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Cartaya R, Rizvi SAA, Manara V, Tesch ML, Franck R. Ferrer Adjustable Speaking Valve for Early Phonation in a Deconditioned Patient. Cureus 2024; 16:e62081. [PMID: 38868548 PMCID: PMC11168738 DOI: 10.7759/cureus.62081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2024] [Indexed: 06/14/2024] Open
Abstract
A patient with multiple comorbidities and an eight-year history of tracheostomy was being treated for tracheitis. At this point, she became incapable of using regular speaking valves, and multiple attempts to reintroduce the speaking valve failed. A Ferrer adjustable speaking valve (FASV) was designed with gradations of outflow closure, allowing air to go through the vocal cords for phonation. The FASV was offered to her through the compassionate use program at the FDA. At 20% initial closure, the patient was able to tolerate the valve and was advanced to 50% closure, at which point she could phonate partially. The use of the valve was terminated at the time of her transfer, 23 days after the initiation of use. This suggests the safety and possible efficacy of using an adjustable speaking valve earlier than regular valves, allowing patients to communicate earlier and further exercise their diaphragms.
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Affiliation(s)
| | | | - Viviane Manara
- Pulmonary and Critical Care, Ferrer Pulmonary Institute, Hallandale Beach, USA
| | - Mari L Tesch
- Research and Development, Dr. Ferrer Biopharma, Hallandale, USA
| | - Rahaghi Franck
- Pulmonary and Critical Care Medicine, Cleveland Clinic Florida, Weston, USA
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2
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Mills CS, Michou E, Bellamy MC, Siddle HJ, Brennan CA, Bojke C. Worth a try or a last resort: Healthcare professionals' experiences and opinions of above cuff vocalisation. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2024; 59:932-946. [PMID: 37902100 DOI: 10.1111/1460-6984.12970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 10/02/2023] [Indexed: 10/31/2023]
Abstract
BACKGROUND Above cuff vocalisation (ACV) involves the application of an external flow of air via the subglottic port of a tracheostomy. ACV can facilitate vocalisation and may improve swallowing and quality of life for patients with a tracheostomy. A recent systematic review highlighted the limited evidence available for the acceptability, effectiveness, safety or optimal implementation of ACV. AIMS To explore the experience of healthcare professionals (HCPs) using ACV and their perceptions of best practice. METHODS AND PROCEDURES Semi-structured interviews were conducted with a range of HCPs with experience using ACV. Topics included: experiences with ACV, management of ACV, opinions about ACV, impact of COVID-19, future directions for ACV and impact on length of stay. Interviews were conducted online from December 2020 to March 2022. Data were analysed using reflexive thematic analysis. OUTCOMES AND RESULTS Twenty-four HCPs were interviewed from seven countries and five professional groups. Four interconnected themes were developed: (1) moral distress amplifying the need to fix patients; (2) subjectivity and uncertainty leading to variations in practice and purpose; (3) knowledge and experience leading to control and caution; and (4) worth a try or a last resort. Theme four contained three sub-themes: (a) part of the toolbox; (b) useful but limited tool; and (c) following the patient's lead. The moral distress experienced by HCPs and their essential 'need to fix' patients seems to underpin the varied opinions of ACV. These opinions appear to be formed primarily on the basis of experience, because of the underlying subjectivities and uncertainties. As knowledge and experience with ACV increased, and adverse events were experienced, most HCPs became more cautious in their approach to ACV. CONCLUSIONS AND IMPLICATIONS More research is needed to reduce the subjectivities and uncertainties surrounding ACV. The implementation of standardised procedures, processes, and competencies may help to reduce the frequency of adverse events and support a more controlled approach. Widening the focus of the purpose of ACV to include swallowing may help to maximise the potential benefits. WHAT THIS PAPER ADDS What is already known on the subject There is limited and low-quality evidence for above cuff vocalisation (ACV) and clinical application and practice varies substantially. However, the reasons for this variation in practice and healthcare professionals' (HCPs') opinions of ACV were unclear. What this study adds HCPs' experiences and opinions of ACV vary as a result of the uncertainty and subjectivity surrounding ACV compounded by their personal experiences with it. A need for caution also appears to emerge as HCPs become more familiar and experienced with using ACV. What are the clinical implications of this work? Implementing standardised procedures, safety processes and competencies may help to compensate for the uncertainty and subjectivity surrounding ACV and may reduce the frequency of adverse events. Widening the focus of purpose of ACV, including swallowing in addition to communication, may increase the number of potential candidates and increase the potential benefits of ACV. Using multidisciplinary team (MDT) simulation training for ACV competency development might help to improve MDT working and ACV implementation.
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Affiliation(s)
- Claire S Mills
- Speech & Language Therapy Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Emilia Michou
- Centre for Gastrointestinal Sciences, The University of Manchester, Manchester, UK
- Speech Language Therapy Department, University of Patras, Patras, Greece
| | - Mark C Bellamy
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Heidi J Siddle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Cathy A Brennan
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Chris Bojke
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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3
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Gentile MN, Irvine AD, King AM, Hembrom AS, Guruswamy KS, Palivela NE, Langton-Frost N, McElroy CR, Pandian V. Enhancing Communication in Critically Ill Patients with a Tracheostomy: A Systematic Review of Evidence-Based Interventions and Outcomes. TRACHEOSTOMY (WARRENVILLE, ILL.) 2024; 1:26-41. [PMID: 39253605 PMCID: PMC11382609 DOI: 10.62905/001c.115440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
Background Tracheostomy, a common procedure performed in intensive care units (ICU), is associated with communication impairment and affects patient well-being. While prior research has focused on physiological care, there is a need to address communication needs and quality of life (QOL). We aimed to evaluate how different types of communication devices affect QOL, speech intelligibility, voice quality, time to significant events, clinical response and tolerance, and healthcare utilization in patients undergoing tracheostomy. Methods Following PRISMA guidelines, a systematic review was conducted to assess studies from 2016 onwards. Eligible studies included adult ICU patients with a tracheostomy, comparing different types of communication devices. Data were extracted and synthesized to evaluate QOL, speech intelligibility, voice quality, time to significant events (initial communication device use, oral intake, decannulation), clinical response and tolerance, and healthcare utilization and facilitators/barriers to device implementation. Results Among 9,228 studies screened, 8 were included in the review. Various communication devices were employed, comprising both tracheostomy types and speaking valves, highlighting the multifaceted nature of interventions. Quality of life improvements were observed with voice restoration interventions, but challenges such as speech intelligibility impairments were noted. The median time for initial communication device usage post-intervention was 11.4 ± 5.56 days. The median duration of speech tolerance ranged between 30-60 minutes to 2-3 hours across different studies. Complications such as air trapping or breathing difficulties were reported in 15% of cases. Additionally, the median ICU length of stay post-intervention was 36.5 days. Key facilitators for device implementation included early intervention, while barriers ranged from service variability to physical intolerance issues. Conclusion Findings demonstrate that various types of communication devices can significantly enhance the quality of life, speech intelligibility, and voice quality for patients undergoing tracheostomy, aligning with the desired outcomes of improved clinical response and reduced healthcare utilization. The identification of facilitators and barriers to device implementation further informs clinical practice, suggesting a tailored, patient-centered approach is crucial for optimizing the benefits of communication devices in this population.
