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Tracheostomies
182
which creates many other sequelae in addition to the loss of speech. An unoccluded tracheostomy tube interferes with effective swallowing, coughing, and
defecation (Kazandjian & Dikeman, 2008).
The restoration of patients’ voices is often a surprising and an emotional
moment for them and their loves ones. Many times, patients haven’t heard their
own voices for weeks or months, and the opportunity to vocalize again is a surprise. They frequently don’t remember that they can use their voice and will
often begin with a whisper. Hearing their own voices speak even a few words
can provide great comfort and restore a sense of well-being.
There are several mechanisms to restore speech. All of them require some
manipulation of the tracheostomy tube or ventilator circuit and almost all require cuff deflation.
There also are several factors that must be considered when planning for
phonation with a tracheostomy. The first consideration is whether or not the patient requires cuff inflation. Most often, patients require cuff inflation because
of the need for positive-pressure ventilation, airway protection, or both. Not all
patients who require positive-pressure ventilation also require cuff inflation.
The most challenging patient is the one who requires cuff inflation for both
airway protection and continuous positive-pressure mechanical ventilation.
For these reasons, it is necessary to have a clear understanding of the patient’s
medical status and treatment plan before attempting to restore speech.
Risk of Aspiration
There are several possible explanations for the risk of aspiration with a tracheostomy tube. The first is decreased elevation and anterior rotation of the larynx
because the trachea is anchored to the strap muscles with the inflated cuff. It
is also thought that esophageal compression causes the cuff to impinge against
the esophageal wall. There is also an attenuation of the reflex of the vocal cords
because airflow is redirected away from the upper airway. In addition, there is a
reduction in subglottal air pressure (Suiter, McCullough, & Powell, 2003).
Leder and Ross (2000) examined 20 consecutive patients using a swallow
study before and after tracheotomy. They found no causal relationship between
tracheostomy and aspiration. All these patients had the same aspiration status
before and after the test. The authors concluded that certain of these patients
had multiple risk factors other than the presence of the tracheostomy tube that
would predispose them to aspirate.
Requirements for Successful Phonation
Patients must be cognitively intact and attempting to communicate before phonation is initiated. Patients who are able to respond to questions appropriately may be ready to be evaluated for phonation. If a patient is not making
some at tempt to speak, he or she is probably not ready to do so. In order to
achieve adequate voice quality, a patient must be able to generate a tracheal
pressure of at least 2 cm H
during speech, and airflow through the upper airway during speech is 3–18 liters per minute (Bard, Slavit, McCaffrey, & Lipton, 1992; Hess, 2005; Holm berg,
Hillman, & Perkell, 1988).
O. In normal people, tracheal pressure is 5–10 cm H2O
2
Chapter 6 Phonation With a Tracheostomy
Methods of Phonation for Patients Who Do Not
6.1
Method of Phonation Special Considerations
Digital occlusion Requires cuffless or cuffed tube with cuff down only.
Capping Requires cuffless tube or TTS or CTS cuff only.
Cuffless fenestrated tube Requires capping either by removal of the standard inner
Speaking valve Patient must be able to tolerate cuff deflation, preferably
Current methods to restore speech can be divided into three major groups:
methods for patients who do not require mechanical ventilation, methods for
those who require continuous mechanical ventilation, and methods for those
who require intermittent positive-pressure ventilation. These methods are
summarized in Tables 6.1 and 6.2.
It is usually relatively easy to restore speech for patients who do not require
positive-pressure ventilation. Most often, all that is required is cuff deflation
or a cuffless tube and capping or finger occlusion. Let us first discuss the more
straightforward approaches to phonation, followed by the more complicated
approaches. It may also be helpful to refer to Figure 6.1 on page 185.
Require Cuff Inflation
cannula or with fenestrated inner cannula.
cuffless tube. Requires sufficient air to pass around outside
of tube.
183
Patients Who Do Not Require Mechanical Ventilation
First, phonation should not be attempted in a patient who is not cognitively
aware and making an effort to speak. There are several methods that will allow
speech for patients who do not require mechanical ventilation.
