Question 16

Outline the advantages and disadvantages of the methods that enable speech in a patient with a tracheostomy tube in situ.

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College answer

Not available.

Discussion

This has appeared before, as Question 17 from the first paper of 2017.

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 contraindications 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

The author has also been present at attempts to facilitate speech by attaching low flow wall oxygen to the above-cuff suction port of the tracheostomy, thereby directing a flow of gas up into the mouth through the vocal cords. The first time you do this, you should expect to have a Yankeur sucker ready, as god-awful filth will rise bubbling from the nethermost hell of that long term patient's airway, forced out by the gas pressure. The author was subsequently surprised to discover that this was not a Mad Hatter sign of senior intensivist cognitive deterioration, but in fact a described technique (McGrath et al, 2016). It was left out of the table above mainly because most people would agree that it does not form a part of the normal spectrum of practice.

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.

McGrath, Brendan, et al. "Above cuff vocalisation: a novel technique for communication in the ventilator-dependent tracheostomy patient." Journal of the Intensive Care Society 17.1 (2016): 19-26.

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