Communication Assessment and Intervention

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66 Terms

1
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Normal Voice and Speech Production Systems

  1. respiratory system

  2. phonatory system

  3. resonance

  4. articulatory system

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Respiratory system

lungs and diaphragm

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phonatory system

larynx

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resonance

pharynx, nasal cavity, oral cavity

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articulatory system

Palate, tongue, teeth, cheeks, lips

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Impact of Upper Airway Diversion: trach

  • Alteration to taste and smell

  • Reduced Secretion Management (sensation)

  • Unproductive cough (inflated cuff)

  • Reduced Subglottic Pressure

  • Reduced Sensation in Larynx

  • Redirection of airflow

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Impact of Upper Airway Diversion..

and the resulting effects

reasons:

  1. laryngeal tissue changes

  2. tracheal injury

  3. reduced laryngeal elevation

effects

  1. loss of voice production

  2. reduced subglottic air pressure

  3. difficulty coordinating voicing and breathing

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laryngeal tissue changes

  • Granulomas, vocal fold lesions, edema

  • Impact on glottic closure

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tracheal injury comes from…

Damage from cuff inflation (necrosis)

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reduced laryngeal elevation

  • Tube size: Larger diameter leaves minimal space for movement

  • Weight of tube: Increased weight = decreased elevation

  • Cuff inflation: Laryngeal tethering

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loss of voice production

  • aphonia

  • dysphonia

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reduced subglottic air pressure

Air exchange at neck reduces air pressure generation

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difficulty coordinating voicing and breathing, particularly on…

the vent

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respiratory specific considerations

COPD, tracheomalacia, sleep apnea, infections, obstructions

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cardiovascular considerations

CVA, tumor, cardiac conditions

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trauma diagnosis considerations

MVA (motor vehicle accident), GSW (gun shot wound), SCI (spinal cord injury)

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degenerative disease considerations

ALS, MS, muscular dystrophy, Guillain-Barre

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physical motor impairment considerations

  • AAC access considerations

  • Stoma occlusion

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specific speech/voice impairment considerations (artic/resonance ability impacted)

  • Glottic cancer, Tongue cancer

  • Dysarthria/anarthria, apraxia, dysphonia/aphonia

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cognitive-linguistic considerations

  • Complexity of communication option

  • Expressive/receptive language, memory, attention

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behavioral considerations

  • Willingness to use the communication option

  • Anxiety, agitation, level of alertness

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Upper Airway and Voice Assessment

At Minimum: ______________________

Ideal Scenario: _____________________

At Minimum: finger occlusion (first step in eval)

Ideal Scenario: laryngoscopy (FEES)

<p>At Minimum: finger occlusion (first step in eval)</p><p>Ideal Scenario: laryngoscopy (FEES)</p>
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Perceptual Voice Assessment

At Minimum: ______________________

Ideal Scenario: _____________________

At Minimum: CAPE-V, GRABAS

Ideal Scenario: stroboscopy (need to look at vibratory characteristics)

<p>At Minimum: CAPE-V, GRABAS</p><p>Ideal Scenario: stroboscopy (need to look at vibratory characteristics)</p>
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What are the 4 main impairment areas you want to consider that will guide your voice/speech assessment and intervention planning?

  1. physical motor impairment

  2. specific speech/voice impairment

  3. cognitive-linguistic

  4. behavioral

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Resulting effects of damage to the laryngeal tissue (from prior intubation or trach) include aphonia and dysphonia. Consider what specifically may contribute to development of Dysphonia

atrophy of VFs, incomplete closure bc they are so weak, laryngeal webbing

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Resulting effects of damage to the laryngeal tissue (from prior intubation or trach) include aphonia and dysphonia. Consider what specifically may contribute to development of aphonia

nerve damage (can’t approximate VFs), stenosis

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oral communication options with a trach

  1. Mouthing Words

  1. Electrolarynx

  2. Trach Occlusion

  3. Vent-Leaking

  4. Speaking Valves (PMV)

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Mouthing Words- how are they helpful?

Easy for some, quick in the moment, functional in many environments

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Mouthing Words- directions for pts

  • over articulation (emphasize)

  • slow down

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Mouthing Words challenges

  • Communication breakdowns are common

  • Dentures facilitate better articulation, but may not be present

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electrolarynx is not just for…

HNC

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electrolarynx pt needs

  • Good oral motor control

  • Physical ability to use

  • Ability to use mouthing words strategies

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electrolarynx challenges

  • Finding the sweet spot (soft tissue spot)

  • Continuous skin contact

  • Volume and noise

  • Training time

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cuff must be _______ for trach occlusion

deflated

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trach occlusion procedure

  1. Take a breath

  2. Trach occluded

  3. Patient phonates

  4. Remove finger for breathing

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trach occlusion challenges

  • Coordination of breath

  • Requires physical use of arm/finger to occlude

  • Infection control

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vent-leaking

  1. Suctioning of the oral cavity

  2. Suctioning of the trach

  3. Cuff deflation to allow leak

  4. RT controls vent settings

  5. Patient speaks on air leak around trach

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vent-leaking challenges

  • Not all patients can tolerate a leak from the machine

  • Must have enough space between the tube and the trachea for the air to move up and out

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speaking valves:

  • cuff:

  • may…

  • check what 2 things?

