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6.14
Airflow of fenestrated
tracheostomy tubes
on inspiration and
expiration. (A)
Cuffless fenestrated
tracheostomy tube.
Note inspiration
around and
through tube and
expiration around
and through tube,
with boost of air
up to vocal cords.
(B) Cuffed fenestrated
tracheostomy tube
with cuff inflated.
Note inspiration and
expiration through
(but not around)
the tube. A small
amount of air is
directed to the vocal
cords on expiration.
(C) Cuffed fenestrated
tracheostomy tube
with cuff deflated. Note
inspiration is through
the tube and around
the deflated cuff.
A small amount of air
is directed to the vocal
cords on expiration.
Chapter 6 Phonation With a Tracheostomy
Several authors have reported cases of subcutaneous emphysema with the
use of fenestrated tracheostomy tubes (Mozart & Stuart, 2001; Orme & Welham,
2006). Orme and Welham reported a case of massive subcutaneous emphysema
shortly after the percutaneous placement of a fenestrated tracheostomy tube.
Later these clinicians were directed to the manufacturer’s instructions, which
directed that a fenestrated tube should not be used in the early postoperative
period and that the position of the fenestration should be checked once placed.
Prior to the maturation of the stoma, air can become displaced into the pretracheal tissues with the use of a fenestrated tube.
Talking Tracheostomy Tube (Cuff Inflated)
A talking tracheostomy is a tube that allows a ventilator-dependent patient to
speak; unlike other methods, it does not require cuff deflation. This tube was
designed for the ventilator-dependent patient who is at high risk for aspiration
or cannot otherwise tolerate cuff deflation. An additional air supply line provides an extra source of air independent of ventilation. This supply line carries
air from a regulated compressed source and terminates with an opening just
above the cuff. When connected to a source of compressed air or oxygen, occlusion of the air control port allows gas flow to be directed to the vocal cords.
Figure 6.15 shows airflow with a talking tracheostomy tube.
For optimal use of the talking tracheostomy, airflow must be adjusted. Starting at 4 liters per minute, the flow can be increased up to 12–15 liters per minute until optimum voice quality is reached. However, one author (Hess, 2005)
cautioned that high flow rates could be associated with a greater risk of airway
injury. At these high flow rates, humidification is important to prevent drying
of laryngeal tissues (Kazandjian & Dikeman, 2008). Because of the continuous
independent flow of air, talking tracheostomy tubes allow speech throughout
the entire respiratory cycle (Tippet & Siebens, 1995).
Tippet and Vogelman (2000) suggested that the adjustment of airflow is a
delicate balance between patient comfort and clarity of speech. A flow rate between 2–15 liters per minute is compatible with speech. A rate of 5 liters per
minute is necessary to produce a whisper, and 8–10 liters per minute is necessary for speech with normal volume. Flow rates above 10 liters per minute have
been reported to be uncomfortable and may necessitate warming and humidifying the airflow to make it more comfortable and reduce the drying effect.
Talking tracheostomy tubes have some disadvantages. Speaking is dependent on a caregiver and a source of compressed gas. The air supply line frequently becomes clogged with secretions and prevents airflow above the cuff.
In this case, it is acceptable to flush the air supply line with 5 ml of sterile water
(Shahvari, Kigin, & Zimmerman, 1977). A source of suction should be provided
to remove the secretions from above the cuff. The accumulation of secretions is
a persistent complication of speaking tracheostomy tubes, and deep subglottic
suctioning above the cuff may be necessary before beginning speaking trials
(Tippet & Vogelman, 2000).
The production of speech with talking tracheostomy tubes requires some
trial and error in order to produce optimal voice quality. Patients need time
to adjust to the new sensation of airflow and practice occlusion of the airflow
port. Theoretically, patients can speak throughout the entire respiratory cycle
203
204
Tracheostomies
6.15
Illustration of airflow with talking tracheostomy tube. Reprinted with permission from
“Preserving Oral Communication in Individuals With Tracheostomy and Ventilator Dependency,”
by D. C. Tippet and A. A. Siebens, 1995.
(2), 55–61. Copyright 1995 by the American Speech-Language-Hearing Association. All rights
4
reserved.