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Affiliation(s)
- Mary N Gentile
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital
| | - Annalise D Irvine
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital
| | - Annamarie M King
- Department of Physical Medicine and Rehabilitation, Indiana University Health
| | | | | | | | | | - Colleen R McElroy
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital
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Gajic S, Jacobs L, Gellentien C, Dubin RM, Ma K. Implementation of Above-Cuff Vocalization After Tracheostomy Is Feasible and Associated With Earlier Speech. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024; 33:51-56. [PMID: 38056485 DOI: 10.1044/2023_ajslp-23-00184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
PURPOSE The purpose of this study was to assess the feasibility of hospital-wide implementation of an above-cuff vocalization (ACV) protocol using ACV-capable tracheostomy tubes and its impact on patient speech in four intensive care unit (ICU) patient populations. METHOD This research was an observational pre-post study that was conducted over a 26-month period and included 323 critically ill adult ICU patients who underwent tracheostomy in a 365-bed academic tertiary care hospital. ACV was assessed using a protocol developed by a multidisciplinary team. Presence of speech was defined as at least one comprehensible word spoken during a speech-language pathologist evaluation. RESULTS Median time-to-speech was 13 days (interquartile range [IQR]: 8-20 days) before the intervention, compared to 9 days (IQR: 6-16 days) after the intervention (p = .0017). In the pre-intervention group, 101 out of 167 (60.5%) patients achieved speech within 60 days, compared to 83 out of 133 (62.4%) patients in the post-intervention group (p = .12). Of the 83 patients who achieved speech in the post-intervention group, 24 (28.9%) did so via ACV, with the remainder using a speaking valve or digital occlusion. Of those 24 patients, seven did not progress to using a speaking valve within the follow-up period. The median number of speech days gained by using ACV was 8 (IQR: 5-18 days). ACV was successful in facilitating speech in 24 out of 29 (82.8%) patients trialed, with no major complications. CONCLUSIONS Routine implementation of ACV after tracheostomy is feasible, safe, and associated with earlier speech in a diverse population of critically ill patients. ACV is an important method to facilitate communication in patients requiring mechanical ventilation with tracheostomy cuff inflation.
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Affiliation(s)
- Srdjan Gajic
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Lauren Jacobs
- Division of Speech Language Pathology, University of Pennsylvania Health System, Philadelphia
| | - Catherine Gellentien
- Division of Speech Language Pathology, University of Pennsylvania Health System, Philadelphia
| | - Randy M Dubin
- Division of Speech Language Pathology, University of Pennsylvania Health System, Philadelphia
| | - Kevin Ma
- Division of Pulmonary, Allergy and Critical Care, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Zaga CJ, Berney S, Hepworth G, Cameron TS, Baker S, Giddings C, Howard ME, Bellomo R, Vogel AP. Tracheostomy clinical practices and patient outcomes in three tertiary metropolitan hospitals in Australia. Aust Crit Care 2023; 36:327-335. [PMID: 35490111 DOI: 10.1016/j.aucc.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 02/24/2022] [Accepted: 03/06/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND There is a paucity of literature in Australia on patient-focused tracheostomy outcomes and process outcomes. Exploration of processes of care enables teams to identify and address existing barriers that may prevent earlier therapeutic interventions that could improve patient outcomes following critical care survival. OBJECTIVES The objectives of this study were to examine and provide baseline data and associations between tracheostomy clinical practices and patient outcomes across three large metropolitan hospitals. METHODS We performed a retrospective multisite observational study in three tertiary metropolitan Australian health services who are members of the Global Tracheostomy Collaborative. Deidentified data were entered into the Global Tracheostomy Collaborative database from Jan 2016 to Dec 2019. Descriptive statistics were used for the reported outcomes of length of stay, mortality, tracheostomy-related adverse events and complications, tracheostomy insertion, airway, mechanical ventilation, communication, swallowing, nutrition, length of cannulation, and decannulation. Pearson's correlation coefficient and one-way analyses of variance were performed to examine associations between variables. RESULTS The total cohort was 380 patients. The in-hospital mortality of the study cohort was 13%. Overall median hospital length of stay was 46 days (interquartile range: 31-74). Length of cannulation was shorter in patients who did not experience any tracheostomy-related adverse events (p= 0.036) and who utilised nonverbal communication methods (p = 0.041). Few patients (8%) utilised verbal communication methods while mechanically ventilated, compared with 80% who utilised a one-way speaking valve while off the ventilator. Oral intake was commenced in 20% of patients prior to decannulation. Patient nutritional intake varied prior to and at the time of decannulation. Decannulation occurred in 83% of patients. CONCLUSIONS This study provides baseline data for tracheostomy outcomes across three large metropolitan Australian hospitals. Most outcomes were comparable with previous international and local studies. Future research is warranted to explore the impact of earlier nonverbal communication and interventions targeting the reduction in tracheostomy-related adverse events.
