Development, feasibility testing, and preliminary evaluation of the Communication with an Artificial airway Tool (CAT): Results of the Crit-CAT pilot study.

BACKGROUND: A purpose-built outcome measure for assessing communication effectiveness in patients with an artificial airway is needed. OBJECTIVES: The objective of this study was to develop the Communication with an Artificial airway Tool (CAT) and to test the feasibility and to preliminary evaluate the clinical metrics of the tool. METHODS: Eligible patients with an artificial airway in the Intensive Care Unit were enrolled in the pilot study (Crit-CAT). The CAT was administered at least twice before and after the communication intervention. Item correlation analysis was performed. Participant and family member acceptability ratings and feedback were solicited. A qualitative thematic analysis was undertaken. RESULTS: Fifteen patients with a mean age of 53 years (standard deviation [SD]: 19.26) were included. The clinician-reported scale was administered on 50 attempts (100%) with a mean completion time of 4.5 (SD: 0.77) minutes. The patient-reported scale was administered on 46 out of 49 attempts (94%) and took a mean of 1.5 (SD: 0.39) minutes to complete. The CAT was feasible for use in the Intensive Care Unit, with patients with either an endotracheal or tracheostomy tube, whilst receiving invasive mechanical ventilation or not, and while using either verbal or nonverbal modes of communication. Preliminary establishment of responsiveness, validity, and reliability was made. The tool was acceptable to participants and their family members. CONCLUSION: The clinician-reported and patient-reported components of the study were feasible for use. The CAT has the potential to enable quantifiable comparison of communication interventions for patients with an artificial airway. Future research is required to determine external validity and reliability.

Swallowing with Noninvasive Positive-Pressure Ventilation (NPPV) in Individuals with Muscular Dystrophy: A Qualitative Analysis.

The purpose of the study is to describe experiences of swallowing with two forms of noninvasive positive-pressure ventilation (NPPV): mouthpiece NPPV (M-NPPV) and nasal bilevel positive airway pressure (BPAP) in people with muscular dystrophy. Ten men (ages 22-42 years; M = 29.3; SD = 7.1) with muscular dystrophy (9 with Duchenne's; 1 with Becker's) completed the Eating Assessment Tool (EAT-10; Ann Otol Rhinol Laryngol 117(12):919-924 [33]) and took part in semi-structured interviews. The interviews were audio recorded, transcribed, and verified. Phenomenological qualitative research methods were used to code (Dedoose.com) and develop themes. All participants affirmed dysphagia symptoms via responses on the EAT-10 (M = 11.3; SD = 6.38; Range = 3-22) and reported eating and drinking with M-NPPV and, to a lesser extent, nasal BPAP. Analysis of interview data revealed three primary themes: (1) M-NPPV improves the eating/drinking experience: Most indicated that using M-NPPV reduced swallowing-related dyspnea. (2) NPPV affects breathing-swallowing coordination: Participants described challenges and compensations in coordinating swallowing with ventilator-delivered inspirations, and that the time needed to chew solid foods between ventilator breaths may lead to dyspnea and fatigue. (3) M-NPPV aids cough effectiveness: Participants described improved cough strength following large M-NPPV delivered inspirations (with or without breath stacking). Although breathing-swallowing coordination is challenging with NPPV, participants reported that eating and drinking is more comfortable than when not using it. Overall, eating and drinking with NPPV delivered via a mouthpiece is preferred and is likely safer for swallowing than with nasal BPAP. M-NPPV (but not nasal BPAP) is reported to improve cough effectiveness, an important pulmonary defense in this population.

Beyond Tracheostomy: Noninvasive Ventilation and Potential Positive Implications for Speaking and Swallowing.

For more than a decade, there has been a trend toward increased use of noninvasive positive pressure ventilation (NPPV) via mask or mouthpiece as a means to provide ventilatory support without the need for tracheostomy. All indications are that use of NPPV will continue to increase over the next decade and beyond. In this article, we review NPPV, describe two common forms of NPPV, and discuss the potential benefits and challenges of NPPV for speaking and swallowing based on the available literature, our collective clinical experience, and interviews with NPPV users. We also speculate on how future research may inform clinical practice on how to best maximize speaking and swallowing abilities in NPPV users over the next decade.

