Communication with patients who have a tracheostomy

The only CICM SAQ to ever discuss the challenges of communicating with tracheostomy patients was tagged with "Communication with patients as part of care in the ICU", a topic from Section 2.2.1 in the second edition of the CICM Syllabus for the Second Part Examination. However, that section is also full of topics related to cultural sensitivity and open disclosure, suggesting that it focuses on the content of communication just as much as the mode of the exchange. There must have surely been some closed-doors debate as to whether this belongs more properly in the 2.1.5 Respiratory section or in Neurology (2.18), but realistically, without a dedicated Airway management section, questions about conveying meaning between staff and speechless patients will always be somewhat homeless. The issue, after all, is not the disengagement of some neurological faculty that commands communication, nor the failure of the respiratory system to provide enough breath for it, but the crude intrusion of a foreign object in the path of the airflow between the lungs and the vocal cords. 

The only time this topic has appeared was Question 28 from the first paper of 2025. 

The best resources for this were papers by Zaga et al (2023), Morris et al (2015) and Hess (2005).  The Morris paper is probably the most comprehensive among these.

Consequences of poor communication with conscious patients

The joke that the intensivist is at their most comfortable in the company of the comatose is not necessarily funny, because shut up. The truth is that staff often report a preference for increasing sedation in response to what they perceive to be the patient's frustration with the process of communication, as a means of ameliorating each other's distress.  "Patients did try to communicate, however this was frequently met with apprehension by the nurse and often resulted in the administration of sedative agents", notes Patak et al (2009); "many professionals prefer caring for a sedated patient to avoid stress caused by communication failure", reported a nursing assistant from a paper by Perelló-Campaner et al (2023). The caregivers involved in such interactions reported decreased job satisfaction and considered that patient care was adversely affected in the majority of cases. The patients themselves often remember all of this, and recall feeling frustrated with their attempts to communicate their basic needs (pain, heat, cold, itch) which made them depressed and anxious (Pakmehr et al, 2017). The upshot of this is:

• Patient psychological effects
  • Depression, anxiety, frustration
  • Poor understanding of their care
  • Poor cooperation with incompletelty understood care
  • Boredom, loneliness, disengagement
• Staff psychological effects
  • Frustration with the process of communication, leading to avoidance and the reliance on sedation
  • Decreased satisfaction with their work
  • Impression of the process of care as deleterious or burdensome
• Effect on care
  • Unmet patient needs in terms of comfort/position/pain relief
  • Misinterpretation of patient communication behaviours as "agitation" and therefore increased sedation, delaying extubation
  • Unrecognised reporting of symptoms lead to preventable complications
• Effect on decision-making
  • Without contributions from the patient, care decisions are one-sided and paternalistic.
  • Care becomes decentered from the patient, and the focus shifts to the family.

Communication at the sedated intubated patient

It is common to observe intensive care staff addressing the unconscious patient in conversational language, in situations where the goal is not to test responsiveness or to communicate the intention to perform some procedure. Elliott & Wright (1999) also noticed reassurances, apologies, the recognition of discomfort, jokes, involving the patient in an interaction with another staff member, and numerous similar things. This is empathy-driven behaviour and is often performed without any sort of goal in mind; in fact authors from a more cynical era remarked that "at times verbal communication with unconscious patients was so nominal that any potential benefit to the patients would have been negligible" (Baker & Meley, 1996). The nineties were the end of an era when this sort of thing was regarded as "reassuring noises". One is obviously not going to develop a personal relationship on the basis of this sort of conversation, but it is still regarded as important for several fairly robust pragmatic reasons. We talk to the sedated, unconscious, brain-injured or even braindead patients, because:

