the fenestration is supposed to reduce granulation tissue from forming.

The Valve Speech Cannula (VSC) is placed inside the fenestrated tracheostomy tube, after removal of the inner cannula.  The VSC redirects the airflow to allow for speech with a cuffed tracheostomy.  During inhalation, the airflow is directed through the speech cannula flap and down into the lungs, to ventilate the patient.  No airflow escapes past the cuff during inhalation. During exhalation, the flap valve closes and the bubble collapses so that the air is redirected past the speech cannula and up through the fenestrated tracheostomy tube.  The air continues through the vocal folds to allow for speech.  It is possible to deflate the cuff  for more oral airflow.

The Low Profile Valve is a seperate device that is used with non-fenestrated uncuffed or fenestrated cuffed tracheostomy tubes for spontaneously breathing patients.  This device should not be used with mechanical ventilation (use the valve speech cannula).

The Exhaled Volume Reservoir is a serperate component that assists in preventing false low-expiratory minute volume alartms that would occur because the exhaled air is directed through the upper airway instead of  back to the ventilator.

The Blom Tracheostomy Tube can be used with a subglottic suctioning cannula, which can suction secretions that are above the tracheostomy from the fenestration.  This may help to prevent ventilator associated pneumonia.

Patient Candidacy for Blom Tracheostomy Tube:

Patient Requirements:

• The patient must be ventilator dependent on a standard or portable ventilator
• The patient must have a Fenestrated Cuffed Blom Tracheostomy Tube
• The patient must be arousable and have the potential to communicate
• The patient may be in volume or pressure ventilation in any ventilatory mode
• The patient does not need to be breathing spontaneously
• The patient does not need to be able to tolerate cuff deflation
• The patient should not have copious, thick secretions requiring suctioning more than five times per hour
• The patient should have a patent, unobstructed upper airway
• FiO₂should not exceed 60%
• PEEP should not exceed 10

Warning: Patients who require PEEP should be placed on ventilators with Flow Trigger or supplemental bled in oxygen.

What ventilator setting changes should be made to facilitate tolerance of the Speech Cannula or alarm management?

Changes may include:

• Increasing the high pressure threshold during volume ventilation to compensate for the negligible restriction to gas flow when air is delivered during inspiration through the flap valve.
• Reducing inspiratory time or increasing peak flow to extend the expiratory phase and decrease the likelihood of air trapping when large tidal volumes, high breath rates, or high pressure control levels are used.
• Patients who require PEEP should be placed on ventilators with flow triggering or supplemental bleed in oxygen.

The Blom is not a specialty or custom tracheostomy tube and can be used as the initial tracheostomy tube.  However, at this time the patient is most likely to be admitted to a hospital with a different tracheostomy tube such as a Shiley, Portex or Bivona. These are more common tracheostomy tubes at this time.  Therefore, the entire tracheostomy tube must be changed to the Blom Tracheostomy Tube, to use the Blom Valve Speech Cannula or the Low Profile Valve.   This is may be more difficult to do, and more costly than the Passy-Muir Speaking Valve.  The PMV can fit onto the hub of all Shiley, Portex, Jackson metal, and Bivona (unable to use with foam filled Bivona).  It seems that the PMV should be trialed first if the patient was admitted with a tracheostomy tube other than the Blom, if the cuff is able to be deflated.

However, the Blom Tracheostomy Tube system is another device that can be utilized in acute or long term care to help improve our patient’s communication.  Patients on mechanical ventilation who are unable to tolerate cuff deflation are ideal candidates for the Blom Tracheostomy Tube to allow for speech.  This may include patients with ALS, cervical spine injury, and progressive neurological disorders.  The Blom Tracheostomy Tube system has shown to be safe and effective and well tolerated in individuals with mechanical ventilation (Kunduk, M. et. al, 2010).

References:

Kunduk, M., Appel, K. Tunc, M., Alanoglu, Z., Alkis, N.Dursun, G., & Ozgursoy, O.B.  Preliminary report of laryngeal phonation during mechanical ventilation via a new cuffed tracheostomy tube.  Respiratory Care. 55(12) 1661-90.

Related posts:

1. Sample Tracheostomy Weaning Protocol
2. SLP role in Decannulation of Tracheostomy Tubes
3. Passy-Muir Valve (PMV) in-line Ventilator Protocol

Speech-Language Pathologists play an important role in improving dehydration in patients with dysphagia.  Dysphagia can frequently lead to dehydration, especially in the elderly.  Dehydration means that the body does not have as much fluids as it should.  It can be caused by not drinking enough fluids or losing too much fluid such as with vomiting/diarrhea. 

