Passy-Muir Valve: Indications and Contraindications for Tracheostomized Patients

A speaking valve, such as the Passy-Muir Valve (PMV), is a one-way valve used for tracheostomized patients. While the Passy Muir valve is the most recognizable, other brands of speaking valves are available, differing in size, design, and valve resistance. This article explores the indications, contraindications, and troubleshooting aspects of using a PMV to restore speech and improve the quality of life for individuals with tracheostomies.

What is a Speaking Valve?

A speaking valve is a removable one-way valve attached to a deflated or cuffless tracheostomy tube. It allows the patient to inhale through the valve. Upon exhalation, the valve closes, directing airflow through the larynx, mouth, and nose. This redirection of airflow enables speech and offers several other physiological benefits.

Benefits of Using a Speaking Valve

The use of a speaking valve offers numerous advantages for tracheostomized patients, including:

Restoration of Speech: As the name suggests, the primary benefit of the speaking valve is to allow the patient to speak and communicate verbally.
Improved Swallowing: The speaking valve maintains subglottic pressure, which is essential for effective and safe swallowing. Research suggests that patients with a closed system (using a speaking valve) have improved airway protection and aspirate less compared to those with an open system.
Enhanced Cough: By restoring positive airway pressure, the valve facilitates the patient's ability to generate a stronger, more protective cough, improving airway clearance.
Restoration of Smell and Taste: Directing airflow through the upper airway can restore a patient's sense of smell and taste.

Indications for Passy-Muir Valve Use

The decision to use a PMV should be based on a thorough assessment of the patient's medical and respiratory status. Generally, a suitable candidate for PMV use meets the following criteria:

Medical Stability: The patient should be medically stable, with stable vital signs, including respiratory rate, heart rate, and oxygen saturation.
Alertness and Arousal: The patient should be awake, alert, and able to follow simple commands.
Adequate Secretion Management: The patient should be able to manage their secretions effectively, either independently or with assistance.
Patent Upper Airway: The patient must have a patent upper airway, allowing for airflow around the tracheostomy tube and through the larynx, mouth, and nose. This can be verified through an airway patency assessment, such as slow cuff deflation and monitoring of baseline parameters.

Example Scenario:

Imagine "Mr. Jones," who is awake, alert, and medically stable with a size 6 cuffed Shiley tracheostomy tube. His nurse reports good secretion management, indicating readiness for a PMV assessment. He sits upright in bed, smiling and calm, with stable vital signs. After receiving education about the PMV, his medical status remains stable, and the assessment proceeds. Slow cuff deflation and monitoring of baseline parameters confirm airway patency, as Mr. Jones exhales around the tracheostomy tube and out through his upper airway. With the PMV in place, he demonstrates a productive cough to clear secretions, and his vital signs remain stable. He speaks with a strong and clear voice, expressing his appreciation for regaining his ability to communicate.

Read also: Muir College: A Unique History

Contraindications for Passy-Muir Valve Use

Certain conditions may contraindicate the use of a PMV. These contraindications are crucial to identify to ensure patient safety and prevent potential complications:

Upper Airway Obstruction: The patient should not have any upper airway obstruction, such as edema, thick or copious secretions, vocal fold paralysis in the adducted position, upper airway tumor, tracheal stenosis, or tracheomalacia.
Foam-Filled Cuff: A foam-filled cuff is an absolute contraindication for PMV use.
Inability to Tolerate Cuff Deflation: The patient must be able to tolerate complete cuff deflation without significant respiratory distress.
Unstable Respiratory Status: Patients with unstable respiratory status, such as those requiring high levels of ventilatory support or experiencing frequent desaturations, may not be suitable candidates for PMV use.

Troubleshooting Challenges with Passy-Muir Valve Use

While many patients experience immediate success with the PMV, some may encounter challenges requiring careful assessment and problem-solving. Here are some common issues and potential solutions:

1. Coughing Upon Cuff Deflation or Valve Placement

Possible Causes:
- Change in airflow and sensation, especially if the patient has been without airflow to the upper airway for an extended period.
- Secretion management issues.
- Back pressure.
- Anxiety.
Possible Solutions:
- With cuff deflation: Pause in cuff deflation, allowing the patient to adjust to airflow. Use very slow cuff deflation. If coughing does not subside, reinflate cuff and do not use a speaking valve. Reintroduce slow cuff deflation after coughing subsides.
- With use of Valve: Remove the Valve. Allow the cough to subside. Replace the Valve. Consider short wear-times to gradually introduce patient to the upper airway airflow.
- Remove the Valve. Suction as needed.
- Remove the Valve and troubleshoot backpressure issues.
- Provide reassurance and education. Work on controlled exhalations through the upper airway and relaxation techniques. Involve family in the sessions.

2. Valve Malfunction

Possible Causes:
- The Valve is dirty.
- Turbulent airflow.
- The Valve needs to be replaced.
Possible Solutions:
- The Valve should be cleaned daily as follows: Swish in warm, soapy water (use a mild soap without fragrance or lotion). Rinse under running water. Shake off and allow PMV to air dry.
- Work on controlled exhalation through the upper airway. Avoid pursed lip breathing or other techniques that build pressure.
- The Valve lifetime is approximately two months with proper care and cleaning.

3. Decreased Oxygen Saturation

Possible Causes:
- Cuff deflation. Oxygen saturation may drop slightly after cuff deflation and PMV placement.
- Inadequate breathing.
- Anxiety.
- Oxygen supplementation not placed.
- Inadequate oxygen support.
Possible Solutions:
- Work with patient on relaxation and deep breathing techniques.
- Cue patient to take deep breaths.
- Provide relaxation guidance and cue to take deep breaths.
- Be sure trach collar is in place and positioned properly. Check if a nasal cannula is appropriate for use while Valve is on patient.
- Remove Valve. Reinflate cuff. Discuss with medical team.

4. Difficulty Tolerating the Valve

Possible Causes:
- Positioning.
- Tracheostomy tube cuff.
- Tracheostomy tube.
- Upper airway obstruction.
Possible Solutions:
- Reposition the patient in an upright, comfortable position with head and neck at midline. Ensure good tracheostomy tube position at midline.
- Check for complete cuff deflation.
- Consider measuring transtracheal pressure with manometry to evaluate airway patency. If needed, consider downsize of tracheostomy tube.
- Consider patient history and possibility for edema; thick, copious secretions; vocal fold injury or paralysis in the adducted position; upper airway tumor; tracheal stenosis; or tracheomalacia, among others.

The Importance of a Multidisciplinary Approach

Troubleshooting PMV use requires a strong knowledge base, critical thinking, and individualized decision-making. A multi- or interdisciplinary team approach has been shown to yield the best outcomes for patients with tracheostomies. Collaboration with the medical team and other healthcare professionals is crucial for improving success rates. When encountering issues with PMV placement, the best approach is to identify the underlying cause of the problem and then work toward a practical solution. Many patients can achieve successful use of the PMV both on and off mechanical ventilation.

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