Transtracheal Pressure for Evaluation of Decannulation Readiness.

BACKGROUND: Pediatric tracheostomy decannulation protocols vary among institutions and may include toleration of Passy Muir Valve (PMV), microlaryngoscopy and bronchoscopy (MLB) findings, and polysomnography evaluation. Transtracheal pressure (TTP) is an objective measurement utilized to evaluate PMV toleration. We aimed to investigate the role of TTP in decannulation candidates and compare TTP measurements with polysomnography and MLB findings. METHODS: A retrospective cohort study of children who underwent TTP measurement during PMV trial between December 2012 and November 2022. RESULTS: A total of 79 patients underwent TTP measurement and MLB evaluation; of these, 16 (20.3%) patients had a capped polysomnography. Twenty-eight (35.4%) patients had TTPs ≤10 cm H2O, and 51 (64.6%) patients had TTPs >10 cm H2O. The most common indication for tracheostomy was upper airway obstruction (n = 41, 51.9%), followed by a need for mechanical ventilation (n = 24, 30.4%). Twenty-five (31.6%) patients were decannulated. Patients with TTPs ≤10 cm H2O had a mean Apnea-Hypopnea Index of 0.17 ± 0.26/h compared with 6.93 ± 7.67/h in those with TTPs >10 cm H2O, p = 0.0365. Patients with TTPs >10 cm H2O were found to have a significantly higher occurrence of airway obstruction (96.1% vs. 46.4%, p < 0.0001) and multilevel airway obstruction (70.6% vs. 21.4%, p < 0.0001) on MLB. Neither TTP measured at time of PMV assessment nor capped polysomnography was associated with successful decannulation. CONCLUSIONS: TTP measurements at time of PMV evaluation are associated with polysomnography and MLB findings. One-time PMV measurements were not indicative of decannulation success. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:3377-3383, 2024.

The effects of transtracheal pressure on the utility of speaking valves in critically ill patients after tracheostomy / 中华物理医学与康复杂志

Objective:To analyze the effect of transtracheal pressure (TTP) on the application of a speaking valve in critically ill patients after tracheostomy.Methods:A retrospective analysis was conducted of 50 patients wearing a speaking valve after tracheostomy. Patients who had been wearing a speaking valve for 30min or more were the tolerance group, while those with less than 30min were the intolerance group. Transtracheal pressure was monitored during resting breathing, forced expiration and speaking. Linear regression models were evaluated to isolate the factors best predicting tolerance. The changes in respiratory muscle contraction before and after wearing a speaking valvs were evaluated using ultrasound. The patients′ satisfaction with wearing a speaking valve was also recorded.Results:TTP during speaking significantly predicted tolerance. The baseline values of diaphragmatic thickening fraction and physical functioning also positively predicted tolerance. Acute physiology and chronic health (APACHE II) score was a significant negative predictor. After wearing the speaking valve, the average contraction of the rectus abdominis, external oblique, internal oblique and transverse abdominis muscles increased significantly. Both groups expressed high satisfaction with the speaking valves.Conclusions:Transtracheal pressure during speaking can help predict the tolerance for wearing a speaking valve among critically ill patients after a tracheostomy. Baseline diaphragmatic thickening fraction, physical functioning and APACHE II score can predict the duration of speaking valve tolerance.

Tracheostomy speaking valve modification in children: A standardized approach leads to widespread use.

BACKGROUND: Tracheostomy is associated with negative effects on voice, speech, and feeding/swallowing. Speaking valves have beneficial effects in these areas but are often contra-indicated in children with airway problems due to high transtracheal pressure (TTP). Valves are modified by drilling to reduce excessive TTP. We hypothesized that a standardized approach to assessment and valve modification by drilling improves valve tolerance and allows widespread successful use. METHODS: Following development of a standardized multidisciplinary protocol for patient selection, valve modification and valve prescription at our center, we retrospectively collected information from clinical notes relating to clinical indication and medical history of all children undergoing speaking valve assessment from February 2014 to June 2017. We designed a questionnaire which was delivered to the parents of children receiving both modified and standard valves enquiring about voice, feeding, communication, and suctioning. RESULTS: Data on 45 children were collected. Thirteen had normal TTP and were given standard valves and 32 had high TTP, all of whom had their valves modified resulting in good tolerance. 17 Children were on positive pressure ventilation at the time of placement. The survey response rate was 83%. Parents report a high degree of satisfaction with modified valves and report positive effects in terms of voice, speech, and feeding/swallowing similar to those reported for standard valves. CONCLUSIONS: Speaking valves can be successfully and safely modified in children, providing valves to many patients previously deemed unsuitable. We report positive parental experiences of these modified valves in line with those reported with standard valves.