If you are having trouble breathing with the Valve in place, remove the Valve immediately. The following are several things you should consider before trying to put the Valve back on again:

• Check both your body position and the position of the tracheostomy tube. If possible, sit upright in the chair or bed, as this will allow for full movement of your diaphragm and other respiratory muscles. Exhaled air should pass easily around the tracheostomy tube and out of your nose and mouth. A small child may be the most comfortable on a caregiver’s lap. Additionally, make sure that the tracheostomy tube is not sitting crooked in the neck, as this can mean that it is crooked in the airway. If the tracheostomy tube is not sitting straight in the airway, it can block the air from being easily exhaled from the lungs, up around the tracheostomy tube, and out of the nose and mouth.
• Check to be sure that the tracheostomy tube cuff is completely deflated. If you have a cuffed tracheostomy tube, there may still be some air left in the cuff, which can block airflow around the tracheostomy tube, decreasing your ability to fully exhale. If you notice that the air seems to slowly leak out of the cuff of your tracheostomy tube, it may mean that the cuff does not stay completely deflated either. You should have your tube evaluated and replaced as soon as possible by your doctor or healthcare professional.
• Check to make sure the tracheostomy tube is clear of secretions. Suction through the tracheostomy tube, as well as through the mouth if needed. Secretions may have built up in the tracheostomy tube. If excess secretions are not removed, breathing can become more difficult and make you uncomfortable.
• Check the amount and type of secretions coming from the tracheostomy tube. A weak cough requiring frequent suctioning, or an infection that is causing secretions to be thicker than usual, need to be considered when using the Valve. These conditions should not stop you from trying the Valve, but you may want to wait to use the Valve until the secretions become thinner and more manageable. Consult your doctor or health care professional if your secretions become thicker, or have changed in any way.

Choose a calm, stress free time of day to trial the Valve. Feeling a certain amount of nervousness is normal when doing anything different involving your tracheostomy tube, but understanding what is happening when using the Valve will help to make you feel more comfortable. Reading the PMV instruction booklet, watching our videos, and talking to your doctor or healthcare professionals will also help you gain a better understanding of how the Valve works, and will provide you with more confidence. You may also call 1-800-634-5397 and ask to speak with our Passy Muir Clinical Specialist for assistance.

Passy Muir Valve users have reported that they will cough when wearing the Valve, especially when they first put the Valve on their tracheostomy tube. This is because the air being exhaled is now going through the throat, instead of out of the tracheostomy tube, and they are feeling secretions that are in the throat.

Sometimes they will cough hard enough that the Valve will pop off the tracheostomy tube. When this happens, check to see if suctioning through the tracheostomy tube or mouth is needed. After suctioning, place the Valve back on the tracheostomy tube.

Be sure to put the Valve on the tracheostomy tube using a quarter turn to the right, (take it off the same way) but do not force the Valve onto the tracheostomy tube.

Most Valve users have found they are able to cough up secretions into their mouth when the Valve is on, and they don’t need to be suctioned as often.

Initial placement of the Valve may stimulate a cough, due to the reintroduction of exhalation and sensation through the upper airway. When airflow is absent, as with an inflated cuff, there is a tendency for secretions to pool in the back of the throat. When secretions are not felt in the upper airway you may not spontaneously cough or swallow.

Placement of the Valve redirects exhalation through the upper airway, restoring sensation, and stimulating a cough. Coughing may continue until the secretions have settled, or have moved into a position that will allow you to remove them. This is beneficial as you now have a more effective secretion clearing mechanism in place with the Valve on.

Usually, coughing subsides, and use of the Valve becomes more comfortable. Keep in mind that more than one suctioning attempt may be required. When coughing persists, and it is not improved by suctioning, or it is uncomfortable to breathe while using the Valve, remove the Valve immediately and speak with your doctor regarding possible causes.

There could be several causes affecting your ability to tolerate using the Valve due to persistent coughing that can include:

• Thick secretions may require more aggressive pulmonary hygiene.
• Changes in your airway that make it difficult to breathe easily may stimulate a dry cough. Airway changes can be due to scar tissue development and should be checked by a physician.
• The tracheostomy tube is too large or the cuff on your tube takes up too much room in your airway. You may want to discuss with your physician downsizing the tracheostomy tube, or changing to a cuffless tube.
• Hypersensitivity that may benefit from medication to desensitize the airway.

It is important to note and tell your doctor when the coughing began. The following questions will help you and your doctor discover the possible causes of your discomfort:

• Did the coughing start immediately the first time you wore the Valve and has never improved?
• Did the coughing begin several weeks after you first began to use the Valve?
• Were there any changes made regarding your airway that may have triggered the coughing, such as a tracheostomy tube change?
• Does your cough sound wet or dry?

NOTE: Do not use the Passy Muir Valve again until you have received clearance from your doctor.

For a plastic tracheostomy tube, make sure that the inner cannula is in place. There are some plastic tubes that must have the inner cannula in place in order to have a 15mm hub. Some plastic tracheostomy tubes come in a low-profile model.

If you have a low-profile model, it usually comes with a second inner cannula that has a 15mm hub. Remove the low-profile inner cannula and replace it with the inner cannula that has the 15mm hub.

For a metal tracheostomy tube, if you have a Jackson Improved Inner Cannula in a size 4, 5, or 6, the PMV^® 2020 (Clear) with PMA^® 2020-S Adapter can be used.

If you do not have a Jackson Improved Inner Cannula, call 1-800-634-5397 and ask to speak with a Passy Muir Clinical Specialist for assistance.

Exhalation through the vocal folds is responsible for producing speech and sound. If the tracheostomy tube has been in place for a while, the vocal folds may be weak from not using them. In addition, there may be a weakness of the diaphragm, which can reduce the amount of breath support you have when you speak. This can make your voice sound soft and weak. If this is the first time the Valve is being used, remember that it may take time and practice to coordinate breathing and voicing. The following exercises can help you get started:

• Take a breath in, and then open your mouth to say “ahhh” while you exhale. Practice this a few times.
• Count slowly from one to five, taking a breath before saying each number. Try this a few times.

If no voice can be produced, an evaluation of the vocal folds by an ENT (ear, nose and throat doctor) may be needed to rule out vocal cord damage, or to assess the tracheostomy tube size.

A speech-language pathologist is often consulted to help improve voice and speech production.

Young children should be encouraged to play games that help them practice blowing air through the mouth (e.g. blowing bubbles, whistles, horns, etc.). You can also encourage them to imitate sounds that you make while they are wearing the PMV.

If there has been a sudden change in your ability to tolerate the PMV, this could indicate a change in your medical condition, such as the presence of blockage (e.g. scar tissue, narrowing, etc.) in the airway that needs to be evaluated by your doctor. It is recommened you check with your doctor before continue use of the Valve

There are several reasons that this may be happening. For instance, your vocal folds may be weak since they haven’t been used much since your tracheostomy. The vocal folds and surrounding muscles may need to be strengthened.

Another possible reason may have to do with your ventilator settings.

If you are experiencing this problem, please have your clinician or caregiver contact our Passy Muir Clinical Specialist at 1-800-634-5397 for additional information.