Stress velopharyngeal incompetence in collegiate trombone players.

Objectives : Symptoms of stress velopharyngeal incompetence (SVPI) have been reported by many wind instrument players. The current study was designed to determine (1) if symptoms of SVPI were accompanied by aeromechanical signs of SVPI and (2) if signs of SVPI differed across musical tasks. Design : Participants were studied during a single recording session. Setting : The study was conducted in a university laboratory. Participants : Participants were 10 collegiate trombone players. They were separated into two groups: six who reported symptoms of SVPI and four who reported no symptoms. Main Outcome Measure : Nasal pressure recorded during trombone playing was used to determine velopharyngeal status (open or closed). Results : None of the participants exhibited an open velopharynx during trombone playing; however, all participants had positive nasal pressure (indicating an open velopharynx) immediately prior to sound onset on at least some of their breath groups. Two participants had positive nasal pressure prior to the vast majority of their productions and were given biofeedback and instruction to change this behavior. Conclusions : Symptoms of SVPI do not necessarily indicate the presence of a velopharyngeal-nasal leak during wind instrument playing but may reflect awareness of air leaks immediately prior to sound production. Pre-sound velopharyngeal-nasal air leaks may be amenable to behavioral modification by biofeedback and instruction. Nasal pressure measurement (using a nasal cannula) provides a simple, yet powerful, way to identify SVPI.

Defining effective communication for critically ill patients with an artificial airway: An international multi-professional consensus.

OBJECTIVES: To define effective communication and identify its key elements specific to critically ill patients with an artificial airway. DESIGN: A modified Consensus Development Panel methodology. SETTING: International video-conferences. MAIN OUTCOME MEASURES: Definition of effective communication and it's key elements. RESULTS: Eight experts across four international regions and three professions agreed to form the Consensus Development Panel together with a Chair and one person with lived experience who reviewed the outputs prior to finalisation. "Communication for critically ill adult patients with an artificial airway (endotracheal or tracheostomy tube) is defined as the degree in which a patient can initiate, impart, receive, and understand information, and can range from an ineffective to effective exchange of basic to complex information between the patient and the communication partner(s). Effective communication encompasses seven key elements including: comprehension, quantity, rate, effort, duration, independence, and satisfaction. In critically ill adults, communication is impacted by factors including medical, physical and cognitive status, delirium, fatigue, emotional status, the communication partner and the nature of the ICU environment (e.g., staff wearing personal protective equipment, noisy equipment, bright lights)." The panel agreed that communication occurs on a continuum from ineffective to effective for basic and complex communication. CONCLUSION: We developed a definition and list of key elements which constitute effective communication for critically ill patients with an artificial airway. These can be used as the basis of standard terminology to support future research on the development of communication-related outcome measurement tools in this population. IMPLICATIONS FOR CLINICAL PRACTICE: This study provides international multi-professional consensus terminology and a definition of effective communication which can be used in clinical practice. This standard definition and key elements of effective communication can be included in our clinical impressions of patient communication, and be used in discussion with the patient themselves, their families and the multi-professional team, to guide care, goal development and intervention.

Effects of sequential swallowing on drive to breathe in young, healthy adults.

Sequential swallowing is the act of swallowing multiple times, without pausing. Because sequential swallowing requires breath-holding, it seems likely that it could increase the drive to breathe. This study was designed to determine if sequential swallowing is accompanied by an increased drive to breathe in young, healthy adults. We predicted that sequential swallowing would be accompanied by prolonged breath-holding in most cases, and that this would be followed by a recovery phase during which ventilation would increase for a brief period. Results showed that not only did healthy participants increase ventilation after sequential swallowing, they also experienced breathing discomfort (dyspnea) despite the fact that they usually continued to breathe during the swallowing sequence. Given that these effects are observable in young, healthy adults, it seems reasonable to assume that individuals with respiratory and/or neurological compromise would also have an increased drive to breathe during sequential swallowing.

