Describe the advantages and disadvantages of the available methods for allowing speech in a patient with a tracheostomy tube in situ.

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College answer

1.    Cuff deflation
Simple cuff deflation may allow patients to speak.

  • Advantages
    • Simple, no additional equipment required
    • Can allow mechanical ventilation to continue
  • Disadvantages
    • May compromise gas exchange
    • Aspiration risk
    • Patient may not be able to generate sufficient air flow if large diameter trache tube in situ
    • Loss of PEEP

2.    Capping tube
Cuff is deflated and patient or caregiver places finger over tracheostomy tube.

  • Advantages
    • Simple, no additional equipment required
  • Disadvantages
    • Does not allow mechanical ventilation to continue
    • Patient may not manage with increased resistance to expiration
    • Requires patient or caregiver to manually occlude tube

3.    Speaking valve e.g. Passy Muir
One-way valve attached to tracheostomy tube.
Gas enters tracheostomy during inspiration but is directed through larynx in expiration.

  • Advantages
    • Simple, tube change not required
    • Can allow mechanical ventilation to continue
    • Provide some PEEP
  • Disadvantages
    • Requires cuff deflation – aspiration risk
    • Risk  of  airway  obstruction  and  death  if  cuff  left  inflated  (major  point  in marking)
    • Loss of humidification
    • Dependant on tube size, laryngeal size, patient may not manage with increased resistance to expiration

4. Sub glottis air insufflation e.g. Pitt tube/Speaking

Tube Gas line with an outlet above the cuff and a thumb port. Patient or caregiver can occlude the port which directs gas through the larynx allowing speech.

  • Advantages
    • Can allow mechanical ventilation to continue
    • Cuff remains inflated reducing risk of aspiration
  • Disadvantages
    • Requires tube change (unless inserted initially)
    • Voice quality poor
    • Requires practice by patient
    • Can be uncomfortable
    • Needs someone to occlude port

5. Fenestrated tube

Specialised tube with fenestration and inner cannula that allows gas to pass to larynx when tube occluded.

  • Advantages
    • Inner cannula can be swapped for non-fenestrated if mechanical ventilation required
    • Can be used with cuff inflated if aspiration risk
    • Allows suction of secretions
  • Disadvantages
    • May require tube change if not inserted originally
    • Increases work of breathing
    • Fenestrations may occlude leading to obstruction risk
    • Difficult to get fenestrations of tube and inner cannula to line up

6. Electronic larynx

Specialised equipment that is held to patient's neck and vibrates when activated and mechanically resonates when words or sounds are mouthed. Uncommon in ICU but has been described.

Additional Examiner Comments:

This was answered poorly. Several candidates failed to mention that the cuff must be delated prior to use of a speaking valve; this omission could lead to serious clinical consequences.

Discussion

Discussion of advantages and disadvantages always benefits from a table-like structure. This table was composed using the excellent 2005 article by Dean R Hess.

Advantages and DIsadvantages of Various Methods for

Allowing Speech in Tracheostomy Patients

Method Advantages Disadvantages

Cuff up, fenestrated tube:
Gas flow is via an additional port above the cuff; 4-6L/min flow. The pt. remains ventilated

  • Allows speech with an inflated cuff
  • Decouples speech and breathing: no loss of ventilation during speech
  • Unless this tube is already in situ, this will require a tube change.
  • Voice quality is poor (whisper) unless you increase the flow to an uncomfortable level
  • Secretions from above can clog the tube
Cuff down, speaking valve:
Gas only exits through the upper airway during exhalation
(one way valve)
  • No need to change the tracheostomy tube
  • Flow rate is good: speech volume resembles normal speech
  • Speech is possible during inspiration and expiration, if ventilated and on PEEP
  • Works best if the patient is not on a ventilator
  • With a ventilator, need to compensate for a high volume of leak (most ventilators will not tolerate this)
  • The cuff needs to be deflated (i.e. the airway is not protected from aspiration)
  • There are many contrandications to such a speaking valve
Cuff down, no speaking valve
i.e. gas freely exists via both the tracheostomy and the upper airway
  • No need to change the tracheostomy tube
  • Flow rate is good: speech volume resembles normal speech
  • Only works in ventilated patients 
  • Only able to speak in inspiration, unless PEEP is high
  • Again, there is a large volume of leak
  • The leak may affect ventilation (i.e. PaCO2 may rise)
Cuff down, finger occlusion - i.e. the patient blocks the tracheostomy and exhales using the upper airway instead
  • No need to change the tracheostomy tube
  • Flow rate might be good (depending on muscle strength)
  • Requires a lot of coordination
  • With the cuff down, no protection from aspiration

References

References

Hess, Dean R. "Facilitating speech in the patient with a tracheostomy."Respiratory care 50.4 (2005): 519-525.

Morris, Linda L., et al. "Restoring speech to tracheostomy patients." Critical care nurse 35.6 (2015): 13-28.