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					EBP & Tracheostomy:
  JUST DO ing IT
NSW Speech Pathology EBP Network
       EBP Extravaganza
       6 December 2006
                                            Emma Clifton
                               Senior Speech Pathologist
                           Blacktown & Mt Druitt Hospitals
                                          (02) 9881 8612
                   Emma.Clifton@swahs.health.nsw.gov.au
        Session Outline

 Tracheostomy   CATs & CAPs … what’s
 new?

 Tracheostomy EBP & clinical practice …
 an emerging relationship

 TracheostomyEBP & the workplace …
 JUST DO ing IT
Tracheostomy CATs & CAPs …
What’s new?
   Clinical Question
      In non-ventilated patients with tracheostomy tubes, does occlusion with a Passy Muir
         Speaking Valve (PMSV) or a one-way valve reduce aspiration?

   CAPs
      Dettelbach et al 1995
      Elpern et al 2000
      Gross et al 2003
      Stachler et al 1996
      Suiter et al 2003


   Clinical Bottom Line
      Occlusion will not always eliminate aspiration, but it can reduce aspiration with thin fluids
      Modified Barium Swallow (MBS) recommended due to high silent aspiration risk


   Changing TDG Clinical Practice
      It is not assumed that if aspiration is occurring that it will be eliminated by use of a
        PMSV/one-way speaking valve, but highlights that more objective assessment is
        frequently indicated
Tracheostomy CATs & CAPs …
What’s new?
   Clinical Question
      In non-ventilated patients with
         head/neck cancer and tracheostomy
         tubes, does occlusion reduce
         aspiration?

   CAPs
      Leder et al 1998
      Logemann et al 1998
      Muz et al 1989
      Stachler et al 1996


   Clinical Bottom Line
      Occlusion can reduce aspiration with
         some of these patients, possibly due to
         changes in swallowing bio-mechanics
      Occlusion immediately post-surgery
         ineffective in reducing aspiration
      MBS recommended
Tracheostomy CATs & CAPs …
What’s new?
         Clinical Question
            In non-ventilated patients with tracheostomy
             tubes, does digital occlusion reduce
             aspiration?

         CAPs
            Leder et al 1996
            Leder et al 2001
            Logemann et al 1998


         Clinical Bottom Line
            Occlusion does not appear to not make a
             significant difference in eliminating aspiration
            MBS recommended
Tracheostomy CATs & CAPs …
What’s new?
   Clinical Question
         In patients with tracheostomy tubes, is the Modified Evans Blue Dye Test (MEBDT) an effective clinical
          indicator in determining aspiration?

   CAPs
       O’Neill-Pirozzi et al 2003
       Belafsky et al 1999
       Belafsky et al 2003
       Brady et al 1999
       Donzelli et al 2001
       Thompson-Henry & Braddock 1995
       Peruzzi et al 2001


   Clinical Bottom Line
         MEBDT may not be sensitive enough to detect trace aspiration, both
               high false -ve rates - when suctioned, up to ~ 46% of the time no blue dyed material will be returned when aspiration
                has occurred under FEES and MBS
               high false +ve rates - when suctioned, up to ~ 20% of the time return of blue dyed material does not actually represent
                aspiration of item tested eg. was it puree? OR was it saliva?
               Note also that food/fluid/saliva can be suctioned from the supraglottis rather than aspirated material


   Changing TDG Clinical Practice
       Clinical Pathways for RPA and Liverpool Hospital no longer state that the MEBDT is essential in the
        Speech Pathologist’s toolbag
Tracheostomy CATs & CAPs …
What’s new?
   Clinical Question
      In non-ventilated patients with tracheostomy tubes, is capping indicated for safe
        and effective decannulation?

   CAP
      Thompson-Ward et al 1999


   Clinical Bottom Line
      Down-sizing + capping and 24-48 hrs cuff deflation both effective
      < 3% re-cannulation with both protocols
      24-48 hrs cuff deflation more efficient in facilitating earlier decannulation and
        reducing medical costs

   Changing TDG Clinical Practice
      Capping not being a ‘must-do’ before safe and effective decannulation
Tracheostomy CATs & CAPs …
What’s new?
      Clinical Question
         Is it safe to feed patients with the
          tracheostomy cuff inflated?

      CAPs
         Pinkus 1973


      Clinical Bottom Line
         Patients with tracheostomy tubes should be
          fed non-orally due to aspiration risk

         … TDG currently re-visiting ...
Tracheostomy EBP & clinical practice …
An emerging relationship
           Other considerations:

              The time factor …
                 to have discussions
                 to ‘let go’ of tools and beliefs
                 to apply the evidence


              Some clinical questions where you would
               expect many papers, to be out there are not

              Robustness of studies in existence
Tracheostomy EBP & the workplace …
JUST DO ing IT
   Having CAPs and CATs with us
    when seeing patients

   Utilising the tracheostomy
    listserve

   Liaising with Librarians for
    automatic notification of new
    articles for our CIAP search

   Time managing for EBP

   Being aware of what exactly is out
    there, so as to be able to assert
    view from a position of strength
References
 NSW Speech Pathology EBP Network:
 Tracheostomy Education for NSW
 Speech Pathologists

				
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