A simple technique for determining velopharyngeal status during speech production.

Clinical evaluation of velopharyngeal function relies heavily on auditory perceptual judgments that can be supported by instrumental examination of the velopharyngeal valve. Many of the current instrumental techniques are difficult to interpret, expensive, and/or unavailable to clinicians. Proposed in this report is a minimally invasive and inexpensive approach to evaluating velopharyngeal function that has been used successfully in our laboratory for several potentially difficult-to-test clients. The technique is an aeromechanical approach that involves the sensing of nasal ram pressure (N-RamP), a local pressure sensed at the anterior nares, using a two-pronged nasal cannula. By monitoring the N-RamP signal, it is possible to determine the status of the velopharyngeal port (open or closed) during speech production. Four case examples are presented to support its clinical value.

Nature and evaluation of dyspnea in speaking and swallowing.

Dyspnea (breathing discomfort) is a serious and pervasive problem that can have a profound impact on quality of life. It can manifest in different qualities (air hunger, physical exertion, chest/lung tightness, and mental concentration, among others) and intensities (barely noticeable to intolerable) and can influence a person's emotional state (causing anxiety, fear, and frustration, among others). Dyspnea can make it difficult to perform daily activities, including speaking and swallowing. In fact, dyspnea can cause people to change the way they speak and swallow in their attempts to relieve their breathing discomfort; in extreme cases, it can even cause people to avoid speaking and eating/drinking. This article provides an overview of dyspnea in general, describes the effects of dyspnea on speaking and swallowing, includes data from two survey studies of speaking-related dyspnea and swallowing-related dyspnea, and outlines suggested protocols for evaluating dyspnea during speaking and swallowing.

A Conceptual Framework for Understanding Speaking Dyspnea.

Purpose A conceptual framework is proposed to better understand the experience of people who have dyspnea (breathing discomfort) when speaking: its nature, its physiological mechanisms, and its impacts on their lives. Method The components of the framework are presented in their natural order. They are a Speaking Domain (Speaking Activities and Speaking Variables), a Physiological Domain (Speech Breathing Variables and Physiological Mechanisms), a Perceptual Domain (Dyspnea), a Symptom Impact Domain (Emotional Responses, Immediate Behavioral Responses, and Long-Term Behavioral Response), and a Life Impact Domain (Short-Term Impacts and Long-Term Impacts). Results We discuss literature that most directly supports these components and includes findings from healthy people and those with disorders in whom speaking dyspnea was either evoked or measured. Caveats are noted where information is limited and further study is needed. A case example is provided to illustrate how to apply the framework. Conclusions This framework provides a broader view of the elements that contribute to the experience of speaking dyspnea. It is meant to guide researchers, clinicians, instructors, caregivers, and those for whom speaking dyspnea is a daily or even a life-long challenge.

Effects of Mouthpiece Noninvasive Ventilation on Speech in Men With Muscular Dystrophy: A Pilot Study.

Purpose The use of noninvasive ventilation (NIV) is on the rise as an alternative to tracheostomy for individuals with neuromuscular disorders with life-prolonging and quality-of-life benefits. This pilot study was designed to determine if mouthpiece NIV (M-NIV) alters speech in individuals with muscular dystrophy (MD). Method Eight men (23-44 years), seven with Duchenne MD and one with Becker MD, who used daytime M-NIV, were asked to sustain phonation, count, and read under three conditions: (a) Uncued (no instructions), (b) With M-NIV (cued to use M-NIV with all speaking breaths), and (c) Without M-NIV (as tolerated). Breath group and inspiratory durations, syllables/breath group, and relative sound pressure level were determined from audio and video recordings. Results Uncued condition: Participants used the ventilator for all inspirations that preceded sustained phonation and counting. During reading, four participants used M-NIV for all inspirations, one never used it, and three used it for some (19%-41%) inspirations. With- versus Without-M-NIV conditions: Breath group duration was significantly longer across all tasks, syllables per breath group were significantly greater during reading, and inspiratory pause duration during reading was significantly longer with M-NIV than without. Sound pressure level was significantly higher during the first second of sustained phonation with M-NIV (though not for counting and reading). Two participants were unable to complete the reading task audibly without using their M-NIV. Conclusions Speech may be better with M-NIV than without because it is possible to produce longer breath groups and some people with severe respiratory muscle weakness may not be able to speak at all without ventilator-supplied air. Nevertheless, the longer inspiratory pauses that accompany M-NIV may interrupt the flow of speech. Future research is needed to determine the most effective way to use M-NIV for speaking and whether training participants in its use can bring even greater speech benefits.

