The use of upper airway structures in a patient with a tracheostomy is a sort of delicate art, resembling the use of a brass or woodwind instrument, involving timing and the deliberate obstruction of various important fingerholes in order to produce speech. In the CICM Part II exam, this topic has come up as a whole 10-mark question (Question 17 from the first paper of 2017) as well as in the context of more equipment related discussions regarding Passy-Muir valves and suchlike.
An excellent overview of the possible methods (including their advantages and disadvantages) is afforded through the excellent 2005 article by Dean R Hess. Those six pages are probably enough for most candidates. The brief summary which follows has been assembled largely from Hess, as well as a couple of other contributors. Given the nature of Question 17 from the first paper of 2017, discussion should probably take the shape of a table describing the advantages and disadvantages of various strategies.
Method | Advantages | Disadvantages |
Cuff up, fenestrated tube: |
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Cuff down, speaking valve: Gas only exits through the upper airway during exhalation (one way valve) |
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Cuff down, no speaking valve i.e. gas freely exists via both the tracheostomy and the upper airway |
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Cuff down, finger occlusion - i.e. the patient blocks the tracheostomy and exhales using the upper airway instead |
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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.