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Affiliation(s)
- Charissa J Zaga
- Department of Speech Pathology, Division of Allied Health, Austin Health Melbourne, Australia; Tracheostomy Review and Management Service, Austin Hospital, Melbourne, Australia; Institute of Breathing and Sleep, Austin Health, Melbourne, Australia; Centre for Neuroscience of Speech, The University of Melbourne, Melbourne, Australia.
| | - Sue Berney
- Institute of Breathing and Sleep, Austin Health, Melbourne, Australia; Department of Physiotherapy, Division of Allied Health, Austin Health, Melbourne, Australia; Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Graham Hepworth
- Statistical Consulting Centre, The University of Melbourne, Melbourne, Australia
| | - Tanis S Cameron
- Tracheostomy Review and Management Service, Austin Hospital, Melbourne, Australia
| | - Sonia Baker
- Department of Speech Pathology, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Charles Giddings
- Department of Ear, Nose and Throat Surgery, Monash Health, Melbourne, Australia
| | - Mark E Howard
- Institute of Breathing and Sleep, Austin Health, Melbourne, Australia; Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
| | - Adam P Vogel
- Centre for Neuroscience of Speech, The University of Melbourne, Melbourne, Australia; Department of Neurodegeneration, Hertie Institute for Clinical Brian Research, Tübingen, Germany; Redenlab, Mebourne, Australia
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Zaga CJ, Chao C, Cameron T, Ross J, Rautela L, Rollinson TC, Marchingo E, Gregson PA, Warrillow S, Atkins NE, Howard ME. A Multidisciplinary Approach to Verbal Communication Interventions for Mechanically Ventilated Adults With a Tracheostomy. Respir Care 2023; 68:680-691. [PMID: 37076435 PMCID: PMC10171346 DOI: 10.4187/respcare.10511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
There is developing evidence with regard to the feasibility, utility, and safety of verbal communication interventions with patients with tracheostomy who are invasively ventilated. In the past 2 decades, research efforts have focused on establishing evidence for communication interventions, including introducing an intentional leak into the ventilatory circuit such as with a fenestrated tube, leak speech or ventilator-adjusted leak speech, the use of a one-way valve in-line with the ventilator, and above cuff vocalization. This narrative review describes the benefits of a multi-disciplinary approach, summarizes verbal communication interventions, and provides guidance on the indications, contraindications and considerations for patient selection. Our clinical procedures based on collective clinical experience are shared. A multidisciplinary team approach enables holistic management across acuity, ventilation, airway, communication, and swallowing parameters. This collaborative approach is recommended to maximize the chance of successful opportunities for patients to communicate safely and effectively.
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Affiliation(s)
- Charissa J Zaga
- Division of Allied Health, Department of Speech Pathology, Austin Health, Melbourne, Australia.
- Department of Audiology and Speech Pathology, University of Melbourne, Melbourne, Australia
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
| | - Caroline Chao
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Australia
- Division of Allied Health, Department of Physiotherapy, Austin Health, Melbourne, Australia
| | - Tanis Cameron
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
| | - Jacqueline Ross
- Division of Allied Health, Department of Physiotherapy, Austin Health, Melbourne, Australia
- Victorian Spinal Cord Service, Austin Health, Melbourne, Australia
| | - Linda Rautela
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Australia
- Division of Allied Health, Department of Physiotherapy, Austin Health, Melbourne, Australia
| | - Thomas C Rollinson
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
- Division of Allied Health, Department of Physiotherapy, Austin Health, Melbourne, Australia
- Department of Physiotherapy, University of Melbourne, Melbourne, Australia
| | - Emma Marchingo
- Clinical Nursing Education, Austin Health, Melbourne Australia
| | - Prudence A Gregson
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
| | - Stephen Warrillow
- Department of Intensive Care, Austin Health, Melbourne, Australia
- Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
| | - Naomi E Atkins
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Australia
| | - Mark E Howard
- Institute for Breathing and Sleep, Austin Health, Melbourne, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
- School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Clayton, Victoria, Australia
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7
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Sutt AL, Fraser JF. Early versus late tracheostomy: what do patients want? Crit Care 2023; 27:151. [PMID: 37076935 PMCID: PMC10116655 DOI: 10.1186/s13054-023-04443-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 04/14/2023] [Indexed: 04/21/2023] Open
Affiliation(s)
- Anna-Liisa Sutt
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD, 4032, Australia.
- Faculty of Medicine, University of Queensland, St Lucia, Brisbane, QLD, 4072, Australia.
| | - John F Fraser
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, St Lucia, Brisbane, QLD, 4072, Australia
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8
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Karlsen MMW, Holm A, Kvande ME, Dreyer P, Tate JA, Heyn LG, Happ MB. Communication with mechanically ventilated patients in intensive care units: A concept analysis. J Adv Nurs 2023; 79:563-580. [PMID: 36443915 PMCID: PMC10099624 DOI: 10.1111/jan.15501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/05/2022] [Accepted: 10/30/2022] [Indexed: 11/30/2022]
Abstract
AIMS The aim of this study was to perform a concept analysis of communication with mechanically ventilated patients in intensive care units and present a preliminary model for communication practice with these patients. DESIGN The Im & Meleis approach for concept analysis guided the study. SEARCH METHODS A literature search was performed in January 2022 in MEDLINE, Embase, CINAHL, psycINFO and Scopus, limited to 1998-2022. The main medical subject headings search terms used were artificial respiration, communication and critical care. The search resulted in 10,698 unique references. REVIEW METHODS After a blinded review by two authors, 108 references were included. Core concepts and terminology related to communication with mechanically ventilated patients were defined by content analytic methods. The concepts were then grouped into main categories after proposing relationships between them. As a final step, a preliminary model for communication with mechanically ventilated patients was developed. RESULTS We identified 39 different phrases to describe the mechanically ventilated patient. A total of 60 relevant concepts describing the communication with mechanically ventilated patients in intensive care were identified. The concepts were categorized into five main categories in a conceptual map. The preliminary model encompasses the unique communication practice when interacting with mechanically ventilated patients in intensive care units. CONCLUSION Highlighting different perspectives of the communication between mechanically ventilated patients and providers through concept analysis has contributed to a deeper understanding of the phenomena and the complexity of communication when the patients have limited possibilities to express themselves. IMPACT A clear definition of concepts is needed in the further development of guidelines and recommendations for patient care in intensive care, as well as in future research. The preliminary model will be tested further. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution, as this is a concept analysis of previous research.