Digital Occlusion (Cuffless Tube or Deflated Cuff )
Digital occlusion is performed with a cuffless tracheostomy tube or with the
cuff fully deflated. Prior to cuff deflation, deep oropharyngeal suctioning should
always be performed to remove secretions accumulated above the cuff. In addition, cuff deflation can be timed to coincide with exhalation to further prevent
secretions from being aspirated.
Digital occlusion should never be attempted with the cuff inflated and ideally
should be done with a cuffless tube. After cuff deflation, a gloved finger of a
caregiver or patient is placed over the opening of the tube. This redirects air to
the upper airway and allows it to pass through the vocal cords, thus producing
sound. If the tracheostomy tube is too large, resistance to airflow around the
tube will prevent comfortable breathing as well as phonation. If the tracheostomy tube is too small, the patient’s voice will be breathy as most of the air will
escape through the stoma rather than through the vocal cords.
Methods of Phonation for Patients Who
6.2
Method of Phonation Special Considerations
Digital occlusion Can be done on cuffed tube with cuff down only. ■
Require Intermittent Mechanical Ventilation
Capping trials when
not on ventilator
Leak speech Requires cuff deflation. ■
Leak speech with
speaking valve
Fenestrated
tracheostomy tube
TTS or CTS cuff is the ideal choice for a patient who ■
requires intermittent cuff inflation.
Procedure involves increasing tidal volume and adjusting ■
to comfortable ventilation and optimal voice quality.
Procedure increases inspiratory time.
■
The addition of PEEP may improve voice quality and ■
increase duration of speech time.
Ventilator alarms must be adjusted because exhaled
■
volume is lost through the ventilator circuit.
Requires cuff deflation. ■
Procedure involves increasing tidal volume and adjusting ■
to comfortable ventilation and optimal voice quality.
Procedure increases inspiratory time.
■
The addition of PEEP may improve voice quality and ■
increase duration of speech time.
Ventilator alarms must be adjusted because exhaled
■
volume is lost through the upper airway.
The addition of speaking valve may improve swallowing
■
and decrease secretions.
HME is ineffective with the valve.
■
Cuff can remain inflated. ■
Requires proper fit of fenestration. ■
Requires adjustment of ventilator settings and alarms ■
because exhaled volume is lost through the upper airway.
Subcutaneous emphysema can occur if using a fenes-
■
trated tube through an immature stoma.
Speaking
tracheostomy tube
Blom tracheostomy
tube
Nomori ventilator
talking tracheostomy
Cuff can remain inflated. ■
Involves adjusting gas flow of 2–15 liters per minute for ■
optimal voice quality.
Requires patient or caregiver to occlude port for phonation.
■
Subcutaneous emphysema can occur if using a speaking ■
tracheostomy tube through an immature stoma.
Cuff can remain inflated. ■
On inhalation, air is delivered to the lungs through the ■
flap valve. Upon exhalation, air passes through the
bubble valve and the fenestration.
The exhaled volume reservoir helps prevent ventila-
■
tor alarms from sounding due to lost returned volume
through the upper airway.
Cuff inflates during inhalation and deflates during exhalation.
■
Currently not available for clinical use. ■
6.1
Phonation algorithm.
Assess current
tube size, type
Ye s
Consider talking
tracheostomy or
Blom tracheostomy
tube.
No
Can patient
tolerate cuff
deflation?
Ye s
Attempt leak speech
trial. Adjust tidal
volume, flow rate,
inspiratory time, PEEP.
Ye s
Does patient
require mechanical
Continuous Inter mittent
Are vital signs
stable?
No
Not ready for
phonation.
ventilation?
No
Change to TTS or
CTS tube.
Capping trial
Can patient
tolerate cuff
deflation?
No
Consider talking
tracheostomy tube
or Blom
tracheostomy tube.
Ye s
Change to
cuffless tube.
Can patient
tolerate finger
occlusion?
Can patient tolerate
timed digital occlusion?
(Inspire through the
tube, block tube on
expiration.)
Use speaking value.
Observe
No
Ye s
Ye s
Capping trial.
