Complex Airway Management with Dr. Lindsay Griffin

This is a transcript from our podcast episode published May 23rd, 2022. The podcast episode is offered for .1 ASHA CEU (introductory level, professional area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime.

A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible.

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[00:01:40] Kate Grandbois: Today's episode we get to welcome back, uh, someone who has been on our podcast before, who we have so much fun with. As a matter of fact, before we even hit the record button today, we've been chatting and laughing for about half an hour.

So we're really excited for today's guest. We are really [00:02:00] excited. Um, we're really excited for today's guest. Welcome back, Dr. Lindsay Griffin. 

[00:02:05] Lindsay Griffin: Thank you. Thank you for having me. I too, am excited to be here. 

[00:02:10] Amy Wonkka: It's always nice to see you. Um, and today you are here with us to discuss complex airway management. Before we get started can you please tell us a little bit about yourself?

[00:02:20] Lindsay Griffin: Sure. So I am Lindsay Griffin and I work at Emerson college where I am an assistant professor. My main topic area is dysphagia or swallowing difficulties in adults specifically, but given my clinical background of working in acute care and in rehab, I also have some clinical experience in complex airway management.

[00:02:49] Kate Grandbois: I am very excited to learn about what that is because as our listeners know, this is very far out our scope of competence and knowledge base, and you're going to teach us all the things [00:03:00] as you always do, but with a couple of laughs along the way, I would be willing to bet. This is very exciting. Very exciting.

Okay. So before we get going and start bombarding you with likely more elementary questions than you're used to, I am going to read through the learning objectives and disclosures. For those of you listening, who have asked that I have skipped these. I can't ASHA makes me read them so I will get through them as quickly as possible.

If you need to put your podcast player on a 1x or a 2x and fast forward, I'm not going to tell anybody. So learning objective number one, describe the difference between tracheostomies and larygectomies. Learning objective number two, explain the SLPs role in management of patients with tracheostomies and laryngectomies and learning objective number three, recognize external resources for acquiring deeper knowledge of complex airway management disclosures, Lindsey Griffin's financial disclosures. Lindsay is an assistant professor at Emerson College, Lindsay Griffin nonfinancial [00:04:00] disclosures, Lindsey as a member of ASHA, SIG 13, and the dysphagia research society.

Kate Grandbois's financial disclosures. That's me. I'm the owner and founder of Grandbois therapy and consulting LLC. And co-founder of SLP nerd cast. My nonfinancial disclosure is I'm a member of ASHA SIG 12, and serve on the AEC advisory group for Massachusetts advocates for children. I'm also a member of the Berkshire association for behavior analysis and therapy MASS ABA the association for behavior analysis international and the corresponding speech pathology and applied behavior analysis special interest group.

[00:04:30] Amy Wonkka:Amy that's me. My financial disclosures are that I am an employee of a public school system and co-founder of SLP nerd cast. And my nonfinancial disclosures are that I am a member of ashes, special interest group 12, and I serve on the AAC advisory group for Massachusetts advocates for children.

We've done it. We've disclosed and given objectives.

[00:04:49] Kate Grandbois: Sometimes when you say disclose, I think you say disclothed, and that makes me giggle. I just wanted to tell you that. 

[00:04:57] Amy Wonkka: Okay. We can research. If that's the word, we can be [00:05:00] smart and funny at the same time. It's fine. It's totally all right, Lindsey, why don't you start us off by telling us, I mean, like Kate said, we really don't don't know much at all here.

Difference between tracheostomies and laryngectomies.

[00:05:12] Lindsay Griffin: Okay. So they are actually quite different vastly different, some would say, um, but are frequently confused from people who don't understand what they are. So a laryngectomy is usually, always, um, completed by a surgeon as a treatment for someone who has head and neck cancer and it is permanent.

It will, uh, always, it will never be better in the fact that the larynx is surgically removed, the voicebox larynx, and it does not grow back. It does not grow back no. So it is permanent, whereas a tracheostomy can be temporary or permanent. [00:06:00] And, um, it is, uh, surgically placed as a way of usually helping, um, with someone's breathing.

Although there are instances in which they're prophylactically placed. So they're placed before somebody has difficulty. If there is suspicion that someone will have difficulty. 

[00:06:18] Amy Wonkka: and silly question number one of many, to come. Tracheostomy, anatomically is below thelevel at the larynx, right?

Like if you're picturing it in your head while you're driving along listening. 

[00:06:30] Lindsay Griffin: Yes, that is correct. It is below the level of the vocal folds is below a level of the lyrics. So the, a small incision is made on the outside of the neck and the trach tube is just sort of rested in that. And the trachtubes that's below the vocal folds.

Correct. 

[00:06:50] Kate Grandbois: So do people get total laryngectomies for things other than cancer or is it really exclusively as a treatment for, [00:07:00] for cancer as the diagnosis?

[00:07:01] Lindsay Griffin: I would say 99% of the time it is because of, a head and neck cancer diagnosis, but no one ever always or nevers in medicine. So you always, you know, odd cases, but usually it's for head and neck cancer.

Okay. 

[00:07:20] Amy Wonkka: So as a clinician, you're probably more likely to encounter somebody who's had a tracheostomy than you are somebody who's had a laryngectomy, unless you're, you know, kind of working in a place that's doing a lot of those types of surgeries. Is that fair to say?

[00:07:32] Lindsay Griffin: Yes, that is fair to say. And in more recent years there's been a big push for organ preservation.

So the, um, face of head and neck cancer has changed drastically over the past few years. So it used to be a disease that a lot of people got, who were smokers and drinkers, and really, they just can't tease apart smoking from drinking. So they lumped them together. It's probably mainly smoking that contributes to head and neck cancer.[00:08:00] 

Um, and then that cancer was commonly, if it was laryngeal cancer, was commonly treated with a total laryngectomy, but with less people smoking over the years, that type of having that cancer has the incidences have decreased. And now we're seeing a larger rise of head and neck cancers spurring from HPV, which is human papilloma virus.

