Use of a Passy-Muir Speaking Valve in a Non-Ventilated Patient

Guideline Development
Tracheostomised infants and children are at risk of speech and language
delay
Placement of a tracheostomy tube significantly affects the childs ability to vocalise
due to reduced air-flow through the upper airway.1-3 The presence of the
tracheostomy tube in infancy may alter development of the supra-laryngeal vocal
tract, resulting in limited tongue movement and altered resonance capacity for vowel
production. 4
Cannulation typically occurs before the childs first birthday during the pre-linguistic
period.5 The pre-linguistic period occurs prior to the development of spoken words.
Contingent vocal response and social feedback to babbling facilitates rapid
phonological development during this period.6 Cooing, crying and babbling not only
promote attachment7, but also lay the critical neuro-developmental foundations for
language learning.6,8 It follows that tracheostomised infants and children are at risk
of speech delay2,4,9-13 and language delay.2,7,14
Prolonged cannulation is associated with voice disorder1,2, oral pharyngeal
dysphagia2,12,15,16, sensory feeding difficulties2,7,12,16, and behavioural difficulties13.
The risk of speech and language delay has been associated with length of
cannulation and age at decannulation3,7 and has been found to persist beyond
decannulation4,7,11-13. Developing an alternative means of communication, including
use of a speaking valve, is considered a vital part of care to facilitate development in
tracheostomised children.2,7,9,12,15,17
Wearing the Passy Muir Speaking Valve facilitates voice
The Passy Muir speaking valve (PMV) enables phonation by redirecting exhaled air
via the glottis and is considered the speaking valve of choice for children for long
term use.18 The PMV has a bias-closed position, compared to the biased-open
position of other available valves.19 It remains closed on exhalation and opens only
on inspiration. On exhalation, air is redirected through the upper airway, promoting
restoration of sub-glottic and glottic pressures and enabling phonation. Aerodynamic
analysis of the PMV has indicated an acceptable level of resistance to airflow20,21
and low levels of air-loss in simulated speech.19,21 Successful placement of the
PMV has been documented in infants as young as 13 days old. 15
PMV placement has been found to improve voice2,7,14,18,22, smell23-25, cough26, and
secretion management23,24 as well as improving overall quality of life and well
being2,23. Improvements to swallow with PMV placement remain controversial.
Several studies have documented improved swallow in the adult population.23,24,26,27
Limited research has been conducted in the paediatric population. Using the PMV is
considered an important step to improve comfort and readiness during a
decannulation process.9,22,28
Development information for Clinical Practice Guideline for the Use of a
Passy-Muir Speaking Valve in a Non-Ventilated Patient.
Speech Pathology CAHS June 2011

Initial Passy Muir Valve trials are often poorly tolerated by Infants and
Children
Exhalation via the glottis may be initially uncomfortable and frightening for the
tracheostomised patient. A prolonged reduction in airflow through the upper airway
following cannulation is associated with drying of pharyngeal membranes and
altered laryngeal tone.29 Adult patients can be warned that PMV placement may be
initially uncomfortable and can be educated as to the anticipated benefits of wearing
the PMV. For infants and children, it may not be possible to communicate what to
expect due to barriers of age and level of cognitive and communication
functioning.2,22 For infants and children, vocalisation may not be achieved on the first
trial, but is usually achieved within three trials. 30
The success of initial speaking valve placement is related to the childs physiological
and behavioural tolerance.22 Behavioural resistance is common during initial PMV
trials with infants and children.2,15,22 Children commonly respond by coughing,
breath-holding, bubble-blowing and forcible exhalations to expel the valve.2,22 The
physiological success of PMV placement is related to the patency of the upper
airway.17,31 Upper airway obstruction is the most common reason for paediatric
tracheostomy placement.5,16 Unfortunately children with upper airway obstruction
often have significant difficulty tolerating a PMV. 15,17,22,31
Manometry Testing is used to discern behavioural from physiological
intolerance
The challenge for the examiner is to discern the underlying basis of intolerance.
Initial valve assessment traditionally involves monitoring of vital signs; heart rate,
peripheral oxygen saturation and work of breathing. Manometry assessment of
passive exhalations provides an additional, non-invasive tool for assessment of
physiological tolerance.31,32 The patency of the upper airway may be inferred using
manometry assessment of trans-tracheal pressure.9,17,31,33
Trans-tracheal pressure (TTP) less than 10cmH20 on PMV assessment is
associated with tolerance of the PMV for short trials.32 TTP less than 5 cmH20 has
been associated with successful transition to full-day use of the valve, as this
indicates the air leak around the tracheotomy tube is large, and the upper airway is
patent.9,17,31,33 Manometry results are superficially inflated if the child attempts to
cough or vocalise during assessment.
For a child with TTP<5cmH20, intolerance is likely to be behavioural. Families should
be educated as to how the valve works, how to monitor the child when using the
valve and what to expect.2,10,30,31 Parental anxiety may transfer to the child,
exacerbating distress. It is important that parents have accurate expectations
concerning likely behavioural responses to initial PMV placement. A realistic
understanding of the childs current communication skills and likely ability to vocalise
should also be communicated. As much as possible, the child should be familiarised
with the procedure. For infants, it is recommended that consistent touch cues or Key
Word Signs are used, including a warning cue and finish cue.
Development information for Clinical Practice Guideline for the Use of a
Passy-Muir Speaking Valve in a Non-Ventilated Patient.
Speech Pathology CAHS June 2011