See downsizing
algorithm.
No
OR
Downsize tube.
Consider fitting for
fenestrated
tracheostomy tube.
Endoscopic
evaluation for
obstruction.
Tracheostomies
186
The biggest safety advantage of digital occlusion is that the patient must
be alert and coordinated enough to perform it. Patients who are not alert can
quickly develop respiratory distress and be unable to summon help. This problem is magnified when the tracheostomy tube is capped. In order for these patients to speak, an assistant must be present in the patient’s room. Patients who
are cognitively alert but unable to use their upper extremities may experience
frustration with the digital occlusion method if they have a lot to say.
Capping, Corking, and Plugging (Cuffless Tube)
Capping is used when the opening of the tracheostomy tube is plugged with a
cap, a cork, or a plug. The nuances of these devices are reviewed in chapter 3,
but they are all designed to prevent air from entering and exiting through the
tracheostomy itself. As a result, some or all of the airflow is redirected around
the tube and up to the vocal cords.
Not all patients should be capped. Capping should not be attempted in
those who cannot tolerate cuff deflation and who are at risk for aspiration. With
the exception of properly fit fenestrated tubes, capping should never be applied
on a standard cuffed (low-pressure, high-volume) tracheostomy tube, even if the
cuff is deflated. If the cuff is deflated and the tube is capped, the patient is forced
to breathe around the tracheostomy tube and the deflated cuff. The bulk of the
deflated cuff adds a great deal of resistance, and it may be difficult or impossible for the patient to ventilate adequately. Additionally, the patient may be
unable to effectively clear secretions around the tube and cuff. The patient may
complain that when coughing, the secretions seem to “get stuck” in his or her
neck. A classic example is a patient with a cuffed tracheostomy tube who had
been capped at an outside hospital. She complained that, as much as she tried,
she was never able to cough out her secretions. Once her tube was changed to
a cuffless version, she immediately coughed out several large mucus plugs and
expressed immediate relief from her symptoms. Figure 6.2 shows the airflow
around a capped tracheostomy tube. Note that both inspiration and expiration
are around the tube and that the outer diameter of the tube must be small
enough to allow the easy passage of air around it.
The Bivona TTS and the Arcadia CTS tracheostomy tubes are the only exceptions to the general clinical rule of not capping a cuffed tube. In this case,
these cuffs function exactly like cuffless tracheostomy tubes with fully deflated
cuffs. The deflated cuff on both of these tubes assumes the shape of the tube
around the shaft, creating no additional resistance when moving air outside
of the tube. (Refer to Figure 12.4 for an illustration of the inflation and deflation characteristics of high-volume, low-pressure versus low-volume, highpressure cuffs.)
When capping a tracheostomy tube, it is important to monitor the patient’s
ability to breathe comfortably around the tube. Often simply changing the tube
to a cuffless version of the same size provides sufficient space to move air.
However, if the patient is unable to breathe comfortably, either there is still not
enough room to move air around the tube, or there is an obstruction within the
airway. In this case, the tube should be downsized. If efforts to phonate are still
unsuccessful, use of a speaking valve can be attempted (discussed later in this
chapter); however, the patient’s airway should be examined for the cause of the
Chapter 6 Phonation With a Tracheostomy
6.2
Airflow with cuffless
tracheostomy
tube, capped. Note
both inspiration
and expiration are
around the outside
of the tube.
187
obstruction. Chapters 11 and 12 provide a broader discussion of the issues associated with downsizing tracheostomy tubes.
The act of capping a tracheostomy tube not only restores phonation, but it
also restores subglottal pressure and improves taste, swallow, cough, and the
Valsalva maneuver. Additionally, the quantity of tracheal secretions tends to diminish after the tracheostomy tube has been capped.
Cuffless Fenestrated Tracheostomy Tube
Another option for phonation is the use of a fenestrated tracheostomy tube.
The fenestrated tube provides an opening on the dorsal aspect of the shaft that
should align centrally within the airway. When properly placed, it provides an
additional boost of air up to the vocal cords. (See chapter 4 for a discussion of
how to properly fit a fenestrated tracheostomy tube.)