American Journal of Speech Language Pathology,
with this tube; however, Leder and Traquina (1989) reported that some patients
have difficulty speaking through inspiration because it feels unnatural. They
recommended that tube occlusion be timed for the expiratory phase of the
ventilator.
Some difficulty has been reported with positioning the tube so its openings
are unobstructed. Positioning is also an issue because of the weight of the ventilator circuit, which can pull the tube down and away from the stoma, resulting
in an air leak. The weight of the ventilator tubing can also cause the rotation of
Chapter 6 Phonation With a Tracheostomy
the tube and the blockage of air vents coming in contact with the tracheal wall
(Tippet & Vogelman, 2000). A malpositioned tube leaks air around the stoma
and makes loud gurgling sounds. In addition, voice quality with this type of tracheostomy tube may not reach more than a whisper (Hess, 2005; Shahvari et al.,
1977). For these reasons, the use of talking tracheostomy tubes with rehabilitation patients may be limited (Tippett & Siebens, 1995).
The speaking tracheostomy tube has also been used to provide continuous
suction above the cuff in patients at risk for aspiration from a large amount of
oropharyngeal secretions. When connected to suction, the removal of up to 600
ml of secretions per day has been reported (Shahvari et al., 1977).
A waiting period of 3–5 days is recommended after the initial tracheotomy
procedure before using a talking tracheostomy tube. The waiting period allows the tract to heal and prevents air leaks through the fresh tissue planes,
which could lead to subcutaneous or mediastinal emphysema (Tippett &
Vogelman, 2000).
205
Nomori Ventilator Talking Tracheostomy Tube.
oped a new talking tracheostomy tube specifically for patients on mechanical
ventilation. The tube has slits along the sides of the shaft and an elastic cuff that
inflates and deflates in synchrony with respirations. The cuff expands on inspiration with positive pressure from the ventilator and deflates on expiration.
Sixteen patients with a variety of underlying conditions used the prototype tube with excellent results. All patients except one were able to speak
with strong voice quality. The one patient who was not able to vocalize had a
conspicuously bent trachea from long-standing tuberculosis. Two patients with
particularly weak voice quality due to COPD and spinal cord injury used the
Passy-Muir valve, which improved the loudness of their voices.
One of the most notable factors from this initial clinical trial is that there
were no complications from this tracheostomy tube. It never became occluded
with secretions, and no cuff problems developed (Nomori, 2004). Many of us
eagerly anticipate its production for clinical use, hopefully in the near future.
However, Hiroaki Nomori recently reported that the new tube has not yet been
approved by the Japanese Ministry of Health and Welfare (based on personal
communication, December 30, 2008).
Blom Tracheostomy Tube System.
gist, developed the Blom tracheostomy tube system; it has recently been introduced to the market and clinical trials are in progress. Its unique design is
intriguing, and initial clinical trials will determine its clinical usefulness. The
tube comes in four sizes: 4, 6, 8, and 10. The fenestrated aperture on the outer
cannula is located only 1 mm above the cuff. This unique placement is intended
to prevent contact with the tracheal mucosa when the cuff is inflated. In addition, it has a subglottic suctioning port to reduce the incidence of ventilatorassociated pneumonia when connected to continuous suction.
In addition to a standard inner cannula and a subglottic suctioning cannula, the Blom tracheostomy tube system (Figure 6.16) also has two additional
cannulas that can provide speech. The speech cannula is designed to allow
speech to those patients who require a fully inflated cuff, while the low-profile
cannula is designed for use with patients who can tolerate cuff deflation. The
Eric Blom, a speech and language patholo-
A Japanese physician devel-
206
Tracheostomies
6.16
Blom tracheostomy tube system. Note fenestration of outer cannula just above the
cuff, speech cannula, and inner cannula with subglottic suctioning port. Reprinted with
permission of Pulmodyne (Indianapolis, IN).
speech cannula is very soft and floppy, fits within the outer cannula, and has
two unique valves—a flap valve and a bubble valve—that function at different
parts of the respiratory cycle.