It's a sexually transmitted disease and it's the same HPV has the same fibers that they're looking for when women have pap smears in the cervix, HPV can lead to cervical cancer. And so when you have a pap smear, they know pretty much where, where the, um, HPV likes to hang out. And so that's the area of, of the cervix in which they scrape, but in the, um, head and neck cancer population.

Where HPV likes to live is [00:09:00] a little, um, it's a little bit more reclusive in the head and neck. And so it's not necessarily an area that they can just like scrape and find out if you have it. The other part is that HPV in some people clears up by itself and no problems develop, and then other people that can lead to cancer.

So in the HPV related cancers that are occurring, the population tends to be younger and they also don't have this history of smoking and drinking. And then the head and neck cancer can also occur in various places. So like the cheek, like the inside of the cheek, the tongue, the base of the tongue still can happen on the vocal folds and around those areas.

But usually the vocal fold areas are more aligned with inhalation of tobacco. 

Kate Grandbois: That's scary. 

Yes. Yes. But with the HPV vaccine that came out a few years ago, hoping that HPV related head and neck cancers will [00:10:00] also go down as more people receive the HPV vaccine, but now there's vaping. So TBD on the outcomes of that.

[00:10:10] Kate Grandbois: So would a patient receive a total laryngectomy, if they had HPV-related cancer in their cheek as in a treatment that is like, sort of like, well, we're going to take it all out just to be safe. Or is this a very specific to it being in the larynx? 

Lindsay Griffin: Yes. 

Kate Grandbois:I told you they were going to be very rudimentary questions.

[00:10:31] Lindsay Griffin: The, uh, total laryngectomies are and partial or inductors are in response to cancer of the larynx specifically. 

[00:10:41] Kate Grandbois: Okay. 

[00:10:43] Amy Wonkka:So these, these two different procedures are really different. We talked a fair amount about laryngectomies. It sounds like that's really specific to a cancer of the larynx, which that demographic is shifting because it's kind of a different [00:11:00] reason that we're seeing people are coming in with these cancers.

Tracheostomies, I feel like even when I was in grad school, you know, I had some patients who had tracheostomies for, for a number of different reasons. I, I wonder if you can talk to us just a little bit about what some of the reasons might be, that you might as a speech pathologist, be working with somebody who has been given a tracheostomy.

[00:11:24] Lindsay Griffin: Sure. So, um, one of the biggest reasons that people get trachs or tracheostomies is because they have prolonged need for mechanical ventilation. So they've had some sort of medical illness, whether it's a stroke or they've had some sort of respiratory disease or something that takes them to the acute care hospital.

And potentially, usually, they are intubated first, which means a breathing tube is in their mouth, goes down the back of their mouth and then through their vocal folds and rests there. And so usually it's like taped across their mouth as well. So it doesn't fall out and they're usually [00:12:00] sedated, uh, to some extent and that's so that they don't pull it out cause it's an uncomfortable process.

And so then that ET tube is what we call it. The one that's in the mouth is then connected via tubes to a ventilator, which is a machine that's helping them to breathe at varying levels. So when someone is well enough, the team, the medical team will. Try to take the ET tube out or at least change the ventilator settings.

And hopefully the person can now breathe on their own. Everything's fine. They, they breathe on their own, but in some instances, um, they aren't able to wean from the ventilator and they've had the ET tube in their mouth so long that it's now we need to figure out a new plan. They're going to need ongoing support.

And so then they have the surgical procedure where this incision is cut on the external part of our neck. And the tracheostomy tube is just laid in into their trachea. That is one of the main reasons [00:13:00] that somebody would get a trach and then that tray can be attached still to the ventilator and they can continue to receive that same level of support, but they also can wake them up now.

So they're not so sedated or not sedated at all and get them sort of up and moving, which then all of those mobility components then, um, increase their, their readiness for rehab and hopefully it helps with their health. 

[00:13:24] Amy Wonkka: There, there are a number of different pieces. I was wondering if you could refresh my memory a little bit about, you know, there's, there's not just one type of trach, right?

There's a lot of different,

[00:13:33] Kate Grandbois: like I remember the word cannula, is that a word that is used as a word, memory?

[00:13:39] Lindsay Griffin: Um, so there are some trachs that have double cannulas using your word. Yeah. And so, uh, they have the part that goes in a person, but then inside of that is another tube and that is really just [00:14:00] for cleaning purposes.

So if the person has a lot of secretions, they tend to have, um, a tray with two cannulas, double cannula, so that you can take out that middle one, clean it or replace it. And. Um, what do you don't have to actually replace the whole trach? Um, trachs also have, can have a cuff. And so that if you are looking at the person outside of their body attached to the trach, there will be kind of like this little balloon filled thing that's hanging off of their trach.

And that corresponds to sort of a little balloon thing inside their body. That's wrapped around the outside of a tray. And so when there is air in the balloon outside of their body, then the balloon that's inside their body is also full of air. And what that does is that it closes off their upper and lower airways from one another.[00:15:00] 

And so they're really just breathing in and out of the trach that is in theur body. Whereas if the cuff is deflated so that there's no air in it, or if it's a cuffless trach, then air can still move around the trach and up through the vocal folds, and then up through the upper airway, whether or not someone can be successful with their cuffed, successful with voicing, um, with their cuff deflated or with a cuffless trach depends on a lot of, um, they're like in like personal factors, like the strength of their respiratory system, for example.

So maybe they have a really strong, um, respiratory system. And so they can get enough air up through the vocal folds, despite having this also hole in their, in their neck. That is a tracheostomy. And so their vocals can still vibrate and still reverb up through their resonance's track and then be articulated and [00:16:00] still make speech.

But what some folks aren't able to do that. Another variation of the trach is the, um, the size of it. So eight is a pretty large one and it is the diameter of the trach is what the number refers to. And then a four is a pretty small one. So usually like a 6, 7, 8 are the more common ones in adults. And so if somebody has an eight, for example, that whole, that external hole, which is really the trach tube in their neck, is going to allow more air to go out of it.

And it's going to take up more room in the trachea versus, um, uh, six for example, which is going to have a smaller diameter. They might be able to push more air up, past it through the vocal folds and use that air for speech. Does that make sense?

[00:16:48] Amy Wonkka: That makes so much sense that that was so informative, what about speaking valves? Is that a thing?