Great care must be taken when using a fenestrated tracheostomy tube.
These tubes can have single or dual cannulas. The dual-cannula fenestrated
tube usually has both a fenestrated and nonfenestrated inner cannula; however, the outer cannula is always fenestrated. The fenestrated inner cannula
is used when phonation is desired. In this case, air passes around and through
the tracheostomy tube. Figure 6.3 shows airflow through a cuffless fenestrated
tracheostomy tube. Note that the resistance of the tube is decreased because air
also moves through the fenestration upon inspiration and expiration.
When a fenestrated tracheostomy tube is capped, quality of voice improves
because all the exhaled air passes through the upper airway as shown in Figure 6.4.
When the nonfenestrated inner cannula is used, the fenestration mechanism is lost, and air cannot reach the vocal cords. However, the nonfenestrated
6.3
Airflow with
cuffless fenestrated
tracheostomy tube,
uncapped. Note
airflow around
and through
fenestrated tube.
6.4
Airflow with
cuffless fenestrated
tracheostomy
tube, capped. Note
inspiration and
expiration around
and through tube.
Chapter 6 Phonation With a Tracheostomy
inner cannula should be used when the patient requires suctioning so that the
suction catheter does not get lodged within the fenestration.
To use the fenestrated tracheostomy tube for phonation, one can either
keep the fenestrated inner cannula in place or remove it so only the fenestrated outer cannula remains. One of two occlusion methods can be used: digital
occlusion or capping. When the fenestrated inner cannula is in place, digital
occlusion should initially be used to ensure the patient is able to breathe comfortably. Capping can take place with a regular cap (inner cannula in place)
or decannulation plug (inner cannula removed). When the cuffless fenestrated
tracheostomy tube is occluded, the patient breathes around and through the tra-
cheostomy tube. This action minimizes the obstruction of the tube itself within
the airway. The decision about whether or not to cap the fenestrated tracheostomy tube depends on the patient’s mental status. Digital occlusion should be
reserved for initial and limited vocalization trials in the patient with slightly
less than optimal cognitive and respiratory reserve.
When phonation is achieved without the fenestrated inner cannula in
place, the inner diameter of the tube is larger, imposing less resistance to airflow and providing easier breathing. Often, 1 or 2 mm enhance the patient’s
ease of breathing. The inner cannula should only be removed in patients with
minimal secretions.
With the fenestrated inner cannula removed, some tracheostomy models
cannot be capped in the standard way. For example, the inner cannulas of the
Shiley, TRACOE Twist, and Blom tracheostomy tubes provide a 15-mm connector, so a standard cap cannot be applied when it is removed. A decannulation
plug is made for this purpose. After the removal of the inner cannula, the decannulation plug is attached directly to the hub of the outer cannula to allow
continuous occlusion of the opening so that airflow is directed through the fenestration and to the upper and lower airway.
189
Speaking Valves (Cuffless Tube or Cuff Deflated)
Speaking valves are one-way valves that allow air into the tracheostomy tube
but prevent it from being exhaled through the valve. Instead, exhaled air is redirected around the tracheostomy tube and through the upper airway. Ideally, a
cuffless tube is used with a speaking valve; however, if using a cuffed tube, it is
essential that the cuff be completely deflated and that air can move easily. The
deflated cuff itself creates an obstruction, so the ability of air to move around it
should be tested before a speaking valve is applied. This can be done by digitally occluding the tube and asking the patient to take a few breaths (simulating
capping). If the patient is unable to breathe comfortably with this maneuver,
the clinician can simulate a speaking valve by allowing the patient to inspire
through the tube and occluding it during exhalation. If it is still uncomfortable for the patient to breathe with this maneuver, the clinician should consider
downsizing the tracheostomy tube or evaluating the patient for upper airway
obstruction.
In order to safely use a speaking valve, the patient should be awake, alert,
attempting to communicate, able to tolerate cuff deflation, and medically stable.