  • Cuff must be deflated

  • May require trach change to a smaller sized trach

  • Check finger occlusion first

  • Check back pressure

  • May be used on or off the vent

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back pressure

hear a whoosh of air after taking off PMV, not enough room for air to escape, need adequate space for air to move around the tube

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what do you monitor closely for speaking valves?

  • Heart rate

  • Respiratory rate

  • O2 saturations

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clinical benefits of PMV

  • improves speech production

  • Improves swallowing and may reduce aspiration

  • restores natural positive airway pressure

  • facilitates secreation management

  • improves oxygenation

  • expedites ventilator weaning and decannulation

  • facilitates infection control

  • improves smell, taste, and sensation

  • facilitates pediatric speech/language development

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<p>Consider the 4 main impairment considerations (slide 7). For each, state which oral communication methods would NOT be appropriate to consider for each in the table below: </p>

Consider the 4 main impairment considerations (slide 7). For each, state which oral communication methods would NOT be appropriate to consider for each in the table below:

knowt flashcard image
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In-Line PMV Assessment on the Vent Steps

  1. Cuff deflation (RT)

  2. RT present to manage vent

  3. PMV placed in-line with vent tube

  4. Pt voices after inhale triggered from vent

  5. Monitor for tolerance

  6. Remove PMV (after trial is over)

  7. Replace vent tubing

  8. RT restores vent settings

  9. Relay the findings to pt and team (are they a good candidate?)

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what happens after In-Line PMV Assessment on the Vent?

trach collar (ideal scenario bc no support from vent)

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PMV on trach collar steps

  1. Cuff deflation

  1. Patient education (explain what will happen)

  1. Finger occlusion

  2. PMV placement

  3. Check back pressure after approx. 15-30 secs (difficulty with airflow movement)

  4. Replace if tolerated, continued speaking

  5. Monitor for about 30 min if tolerated (can wear for a meal)

<ol><li><p>Cuff deflation</p></li></ol><ol start="2"><li><p>Patient education (explain what will happen)</p></li></ol><ol start="3"><li><p>Finger occlusion</p></li><li><p>PMV placement</p></li><li><p>Check back pressure after approx. 15-30 secs (difficulty with airflow movement)</p></li><li><p>Replace if tolerated, continued speaking</p></li><li><p>Monitor for about 30 min if tolerated (can wear for a meal)</p></li></ol><p></p>
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why do we do finger occlusion first?

to see if they can generate voice and mobilize air

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PMV Stop Criteria (On or Off the Vent)

  • Back pressure at trach site

  • HR > 20bpm from baseline

  • RR > 35

  • O2 < 90

    • we don’t want to see spikes in these areas

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Troubleshooting: Maximizing Airflow Around the Trach

  1. Trach modification (most common)

  2. Switch to fenestrated trach

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Trach modification

size & cuff

  • Pts often started with 8-0 CUFFED for vent use

  • Downsize to 6-0 CUFFLESS often required for smaller stature patients

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Switch to fenestrated trach

  • Must have fenestrated inner cannula

  • Risk of granulation tissue growing into trach

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Contraindications for Speaking Valves

  • Tracheal or laryngeal stenosis

  • Airway obstruction

  • Inability to tolerate cuff deflation

  • End-stage pulmonary disease

  • Unstable medical/pulmonary status

  • Laryngectomy (physically separate from upper airway)

  • Severe anxiety

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My patient can’t wear the PMV because…

“… they had a severe brain injury”

“… they have too many secretions”

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Secretions increase in response to …

trach tube in airway

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Excess secretions are result of…

poor laryngeal/pharyngeal sensation, reduced subglottic pressure, poor cough strength

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_______% reduction in secretion accumulation with PMV

40%

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“…they had a severe brain injury”

  • Early placement increases sensation to upper airway

  • May promote vocalizations

  • Requires closer SLP/RT monitoring

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Training Speech with a PMV Steps

  1. Patient must first acclimate to the valve wear

  2. Cue the patient to inhale

  3. Open vowel on exhale (ah)

  4. Inhale- voice- inhale

  5. Work up the speech hierarchy (vowel, syllable, word,…)

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articulation intervention

  • Facial ROM and strengthening exercises

  • Open vowels, Syllables, Words, Phrases, Sentences, Reading, Spontaneous speech

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resonance intervention

  • Improving oral/nasal resonance with voice techniques

  • SOVT (lip-trills, hum), resonant voice exercises

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phonation intervention

  • Direct voice treatments

  • glottal adduction exercises (Phorte, LSVT), vocal function exercises (pitch range),

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respiration intervention

  • Improve inspirtory and expiratory strength (IMST/EMST)

  • Target respiratory-phonatory coordination

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Non-Oral Communication Supports

  • Call Light/Buzzer

  • Writing

  • Yes/No Response system

  • Low-Tech Communication Boards

  • Text to Speech App

  • High-Tech AAC SGDs

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List 2 contraindications for PMV wear

  1. laryngectomy

  2. severe anxiety

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In your own words, what does back pressure mean?

inability to efficiently move air like we need to

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Describe aloud what the process is for PMV placement with a patient

this valve is going to go over your trach tube

make sure that your balloon is deflated becuase we need the air to come up to the VFs in order for your to voice.