Special Feature
Facilitating Speech in the Patient With A Tracheostomy
By Dean R. Hess, PhD, RRT, Respiratory Care, Massachusetts General Hospital, Department of Anesthesiology, Harvard Medical School, is Associate Editor for Critical Care Alert
Dr. Hess reports no financial relationship relating to this field of study.
Introduction
A tracheostomy decreases the ability of the patient to communicate effectively. However, it is possible to restore voice in many patients with tracheostomy who are cognitively intact and free of laryngeal or pharyngeal dysfunction. The ability to speak improves the quality of life for a patient with a tracheostomy. There are a variety of techniques to achieve speech in patients who have a tracheostomy, and are either ventilator-dependent or breathing spontaneously.
The Ventilator-Dependent Patient With A Tracheostomy
The talking tracheostomy tube was designed to assist the patient to speak. With the cuff inflated, a gas line with a thumb port is connected to a pressurized gas source. Flow is adjusted to 4-6 L/min and the thumb port is occluded by the patient or caregiver. Gas exits above the cuff and passes through the larynx, allowing the patient to speak in a soft whisper. Because the talking tracheostomy tube allows speech with the cuff inflated, it decouples speech and breathing. There is no loss of ventilation during speech, and the inflated cuff reduces the risk of aspiration.
The talking tracheostomy tube has limited use, however, for several reasons. It requires a tube change, unless this tube was inserted at the time of the tracheostomy procedure. In many cases, the voice quality is not good—a whisper at best. Much of the added flow may leak from the stomal site if the resistance to airflow retrograde through the stoma is less than that through the upper airway. Upper airway secretions can interfere with the quality of voice and secretions above the cuff can lead to a clogged gas line. Another important limitation is the need for an assistant to control gas flow for many patients.
The speaking valve is a one-way valve designed to attach to the proximal opening of the tracheostomy tube. Using a speaking valve with the cuff deflated or with a cuffless tube, gas flows from the ventilator into the tracheostomy tube during inhalation but exits through the upper airway during exhalation. Pharyngeal and tracheal secretions should be cleared before the cuff is deflated and the cuff must be completely deflated before placing the speaking valve. It may be necessary to increase the delivered tidal volume in order to compensate for volume loss through the upper airway during the inspiratory phase.
The alarms on most critical care ventilators are intolerant of a speaking valve. This can be addressed by using a ventilator with a speaking valve mode (eg, Puritan-Bennett 760) or a homecare ventilator. Adequate cuff deflation, tracheostomy tube size, tracheostomy tube position, and upper airway obstruction should be assessed if the patient is unable to tolerate the speaking valve. A speech-language pathologist can help patients who have difficulty using the speaking valve.
Cuff-down techniques can be used to facilitate speech without the use of a speaking valve. Manipulations on the ventilator can be used to allow the patient to speak during both the aspiratory phase and expiratory phase. Moreover, the lack of a speaking valve may increase safety should the upper airway become obstructed. If the cuff is deflated, gas can escape through the upper airway during the inspiratory phase which has been shown to be about 15% of the delivered tidal volume. This leak results in the ability to speak during the inspiratory phase.
It has been shown that increasing the inspiratory time setting on the ventilator increases breathing rate. If the PEEP setting on the ventilator is zero, most of the exhaled gas exits through the ventilator circuit rather than the upper airway, limiting the ability to speak during the expiratory phase. If PEEP is set on the ventilator, then expiratory flow is more likely to occur through the upper airway which increases breathing rate. The use of a longer inspiratory time and higher PEEP are additive in their ability to improve speaking rate. By prolonging the inspiratory time and using PEEP, mechanically ventilated patients with a tracheostomy may be able to use 60 to 80% of the breathing cycle for speaking.
Anecdotally, I have observed such patients who are able to speak throughout the entire ventilatory cycle without any pauses for breathing. In the presence of a leak through the upper airway, the ventilator may not cycle appropriately during pressure support ventilation, resulting in a prolonged inspiratory phase. Although this is usually considered undesirable, it might facilitate speech with minimal effect on gas exchange.
The Non-Ventilated Patient With A Tracheostomy
Although not common practice, a talking tracheostomy tube can be used in a patient with a tracheostomy who is not mechanically ventilated. This might be considered in a patient who is able to speak but is at risk for aspiration with cuff deflation. Another approach is cuff deflation and finger occlusion. With the cuff down (or with a cuffless tube), patients or their caregivers can place a finger over the proximal opening of the tracheostomy tube to direct airflow through the upper airway and thus produce speech.
Cuff deflation and the use of a speaking valve is probably the most common method used to facilitate speech in spontaneously breathing patients with a tracheostomy tube. There are several contraindications to the use of a speaking valve. These are listed in the Table.
| Table |
| Contraindications to the Use of a Speaking Valve |
|
In addition to the contraindications listed in the table, the speaking valve is generally inappropriate in a patient at risk of gross aspiration. The input of a speech-language pathologist can be valuable to assess the risk of aspiration with cuff deflation.
The patient must be able to exhale effectively around the tracheostomy tube when the speaking valve is placed. This can be assessed by measuring tracheal pressure with the speaking valve in place. If the tracheal pressure is > 5 cm H2O during passive exhalation (without speech) with the speaking valve in place, this may indicate excessive expiratory resistance. The upper airway should be assessed for the presence of obstruction (eg, tumor, stenosis, granulation tissue, secretions). Consideration should be given to downsizing the tube. The cuff on a tracheostomy tube can also create an obstruction, even when deflated. Consideration should be given to the use of an uncuffed tube, a tight-to-shaft cuff, or a fenestrated tracheostomy tube.
Once the speaking valve is placed, carefully assess the patient’s ability to breathe. If the patient exhibits signs of respiratory distress, remove the speaking valve immediately and reassess that the upper airway is patent. Oxygen can be administered while the speaking valve is in place using a tracheostomy collar or an oxygen adapter on the speaking valve. Some patients have significant inspiratory flow through the upper airway with the speaking valve is placed and desaturate with speaking valve placement. When this occurs, oxygen administration by nasal cannula is required.
Use of a speaking valve may have benefits in addition to allowing speech. Some studies have suggested that the speaking valve may improve swallowing, and decrease the risk of aspiration, although this has been debated by others. Because the patient inhales through the tracheostomy tube and exhales through the upper airway when a speaking valve is in place, dead space may be reduced, although this has not been formally studied. The use of a speaking valve may also allow the patient to control exhalation (eg, pursed lips in the patient with COPD), but too this has not been adequately studied. Improvements in olfaction have been reported with the use of a speaking valve.
Summary
A variety of techniques are available to facilitate speech in the patient with a tracheostomy. Teamwork between the patient and the patient care team (ie, respiratory therapist, speech-language pathologist, nurse, and physician) can result in restoration of speech in many patients with a long-term tracheostomy.
Additional Reading
- Hess DR. Facilitating speech in the patient with a tracheostomy. Respir Care. 2005;50:519-525.
- Hoit JD, et al. Clinical ventilator adjustments that improve speech. Chest. 2003;124:1512-1521.
- Shea SA, et al. Competition between gas exchange and speech production in ventilated subjects. Biol Psychol. 1998;49:9-27.
- Hoit JD, et al. Speech production during mechanical ventilation in tracheostomized individuals. J Speech Hear Res. 1994;37:53-63.
- Prigent H, et al. Comparative effects of two ventilatory modes on speech in tracheostomized patients with neuromuscular disease. Am J Respir Crit Care Med. 2003;167(2):114-119.
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