Speaking dyspnea in Parkinson's disease: Preliminary findings.

PURPOSE: To determine if people with Parkinson's disease (PD) experience dyspnea (breathing discomfort) during speaking. METHOD: The participants were 11 adults with PD and 22 healthy adults (11 young, 11 old). Participants were asked to recall experiences of breathing discomfort across different speaking contexts and provide ratings of those experiences (Retrospective ratings); then they rated the breathing discomfort experienced while performing speaking tasks that were designed to differ in respiratory demands (immediate Post-Speaking ratings). RESULTS: Participants with PD reported experiencing breathing discomfort during speaking significantly more frequently (approximately 60 % of the time) than did healthy participants (less than 20 % of the time). Retrospective ratings did not differ significantly from Post-Speaking ratings. Breathing discomfort was experienced by the fewest number of participants with PD for Conversation (two) and Extemporaneous Speaking (three) and by the greatest number for Extended Reading (ten) and Long Counting (nine), although the magnitude of the ratings generally reflected only "Slight" discomfort. Breathing discomfort was most frequently described as air hunger and breathing work, less frequently as mental effort, and very rarely as lung tightness. A few participants with PD reported experiencing emotions associated with their breathing discomfort and most reported using strategies to avoid breathing discomfort in their daily lives. CONCLUSIONS: Individuals with PD are more apt to experience speaking dyspnea than healthy individuals, especially when speaking for extended periods or when using long breath groups. Such dyspnea may contribute to a tendency to avoid speaking situations and thereby impair quality of life.

Experiences of Speaking With Noninvasive Positive Pressure Ventilation: A Qualitative Investigation.

Purpose The aim of this study was to describe experiences of speaking with 2 forms of noninvasive positive pressure ventilation (NPPV)-mouthpiece NPPV (M-NPPV) and nasal bilevel positive airway pressure (BPAP)-in people with neuromuscular disorders who depend on NPPV for survival. Method Twelve participants (ages 22-68 years; 10 men, 2 women) with neuromuscular disorders (9 Duchenne muscular dystrophy, 1 Becker muscular dystrophy, 1 postpolio syndrome, and 1 spinal cord injury) took part in semistructured interviews about their speech. All subjects used M-NPPV during the day, and all but 1 used BPAP at night for their ventilation needs. Interviews were audio-recorded, transcribed, and verified. A qualitative descriptive phenomenological approach was used to code and develop themes. Results Three major themes emerged from the interview data: (a) M-NPPV aids speaking (by increasing loudness, utterance duration, clarity, and speaking endurance), (b) M-NPPV interferes with the flow of speaking (due to the need to pause to take a breath, problems with mouthpiece placement, and difficulty in using speech recognition software), and (c) nasal BPAP interferes with speaking (by causing abnormal nasal resonance, muffled speech, mask discomfort, and difficulty in coordinating speaking with ventilator-delivered inspirations). Conclusion These qualitative data from chronic NPPV users suggest that both M-NPPV and nasal BPAP may interfere with speaking but that speech is usually better and speaking is usually easier with M-NPPV. These findings can be explained primarily by the nature of the 2 ventilator delivery systems and their interfaces.

Respiratory and laryngeal function during spontaneous speaking in teachers with voice disorders.