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Affiliation(s)
| | - Anna Holm
- Department of Public Health, Aarhus University, Aarhus C, Denmark.,Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Monica Evelyn Kvande
- Department for postgraduate studies, Lovisenberg Diaconal University College, Oslo, Norway
| | - Pia Dreyer
- Department of Public Health, Aarhus University, Aarhus C, Denmark.,Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Judith Ann Tate
- Center of Healthy Aging, Self-Management and Complex Care, The Ohio State University College of Nursing, Columbus, Ohio, USA
| | - Lena Günterberg Heyn
- Center for Health and Technology, Faculty of Health and Social Sciences, University of South-Eastern Norway, Drammen, Norway
| | - Mary Beth Happ
- Center of Healthy Aging, Self-Management and Complex Care, The Ohio State University College of Nursing, Columbus, Ohio, USA
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Zaga CJ, Freeman-Sanderson A, Happ MB, Hoit JD, McGrath BA, Pandian V, Quraishi-Akhtar T, Rose L, Sutt AL, Tuinman PR, Wallace S, Bellomo R, Berney S, Vogel AP. Defining effective communication for critically ill patients with an artificial airway: An international multi-professional consensus. Intensive Crit Care Nurs 2023; 76:103393. [PMID: 36706499 DOI: 10.1016/j.iccn.2023.103393] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/10/2023] [Accepted: 01/16/2023] [Indexed: 01/27/2023]
Abstract
OBJECTIVES To define effective communication and identify its key elements specific to critically ill patients with an artificial airway. DESIGN A modified Consensus Development Panel methodology. SETTING International video-conferences. MAIN OUTCOME MEASURES Definition of effective communication and it's key elements. RESULTS Eight experts across four international regions and three professions agreed to form the Consensus Development Panel together with a Chair and one person with lived experience who reviewed the outputs prior to finalisation. "Communication for critically ill adult patients with an artificial airway (endotracheal or tracheostomy tube) is defined as the degree in which a patient can initiate, impart, receive, and understand information, and can range from an ineffective to effective exchange of basic to complex information between the patient and the communication partner(s). Effective communication encompasses seven key elements including: comprehension, quantity, rate, effort, duration, independence, and satisfaction. In critically ill adults, communication is impacted by factors including medical, physical and cognitive status, delirium, fatigue, emotional status, the communication partner and the nature of the ICU environment (e.g., staff wearing personal protective equipment, noisy equipment, bright lights)." The panel agreed that communication occurs on a continuum from ineffective to effective for basic and complex communication. CONCLUSION We developed a definition and list of key elements which constitute effective communication for critically ill patients with an artificial airway. These can be used as the basis of standard terminology to support future research on the development of communication-related outcome measurement tools in this population. IMPLICATIONS FOR CLINICAL PRACTICE This study provides international multi-professional consensus terminology and a definition of effective communication which can be used in clinical practice. This standard definition and key elements of effective communication can be included in our clinical impressions of patient communication, and be used in discussion with the patient themselves, their families and the multi-professional team, to guide care, goal development and intervention.
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Affiliation(s)
- Charissa J Zaga
- Department of Speech Pathology, Division of Allied Health, Austin Health, Melbourne, Australia; Audiology and Speech Pathology, The University of Melbourne, Melbourne, Australia; Centre for Neuroscience of Speech, The University of Melbourne, Melbourne, Australia; Institute of Breathing and Sleep, Austin Health, Melbourne, Australia.
| | - Amy Freeman-Sanderson
- Graduate School of Health, University of Technology, Sydney, Australia; Royal Prince Alfred Hospital, Sydney, NSW, Australia; Critical Care Division, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Mary Beth Happ
- Center for Healthy Aging, Self-Management & Complex Care, The Ohio State University College of Nursing, United States of America
| | - Jeannette D Hoit
- Department of Speech, Language, and Hearing Sciences, University of Arizona, Tucson, AZ, United States of America
| | - Brendan A McGrath
- Manchester Academic Critical Care, Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, the University of Manchester, Manchester Academic Health Science Centre, United Kingdom; Department of Anaesthesia, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Vinciya Pandian
- Department of Nursing Faculty, Johns Hopkins University, Baltimore, MD, United States of America; Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, United States of America
| | | | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom
| | - Anna-Liisa Sutt
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Pieter R Tuinman
- Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Cardiovascular Sciences, The Netherlands
| | - Sarah Wallace
- Manchester Academic Critical Care, Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, the University of Manchester, Manchester Academic Health Science Centre, United Kingdom; Department of Speech Voice and Swallowing, Wythenshawe Hospital, Manchester University NHS Foundation Trust, United Kingdom
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
| | - Sue Berney
- Department of Physiotherapy, Division of Allied Health, Austin Health, Melbourne, Australia; Physiotherapy, The University of Melbourne, Melbourne, Australia
| | - Adam P Vogel
- Audiology and Speech Pathology, The University of Melbourne, Melbourne, Australia; Centre for Neuroscience of Speech, The University of Melbourne, Melbourne, Australia; Department of Neurodegeneration, Hertie Institute for Clinical Brain Research, Tübingen, Germany; Redenlab, Melbourne, Australia
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10
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Boggiano S, Williams T, Gill SE, Alexander PDG, Khwaja S, Wallace S, McGrath BA. Multidisciplinary management of laryngeal pathology identified in patients with COVID-19 following trans-laryngeal intubation and tracheostomy. J Intensive Care Soc 2022; 23:425-432. [PMID: 36751349 PMCID: PMC9679906 DOI: 10.1177/17511437211034699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background COVID-19 disease often requires invasive ventilatory support. Trans-laryngeal intubation of the trachea may cause laryngeal injury, possibly compounded by coronavirus infection. Fibreoptic Endoscopic Evaluation of Swallowing (FEES) provides anatomical and functional assessment of the larynx, guiding multidisciplinary management. Our aims were to observe the nature of laryngeal abnormalities in patients with COVID-19 following prolonged trans-laryngeal intubation and tracheostomy, and to describe their impact on functional laryngeal outcomes, such as tracheostomy weaning. Methods A retrospective observational cohort analysis was undertaken between March and December 2020, at a UK tertiary hospital. The Speech and Language Therapy team assessed patients recovering from COVID-19 with voice/swallowing problems identified following trans-laryngeal intubation or tracheostomy using FEES. Laryngeal pathology, treatments, and outcomes relating to tracheostomy and oral feeding were noted. Results Twenty-five FEES performed on 16 patients identified a median of 3 (IQR 2-4) laryngeal abnormalities, with 63% considered clinically significant. Most common pathologies were: oedema (n = 12, 75%); abnormal movement (n = 12, 75%); atypical lesions (n = 11, 69%); and erythema (n = 6, 38%). FEES influenced management: identifying silent aspiration (88% of patients who aspirated (n = 8)), airway patency issues impacting tracheostomy weaning (n = 8, 50%), targeted dysphagia therapy (n = 7, 44%); ENT referral (n = 6, 38%) and reflux management (n = 5, 31%). Conclusions FEES is beneficial in identifying occult pathologies and guiding management for laryngeal recovery. In our cohort, the incidence of laryngeal pathology was higher than a non-COVID-19 cohort with similar characteristics. We recommend multidisciplinary investigation and management of patients recovering from COVID-19 who required prolonged trans-laryngeal intubation and/or tracheostomy to optimise laryngeal recovery.
