Role of the Speech Language Pathologist

Assessment of ventilator-dependent patients includes  consideration of the following:

  Posture (body, head, face) and positioning

  Oral-peripheral examination

  Dentition and swallowing

  Primitive oral reflexes

  Laryngeal function (MPT, quality, volume, cough, throat 

    clearing, ability to impound air)

  Behavior (alert, cooperative, confused)

  Ability to follow directions; language and speech skills

  Palatal function (VP closure, nasal emission, mouth  

    breathing, gag reflex)

  Hand/eye coordination

  Cognitive abilities

  Medical status

  Airflow rate through the glottis if the use of a "talking" 

     tracheostomy is used.

  Resource and support availability and the attitudes and 

      motivation of patient, staff, and family members.

Speaking tracheostomy tubes:

    Daily voice therapy:

    stimulate vocal fold adduction.

    synchronize airflow through the speaking tube with 

     adduction of folds.

   improve speech articulation.

   promote coordination between speech production and 

     ventilator support for breathing.

   train patients (when possible) in self-use of the airflow line 

     for speech.

   eliminate anxiety.

Techniques used:

   a cough or throat clearing maneuver is used to stimulate fold 

     adduction.

   the reflexive sound is shaped into a sustained vowel.

   vowels are gradually shaped into connected speech

   light finger pressure is placed on the ventilator hose attached 

     to the hub of the tracheostomy rube.  This positions the tube 

       optimally to eliminate any air leak at the tracheostomy 

       tube-skin interface.

   the patient is trained to occlude the airflow line and speak 

     only during the expiration phase of ventilation.

   provide 50 cm of extra airflow tubing to make it easier to 

    locate and occlude the line.

   maintain the perpendicular insertion of the airflow line where 

     it enters the tracheostomy tube, to avoid kinking.

If problems occur:

    is the patient able to adduct folds?

    are the fenestrations clogged with secretions?

    are the neck straps too loose?

    are the ventilator hoses rotating the tube causing the 

      fenestrations to be blocked by the tracheal wall?

    is there air leakage because of inadequate locking of the inner 

      and outer cannulas at the hub?

    is there kinking of the airflow line tubing just before it 

       enters the tracheostomy tube?

Competencies:

     know alterations in anatomy and physiology subsequent to 

        total and partial laryngectomy and tracheotomy.

     describe communicative options available to clients with 

       altered anatomy and physiology.

     demonstrate ability to develop clinical care paths, including 

       (a) surgical and medical management, (b) fitting and 

        maintenace of prosthetic devices, (c)behavioral therapy, (d) 

        counselling, (e) interdisciplinary communication.

     find solutions to problems that occur with use of prosthesis, 

        client's care of prosthesis, and family support and make 

         appropriate referrals as needed.

     enforce strict safety procedures and adhere to universal 

         precautions.

     review the literature and be committed to be current with 

       new developments and insights through continuing 

       education.

     demonstrate the ability to communicate with clients, 

       families, the public, allied health professionals, and 

       educators concerning best practices in rehabilitation of 

       clients.

    understand the role and scope of practice of respiratory 

       therapists and have knowledge of ventilators, danger signals 

      of respiratory distress, and the speech-language pathologist's 

      responsibilities as a part of the rehabilitation team.

   explain the reasons for selecting specific prostheses for clients

   evaluate, monitor, and adjust treatment approach and 

      procedures in response to feedback, changes in medical status, 

      and new information.

   demonstrate the ability to educate allied health professionals 

    on necessary precautions to avoid damage to the vocal 

    mechanism during intubation, extubation, and/or protracted 

    intubation.

    demonstrate the ability to educate allied health professionals 

      on other effects and complications involved in the in the 

      intubation process.

    demonstrate the ability to communicate with allied health 

      professionals concerning tips to minimize complications 

     involved in the intubation process.