[00:16:57] Lindsay Griffin: Those are a thing before I [00:17:00] talk about speaking balance, I just want to just sort of go back to your other question about why people might get traipse in addition to prolonged need for mechanical ventilation. Um, another reason that somebody might get a trait is prophylactically. So before they actually need it.

And we see that sometimes in the head and neck cancer population or the ALS population. And so with head and neck cancer, if their cancer is close enough to the airway, that the medical team suspects, that one, the part, when the person begins to receive chemo or radiation, and things start to swell that it might occlude their airway, then they would get a trake placed prophylactically just while they're undergoing treatment.

And then once their treatment is over, then it would be removed. Um, for folks with ALS some choose to, um, go on a ventilator, um, sometimes at home, toward, as the disease progresses. And so even before they need the trach or vent for, um, actual breathing, sometimes they have the trach placed [00:18:00] so that when it comes time to need mechanical ventilation, they will, um, just have the trick as well as actually the G-tube usually placed surgically as well, because both of these, the trach and the G-tube require some anesthesia to be placed.

And usually by the time that they get to the point where they need the trach for breathing, then it becomes a little unsafe for them to have the anesthesia so they can sometimes have it placed early as well. And then the finals, and then I'm going to mention is usually for secretion management and you see that you tend to see that, um, you can see it across the lifespan, but in kids sometimes you'll see trachs placed for, um, if they just have a lot of secretions in their aspirating that, and they need a lot of, um, we call it pulmonary toileting.

Basically they need like a lot of sectioning and help to get their, um, secretions up. Then a trach can be placed to help with those things. Because the other thing about trachs is that it allows for direct suctioning of secretions, um, with a suction catheter that you, you being SLPs [00:19:00] as well can put in the trach on the outside of the person's body and suction the stuff that's hanging out.

[00:19:08] Kate Grandbois: that was always a lot of vocabulary that I'm just not familiar with.

Particularly pulmonary toileting, never heard that term. Is that really what it’s called? 

[00:19:18] Lindsay Griffin: Yeah. Feel free to use that

Amy Wonkka: catchy.

[00:19:24] Kate Grandbois: You've given. I mean, this is, this sounds like a very complicated process. It sounds very intimidating. And I have a question that's related to our next learning objective in terms of safety and training. So when an SLP is involved in the team, I mean, I'm thinking about myself as a new grad. There is no way that I would have been qualified to do any of those things.

And I know, you know, we go into our workplaces and we have supervisors and we have CF supervision, but I'm, I'm under the impression that this is a [00:20:00] medically fragile situation that requires a lot more training for safety purposes. Is that an accurate assumption?

[00:20:06] Lindsay Griffin: Um, yes. This is a population that tends to be more fragile and you do need some extra training.

Um, when I was interviewing for CFs. I didn't have any experience in complex airway. And I really wanted some, so when I, when I got my CF, I was hounding my CF supervisor repeatedly for experience in complex airway, which she eventually granted, which, I mean, it makes sense that it wasn't like day one, but I wanted it to be, I was so excited.

So, um, I always tell students that anytime that they can even just be in the room with somebody who has a complex airway and asking questions about it, that it is good to have in your back pocket. 

[00:20:50] Amy Wonkka: And I mean, there are also, I'm sure a lot of other professionals that you can learn from not just the speech pathologist, but maybe respiratory therapists, [00:21:00] physicians, surgeons, it's such a specialized area of the field.

[00:21:04] Lindsay Griffin: It is, it is. Um, yeah. ENTs, surgeons. Pulmonary pulmonary pulmonologists and definitely respiratory therapist. I would say even, even respiratory therapists are the most accessible of the list that we just, we just went through. And when I worked, I worked at an LTAC, a long-term acute care hospital as, as my CF.

And so our respiratory therapists were just like wandering around caring for patients and I'd be like, Hey, can we talk about what PEEP is? Because I just couldn't understand some of these terms that I was reading about. So, and they were obviously, so-so, so-so helpful. 

Kate Grandbois: What's peep. 

Lindsay Griffin:Peep is, I don't know why it took me so long to understand what the heck this is, but you know, if you think about your lungs and there's these little air filled sacs that just keep getting smaller and smaller and smaller, the smallest of them are called the alveoli and everyone's alveoli.[00:22:00] 

Tiny bits of air in them to keep them inflated, they cannot be completely deflated or we will suffocate. And so that air is called that tiny little bit of air in the alveoli is called peep. And the reason that it was something that kept coming up and notes was that when somebody is on a ventilator, one of the settings is the amount of peep that the vent is providing to the patient.

And I, and, and sometimes that can be the higher levels of peep that they're receiving means they’re, they need more vent support than somebody who has a lower amount of peep. And so I, I understood that concept, but I wanted to know like what the heck is peep and one day. Claire, the respiratory therapist finally got through to me and I was like, wow

[00:22:46] Kate Grandbois: Claire, the respiratory therapist has now contributed to educating however many people are listening to this. So thank you, Claire is a trickle down effect of knowledge, right there. There you go. This is why we need to learn from our peers more often.

[00:22:57] Lindsay Griffin: That's right. [00:23:00] There's also really great external resources too, that, um, anyone who's wanting, um, experience with complex airway should definitely think about, Passy-Muir valve, which are the speaking valves that you mentioned that I would love to talk more about.

But Passy-Muir is one of the bigger names of the speaking valve companies, and they have a ton of free resources on their website for clinicians about what the heck is a speaking valve and how do I assess for it and what things do I need to know. And they also have really great reps who will come out and do in-services to like the whole rehab community at your hospital or whatever the case may be if you request them. 

[00:23:43] Amy Wonkka: It's funny because one of the things we were talking about before we started talking with the recording feature on was just like these funny analogs between the area of AAC, where Kate and I work and you know, this area of dysphagia. And I think that that's one piece that's another kind [00:24:00] of commonality is, you know, having these relationships with the vendors of the equipment that you may be using with your patients and just knowing that they are a resource where you can learn so much and don't hesitate to, to kind of seek that information out and learn more from the people who are actually making the products that you're using or might be using.