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Affiliation(s)
- Sarah Boggiano
- Department of Speech, Voice and Swallowing, Wythenshawe
Hospital, Wythenshawe, UK,Manchester University NHS Foundation Trust, Manchester, UK
| | - Thomas Williams
- University Hospitals of Morecambe Bay NHS Foundation Trust,
Lancaster, UK,Thomas Williams, University Hospitals of
Morecambe Bay NHS Foundation Trust, Lancaster, UK.
| | - Sonya E Gill
- Manchester University NHS Foundation Trust, Manchester, UK,Acute Intensive Care Unit, Wythenshawe Hospital, Wythenshawe,
UK
| | - Peter DG Alexander
- Manchester University NHS Foundation Trust, Manchester, UK,Acute Intensive Care Unit, Wythenshawe Hospital, Wythenshawe,
UK,Manchester Academic Critical Care, Division of Infection,
Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of
Biology, Medicine and Health, the University of Manchester, Manchester Academic
Health Science Centre, Manchester, UK
| | - Sadie Khwaja
- Manchester University NHS Foundation Trust, Manchester, UK,Department of Head & Neck Surgery, Wythenshawe Hospital,
Wythenshawe, UK
| | - Sarah Wallace
- Department of Speech, Voice and Swallowing, Wythenshawe
Hospital, Wythenshawe, UK,Manchester University NHS Foundation Trust, Manchester, UK,Acute Intensive Care Unit, Wythenshawe Hospital, Wythenshawe,
UK
| | - Brendan A McGrath
- Manchester University NHS Foundation Trust, Manchester, UK,Acute Intensive Care Unit, Wythenshawe Hospital, Wythenshawe,
UK,Manchester Academic Critical Care, Division of Infection,
Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of
Biology, Medicine and Health, the University of Manchester, Manchester Academic
Health Science Centre, Manchester, UK
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11
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Mills CS, Michou E, Bellamy MC, Siddle HJ, Brennan CA, Bojke C. Determining the Prevalence, Implementation Approaches, and Opinions of Above Cuff Vocalization: A Survey of Health Care Professionals. Arch Phys Med Rehabil 2022; 103:394-401. [PMID: 34562433 PMCID: PMC8890002 DOI: 10.1016/j.apmr.2021.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 08/05/2021] [Accepted: 08/20/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To conduct an international survey to investigate the use of above cuff vocalization (ACV) and how practice and opinion differs. DESIGN Observational, cross-sectional online survey. SETTING Critical care, acute, rehabilitation, long-term care, and community. PARTICIPANTS Health care professionals involved in tracheostomy care or weaning (N=243). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Tracheostomy management, prevalence, personal experiences and opinions, and barriers to use. Quantitative data were reported descriptively, and content analysis was conducted with qualitative data. RESULTS The survey was completed by 243 health care professionals from 9 professional groups and 25 countries, with most responses from the United Kingdom (54%) and speech and language therapists (55%). ACV was used in 39% of services (n=93). Sixty percent (n=50/83) of health care professionals with direct experience of ACV had used it with <10 people. Implementation of ACV varied widely concerning procedures, contraindications, safety processes, professionals involved, competencies, staff training, delivery, and outcome measures. The top benefits were communication (n=76/93; 82%), mood (n=62/93; 67%), and laryngeal sensation (n=49/93; 53%). Complications included discomfort (n=54/93; 58%) and strained vocal quality (n=39/93; 42%). Barriers to ACV implementation included lack of knowledgeable staff (n=92/238; 39%) and lack of access to training (n=73/238; 31%). CONCLUSIONS ACV uptake varies internationally with no standardized approach to ACV delivery. Diversity of opinions on approaches and benefits exist. Serious complications are infrequent, but minor complications are common. Future research is needed to establish optimal ACV implementation to maximize benefits and minimize risks.
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Affiliation(s)
- Claire S Mills
- Speech and Language Therapy Department, Leeds Teaching Hospitals National Health Service Trust, Leeds, United Kingdom; Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom.