The prevalence of oropharyngeal functional dysphagia is very high: it affects more than 30% of patients who have had a cerebrovascular accident; 52%–82% of patients with Parkinson’s disease; 84% of patients with Alzheimer’s disease, up to 40% adults aged 65 years and older, and more than 60% of elderly institutionalized patients (Clave, P., et. al, 2004; Elkberg, O., e. al, 2004)   Sometimes, these patients may have both dysphagia and dehydration.  Dehydration is one of the most common causes of hospitalization among elderly individuals who live in the community or long term care facilities.

Risks for dehydration:

Risks for dehydration are numerous in the elderly.  A major risk factor is when a patient is on multiple medications.  Many medications can cause dysphagia and reduce salivary flow.  Patients with dry mouths and reduced salivation have difficulty chewing foods.  Another factor is mobility.  Elderly patients may not be able to get up to get a glass of water.  They also may forget that they haven’t eaten/drank.  These patients need to be offered food and drink, even if the patient is not asking for it. 

Patients on modified diets also are at risk for dehydration.  Patients with thickened fluids may be noncompliant because they dislike the thickened fluids and therefore the intake of fluids is minimal, leading to dehydration.  The Frasier water protocol has been developed to help reduce dehydration and improve quality of life.  Patients aspirating thin liquids, are allowed free water between meals.  It was intended for those who are able to participate in three hours of physical therapy 6 times/week. Studies showed that these patients did not have a significantly higher risk of getting aspiration pneumonia. 

One study,  compared patients aspirating on thin liquids given free water to a control group who were not given free water.  The patients were placed as aspirators only after a bedside swallow evaluation (not all underwent videofluroscopy).  The patients who received the free water  (14.3%) compared to the control group (no cases), suggested a causal relationship between aspiration of water and the development of lung complications including aspiration pneumonia(Karragianas, M., 2011).  The water protocol should be used with caution on patients who are immobile with multiple medical conditions. 

Consequences of dehydration:

Negative consequences of dehydration include changes in drug potency, trouble with healing from infections and wounds, urinary tract infections, constipation, confusion, lethargy, acute renal failure, and a malfunctioning cardiac system.

Lab Values indicating dehydration:

Speech-language pathologists should be mindful of laboratory values indicating dehydration. A patient with diabetes may have an elevated blood sugar level, which can cause sugar to spill over into the urine and adding water, results in dehydration. The condition is accompanied by frequent periods of urination.  Electrolytes may be imbalanced or there can be a lack of potassium, sodium and chloride to help the body function properly.  Check the BUN and Creatinine.  High BUN and creatinine may suggest dehydration.  The color and clarity of urine, the urine specific gravity (the mass of urine is compared with that of equal amounts of distilled water), and the presence of ketones (carbon compounds—a sign the body is dehydrated) in the urine may all help to indicate the degree of dehydration.
It is important to use a multidisciplinary approach to diagnosis and treatment of dysphagia and dehydration.  If a person is losing weight or not eating as much, the speech-language pathologist can speak with the dietitian about the resident’s nutrition and hydration status.  Together, collaborate in ways to improve dehydration.

Components of a Comprehensive Hydration Program:

1. Educate the staff and families on warning signs for dehydration and ways to prevent dehydration.

2. Estimate the patient’s fluid needs on initial assessment, quarterly, yearly and any significant changes. 

3. Develop and maintain a comprehensive care plan that documents the resident’s dehydration risk factors, estimated fluid needs and an individualized plan for meeting fluid needs.

4. Establish a facility standard for the minimum amount of fluid served on meal trays each day and assure that residents receive adequate assistance at mealtime.

 5. Provide a large water cooler at each nursing station and replenish with fresh cool water daily. Make sure that 10–12 oz cups are readily available (cup holders may be needed). Develop a procedure for how coolers are washed and sanitized.

 6. Use 8oz cups to provide fluids at each medication pass.

 7. Start systematic fluid passes by using a hydration cart at least twice daily and offer a variety of fluids. Use 10 -12oz cups and include fluid selections that are new for residents, such as tropical punches, caffeine free sodas and ethnic beverages that are favorites for your resident population.

8. Set up hydration stations in the Rehabilitation and Activities Departments.

 9. Implement a visual system, such as a picture of a drop of water next to the resident’s name on his/her door, so that staff can easily identify residents at highest risk for dehydration.

 10.Implement a mealtime and between meals fluid intake documentation system.

 11. Establish a system for providing the facility’s Registered Dietitian (RD) and/or Diet Technician (DTR) with a copy of current hydration related laboratory values. The RD and/or DTR review the laboratory results, complete a timely assessment of the resident’s hydration status and update the resident’s hydration plan of care as needed. 

12. Implement quality assurance monitoring of the Comprehensive Hydration Program.

References:

Clavé P, Terré R, de Kraa M, Serra M. Approaching oropharyngeal dysphagia. Revista Espanola de Enfermedades Digestivas. 2004;96(2):119–131. [PubMed]

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