[00:24:22] Kate Grandbois: And I I'm pretty sure Passy Muir has. Um, I'm pretty sure they have free ASHA courses for free Ashesi use on their website, just as another. 

[00:24:37] Lindsay Griffin: I and another brand is called Shiley and Shiley has some resources too, but not as, not as well known as Passy Muir. PMV has also Passy Muir valve, the lingo.

I will say that, um, a lot of the research that Passy Muir talks about on their website, they paid for that research. So, you know, be aware of [00:25:00] potential bias, but the product is a good product and very well used and they do offer free CEUs. It can be a wealth of information. 

[00:25:09] Kate Grandbois: Well, that sort of brings us to a more direct question about our second learning objective about the SLPs role.

So, you know, as quote unquote experts of the larynx area, you know what, assuming that an SLP who is interested in learning more about this has access to the resources that I know you haven't totally finished telling us about, but you will. So interested in this area, consuming a lot of resources, consuming a lot of CEU's let's even play, pretend that they have a mentor or a supervisor who's going to take them under their wing, which I know is not standard in a lot of work settings, but let's play pretend. Since we have two very different presentations between a tracheostomy and a laryngectomy.

How does the SLPs role [00:26:00] differ between those two presentations? I guess would be my first question. 

[00:26:05] Lindsay Griffin: So for tracheostomies or trachs, it tends to be. Having them tends to tends to be more, short-term not for everyone, but a majority of people. And so, um, one of our biggest roles is assessing for speaking valve tolerance and that it can be done in an acute care.

It can be done at any levels of care, even outpatient. And, um, speaking valves are typically thought about going on trachs, but there also are speaking valves that are called, um, that are also, that are speaking valves, but they're, they're inline valves. And so somebody who has vented with a trach can also, um, use a speaking valve to be able to communicate.

Although that is my experience done less often because. If somebody has vented, they maybe are on the way to not being on the vent anymore. And so [00:27:00] sometimes healthcare facilities will just wait until they're off the vent. But in some instances it has been that in my experience, it's been really effective ways for people to communicate their medical wishes, have conversations with loved ones with healthcare providers, or just be able to communicate that their foot itches and they wish somebody would scratch it.

So, um, inline valves certainly are something to consider, but I think that the more traditional thing that we think about is putting a speaking valve on somebody who's trached, but not vented. And, um, a speaking valve is a one-way valve, so it allows air to go in to the person, but then when they exhale or when the air is coming up from the lungs, um, the valve closes off.

And then the air is forced up through their vocal folds through the residence track into their articulators so that they have speech similarly to how, how we do. 

[00:27:54] Amy Wonkka: I mean, obviously its speech itself is a super big benefit of a speaking valve. Are [00:28:00] there other benefits to using a speaking valve as well in terms of maybe oral care or, um, swallowing maybe.

[00:28:07] Lindsay Griffin: Yes. So there is research to suggest and Passy Muir is the maker of some of this research that when the, when somebody is wearing a speaking valve and it has, they have more of a restored function of, of pressures and sensation and connection of the upper and lower airways that they're swallowing can be safer as well as a result.

And so there is a push for somebody to eat with the speaking valve. Although, depending upon the person, plenty of people can eat without speaking valves as well. But if you think about the primary reason that somebody has a speaking valve, which is the fact that they had this prolonged need for mechanical ventilation, if you think about it from like a rehab, [00:29:00] getting stronger sort of spectrum, okay, now they don't need mechanical ventilation.

They have just a trach are they strong enough to be eating orally or do we really need to be working on the breathing aspect first? So I always tell my students in dysphagia that breathing trumps swallowing, somebody needs to be able to breathe before you can swallow. And so maybe somebody is, has an open trach, which means no speaking valve a majority of the time, but they can handle some speaking valve trials.

And if their respiratory system was stronger, they could go to the speaking valve all the time. So then you would have to balance. Is the respiratory system strong enough to eat if the respiratory system is not strong enough to tolerate a speaking valve all the time. So sometimes that is the decision for why they're not eating yet because they still need to get stronger from the respiratory perspective.

So then assuming they're able to tolerate the speaking valve during all waking hours, then [00:30:00] following that they usually do, um, capping trials. And then, which is basically just like closing off the trach tube and basically restores the, uh, airway to typical functioning. And once they're able to tolerate capping trials, then the trach is just literally removed, very simple.

And the incision usually closes up very quickly within like 24 hours. But it will sometimes have gauze over it just to keep it clean. So usually when someone is wearing a speaking valve frequently is when we start to think about swallowing, not in all instances, but certainly in a lot of instances. So a speaking valve can help with that.

Um, one of the biggest things I would like to say about speaking valves is that if somebody has a cuffed trach, so that's that balloon that's hanging out the side of them and that balloon has air in it then the balloon that's inside that's also wrapped around their trach also has air in it. [00:31:00] If you put a speaking valve on somebody, while both of those tubes, both of those balloons have air in it, they will suffocate.

So it is incredibly important that you only place a speaking valve on somebody when the cuff is deflated. And that is again, because the speaking valve was a one-way valve. So air comes in. The speaking valve, but then basically the person can't exhale because the cuff is inflated. So there's no way for the air to go up through the vocal folds, but also the speaking valve was present.

So there's no way for the air to come out of the trach and so they can suffocate. So it is incredibly important to only place the speaking valve on someone who you have tried to pull out all, all, all of the air from a cuff to trach. 

[00:31:46] Amy Wonkka:So  just to say that one more time

[00:31:48] Kate Grandbois: I was going to say I'm sitting here at this very serious look on my face.

That sounds horrible 

[00:31:54] Amy Wonkka: If we’re putting a speaking valve on an  inflated cuff.

[00:31:55] Lindsay Griffin: Yes. And you don't know what those words mean, then [00:32:00] just don't place those speaking valve. 

[00:32:02] Kate Grandbois: And I feel like if you don't know what those words means, you should maybe seek some additional supports or continuing education or supervision or something before, before you're in a position to be making that decision in a vacuum.

If someone's life is on the line, that's, that's a really big deal and a tremendous responsibility.