PURPOSE: To determine if respiratory and laryngeal function during spontaneous speaking were different for teachers with voice disorders compared with teachers without voice problems. METHOD: Eighteen teachers, 9 with and 9 without voice disorders, were included in this study. Respiratory function was measured with magnetometry, and laryngeal function was measured with electroglottography during 3 spontaneous speaking tasks: a simulated teaching task at a typical loudness level, a simulated teaching task at an increased loudness level, and a conversational speaking task. Electroglottography measures were also obtained for 3 structured speaking tasks: a paragraph reading task, a sustained vowel, and a maximum phonation time vowel. RESULTS: Teachers with voice disorders started and ended their breath groups at significantly smaller lung volumes than teachers without voice problems during teaching-related speaking tasks; however, there were no between-group differences in laryngeal measures. Task-related differences were found on several respiratory measures and on one laryngeal measure. CONCLUSIONS: These findings suggest that teachers with voice disorders used different speech breathing strategies than teachers without voice problems. Implications for clinical management of teachers with voice disorders are discussed.

Development of Velopharyngeal Closure for Vocalization During the First 2 Years of Life.

Purpose: The vocalizations of young infants often sound nasalized, suggesting that the velopharynx is open during the 1st few months of life. Whereas acoustic and perceptual studies seemed to support the idea that the velopharynx closes for vocalization by about 4 months of age, an aeromechanical study contradicted this (Thom, Hoit, Hixon, & Smith, 2006). Thus, the current large-scale investigation was undertaken to determine when the velopharynx closes for speech production by following infants during their first 2 years of life. Method: This longitudinal study used nasal ram pressure to determine the status of the velopharynx (open or closed) during spontaneous speech production in 92 participants (46 male, 46 female) studied monthly from age 4 to 24 months. Results: The velopharynx was closed during at least 90% of the utterances by 19 months, though there was substantial variability across participants. When considered by sound category, the velopharynx was closed from most to least often during production of oral obstruents, approximants, vowels (only), and glottal obstruents. No sex effects were observed. Conclusion: Velopharyngeal closure for spontaneous speech production can be considered complete by 19 months, but closure occurs earlier for speech sounds with higher oral pressure demands.

Speaking-related dyspnea in healthy adults.

PURPOSE: To reveal the qualities and intensity of speaking-related dyspnea in healthy adults under conditions of high ventilatory drive, in which the behavioral and metabolic control of breathing must compete. METHOD: Eleven adults read aloud while breathing different levels of inspired carbon dioxide (CO(2)). After the highest level, participants provided unguided descriptions of their experiences and then selected descriptors from a list. On a subsequent day, participants read aloud while breathing high CO(2) as before, then rated air hunger, physical exertion, and mental effort (with definitions provided). Recordings were made of ventilation (with respiratory magnetometers), end-tidal partial pressure of CO(2), transcutaneous PCO(2), oxygen saturation, noninvasive blood pressure, heart rate, and the speech signal. RESULTS: Unguided descriptions were found to reflect the qualities of air hunger, physical exertion (work), mental effort, and speech-related observations. As CO(2) stimulus strength increased, participants experienced increased perception of air hunger, physical exertion, and mental effort. Simultaneous increases were observed in ventilation, tidal volume, end-inspiratory and end-expiratory volumes, expiratory flow during speaking, nonlinguistic junctures, and nonspeech expirations. CONCLUSION: Two qualities of speaking-related dyspnea--air hunger and physical exertion--are the same as those reported for many other types of nonspeech dyspnea conditions and, therefore, may share the same physiological mechanisms. The mental effort quality associated with speaking-related dyspnea may reflect a conscious drive to balance speech requirements and ventilatory demands. These findings have implications for developing better ways to evaluate and manage clients with respiratory-based speech problems.

Influence of visual information on the intelligibility of dysarthric speech.

PURPOSE: To examine the influence of visual information on speech intelligibility for a group of speakers with dysarthria associated with Parkinson's disease. METHOD: Eight speakers with Parkinson's disease and dysarthria were recorded while they read sentences. Speakers performed a concurrent manual task to facilitate typical speech production. Twenty listeners (10 experienced and 10 inexperienced) transcribed sentences while watching and listening to videotapes of the speakers (auditory-visual mode) and while only listening to the speakers (auditory-only mode). RESULTS: Significant main effects were found for both presentation mode and speaker. Auditory-visual scores were significantly higher than auditory-only scores for the 3 speakers with the lowest intelligibility scores. No significant difference was found between the 2 listener groups. CONCLUSIONS: The findings suggest that clinicians should consider both auditory-visual and auditory-only intelligibility measures in speakers with Parkinson's disease to determine the most effective strategies aimed at evaluation and treatment of speech intelligibility decrements.