| | - Emilia Michou
- Centre for Gastrointestinal Sciences, University of Manchester, Manchester, United Kingdom; Speech Language Therapy Department, University of Patras, Patras, Greece
| | - Mark C Bellamy
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom
| | - Heidi J Siddle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom; Department of Podiatry, Leeds Teaching Hospitals National Health Service Trust, Leeds, United Kingdom
| | - Cathy A Brennan
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Chris Bojke
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
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12
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Rose L, Sutt AL, Amaral AC, Fergusson DA, Smith OM, Dale CM. Interventions to enable communication for adult patients requiring an artificial airway with or without mechanical ventilator support. Cochrane Database Syst Rev 2021; 10:CD013379. [PMID: 34637143 PMCID: PMC8507432 DOI: 10.1002/14651858.cd013379.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Inability to communicate in a manner that can be understood causes extreme distress for people requiring an artificial airway and has implications for care quality and patient safety. Options for aided communication include non-vocal, speech-generating, and voice-enabling aids. OBJECTIVES To assess effectiveness of communication aids for people requiring an artificial airway (endotracheal or tracheostomy tube), defined as the proportion of people able to: use a non-vocal communication aid to communicate at least one symptom, need, or preference; or use a voice-enabling communication aid to phonate to produce at least one intelligible word. To assess time to communication/phonation; perceptions of communication; communication quality/success; quality of life; psychological distress; length of stay and costs; and adverse events. SEARCH METHODS We searched the Cochrane Library (Wiley version), MEDLINE (OvidSP), Embase (OvidSP), three other databases, and grey literature from inception to 30 July 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi-RCTs, cluster-RCTs, controlled non-randomised parallel group, and before-after studies evaluating communication aids used in adults with an artificial airway. DATA COLLECTION AND ANALYSIS We used standard methodological procedures recommended by Cochrane. Two review authors independently performed data extraction and assessment of risk of bias. MAIN RESULTS We included 11 studies (1931 participants) conducted in intensive care units (ICUs). Eight evaluated non-vocal communication aids and three voice-enabling aids. Usual care was the comparator for all. For six studies, this comprised no aid; usual care in the remaining five studies comprised use of various communication aids. Overall, our confidence in results regarding effectiveness of communication interventions was very low due to imprecision, measurement heterogeneity, inconsistency in results, and most studies at high or unclear risk of bias across multiple domains. No non-vocal aid studies reported our primary outcome. We are uncertain of the effects of early use of a voice-enabling aid compared to routine use on ability to phonate at least one intelligible word (risk ratio (RR) 3.03, 95% confidence interval (CI) 0.18 to 50.08; 2 studies; very low-certainty evidence). Compared to usual care without aids, we are uncertain about effects of a non-vocal aid (communication board) on patient satisfaction (standardised mean difference (SMD) 2.92, 95% CI 1.52 to 4.33; 4 studies; very low-certainty evidence). No studies of non-vocal aids reported quality of life. Low-certainty evidence from two studies suggests early use of a voice-enabling aid may have no effect on quality of life (MD 2.27, 95% CI -7.21 to 11.75). Conceptual differences in measures of psychological distress precluded data pooling; however, intervention arm participants reported less distress suggesting there might be benefit, but our certainty in the evidence is very low. Low-certainty evidence suggest voice-enabling aids have little or no effect on ICU length of stay; we were unable to determine effects of non-vocal aids. Three studies reported different adverse events (physical restraint use, bleeding following tracheostomy, and respiratory parameters indicating respiratory decompensation). Adverse event rates were similar between arms in all three studies. However, uncertainty remains as to any harm associated with communication aids. AUTHORS' CONCLUSIONS Due to a lack of high-quality studies, imprecision, inconsistency of results, and measurement heterogeneity, the evidence provides insufficient information to guide practice as to which communication aid is more appropriate and when to use them. Understanding effectiveness of communication aids would benefit from development of a core outcome measurement set.
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Affiliation(s)
- Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Anna-Liisa Sutt
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- School of Clinical Medicine, The University of Queensland, Brisbane, Australia
| | | | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Orla M Smith
- Critical Care, St Michael's Hospital, Toronto, Canada
| | - Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
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13
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Mills CS, Michou E, King N, Bellamy MC, Siddle HJ, Brennan CA, Bojke C. Evidence for Above Cuff Vocalization in Patients With a Tracheostomy: A Systematic Review. Laryngoscope 2021; 132:600-611. [PMID: 33932229 DOI: 10.1002/lary.29591] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/13/2021] [Accepted: 04/17/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVES/HYPOTHESIS To determine how above cuff vocalization (ACV) is implemented in clinical practice, to identify what evidence exists on the effectiveness and safety of ACV, and to evaluate the acceptability of ACV. STUDY DESIGN Systematic review. METHODS A literature search was conducted in eight databases (MEDLINE, Embase, AMED, CINAHL, Cochrane Library, PsycINFO, Scopus, and Web of Science) in May 2019 and updated in June 2020. Two reviewers independently screened, selected, and extracted data. Study quality was appraised using the Joanna Briggs Institute Critical Appraisal Tools and a narrative synthesis was conducted. Systematic review registration number: CRD42019133942. RESULTS The searches identified 1327 records. The 13 eligible studies included four case studies, three case series, four observational studies without a control group, one quasi-experimental study, and one randomized controlled trial. Study quality was low, with most studies having high risk of bias. There was a high level of heterogeneity in study design and outcome measures used. Detailed information on ACV application and dose-delivered was lacking in 12 studies. Positive effects were reported for communication (n = 7), swallowing (n = 4), cough response (n = 2), and quality-of-life (n = 2), but with inconsistent use of objective outcome measures. There is limited quantitative or qualitative evidence for acceptability. Adverse events and complications were reported in nine studies, and four highlighted the importance of involving an experienced speech and language therapist. CONCLUSIONS There is limited evidence for the acceptability, effectiveness, safety, or optimal implementation of ACV. The evidence is insufficient to provide recommendations regarding optimal intervention delivery. Future research should ensure detailed recording of ACV delivery and utilize a core outcome set. Laryngoscope, 2021.