Figure 6.17 shows the airflow with the Blom tracheostomy tube system. The
flap valve, located at the tip of the speech cannula, opens during inhalation,
allowing air to flow through the tube and into the trachea. At the same time,
the bubble valve, located along the dorsal aspect of the speech cannula, expands into the fenestration and seals it, preventing air from escaping into the
upper airway. On exhalation, the flap valve closes and the bubble valve collapses, exposing the fenestration and directing the airflow through it and up
to the vocal cords. Another unique feature of this tracheostomy tube is the exhaled volume reservoir, which prevents the ventilator from recognizing false
low-volume readings as air is redirected through the upper airway rather than
through the ventilator. This feature is likely to be appealing to practitioners who
manage ventilators, because, to date, there are no described methods to prevent
low-volume alarms as exhaled air is diverted from the expiratory limb of the
ventilator. The manufacturer recommends that use of laser or electrosurgery
electrodes should be avoided with this tube to prevent the release of toxic gases
and fire in an oxygen-rich environment.
Chapter 6 Phonation With a Tracheostomy
207
6.17
Airflow with Blom tracheostomy tube on inspiration and expiration. As air is inspired through the
tube, the flap valve (located at the distal tip of the tube) opens. The flexible bubble valve (located on the
dorsal shaft of the tube) also expands, covering the fenestration in the outer cannula. On exhalation,
the flap valve closes, allowing airflow around it and collapsing the bubble valve to allow air through the
fenestration and to the vocal cords. Reprinted with permission of Pulmodyne (Indianapolis, IN).
Summary
The many options available to restore phonation make it difficult at times to
determine the best method for a particular patient. The best method is often the
simplest, but numerous factors must be considered. The first factor in determining the optimal choice for phonation is if the patient requires mechanical ventilation. The second factor is whether the patient can tolerate cuff deflation. When
continuous mechanical ventilation is not required, a cuffless tube with capping
trials works well for the majority of patients. For patients who require intermittent mechanical ventilation, a TTS or CTS tube with capping trials allows the
flexibility of a cuff and provides minimal resistance to airflow. Patients on continuous mechanical ventilation who can tolerate cuff deflation can be managed
with leak speech. Those patients who are on continuous mechanical ventilation
and require cuff inflation usually provide the greatest challenge. Available options are talking tracheostomy tubes and the Blom tracheostomy tube system.
Fenestrated tracheostomy tubes are rarely used and must be fit individually to
ensure the central placement of the fenestration within the airway.
208
Tracheostomies
Health professionals must recognize the importance of a patient’s voice
to his or her well-being and for effective communication with the health care
team. The restoration of a patient’s voice is often an emotional moment and
can represent the beginning of a return to normal for the patient. It requires
patience and an individual, methodical approach to determine the best strategy
for each individual patient.
Key Points
Speaking valves are ideally used with a cuffless tracheostomy tube but ■
may be used with a completely deflated cuff as long as the patient’s ability to breathe comfortably has been thoroughly assessed.
■
For patients who do not require continuous mechanical ventilation, a cuffless tube with capping trials allows phonation for the majority of patients.
■
For patients who require intermittent mechanical ventilation, a TTS or
CTS tube with capping trials allows the flexibility of a cuff and offers
minimal resistance to airflow when deflated.
■
Ventilator-dependent patients who can tolerate cuff deflation can be
managed with leak speech, but those who are on continuous mechanical
ventilation and who require cuff inflation usually provide the greatest
challenge.
References
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Chapter 6 Phonation With a Tracheostomy
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Care of the
Tracheostomy
Patient
Linda L. Morris
7
The tracheostomy patient requires vigilant care, especially in the first several
postoperative days. Meticulous care and maintenance of the tracheostomy tube
can prevent many complications. This chapter discusses the care required for
the patient with a tracheostomy, including maintaining the tube, cleaning the
inner cannula and stoma, caring for the cuff, mobilizing secretions, and caring
for other tracheostomy appliances such as the T-tube. In addition, considerations for patients at home will also be reviewed, including managing home
emergencies.
Maintenance of the Tracheostomy Tube
General care of the tracheostomy patient includes ensuring the presence of everyday and emergency supplies at all times, as well as complete familiarity with
care of the tube. Bedside supplies, listed in Table 7.1, should include an extra
tracheostomy tube of the same size and one size smaller, an obturator of appropriate size and type, a suction source and appropriately sized suction catheters, a
211