Respiratory dysfunction and management in spinal cord injury.

Respiratory dysfunction is a major cause of morbidity and mortality in spinal cord injury (SCI), which causes impairment of respiratory muscles, reduced vital capacity, ineffective cough, reduction in lung and chest wall compliance, and excess oxygen cost of breathing due to distortion of the respiratory system. Severely affected individuals may require assisted ventilation, which can cause problems with speech production. Appropriate candidates can sometimes be liberated from mechanical ventilation by phrenic-nerve pacing and pacing of the external intercostal muscles. Partial recovery of respiratory-muscle performance occurs spontaneously. The eventual vital capacity depends on the extent of spontaneous recovery, years since injury, smoking, a history of chest injury or surgery, and maximum inspiratory pressure. Also, respiratory-muscle training and abdominal binders improve performance of the respiratory muscles. For patients on long-term ventilation, speech production is difficult. Often, practitioners are reluctant to deflate the tracheostomy tube cuff to allow speech production. Yet cuff-deflation can be done safely. Standard ventilator settings produce poor speech quality. Recent studies demonstrated vast improvement with long inspiratory time and positive end-expiratory pressure. Abdominal binders improve speech quality in patients with phrenic-nerve pacers. Recent data show that the level and completeness of injury and older age at the time of injury may not be related directly to mortality in SCI, which suggests that the care of SCI has improved. The data indicate that independent predictors of all-cause mortality include diabetes mellitus, heart disease, cigarette smoking, and percent-of-predicted forced expiratory volume in the first second. An important clinical problem in SCI is weak cough, which causes retention of secretions during infections. Methods for secretion clearance include chest physical therapy, spontaneous cough, suctioning, cough assistance by forced compression of the abdomen ("quad cough"), and mechanical insufflation-exsufflation. Recently described but not yet available for general use is activation of the abdominal muscles via an epidural electrode placed at spinal cord level T9-L1.

A clinical method for the detection and quantification of quick respiratory hyperkinesia.

PURPOSE: Quick respiratory hyperkinesia can be difficult to detect with the naked eye. A clinical method is described for the detection and quantification of quick respiratory hyperkinesia. METHOD: Flow at the airway opening is sensed during spontaneous apnea (rest), voluntary breath holding (postural fixation), and voluntary volume displacement (intentional movement). The method is designed to reveal quick respiratory hyperkinesia independent of the function of the larynx and/or upper airway. Theory underlying the method is discussed, and a protocol is offered for clinical use. CONCLUSIONS: This method may be useful to neurologists, pulmonologists, and speech-language pathologists. Because it depends on nonspeech observations, its application to speech and/or voice production must be inferred.

Listener perception of respiratory-induced voice tremor.

PURPOSE: The purpose of this study was to determine the relation of respiratory oscillation to the perception of voice tremor. METHOD: Forced oscillation of the respiratory system was used to simulate variations in alveolar pressure such as are characteristic of voice tremor of respiratory origin. Five healthy men served as speakers, and 6 clinically experienced women served as listeners. Speakers produced utterances while forced sinusoidal pressure changes were applied to the surface of the respiratory system. Utterances included vowels and sentences produced using usual loudness, pitch, quality, and rate, and vowels produced using different loudness, pitch, and quality. Perceptual tasks included detection threshold for voice tremor and pair comparison judgments in which listeners identified the sample with the greater magnitude of voice tremor. RESULTS: The mean detection threshold for voice tremor was 1.37 cmH(2)O (SD = 0.47) for vowel utterances and 2.16 cmH(2)O (SD = 1.52) for sentence utterances. Tremor magnitude was judged to be different for vowel and sentence utterances, but not for different vowels. Results revealed differential effects for loudness, pitch, and quality. CONCLUSIONS: These findings offer implications for the evaluation and management of voice tremor of respiratory causation.