If the patient is at risk for aspiration, a speaking valve should not be used (Hess,
2005). Figure 6.5 shows airflow with a speaking valve and a cuffless tracheostomy
Tracheostomies
190
6.5
Airflow with cuffless
tracheostomy tube
and speaking valve.
Note inspiration is
through the tube,
but expiration is
around the tube.
tube. Air is inspired through the tube, and the valve closes upon expiration,
forcing air through the upper airway. There are several different types of valves
available, and they all have slightly different characteristics (see Table 6.3).
Early piston-type valves included the Toremalm valve, a flap valve by Emery,
an adaptation of a Jackson tube by Cowan, and a two-way valve that could be
rotated to allow inspiration only or both inspiration and expiration. When this
two-way valve was used for inspiration only, it could also be used as a speaking
valve (Saul & Bergstrom, 1979; Tippet & Vogelman, 2000; Toremalm, 1968). It is
unclear whether any of these older valves are still in clinical use.
In 1993, Fornataro-Clerici and Zajac completed a study on the commercially
available valves at that time, including those made by Kisner, Montgomery, Olympic, and Passy-Muir. They evaluated each valve’s individual aerodynamic characteristics. The internal diaphragm of one-way valves is either in the open (bias
open) or closed position at rest (bias closed). This position may have implications for work of breathing. The Kisner valve, which is no longer manufactured,
was bias closed and attached to a metal tracheostomy tube. The Montgomery
valve is bias open and has a unique “cough release” feature. This eliminates
the possibility of the valve being blown off the tube. When the patient coughs,
the diaphragm partially dislodges from the housing and must be pushed back
into place. The Olympic valve is also bias open. It is T-shaped and can be used
for oxygen delivery. It also has a removable cover that permits suctioning without removal of the valve. The Passy-Muir valve is bias closed in design, which
means that the valve stays closed except when inspiratory effort is used to open
the valve. None of these early valves were designed for use with a patient on a
mechanical ventilator.
These valves were tested in a laboratory for their aerodynamic properties at
four different flow rates. Resistance was calculated with each valve alone or with
the valve attached to a tracheostomy tube. The results showed that the Kisner
valve created significantly more resistance at all flow levels than the other valves
Chapter 6 Phonation With a Tracheostomy
Types of One-Way Speaking Valves
6.3
Valve Design Unique Features
Montgomery Ventrach Bias-open flap valve For ventilator-dependent ■
patients
Passy-Muir Bias-closed flap valve Several models are available
Olympic Trach Talk Bias-open flap valve Noticeable click with closure
Shiley Phonate Bias-closed flap valve Silicone diaphragm with hinged
Montgomery speaking
valve
Eliachar speaking valve Flap valve For use with Hood stoma stent ■
Bias-closed flap valve Cough-release feature
■
PMV 005 (white), 007 (aqua), ■
2000 (clear), and 2001 (purple)
can be used with ventilatordependent patients.
■
of valve
■
cap; one model has oxygen port
■
Removable cover for suctioning ■
191
TRACOE Phon Assist Flap valve Oxygen supply port ■
Adjustable airflow mechanism ■
With twist of housing, patients ■
can “dial up” desired level of
airflow
Shikani-French Ball valve For use with either plastic or
Tucker Flap valve Fenestrated flap on inner can-
available at that time. Since then, several new valves have been developed, and
others have been redesigned. Zajac, Fornataro-Clerici, and Roop (1999) updated
their previous study with six valves on the market in 1999—the Montgomery
speaking valve, the Olympic Trach Talk, the Shiley Phonate Speaking valve, the
Montgomery Ventrach (Figure 6.6), and the Passy-Muir PMV
TM
PMV
change in design from its previous configuration. It was designed for use with
the Montgomery cannula and comes in compatible sizes. The Olympic Trach
Talk is a bias-open valve with a spring-loaded mechanism. Exhaled air forces
2001 (purple; Figure 6.7).
The new Montgomery speaking valve has a bias-closed diaphragm—a
■
metal tubes
Less inspiratory effort than
■
others tested
■
nula that opens on inhalation
and closes on exhalation
TM
007 (aqua) and