Okay. So we've talked about the, I mean, I I'm, I have so many additional questions too, but before I get to it about the medical team and collaboration with other professionals, because presumably you are not doing any of these things by yourself as the SLP, you're doing these things in conjunction with respiratory and nursing, I would imagine.

And all these other kinds of things let's can we shift a little bit for a second and talk about the laryngectomy portion? So what is the SLPs role for a patient who has had a laryngectomy? 

[00:32:57] Lindsay Griffin: So, as we talked about, the larynx is [00:33:00] removed during a laryngectomy, which means the person is no longer able to speak.

[00:33:04] Kate Grandbois: I'm still giggling when, when Amy said, and it can't go back, grow back because that's like the funniest, of course it can’t. I just thought it was 

[00:33:12] Amy Wonkka: Our liver can grow back. There are funny parts of the body that it's 

[00:33:16] Kate Grandbois: just the liver right?

Is there another part of our body that can grow back?

[00:33:27] Kate Grandbois: Okay. Can continue. We can table that for another time.

[00:33:32] Lindsay Griffin: So, um, yes, so it is, uh, removed and so they can't speak. And so, um, if you can see someone before they have the total laryngectomy, then certainly part of your role would be trying to figure out if they would be open to doing some voice banking, because then we could potentially build a voice for them after their [00:34:00] laryngectomy, which still sounds like them, which can be huge.

There are some companies that specialize in using your own voice to build a huge collection of everything you could want to say. Um, but then there are also just some instances of like recording some well-known phrases on your phone that then you can play to your loved one, like telling your, your partner that you love them or reading a book to your kids or whatever.

Maybe you always say that one silly phrase. And so people are gonna miss hearing that. And so you say that, so trying to record some things that are meaningful for the person, if they're open to it, some folks when they're diagnosed and then find out they need a total, total laryngectomy, or just in such shock.

And they it's, they're like, yeah, we'll get to it. And then maybe they never do so obviously approaching it with caution. If you can see someone before the surgery, that's a great strategy, as well as talking to them about what, what methods of communication they're [00:35:00] going to use immediately after surgery.

And also of course, doing education about like what it's going to be like, um, after surgery, when you, when they can't communicate in the same way. So some people write, some people get AAC devices will be this voice banking. There are, you know, like low tech, AAC boards that are in the hospital that people can point to.

Like, I need to go to the bathroom, for example, things like that, but trying to restore communication the best that you can beforehand and giving people an idea of what, what it's going to be like after, because as Amy said, larynx doesn't grow back. And so this is permanent. And then let's say, they have the total laryngectomy.

They are able to communicate in the short term and now that, um, things are more stable. The next thing that we think about is restoring speech and there are three main methods that we can do that with depending upon the [00:36:00] person. And so 

[00:36:02] Kate Grandbois: I think I remember two of them and I'm going to, I'm going to throw my I'm going to let myself be vulnerable here and see if I can.

So one of them, there is a device that causes vibration that can be shaped by the pharynx, right? 

[00:36:16] Lindsay Griffin: Yes. That's called the electrolarynx. 

[00:36:21] Kate Grandbois: And then I want you to tell us about all of these in more detail before I list them. So this is the other one is a method where you swallow air and shape and use vibration with the top sphincter of your esophagus..

[00:36:34] Lindsay Griffin: Yes. Wow. 

[00:36:38] Kate Grandbois: I learned something in graduate school. I was paying attention most of the time. Um, I don't remember the other ones 

[00:36:45] Lindsay Griffin: like those. So go ahead, Amy. Do you want to, 

[00:36:47] Kate Grandbois: oh, do you remember the third one dream team? Come on

[00:36:49] Amy Wonkka: No I have nothing to contribute to this. Other than saying I asked Google and the liver is the only organ that grows back.

[00:36:55] Kate Grandbois: So thank you for asking Google for all of our listeners who were on the edge of their [00:37:00] seats about body parts, they grow back. Okay. So those are two what's another one.

[00:37:04] Lindsay Griffin: Third is a puncture, which is frequently just abbreviated to T E P

Kate Grandbois: tracheoesophagealpuncture. What is that? 

Lindsay Griffin: Okay, so the TEP, the surgeon creates a hole between the back of the trailer. And the esophagus and then the patient will have a prosthesis placed, um, which is a one-way silicone valve that allows the air to flow from the trachea to the esophagus and then to speak. They have to close off the stoma or the hole that's on their neck now, which is a direct access to their trachea.

Um, they have to close it off, usually with a finger to redirect the air through the TEP prosthesis, unless they have [00:38:00] a tracheal stoma valve, then, then the air just naturally goes through and they don't have to place their finger. And this tends to be a source of confusion for anyone who works with patients, but not necessarily in complex airway.

When I worked in acute care, we would get many consults for patients who were coming into acute care for something unrelated to their, to their airway. Maybe they fell and broke their hip. Maybe they had a heart attack. And many years ago they had had a total laryngectomy and they had something different about their neck.

And so the medical team would consult speech and say, this person has a trach and we don't know how they communicate, but then when you would go and speak to the patient, it's just an old laryngectomy with a TEP. Um, and they have no problems with it and they didn't need to see us at all. So because the, um, stoma is present [00:39:00] on the outside of the neck.

And also sometimes there are some things in that stoma that help the person to talk. They can, it can be confusing for people who don't work in complex airway. So when the sort of taking like five steps back when the larynx is removed from a total laryngectomy, the trachea is basically rerouted to end at the neck.

So there's a hole, that's a permanent hole in the person's neck. And now they're called neck breathers by some people. And, and that can be important to know, because when you are giving somebody CPR who has a total laryngectomy, you actually have to give the breaths to the stoma, the hole in the neck versus, um, on the mouth and nose, because now the upper and lower airway are no longer connected, which is also why some people in hospitals are confused about the presentation in front of them.

[00:39:57] Kate Grandbois: Wow. Okay. That was, that was a lot. Um, I'm [00:40:00] I, my, my anatomy is really rusty, so I'm, I have the diagram in my head, but keep going. 

[00:40:06] Lindsay Griffin: Okay. So part of the SLP role is to help with placing the TEP and then also doing TEP changes because this little silicone valve is in the person's stoma forever. And so, you know, sometimes it gets dirty and needs change so that it doesn't, um, cause any infections or sometimes the stoma will get bigger, you'll need a different size, things like that.

