It’s okay So, Spencer’s been here for about three weeks I think. And he had an arterial vascular malformation that ruptured close to his brain stem and so he had a pretty sever brain injury from that. So in terms of therapy we use the Passy-Muir Valve to help with, you know- speech. We’ll use it for different reasons, for feeding and swallowing and protecting the airway that way. From a PT and OT standpoint, when you have an open trach, you have no ability to really have a strong- Sorry, it’s really loud in here. You have no ability to have any real control over your trunk. So if you have the ability to close off, and kind of hold your breath, you can provide yourself with more trunk control and stability. You can use your diaphragm for a little bit of stabilization to help your trunk and head- He’s really listening. when you have that PMV on, but you can’t really do that with just an open airway. So that helps us with balance, with working on walking, just endurance for cardiopulmonary activities and things like that too. So- This especially with people that have lower tone on their trunk particularly Because when they do have that open trach, they don’t have to work very hard it just comes in and out you know maybe I’m gonna have a lot of secretions it can be more challenging, but We want you to work harder so that you get better, okay? And then it helps your balance and all that other kind of stuff. How about if we go ahead and slip his Passy-Muir Valve on? Nice and slow Spence. Maybe you can cough a little easier or swallow. He’s fine pressure-wise. We can try on more time. If you can lean him forward maybe one more time and I can move the pillow down. Good. His first two breaths had a subglottic pressure of about twelve and he’s come down ever since that first breath to about six Sara, um how do you incorporate? Like, and maybe you set this already, some of the merry mastery techniques with Spencer for his goals and how does a Passy-Muir play into using some of those techniques? It’s any of the muscle and respiratory retraining techniques are much more beneficial when they have either the PMV or the cap on. Because without it, you just again have that open airway, and there’s no resistance against your diaphragm. So there’s no reason for you to turn it on to push air out to work on getting all that CO2 out. And then taking a big deep breath. Do you do any of the lateral costal- Mhmm breathing? Those kinds of things? Yes. I kind of have my hands here in that lateral-costal position, just feeling how he’s breathing right now. Um and you know in his case when we were working on those breathing techniques, he can’t follow my commands for me to say okay “take a deep breath in” We’re going to do it together or something like that. It has to be all my facilitation for him, and we can elicit those bigger deep breaths. I’m going to stop talking for a minute so I can feel important my hands. There you go. Let’s try it again Spence. We’re going to try and take a big deep breath in okay, buddy. Use that diaphragm. Good. He hardly has any pressures. So basically you start out following his natural breathing rhythm. Mhm and he’s a little bit inconsistent though. He’s speeding up a little bit. And then the goal is to then help him initiate a deeper, a deeper breath. And then the next step from that, you know speech works on voicing too but we also use that dynamic talking and active use of your diaphragm so talking is eccentric control of the diaphragm. It’s controlling it, it’s using it for breath control versus postural support if you’re bearing down or something like that. The next step of just taking a big deep breath in is we can provide some vibration here, and that can help him realize that his diaphragm is there, that it’s a muscle. And help him turn it on it slowly control it and then we can get some voicing sounds. And that’s another way of retraining that diaphragm because the inhalation, it’s a concentrate, the muscle shortening. It’s not as a controlled of an activity, unless you’re working on like with the incentive spirometer or something like that breathing and slow and deep but we usually try and get a big breath in a big response and then control the eccentric contraction, the exhalation portion of it, is more beneficial from a therapy mobility standpoint So you know for somebody that might have be more alert, not necessarily a brain injury, we will be working on walking with talking and strengthening the diaphragm and you can’t do that if you don’t have a PMV on. You can try and have them whisper, but we don’t want them to damage their airway by trying to talk around that open trach. So we don’t encourage that as much. We just don’t have the ability to work on it. There you go Spence. That was you buddy. What’d you think of that? He doesn’t often phonate does he? No. No, no he’ll cough but he hasn’t made any motion. Did you know that was your voice Spencer? I missed you, sorry. When I expand, try and bring his shoulders back so we can facilitate that deeper breath, okay? Yep, that was him. We’re gonna just get you talking. What do you think Spence? Do it again? I see you waving your hand, can you tell everybody hi? Four bubbles, yeah. I’ll help you after this one okay? You’re holding your breath. Don’t hold it. Don’t be shy. I don’t think we’ve heard any voicing from him before. That was you Spence, that was your voice. And that technique seemed to really be something. Yeah, helpful for that. Yeah. It’s a pretty successful technique to start initiating voicing. It’s called agonistic rehearsals It’s Mazory’s turn for it. So I’m kind of following his breathing again. As he breathes in, my hand goes out, as he breathes out my hand goes in. And then I provide again that quick stretch at the end of his exhalation. And I slowly move my hand out to encourage you to fill up that space where my hand is, so that diaphragm descends and is pushing those abdominal contents out when he’s breathing in. Many of them have been trained in those merry mastery techniques and we’ve just seeing great results from manual stimulation or initiation. Which Sarah is doing a great job and because an open trach doesn’t have that anatomical peep or that natural back pressure that we have, by using the Passy-Muir Valve, since that restores that closed system, that is what helps meet these techniques effective. And Sarah does a great job. Getting more response from the diaphragm, scoop than I was from the lateral costal facilitation. I think it’s a little bit more of a cue- to take a little deeper breath there. Good job Spence! Alright buddy.