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PAPER (ENG) - Effect of A Tracheostomy Speaking Valve On Breathing-Swallowing Interaction
PAPER (ENG) - Effect of A Tracheostomy Speaking Valve On Breathing-Swallowing Interaction
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Helene Prigent
Michele Lejaille
Effect of a tracheostomy speaking valve
Nicolas Terzi on breathingswallowing interaction
Djillali Annane
Marjorie Figere
David Orlikowski
Frederic Lofaso
[11]. Other studies [1216] confirmed these findings and patients were tested with (SV?) and without (SV-) a
established that the expiratory activity surrounding swal- Passy-Muir speaking valve (Passy-Muir Inc, Irvine, CA,
lowing helped to prevent the passage of noxious chemicals USA), in random order. A syringe was used to place water
and microbes from the mouth to the lungs. However, tra- boluses in the mouth. In each condition, three bolus sizes
cheostomised patients expire at least in part through the (5, 10, and 15 mL) were administered in random order.
tracheostomy tube [6], which may eliminate the protection Four sets of three boluses were studied, taking care not to
afforded by expiration to the upper airways, unless the use the same bolus size twice consecutively. The study
expired gas is directed towards the upper airways by an SV. participants were blinded to bolus size. They were
The aim of this study was to investigate upper airway and instructed to swallow normally while trying to be as
tracheostomy tube flows during swallowing and to assess efficient as possible.
breathingswallowing interactions with and without an SV
in a selected population of stable tracheotomised patients.
Data analysis
tracheostomised because of either severe progressive In the SV? condition, the peak positive pressure in the
respiratory failure or patient refusal to use an alternative tracheostomy tube occurred during swallowing and the
interface (nos. 2, 3, and 7). Patient 6 met criteria for mean pressure value ranged from 1.4 to 8.6 cmH2O. The
ventilatory assistance (severe respiratory failure, hyper- volume swallowed did not influence tracheostomy tube
capnia, and nocturnal hypoventilation) but refused to be pressure (ANOVA, p = 0.23). An example is shown in
ventilated. Mean duration of invasive ventilation per day Fig. 1b.
was 15 6 h.
Piecemeal deglutition occurred in all patients, with each The percentage of swallows followed by expiration was
bolus often requiring several swallows over several not significantly different between SV- and SV?
breathing cycles. However, the duration of swallowing, (Table 2) and was not influenced by bolus size (Table 2).
the number of swallows per bolus, and the number of However, when swallows were followed by expiration,
ventilatory cycles per bolus did not differ significantly the volume expired through the upper airway after expi-
between SV- and SV? (Table 2). In contrast, increasing ration was considerably lower in SV- (mean values
the bolus size significantly increased the total bolus below 20 mL) compared with SV? (ANOVA, valve
swallowing time, number of swallows per bolus, and effect p = 0.0003, Fig. 2), although the total expired
number of breathing cycles per swallow (Table 2). volume during and after swallowing was higher (but not
In the SV- condition, leaks occurred through the significantly) in SV- than in SV? (5 mL bolus size:
tracheostomy tube during all expirations. In addition, 139 80 vs. 124 62 mL; 10 mL bolus size: 144 63
during expirations bracketing swallowing, leakage vs. 104 56 mL; and 15 mL bolus size: 151 60 vs.
through the tube continued before, during, and after the 112 59 mL, respectively; ANOVA, valve effect:
swallowing period, as shown in the example in Fig. 1a. p = 0.12)
Table 2 Swallowing variables per bolus according to bolus size (5, 10, or 15 mL) and test condition: without (SV-) and with (SV?) a
tracheostomy valve
5 mL 10 mL 15 mL ANOVA (p value)
SV- SV? SV- SV? SV- SV? SV effect Volume effect
Duration of swallowing (s) 2.5 2.4 2.9 3.8 3.8 2.7 4.4 4.4 4.5 3.2 4.6 4.8 0.62 0.001
Number of swallows per bolus 1.6 1.0 1.6 1.1 2.2 1.2 2.1 1.4 2.6 1.3 2.3 1.7 0.37 0.001
Number of ventilatory cycles per bolus 1.0 0.0 1.2 0.4 1.3 0.6 1.7 1.0 1.3 0.6 1.6 1.1 0.44 0.006
% of swallows followed by expiration 65 34 82 24 72 28 78 21 62 30 74 28 0.37 0.51
88
Fig. 1 Breathingswallowing
interaction in a tracheostomised
patient without (a) and with
(b) a speaking valve. The
upper-airway zero-flow periods
within the swallowing periods
are shaded in grey. Panel
a without the SV, the persistent
expiratory leak through the
tracheostomy tube during
swallowing apnoea resulted in
the lack of upper airway flow
(arrows). Panel b with the SV,
no leakage occurred through the
tracheostomy during
swallowing apnoea but a small
inspiratory spike (hollow
arrow) coinciding with the end
of the apnoea occurred, at a
time when tracheal pressure
was positive (solid arrow),
excluding a concomitant
inspiratory effort as the cause of
this spike
Discussion
This study showed that, without an SV, a significant part
of the expiratory flow leaked through the tracheostomy
tube. Leakage also occurred during upper airway occlu-
sion due to swallowing. Adding an SV to prevent leakage
through the tube did not significantly change the per-
centages of expirations occurring before and after
swallowing. However, the SV increased the expired vol-
ume through the upper airway after swallowing, which
was negligible without the SV.
Other findings were as follows. In both the SV? and
the SV- conditions, an inspiratory nasal flow spike
occurred nearly consistently at the end of the nasal zero Fig. 2 Comparison of expiratory volume through the upper airway
after swallowing each bolus size with (black columns) and without
flow curve (Fig. 1a, b), as previously described [12, 15]. (striped column) a speaking valve (ANOVA; valve effect
This spike coincided with the airway reopening during p = 0.0003; volume effect p = 0.54)
descent of the hyolaryngeal complex [15] and with a
slight negative pharyngeal pressure dip occurring with the as indicated by the finding in our study and an earlier
offset of pharyngeal contraction [12]. Accordingly, we study [6] of significant and continuous expiratory leakage
observed a concomitant peak of positive tracheal pressure through the tracheostomy tube during swallowing brack-
(Fig. 1b), confirming that the inspiratory spike was not eted by expiration.
related to an inspiratory effort. This spike was not taken Swallowing during expiration produces several bene-
into account in our measurements. fits. Expiration facilitates vocal cord adduction, thus
A study in healthy volunteers showed the occurrence affording a protective set point for further laryngeal clo-
of diaphragmatic activity consistent with active breath- sure as the swallow progresses [21]. In addition, the
holding that preserved the expiratory volume just before positive tracheal pressure facilitated by expiration plays a
swallowing, thereby allowing expiration at the end of the pivotal role in maintaining the glottis closure reflex [6,
swallowing apnoea [20]. However, this activity was not 22]. Finally, expiratory flow towards the upper airway
sufficient to induce breath-holding during swallowing in after swallowing expels liquid or food particles misdi-
tracheostomised patients with open tracheostomy tubes, rected toward the trachea during swallowing [1216].
89
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