And so some people can do those on their own and then other people, um, depending upon the TEP would need help from an SLP to do that.

[00:40:38] Kate Grandbois:  Interesting. So tell us about the other ones that I mentioned the electro larynx and the sphincter one. 

[00:40:43] Lindsay Griffin: Yeah. Okay. So, um, the artificial larynx is the, the main brand is electrolarynx.

So they're sort of used interchangeably kind of like saying PMV versus speaking valve again, they're just a brand name versus not. And so the, um, artificial [00:41:00] larynx generates sound. It makes this buzz sound. And when the person holds it up to their neck or, or there are some that you can place it in your oral cavity, in your mouth, then they're able to shape that sound, that buzz that's created from the artificial larynx and shape that using the, um, speech articulators and make and make speech.

And so I think like within the past few years, I've seen plenty of commercials about like, don't smoke, or you might have a voice box like this. And so if, if you can remember those commercials, that's what it looks like. Uh, esophageal speech, like you mentioned to the person basically like swallows air and then kind of like burps it out.

And as they're doing that, it makes the PES which is the pharyngoesophageal segment. It's the top part of the esophagus. It makes it vibrate. And then they can shape that vibration again, using their articulators to make speech. But this doesn't work for [00:42:00] everyone based on the amount of tissues that were taken during the total laryngectomy.

Sometimes there's not enough PES or pharyngoesophageal segment to vibrate to produce sound. 

[00:42:11] Kate Grandbois: I would also imagine that would take some training. I mean, in order to learn how to do that. So. I mean, everybody's heard there, their younger brother burp the alphabet. Right. But you want as a speech pathologist, as a professional, trying to empower someone to be able to communicate with their best self, I would imagine that would take some training to make it sound in such a way that they was aligned with the patient's wish to communicate, I guess.

[00:42:41] Lindsay Griffin: Yes, for sure. Both using the esophageal speech method, as well as using the artificial larynx, both take practice and SLPs can help with both of those things. Um, the artificial larynx especially usually has to be placed in a certain location and that's variable among the patients. So [00:43:00] it's not just, just about moving it around and finding that sweet spot that gives them the best voicing.

[00:43:08] Kate Grandbois: Interesting. Is there any drawback to the esophageal speech in terms of constantly putting air in your, in your esophagus, does it have any, are there any other side effects, like reflux or consistent need to burp because all the air didn't come out or something I don't know. Are there any other like, drawbacks to that method?

[00:43:32] Lindsay Griffin: Not that I'm aware of from like a anatomy physiology perspective, some people can be quite good at it, whereas others just maybe can never get it. So it's more individual variability and also about like which parts are still remaining. What can you, do you have enough tissues to vibrate? 

[00:43:53] Kate Grandbois: Okay. So let's talk about the team.

You're part of a team in this environment. I would imagine a hundred percent of the time.

[00:43:57] Lindsay Griffin: Yes. This is true. 

[00:43:59] Kate Grandbois: [00:44:00] Well, who are you working most closely with? Most of the time, which individuals 

[00:44:06] Lindsay Griffin: for laryngectomy, if it's a new laryngectomy you're going to be working with usually like the oncologist, the ENT, which also tends to be the surgeon.

But if they're not then a surgeon, respiratory, nursing, if they're inpatient, obviously the patient and family. And if you don't know a ton about laryngectomies another SLP who does, and then another resource that's pretty good for laryngectomies is similar to passy muir makes speaking valves, Blom-Singer makes laryngectomy supplies.

And they also have a lot of really great continuing and resources on their website. And then they'll also do in-services and they have really great like patient support systems as well. So they, if you, if a patient contacts [00:45:00] them, they they'll give them samples of things to try to see if they like it and provide a lot of education.

I don't think that their educational materials on their website offers ASHA CEUs, but it's still a great learning resource for sure. 

[00:45:13] Kate Grandbois: And are there overlapping scopes with other professionals? I can be difficult to navigate in terms of what our role is on the team as SLPs versus it's just sounds like there are so many moving parts and it's so complicated.

I have to imagine that there are some shared responsibilities that could be determined by workplace norms or licensure standards.

[00:45:34] Lindsay Griffin: Yeah, I'm sure. There are like about who, about caring for the laryngectomy and also like who gets to educate the patient on the laryngectomy? I think pretty much probably everyone educates the patient on some level about what those specific instances are.

But I think for the most part, it's understood that we're, we're there to help with communication and speech. And that [00:46:00] really is like pushed and understood as part of our role and are under our umbrella. And I, and I think mainly the other members will say, well, talk to speech about that because I mean, who doesn't want to be able to communicate as you fine AAC ladies know.

[00:46:18] Amy Wonkka: Well, and you mentioned earlier voice banking and how, you know, some patients may choose to do some voice banking. If that's something that's an option available to them. And I did just want to put out there, John Costello at Boston children's hospital has done so much with voice banking that not, not that I, I know much about using it in the context of a laryngectomy, but that might be another really nice place to look. If you are an SLP, who's interested in learning more about that. 

[00:46:46] Lindsay Griffin: Yeah. Um, yeah, he also does it for ALS too. So not just for the head and neck cancer population. I was recently like within the past year or two, I was at Boston children's in Waltham where John Castello works because my son has [00:47:00] had tubes in his ears and we were just going for like a regular checkup.

And we were waiting in the waiting room and I heard a voice behind me come out and introduce himself to a patient and said, hi, I'm John Costello. And I, whatever the introduction was. And I whipped my head around as if I had just seen a celebrity and I was like said to my three-year-old at the time.

That's John Costello. And he was like, okay, no, but like, he's kind of a big deal here. It was a very celebrity sighting for me. He has no idea who I am, but I did see any person once I didn't get his autograph but I should have

[00:47:29] Kate Grandbois: He’s the nicest, he was my professor. And he's the nicest, nicest man. Hi John, if you're listening, I'm sure you're not, but I've shared cases with him.

He's just the most collaborative, wonderful clinician. And if anybody is listening is interested in reading any of his work. I know he's published a couple of things through children's hospital with our chain. He's just contributed so much to the field. So thank you, John, for your work and you're the best.

