PMV Trial Procedure for the SLP

Why It Works (The Physiology You Need to Know)

• Inhalation: valve opens → air flows into trachea/lungs normally
• Exhalation: valve closes → air must travel upward past the vocal cords, restoring subglottic pressure
• This restores laryngopharyngeal sensation, improves glottic closure timing, and reduces penetration/aspiration

Pre-Trial Checklist (Before You Walk In)

Step-by-Step: PMV Trial on a Non-Ventilated Patient

Phase 1 — Set Up and Educate

1. Explain the procedure to the patient and family: what the valve does, how breathing will feel different (harder to exhale at first), what sensations are normal (cough, throat clearing), and STOP criteria.
2. Position patient upright — minimum 45°, preferably 90°. Upright positioning facilitates lung expansion and reduces aspiration risk.
3. Baseline vitals — record SpO₂, HR, RR before you touch anything.
4. Establish a backup communication system (letterboard, paper/pen, eye blink code) in case the patient cannot tolerate the valve.

Phase 2 — Pre-Placement Suctioning

1. Suction oropharynx first (oral suction) — clear pooled secretions above the cuff before deflating.
2. Suction trachea as needed.

Phase 3 — Cuff Deflation (critical safety step)

1. Slowly and completely deflate the cuff using a 10 cc syringe. Gradual deflation gives the patient time to adjust to the shift in airflow and allows residual pooled secretions to be coughed or suctioned away.
2. Re-assess for suctioning — secretions sitting on top of the cuff will now fall. Suction again if needed.
3. Confirm upper airway patency — look and listen for:
   • Coughing or throat clearing
   • Vocalizations or reflexive oral movements
   • Exhaled airflow felt at mouth/nose when you hold your hand there
   • This is your glottic patency check: if no airflow reaches the upper airway, the PMV is contraindicated at this time.

Phase 4 — Finger Occlusion Trial (Optional but Recommended)

1. If the patient is alert enough, occlude the trach hub with a gloved finger momentarily. If the patient can breathe adequately with the hub occluded, they are much more likely to tolerate the PMV. This is a low-risk screening step.

Phase 5 — PMV Placement

1. Stabilize the trach tube: place one hand on the trach flange/neck plate — do NOT press down on the trachea or create discomfort.
2. Attach the PMV to the trach hub with the other hand. Give it a ¼ turn clockwise to lock. Do not force it; a forced placement makes removal difficult.
3. For PMV 2000/2001: attaches directly to the 15 mm hub. For PMV 007: may require an adapter inline.

Phase 6 — Monitoring During the Trial

1. Continuously monitor for the following STOP criteria — remove the PMV immediately if any occur:

1. Do not remove HME (heat-moisture exchanger) and use PMV simultaneously — these are incompatible.
2. Duration target for first trial: 15–20 minutes as stated in your plan. Increase by ~10 min each subsequent session toward the 4–8 hour/day goal.

Phase 7 — Sensory Priming WITH the PMV In Place

• Thermal-tactile stimulation (anterior faucial arches with cold/pressure)
• Sour bolus stimulation (small sour liquid if safe) — heightened laryngeal chemoreceptor response with restored airflow
• Effortful throat clear / volitional cough — now possible with subglottic pressure restored
• Vocalization tasks — sustained /a/, counting — confirms VF adduction and builds sensorimotor relearning
• FEES or clinical observation of swallow — if dysphagia assessment is the goal, now is the time to trial small boluses (starting with thin liquid via teaspoon or syringe) while observing penetration/aspiration behavior. The restored subglottic pressure should reduce the aspiration events seen without the PMV.

Phase 8 — Removal and Post-Trial

1. Remove the PMV: stabilize the trach neck plate with one hand → gently pull or twist the PMV off with the other hand. Twist right, not left — leftward rotation can inadvertently unlock the inner cannula.
2. If the patient did not tolerate: re-inflate the cuff, return to baseline vent/O₂ settings, document STOP criteria met.
3. Post-trial vitals — confirm return to baseline.
4. Post-trial suction as needed.
5. Clean the PMV: mild pure soap + tepid water → rinse thoroughly with cool water → air dry. No hot water, bleach, peroxide, vinegar, alcohol, or autoclaving — these destroy the silastic membrane. PMV is single-patient use; replace if it becomes noisy/vibrating or after ~2 months.

Contraindications — Know These Cold

Ventilated Patients — Key Differences

• Record baseline PIP and tidal volume before cuff deflation
• After cuff deflation, note the air leak — significant leak confirms upper airway patency
• Place PMV in-line (between inline suction catheter adapter and flex tubing)
• Volume augmentation: may increase tidal volume up to +200 cc without physician order; do not exceed baseline PIP
• Adjust sensitivity to prevent auto-cycling
• RT manages ventilator; SLP manages valve trial and swallowing assessment simultaneously

Documentation Points

• Pre/post vitals (SpO₂, HR, RR)
• Trach tube type, size, cuff status
• Glottic patency confirmation method (FEES findings as noted, finger occlusion result)
• Duration tolerated
• Vocal quality (wet/dry, hoarse, clear)
• Penetration/aspiration on any bolus trials (PAS scale if FEES done)
• Patient/family education provided
• Plan for wear-time progression
• Any STOP criteria triggered

Evidence Summary