I have learnt so much from the speech and language pathologists at John Hopkins. I have seen their practice throughout my visit as well as spending a full day with Therese Cole firstname.lastname@example.org
Therese is the clinical SLP specialist at John Hopkins and is heavily involved with the tracheostomy programme.
Background of SLP in the USA:
Speech and language pathologist in the US have an advanced and established training programme.
They will do 4 years at undergraduate, followed by a 2 year masters degree and then a 1 year fellowship.
They then can start within the hospital setting were they work up from Level 1 to 3. Similar to the respiratory therapists.
SLP at John Hopkins:
They have 7 SLP’s at John Hopkins, and 1 coordinator. Of the 7 SLP’s they have 1 clinical specialist, 3 level 2 staff and 3 level 1 staff.
As with most health care professions they complete in service trainings and competencies to enhance their learning and develop their skills.
They have a large range of roles covering 3 areas:
• Patient swallow
• Tracheostomy weaning
There training in these areas allows them to be autonomous in their practice and develop their skills further to be able to:
• Preform video fluoroscopy and FEE’s (as well as interpret them)
o These are always preformed with swallow assessments on trache patients.
• Tracheostomy cuff deflation and tracheal suctioning
• Trials of speaking valves including in-line valves
IM SORRY THERESE IVE PROBABLY MISSED LOADS!!
They receive all their referrals electronically, and depending on the consult required they may also be contacted in person. For tracheostomy’s typically this is also discussed during ward rounds and trache rounds.
For swallow referrals there is a set protocol. If a patient has been ventilated for longer than 72 hours (due to the > risk of vocal cord disruption), if they have a tracheostomy and if they have any other evident underlying risk factors e.g. bulbar palsy, the nursing staff will refer to SLP for an assessment.
For all other assessments the nursing staff carry out a ‘3 Ounce’ swallow assessment, which if they fail the patients are kept ‘nil by mouth’ until an SLP assessment.
Overview of my observations:
As I stated I spent a whole day with SLP as well as seeing their practice throughout my visit. So what did I see?:
Therese first showed my though some videos of the success they have had with ‘talking tracheostomies’ = those with sub-glotic ports.
They are using these on patient who are unable to have the cuff deflated, still requiring ventilatory support and patients that are cognitively suited.
They will use a flow rate of oxygen which is the lowest amount to make a reasonable phonation. For them this has ranged between 1-6lt of O2.
I saw videos showing the patients ability to occlude an aperture on the line allowing the oxygen flow thought the vocal cords when they wanted to speak. Therese encourages her patients to only allow flow when they want to speak, and if able, time this with an exhale on the ventilator, recreating good timing of voice for if that patient is able to be weaned in the future.
Although you have to be very selective with which patient you trial this technique with, as well as often requiring a tube change to introduce a custom trache which allows this function. This technique provides patients with a voice who otherwise may never have one. It also allows for stimulation of the vocal cords and upper respiratory tract which may also improve a patents swallow.
Most patients who have been intubated or had a tracheostomy say that one of, if not the biggest frustration/problem they faced, was the inability to talk or communicate.
We next then saw a patient for a bedside swallow assessment. This was a patient that had already been assessed and we were seeing if she could manage more challenging consistencies allowing for a full diet. The patient had been ventilated for a bad pneumonia in the week proceeding.
SLP did a full check of the patients oral motor movements (inc sensation on some patients where necessary). They then assessed the patient swallow of just saliva = palpation.
She then move from ice chips up to mixed consistency food, monitoring RR and SpO2 throughout.
A plan was then made on the patients new diet abilities and the MDT informed. They also have bedside reminders for staff and patients.
In line speaking valve:
We then saw a patient to trial an inline speaking valve.
Their team have some indications for starting to use an inline valve. The patient has to be on a PEEP of 5 or lower and an FiO2 of .40 or lower.
For this assessment both the SLP and the RT where present.
For the assessment the vent has to be turned to NIV mode, due to it attempting to correct the leak if not as well as alarming heavily!!
This patient had a size 8 non fenestrated trache in situ, fiO2 of .4 and PEEP of 5. They where cognitively not intact and therefore the assessment was difficult.
The SLP deflated the cuff as the RT suctioned simultaneously, attempting to catch any secretions before they hit the carina and simulate a prolonged cough reflex. At this point any drop in tidal volume was recorded.
With a piece of flexi ‘elephant’ tubing the passy-muir valve was place in situ. Due to this patients cognitive status the team where only able to encourage the voice and struggled to gain any feedback apart fromobservations.
From the assessment the SLP will then make recommendations for the use of the valve (when and how long for). In this case the patient was not able to tolerate the valve and no phonation was heard. However due to the size 8 tube, it was questionable how much of a leak there was and therefore how much feedback the patent was getting.
Therefore the plan was made not to continue any speaking trials and to consult the team regarding downsizing the tube on the next trache change.
The SLP team conduct these with a radiologist present. They are able to take most patient groups to radiology to conduct this study, even ventilated tracheostomy patients.
The patent is posited as upright as possible. The machine can then be placed in either a lateral or AP view.
The patient is then assessed by the team. They will take images as the patient is carrying out each request and swallow. During this time the SLP can add in techniques to assist the patient as required e.g. chin tucks, turning the head left or right, holding breaths.
Both SLP can then review the videos, in realtime and retrospectively and make a plan for the patient. If the imaging is conclusive then they can give the patient an answer straight away, if not the images are reviewed and a plan is made within the next 30mins to 1 hour. The speech and language pathologist and the radiographer will collaborate on their findings but write separate reports.
I was lucky enough to observe one of these assessments in my time at JHH. The team has really good inter-professional working relationships, and value each others expertise. The SLP lead the assessment in this case. The patient was tried with various consistencies for them to assess his swallow. As each consistency was assessed and then the patient was progressed appropriately giving more challenging substances such as thin fluids. Obviously each swallow was given a radio-contrast such as barium so the swallow could be observed fully, for things such as aspiration and clearance.
For this patient they where able to give them a result and allow them to start a particular diet. However we still when through all the videos afterwards to check the results and document the findings as well as making a plan for ongoing care and/or re-imaging.
For my project it was great to see how this more advanced role of SLP at JHH helps with there tracheostomy weaning programme. It makes sense to me that those trained in voice production and swallow have a dominant role with the weaning and advancement of patients tracheostomies. Because they are also able to tracheal suction this makes them able to carry out this role autonomously in some cases.
It was also nice to see the number of inter-professional relationships that SLP are a part of within specific tasks outside of the MDT ward round. Showing again that an MDT approach goes far beyond patient discussions and ward rounds, but into their care and interventions.