Physiological intolerance is indicated by dyspnoea and TTP 10cmH20 on passive

exhalation. TTP exceeding 10cmH20 is associated with narrowing of the upper
airway or insufficient leak around the tracheostomy tube.17,31 Excessive TTP may be
adequately reduced by downsizing the tracheostomy tube and thereby increasing
the leak to breathe around the tube.9,32 However, there are cases where this is
either not possible or unsuccessful, with persisting TTP on exhalation. For these
failed cases, drilling the valve may alleviate excessive TTP whilst still facilitating
phonation. 17,34,35
Drilling a hole in the PMV provides a pressure relief port to reduce transtracheal pressure. This may allow comfortable exhalation and enable
phonation for children with upper airway obstruction.
For cases where the tube has been appropriately down-sized and there is known
upper airway obstruction, a drilled hole may alleviate excessive TTP whilst still
facilitating phonation. This innovative practice was originally described in 199934 and
recently in 200917.
The drilling of a speaking valve results in the presence of a relief port to enable
partial exhalation through the tracheostomy tube whilst wearing the PMV. Pneumatic
benefits to swallow and secretion management obtained through one-way valve use
are presumably lost by the presence of the hole. Secretions gather in the
tracheostomy tube, requiring removal of the PMV for suctioning. However,
vocalisation using the drilled PMV may be achieved due to the presence of an
effective relief port in cases where use of a standard PMV would otherwise be
contraindicated.17 Drilling of the valves is standard practice at Cincinnati Childrens
Hospital Medical Centre and Bostons Childrens Hospital40 but is not yet well
described in the literature. Drilled valves have been trialled with ten cases at PMH
with promising results39.
PMH Retrospective Case Series: Drilling a PMV to promote Tolerance and
Phonation
A retrospective case series audit was completed reviewing ten charts of
tracheostomised children trialled with a drilled speaking valve over the period
between January 2008 and January 2010. Ethics approval was gained through the
hospital Governance board (Reference 127QP).
Patients were tracheostomised infants and children aged 2 months 15 years
(mean: 3 years 2 months; median 19 months) who had significant upper airway
obstruction at a laryngotracheal level, some had additional obstruction at a
supralaryngeal level. All patients were aphonic.
The included patients had failed a trial of a standard PMV with TTP range
>10cmH20 on passive exhalation as measured using a handheld manometer.
Downsizing of the tracheostomy tube was either already completed or inappropriate.
Referral and permission for trial of a drilled speaking valve was received from the
childs ENT surgeon and their guardians. Patients were excluded if their upper
airway diagnosis was too severe (e.g. Grade 4 subglottic stenosis) or if the patient
was medically unstable, unable to tolerate cuff deflation or had severe oral aversion.
Development information for Clinical Practice Guideline for the Use of a
Passy-Muir Speaking Valve in a Non-Ventilated Patient.
Speech Pathology CAHS June 2011

The trial of the standard and drilled speaking valves was conducted within a single
session. Patients were assessed wearing a Passy-Muir valve with up to two 1.6 mm
holes drilled in the side of the valve. Patients progressed to trials if trans-tracheal
pressures measured less than 10cmH20.
Eight patients progressed to trial with 5 of 8 patients able to phonate within one
week and 6 of 8 able to tolerate wearing the valve for 2 hours periods within 2
weeks of introduction. All eight patients were able to phonate within six months of
valve introduction.
These findings support drilling Passy-Muir speaking valves as a promising option to
facilitate phonation in tracheostomised children with upper airway obstruction, with
potential positive implications for speech and language development.

Development Team
1st phase release: February, 2010
PMH Working Group
Ali Buckland
Shyan Vijayasekaran
Toni Ilich
Lara Jackson
Jodi Lipscombe
Julie McLean
Paul Darcy

Senior Speech Pathologist, PMH

Otolaryngologist. Head & Neck Surgeon.
CNC Technology Dependent Children.
CNC Technology Dependent Children.
HOD. Speech Pathology.
CNS ENT
Nursing Director. Surgical Services, PMH

2nd phase release: November, 2010

PMH Reference Group
Geoff Knight
Andrew Wilson
Prof. Le Soeuf
Prof. Francis Lannigan
Karen Laurie
Tu Trang Tran
Holly Cameron
Corina Gill
Thila Raja
Jean Bailey
Bronwyn Fitzgerald
PMHJane Ryan

HOD. PICU. PMH.

Consultant Respiratory Medicine. PMH.
HOD. Respiratory. PMH.
Otolaryngologist. Head & Neck Surgeon
CNC A/PICU Nurse Manager. PMH.
A/ ENT Coordinator- Clinical Nurse ENT/ Respiratory
Medicine PMH Theatre
Senior Speech Pathologist. PMH.
Senior Speech Pathologist. PMH.
Senior Speech Pathologist. PMH.
Senior Speech Pathologist. PMH.
Senior Speech Pathologist. PMH.
CNC Infection Control. PMH.

Development information for Clinical Practice Guideline for the Use of a

Passy-Muir Speaking Valve in a Non-Ventilated Patient.
Speech Pathology CAHS June 2011

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Passy-Muir Speaking Valve in a Non-Ventilated Patient.
Speech Pathology CAHS June 2011

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Speech Pathology CAHS June 2011

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Development information for Clinical Practice Guideline for the Use of a

Passy-Muir Speaking Valve in a Non-Ventilated Patient.
Speech Pathology CAHS June 2011