And maybe we can convince you to come on as a guest sometime, but that's a, [00:48:00] another topic topic for another time. Okay. So. I'm thinking about SLPs, who are listening, who, you know, we've gone through, you know, not only the difference between these two things, but there are different levels of complexity, the different levels of knowledge that you need to have the roles on the team.

Let's talk a little bit more about our last learning objective in terms of other resources and things that SLP has can do to expand their knowledge base in this area. Because as you said, having been the SLP and their CF really is like chomping at the bit to get this experience I'm operating under the assumption that this is something that not a ton of SLPs have an, have a lot of competency.

And is that a fair 

[00:48:49] Lindsay Griffin: assumption or. Yeah, I think that it is a fair assumption. And I also think that it's important to differentiate that just because someone has experience with Trex doesn't mean that they would [00:49:00] have equal understanding of, or experience with laryngectomies and vice versa. So even though they're both dealing with the airway, they're both dealing with airway in much different ways.

And so, um, just because you have access to materials about one doesn't necessarily mean you would have the same access or knowledge about the other. I have a ton more experience with tricks than I do with laryngectomies. Even though I worked on a head and neck cancer multidisciplinary team when I worked in acute care.

So, you know, you never know in terms of like ways that you would seek information, always continuing ed classes, always your colleagues from varying disciplines, as well as the SLPs that you work with. And then these companies that make these devices or. Pieces also have a lot of these really great continuing ed, um, information on our websites and articles are always a great place to gain information.

[00:49:59] Amy Wonkka: I would [00:50:00] imagine too, that it's the, it's the type of placement just having had, had having had a placement like this. When I was in grad school, I worked with part of my placement was acute care subacute care TRACON van. Um, and it definitely seemed like it was sort of hard to get into that area of the field if you wanted to.

Um, so I think it seems like the type of job that there would be kind of a long onboarding process relative to SLPs who maybe go work in a public school. You're kind of, here's your, here's your caseload? Go ahead. Run with it. I would imagine it's a different experience if you're working. With people who are having tricky ostomies or laryngectomies.

[00:50:44] Lindsay Griffin: Yeah, for sure. I, and, um, for example, like when I was doing inline inline speaking valves in acute care, I never did that without having a respiratory therapist with me, it wasn't something that I was comfortable doing on my own [00:51:00] part of that is because the vent beeps continuously, because it thinks the person is not getting the oxygen or the air they'll, um, support that they need.

And so part of that is that the respiratory therapist will monitor the vent settings, which is something I've never done. Mainly. That is always something that the RTS have done when I'm doing anything that requires modification of vent settings. That is, that is their job. I don't understand the vent nearly to the extent that they.

Well, and we talk a 

[00:51:28] Amy Wonkka: lot on this show about scope of practice and scope of competence, right? Because technically, you know, we, we all pass the Praxis for all speech language pathologists here, but very clearly this is not in my scope of competence, nor is it in Kate's scope of competence. And we talk a lot about like that self-awareness as a clinician and how important it is to know what you don't know and know when you need help and know when you need to collaborate with other people.

Um, and I would imagine that is to some extent, even more [00:52:00] important in a medically based setting. 

[00:52:03] Lindsay Griffin: Yes, absolutely. Do not have a false sense of, I got this, certainly seek out help. I usually tell three cautionary tales about my false self confidence when I was practicing. Would you like to hear it from? Yes, please.

[00:52:22] Amy Wonkka: I would like to, and then I'll feel afraid.

[00:52:28] Lindsay Griffin: Okay. So, um, the first is that when I was working in acute care, at one point I had a patient who I thought had had his cuff deflated before, and it turns out he had not. And, um, I was fitting in for speaking valve for the first time and ID flee. He was sitting in liquid in the chair, his SATs were hundreds.

Perfect. He was starting in the nineties. You want them to be above 90? And so that just means that his oxygenation was good. And so I deflated this cuff and put the speaking [00:53:00] valve on him as one does. And. Uh, he was fine for a few seconds, maybe a few minutes. And then all of a sudden his SATs started dropping and dropping and dropping and they dropped to like the seventies and yeah, it was very bad and he was in the ICU.

So we had a lot of nursing support and the nurse came running in because she could see the monitors going crazy. And basically we got him back under control and he was okay. But really that I did that because I didn't suction him before I deflated as cuff and everything that was sitting on top of the cuff just fell into his airway and caused him to dissent.

So my cautionary tale number one is to always suction the patient's trake before deflating the cuff. Whether you think they've had it done or 

[00:53:49] Kate Grandbois: not lesson learned, I'm very scared 

[00:53:52] Lindsay Griffin: move on. Yes. The second one was even worse, actually like my license revoked for [00:54:00] telling these stories. The second one was I had this patient who, um, was in the Altec.

He had just recently had a trake placed prophylactically because he was going to be having, um, chemo, radiation for head and neck cancer. And he had a very large base of tongue, um, mass. And they were afraid I was going to include his airway as he swelled. And so we had the training, it was an uncuffed trake and he was very sad in the room when I first met him.

Um, and I was seeing him for a speaking valve evaluation. And, um, because he had just had the, the trake placed usually around the trake on that outside of person's neck is a piece of goals and that's usually like, just for comfort. And then also attached to the trait is kind of like a foamy thing that is Velcroed on each side.

And it holds the tray in place because otherwise the trade could just fall out. So, um, I thought I'm going to do, [00:55:00] do a really nice thing here and change the goals that is under his trait, because it was like really bloody and full of secretions. And like, if you're already sad who wants to then have that?

Right. So I removed both Velcro pieces from the parts that's wrapped around his neck, keeping the tray in place. And I took the goals out. But before I go put the gauze back in, he caught. And his trait flew out of his body and on to the floor of a hospital. Oh my God. 

[00:55:33] Amy Wonkka: It's a 

[00:55:33] Lindsay Griffin: bad place for your trick to be.

Yes, that is true. I mean, like, thank God he didn't need it for, um, breathing at this point in his life, it was just prophylactically placed. So they had to call code blue and respiratory came running in and they gave him a new trick and, and he was okay, but that is still a horrifying experience that I did.