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Affiliation(s)
- Claire S Mills
- Speech and Language Therapy Department, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.,Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Emilia Michou
- Centre for Gastrointestinal Sciences, The University of Manchester, Manchester, United Kingdom.,Speech and Language Therapy Department, University of Patras, Patras, Greece
| | - Natalie King
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Mark C Bellamy
- Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, United Kingdom
| | - Heidi J Siddle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,Department of Podiatry, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Cathy A Brennan
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Chris Bojke
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
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14
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Wallace S, McGrath BA. Laryngeal complications after tracheal intubation and tracheostomy. BJA Educ 2021; 21:250-257. [PMID: 34178381 DOI: 10.1016/j.bjae.2021.02.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2021] [Indexed: 12/20/2022] Open
Affiliation(s)
- S Wallace
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - B A McGrath
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,University of Manchester Academic Critical Care, Wythenshawe Hospital, Manchester, UK
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15
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Petosic A, Viravong MF, Martin AM, Nilsen CB, Olafsen K, Berntzen H. Above cuff vocalisation (ACV): A scoping review. Acta Anaesthesiol Scand 2021; 65:15-25. [PMID: 32920849 PMCID: PMC7756796 DOI: 10.1111/aas.13706] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 09/02/2020] [Accepted: 09/04/2020] [Indexed: 12/21/2022]
Abstract
Introduction Patients in intensive care frequently suffer from not being able to communicate verbally. The aim of this scoping review was to study the safety and effectiveness of the above cuff vocalisation (ACV) on speech and quality of life (QOL) in patients dependent on a cuffed tracheostomy. Methods A scoping review was conducted. The databases Ovid Medline, Cochrane Library, and Embase were systematically searched in May 2020. We included clinical studies with patients exposed to ACV where speech, QOL or safety issues were assessed. Results Overall, 17 studies were included, of which 15 were observational and 2 were randomised controlled trials. Totally, 231 patients were included. ACV enabled most of the included patients (115/131; 88%) to speak with an audible voice or whisper (moderate quality of evidence). Voice related QOL (V‐RQOL) and QOL in mechanically ventilated patients (QOL‐MV) improved from pre‐ to post‐ ACV compared to a control group not tolerating a one‐way speaking valve (P = .01 and P = .04, respectively) (very low quality of evidence). Several minor complications or problems were reported in 20/75 (27%) cases in addition to two serious adverse events: subcutaneous emphysema in one patient where the tracheostomy was dislodged and a distended trachea in another due to the misconnection of continuous gas to the cuff (low/ very low quality of evidence). Conclusion ACV facilitated communication in patients dependent on a cuffed tracheostomy and attempting to communicate. Quality of evidence in improved V‐RQOL and QOL‐MV was very low. Several minor complications and two serious adverse events were reported.
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Affiliation(s)
- Antonija Petosic
- Division of Emergencies and Critical care Department of Postoperative and Intensive care Oslo University Hospital Oslo Norway
- Faculty of Medicine Institute of Health and Society University of Oslo Oslo Norway
| | - Marit F. Viravong
- Medical Division Department of Clinical Services, Physiotherapy Service Oslo University Hospital Oslo Norway
| | - Anna M. Martin
- Medical Division Department for Clinical Services, Speech and Language Therapy Service Oslo University Hospital Oslo Norway
| | - Cecilie B. Nilsen
- Division of Emergencies and Critical care Department of Postoperative and Intensive care Oslo University Hospital Oslo Norway
| | - Kjell Olafsen
- Division of Emergencies and Critical care Department of Anesthesiology Oslo University Hospital Oslo Norway
| | - Helene Berntzen
- Division of Emergencies and Critical care Department of Postoperative and Intensive care Oslo University Hospital Oslo Norway
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16
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Vergara J, Starmer HM, Wallace S, Bolton L, Seedat J, de Souza CM, Freitas SV, Skoretz SA. Swallowing and Communication Management of Tracheostomy and Laryngectomy in the Context of COVID-19: A Review. JAMA Otolaryngol Head Neck Surg 2020; 147:2771746. [PMID: 33057590 DOI: 10.1001/jamaoto.2020.3720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IMPORTANCE The care of patients with a surgically modified airway, such as tracheostomy or laryngectomy, represents a challenge for speech-language pathologists (SLPs) in the context of the coronavirus disease 2019 (COVID-19) pandemic. The objective was to review available publications and practice guidelines on management of tracheostomy and laryngectomy in the context of COVID-19. This study performed a review and synthesis of information available in the PubMed database and from national SLP organizations across 6 countries. OBSERVATIONS From the search, 22 publications on tracheostomy and 3 referring to laryngectomy were identified. After analysis of titles and abstracts followed by full-text review, 4 publications were identified as presenting guidelines for specific approaches to tracheostomy and were selected; all 3 publications on laryngectomy were selected. The main guidelines on tracheostomy described considerations during management (eg, cuff manipulation, suctioning, valve placement) owing to the increased risk of aerosol generation and transmission during swallowing and communication interventions in this population. Regarding laryngectomy, the guidelines focused on the care and protection of both the professional and the patient, offering recommendations on the management of adverse events and leakage of the tracheoesophageal prosthesis. CONCLUSIONS AND RELEVANCE Frequent guideline updates for SLPs are necessary to inform best practice and ensure patient and health care worker protection and safety while providing high-quality care and rehabilitation.
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Affiliation(s)
- José Vergara
- Department of Surgery, University of Campinas, Campinas, São Paulo, Brazil
| | - Heather M Starmer
- Division of Head and Neck Surgery, Department of Otolaryngology, Stanford University, Palo Alto, California
| | - Sarah Wallace
- Department of Speech, Voice and Swallowing, Manchester University NHS Foundation Trust, Manchester, England
| | - Lee Bolton
- Speech and Language Therapy Service, Imperial College Healthcare NHS Trust, London, England
| | - Jaishika Seedat
- Department of Speech and Hearing Therapy, University of Witwatersrand, Johannesburg, South Africa
| | | | - Susana Vaz Freitas
- Faculty of Health Sciences, Speech Therapy Department, University Fernando Pessoa, Porto, Portugal
- ENT Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
- Laboratório de Inteligência Artificial e Análise de Dados, LIAAD-INESCTEC, Porto, Portugal
| | - Stacey A Skoretz
- School of Audiology and Speech Sciences, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
- Centre for Heart Lung Innovation, St Paul's Hospital, Vancouver, British Columbia, Canada
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17
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Whitmore KA, Townsend SC, Laupland KB. Management of tracheostomies in the intensive care unit: a scoping review. BMJ Open Respir Res 2020; 7:e000651. [PMID: 32723731 PMCID: PMC7390235 DOI: 10.1136/bmjresp-2020-000651] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/20/2020] [Accepted: 06/25/2020] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES While there is an extensive body of literature surrounding the decision to insert, and methods for inserting, a tracheostomy, the optimal management of tracheostomies within the intensive care unit (ICU) from after insertion until ICU discharge is not well understood. The objective was to identify and map the key concepts relating to, and identify research priorities for, postinsertion management of adult patients with tracheostomies in the ICU. DESIGN Scoping review of the literature. DATA SOURCES PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature were searched from inception to 3 October 2019. Additional sources were searched for published and unpublished literature. ELIGIBILITY CRITERIA We included studies of any methodology that addressed the a priori key questions relating to tracheostomy management in the ICU. No restrictions were placed on language or year of publication. DATA EXTRACTION AND SYNTHESIS Titles and abstracts were screened by two reviewers. Studies that met inclusion criteria were reviewed in full by two reviewers, with discrepancies resolved by a third. Data were extracted for included studies, and results mapped along the prespecified research questions. RESULTS 6132 articles were screened, and 102 articles were included for detailed analysis. Protocolised weaning was found to be successful in liberating patients from the ventilator in several cohort studies. Observational studies showed that strategies that use T-pieces and high-flow oxygen delivery improve weaning success. Several lines of evidence, including one clinical trial, support early cuff deflation as a safe and effective strategy as it results in a reduced time to wean, shorter ICU stays and fewer complications. Early tracheostomy downsizing and/or switching to cuffless tubes was found to be of benefit in one study. A substantial body of evidence supports the use of speaking valves to facilitate communication. While this does not influence time to wean or incidence of complications, it is associated with a major benefit in patient satisfaction and experience. Use of care bundles and multidisciplinary team approaches have been associated with reduced complications and improved outcomes in several observational studies. CONCLUSIONS The limited body of evidence supports use of weaning protocols, early cuff deflation, use of speaking valves and multidisciplinary approaches. Clinical trials examining post-tracheostomy management strategies in ICUs are a priority.
