2. All of the patients were placed on portable volume, or when preferred by the patient, pressure ventilators. The cuffs were completely deflated for increasing periods hourly until cuff deflation could be tolerated throughout daytime hours. Partial cuff deflation was then used overnight. The delivered insufflation volumes were increased to maintain the same ventilator pressures as with the cuff inflated. When necessary, the patients tracheostomy tube diameter was changed to permit sufficient leakage for speech while maintaining adequate fit to permit effective assisted ventilation with delivered ventilator volumes generally 1 to 2 L. The set volume was titrated to maintain Pco2 levels between 35 and 40 mm Hg. Tracheal integrity, tracheostomy tube width, and volitional glottic and vocal cord movements determined the amount of the delivered air to enter the lungs and the amount to “leak” up through the vocal cords with each breath. This leakage was used for inspirator) cycle speech. Along with end-tidal Pco2, oximetry has been used more recently for sleep monitoring. Oxygen saturation was maintained above 85 percent with a mean of 95 percent or greater during sleep. buy ortho tri-cyclen
Speech was crescendo/decrescendo with the rhythm dependent on the cycling ventilator while on IPPV with a deflated tube cuff. A low speech volume indicated either inadequate insufflation volume, a tracheostomy tube that was too wide, or subglottic obstruction, usually by granulation tissue. For these patients, optimal insufflation volumes for normal ventilation and more effective speech were obtained by cuff removal, by placing a narrower diameter tracheostomy tube, or by the surgical ablation of the granulation tissue when indicated. A one-way valve was placed at the expiratory valve for one patient, permitting him continuous speech.
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