I did do that. And, um, [00:56:00] respiratory, then we, you know, we talked about it. There was an incident. I'm not above saying that. And, um, which is fine. It should have been, they said that in the future, should I want to remove anyone's gauze to just undo the Velcro on one side of the tray tie? Not both. And keep your hand on the, like the outside part of the, which is called the flange, so that should they cough, it would still remain in that.

[00:56:29] Kate Grandbois: Okay. Lesson number two, only undo one side and keep your hands. Yeah, I'm the flange. Yep. 

[00:56:34] Lindsay Griffin: That's right. The third cautionary tale was, as you recall, I said I was desperate for treatment experience during my CF. So on the very first patient that my CF supervisor took me to see who had a trake. I was just like, I was in it.

I was standing at the edge of his bed. I was just watching everything that was happening. And the first thing that she did [00:57:00] see, point number one was she suctioned him. And so you put the suction catheter in the person's true. And sometimes that will make them cough. So I'm standing at the edge of the bed ready to go.

And when she suctioned him, he coughed so strongly that his secretions shot across his bed, onto my face and onto my scrubs. My favorite story lesson number three is not to stand in front of an open trait. Right. CF supervisor was standing to the side of the patient when she suctioned him as I should have been doing as well.

Wow. And then I always carried extra scrubs in my locker. So like that's maybe less a number for wow. 

[00:57:45] Kate Grandbois: So first of all, thank you for sharing because none of us, all of us who are seasoned clinicians or who go on to be researchers make mistakes. And that's how we learned vulnerability is a key component of moving our lives forward.

So thank you for [00:58:00] sharing. Yes. And it's also making me think that. Anybody who is listening, who wants to learn more about this? The importance of having peers and colleagues and mentorship. And I encourage everyone to find someone and reach out to someone. I mean, so part of our podcasting adventure is contacting people and.

I would say nine and a half out of 10 people, almost everyone in our fields. Uh, at least that we've contacted is excited to share their knowledge, excited, to teach excited, to participate in exchanging, you know, giving knowledge onto people who are, who are looking to learn. So if you're listening and you really want to learn more about this, I would encourage you to start contacting people, find someone at a local hospital.

You know, people are often really open to mentorship. We just, it's not a norm in our field to ask, and it's not a norm in our field to have that as a component of [00:59:00] your job. So not that a men, not that making mistakes is still impossible with a mentor, but it's really nice to have someone you trust to say, Hey, I did this wrong.

Can you tell me how to do it better and be vulnerable with that person in terms of, you know, learning. 

[00:59:16] Amy Wonkka: Because it's impossible to do everything perfectly. Here's just your, your little, self-help a reminder of the podcast. 

[00:59:24] Lindsay Griffin: I have 

[00:59:24] Kate Grandbois: to remind me of that all the time for 

[00:59:26] Amy Wonkka: anybody who's listening. It's true.

Aren't perfect. We all make mistakes. That's part 

[00:59:31] Lindsay Griffin: of what makes us, I just told you three of my largest mistakes like of my life. And I also would just like to clarify that, that those three things happened over the span of several years. I wasn't like nurse ratchet going in there, like murdering every trait patient.

It was like, I would do a lot of really, really good things. And then like periodically make these terrible mistakes. 

[00:59:55] Kate Grandbois: But even, 

[00:59:55] Amy Wonkka: even if it's not, you know, something that you look back on it. [01:00:00] Cringe overtly about, I think that, that, that really is something that Kate and I talk about a lot on this show, I think is, is the idea that if you're not constantly sort of reflecting on your practice all the time, even those of us who've been doing this for quite a while, at this point, there are still things that I'm doing now today that I will look back on in five to 10 years and think, oh, I did that.

[01:00:23] Lindsay Griffin: Huh? Wow. 

[01:00:25] Amy Wonkka: So, you know, I think that that's part of just being a reflective clinician also. And then you learn the big things. Like don't stand in front 

[01:00:32] Lindsay Griffin: of an open trade. Yeah, that's 

[01:00:34] Kate Grandbois: true. In our last couple of minutes, is there, are there any additional resources or partying, you know, closing thoughts that you want to share with our listeners?

[01:00:45] Lindsay Griffin: I think something that I would say is if this is something that you're interested in, definitely seek out the resources, do like the book learning component of it, and then seek out a person who will [01:01:00] be with you every step of the way so that you're not standing in front of the trake and you're not letting tricks fall out.

And you're learning how to suction people and putting it all together in a way that is the safest for the patient. Um, and this is an area that the patients are fragile and you do want to treat them as such, but also you aren't working alone on this. And so barring any justice. Terrible decision. Like the three I shared with you, the patients are going to be okay.

So they're fragile. You should be aware of that, but you also shouldn't be afraid of it either because you are functioning on this team in a way that everyone's trying to do the best for the patient and just leaning on those resources, I think is important. 

[01:01:50] Kate Grandbois: You're the best. Thank you so much for coming and hanging out with us again.

You're so knowledgeable and. Just fun with this was really, really [01:02:00] great. Lovely. Well, maybe we can, can we, maybe we can convince you to come back for a third installment, but we'll see, we'll see. I re we just really appreciate all your wisdom and storytelling, and you've just got so much to share. So thank you again for being here.

Thank you. I appreciate that. And to everybody who's listening, if you are driving, running, biking, folding laundry, whatever you're doing, there will be a list of, um, resources in the show notes. That is. So in case you couldn't take notes in your, what was that book or what was that website? Everything is listed in the show notes in your phone and your podcast player.

Um, it's also listed on our website if you want to reference it again in the future. And I think that's it. Thanks again, Lindsay so much for joining. Thank you so much for joining us in today's episode, as always, you can use this episode for Ashesi use. You can also potentially use this episode for other credits, [01:03:00] depending on the regulations of your governing body.

To determine if this episode will count for professional development in your area of study, please check in with your governing bodies or you can go to our website, www dot dot com. All the references and information listed throughout the course of the episode will be listed in the show notes. And as always, if you have any questions, please email us at info at dot com.

Thank you so much for joining us and we hope to welcome you back here again soon.