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Affiliation(s)
- Kirsty A Whitmore
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Shane C Townsend
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
| | - Kevin B Laupland
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
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18
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McGrath BA. Above cuff vocalization (ACV): an additional benefit of subglottic suction tracheostomy tubes. Minerva Anestesiol 2020; 87:113-114. [PMID: 32549550 DOI: 10.23736/s0375-9393.20.14878-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Brendan A McGrath
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK -
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19
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Barriers to and facilitators for the use of augmentative and alternative communication and voice restorative strategies for adults with an advanced airway in the intensive care unit: A scoping review. J Crit Care 2020; 57:168-176. [PMID: 32163752 DOI: 10.1016/j.jcrc.2020.02.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/20/2020] [Accepted: 02/22/2020] [Indexed: 01/23/2023]
Abstract
PURPOSE To identify barriers and facilitators for the use of augmentative and alternative communication (AAC) and voice restorative strategies for adult patients with an advanced airway in the intensive care unit (ICU). MATERIALS AND METHODS Scoping review searching five databases between 1990 and 2019. We screened 13, 167 citations and included all study types reporting barriers and/or facilitators to using communication strategies in an ICU setting. Two authors independently extracted and coded reported barriers and facilitators to the Theoretical Domains Framework (TDF) domains. RESULTS Of the 44 studies meeting inclusion criteria 18 (44%) used qualitative, 18 (44%) used quantitative, and 8 (18%) used mixed methods. In total, 39 unique barriers and 46 unique facilitators were identified and coded to the domains of the TDF. Barriers were most frequently coded to the Skills, Environmental Context and Resources, and Emotion domains. Facilitators were most frequently coded to Reinforcement, Environmental Context and Resources, and Social and Professional Roles/Identity domains. Thematic synthesis produced four potentially modifiable factors: context, emotional support, training, and decisional algorithms. CONCLUSIONS Identified barriers (skills, environment, resources, emotions) and facilitators (reinforcement, resources, roles) to ICU communication strategy use in the literature may be modified through formal training and role support.
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20
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Zaga CJ, Berney S, Vogel AP. The Feasibility, Utility, and Safety of Communication Interventions With Mechanically Ventilated Intensive Care Unit Patients: A Systematic Review. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2019; 28:1335-1355. [PMID: 31296037 DOI: 10.1044/2019_ajslp-19-0001] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Purpose The aim of this study was to conduct a systematic review of the literature relating to the feasibility, utility, and safety of augmentative and alternative communication (AAC) interventions and tracheostomy-related communication interventions with mechanically ventilated adult patients in the intensive care unit (ICU). Method MEDLINE, Embase, and PsycINFO databases were searched for relevant articles. Studies were included if (a) they were performed in the ICU, (b) they involved participants > 18 years of age, (c) > 85% of participants were mechanically ventilated, and (d) they reported on content that related to the feasibility and/or utility and/or safety of AAC intervention and/or tracheostomy-related communication intervention. Studies were extracted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The levels of evidence for included studies were assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) guidelines. Results Forty-eight studies met the inclusion criteria. Different communication interventions relating to intubated and tracheostomized mechanically ventilated patients were reviewed, including (a) communication boards, (b) electrolarynx, (c) high-technology AAC devices, (d) tracheostomy tubes with communication-enabling features, (e) one-way valve in line with the ventilator, (f) ventilator-adjusted leak speech, (g) ventilator adjustments and one-way valve, and (h) multiple interventions. Forty-seven of 48 studies examined the feasibility and utility of the interventions. Sixteen studies examined the safety of the interventions. The included studies were composed of randomized controlled trials (n = 2), quasi-experimental studies (n = 7), cohort studies (n = 8), case-control (n = 1), case series (n = 23), and case reports (n = 7). The levels of evidence varied and ranged from high (n = 2), moderate (n = 7), low (n = 9), and very low (n = 30). Conclusions There is developing evidence that communication interventions with mechanically ventilated ICU patients are feasible, have utility, and are safe. Further research is warranted to guide speech pathologist-directed intervention to improve patient outcomes and the patient experience in the ICU.
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Affiliation(s)
- Charissa J Zaga
- Speech Pathology Department, Austin Health, Melbourne, Australia
- Centre for Neuroscience of Speech, The University of Melbourne, Australia
- Tracheostomy Review and Management Service, Austin Health, Melbourne, Australia
| | - Sue Berney
- Department of Physiotherapy, Austin Health, Melbourne, Australia
- Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Australia
| | - Adam P Vogel
- Centre for Neuroscience of Speech, The University of Melbourne, Australia
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research, Tübingen Germany
- Redenlab, Melbourne, Australia
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