• Addressing them by their name serves to preserve their identity, and by remaining Stephen instead of Bed 9, they are potentially going to attract a more humanistic approach to their management (Suleiman, 2025). Moreover it is a way of demonstrating our respect for the patient and this has value on a cultural level, i.e. we as a medical/nursing culture respect patients and demonstrate this in our behaviour towards them. Brown et al (2018) go into more detail about this.
• Depersonalising the patient and creating a distance between their former conscious self and their current state can lead to moral distress in the staff, and lead to burnout. Furthermore, it is contagious (Foulk et al, in 2016, found that rude behaviour spreads through staff and contaminates culture)
• Emotional detachment permitted by silently going about your work may be unhelpful, as it may prevent the clinician from interpreting the behaviour of the patient correctly (eg. distress becomes "agitation").
• It is always impossible to determine exactly how much the unconscious patient is absorbing and retaining, and data suggest that even fairly well sedated people tend to have some recollection of their experience, which means they may benefit from hearing themselves being addressed and having their condition acknowledged.
• And even if they did not, we should probably still communicate with them in a respectful manner, because that seems like the correct position to take. Consider an argument that the practice of speaking to the unconscious is somehow performative. That would imply that the respect stops when the patient or their family are no longer there to witness it; and that is obviously an unpalatable position. Respect does not need an audience and would still have cultural value in a silent vacuum (consider that we put flowers on graves, etc).

In short, there is some advantage to talking to the ICU patients, even when it seems like they cannot perceive your presence.

Communication with the sedated intubated patient

Sedation is not a barrier to communication. Consider the dose of agent required to sustain sedation during a colonoscopy, as compared to the doses used in ICU for sedation of patients being ventilated with spontaneous modes - the effect on consciousness is obvious and non-trivial but patently sub-anaesthetic. With 2mg/kg/hr on board (20ml/hr for a 100kg patient) the healthy volunteers from Zacny et al (1992) performed much as one might at the local pub, slurring their speech and failing various psychomotor tests. We have all communicated with people in this sort of state at Christmas parties and  in moonlit parks. Yes, these people were not also experiencing the effects of prolonged drug accumulation organ failure or head injury, but the bottom line is that the level of sedation usually observed in the ICU is not enough to completely abolish the desire or the ability to communicate in some basic way. 

What way would that be? and what would they have to say? Khalaila et al (2011) interviewed several to find out. Turns out, it was serious stuff. The vast majority had distinct recollections of not being able to speak, and 80% were "moderately to severely bothered" by the experience. This sentence is of course insane, and none of the readers are likely to be able to relate to it. A young healthy doctor in the prime of their adulthood is unlikely to have been "moderately to severely bothered" by any physical discomfort since suffering greenstick fractures on the schoolyard, and will therefore have no frame of reference for the experience of their intubated patients. The most maddening sensation they could not communicate appeared to be thirst, second only to the inability to swallow secretions pooling at the back of their throat. The temperature the nurse thinks they need is never the temperature they actually want, and they are unable to tell you that they are hot when you have tucked them neatly into a folded blanket just before morning handover. They itch, but they are kept from scratching their nose, because each time their hand rises to their face they are restrained. The list goes on.

Communication is therefore essential. Fortunately, the extubated humans have devised a series of excellent strategies, ranging from the highly sophisticated to the crudest.

• Attention-generating devices: clickers, buzzers, lights, bells (these are simple enough that they can be operated by any limb, or even the mouth)
• Communication boards with words, letters or symbols
• Writing implements, ranging from pen and paper to whiteboards
• Electronic methods
  • iPads with apps, eg. the SCCM Patient Communicator App (though there are hundreds like it)
  • Mouse, keyboard, laptop
  • Touchscreen and stylus, if they have the dexterity
  • Something like the MOCS if they do not (but the upper limbs have enough power to move against gravity)
  • Bluetooth-operated foot pedals if the arms are not working
  • Eye tracking software if nothing is working
  • Though still adrift in the liminal space between technology and fiction, EEG-mediated communication systems for patients with locked-in syndrome were tested by Xiaoxiao et al (2020) with modest success (they were using it to navigate a wheelchair, but the concept is elastic and could extend to communication)

These, of course, are not unique to the intubated patient, and can transfer directly to the patient with a tracheostomy; but the patient with a tracheostomy has a much larger range of options.

Communication with the awake ventilated patient who has a tracheostomy

The fact that their vocal cords are no longer splinted open by a rigid tube opens a range of options for communication, from simply more of the same (the patient is now usually much less sedated and has fewer things in their arms) to something much more sophisticated (eg. occasionally, actual speech). Zaga et al (2023), Morris et al (2015) and Hess (2005) were excellent resources for this.

Possibilities include:

• Mouthing words. With the tube gone, a patient with intact facial neuromuscular function may be able to speak silently to lip readers, make facial expressions, and indicate directions with eye gestures.
• Tongue clicks: there are numerous sounds one can make without requiring air flow through the upper aerodigestive tract, and these can sometimes be surprisingly loud. This becomes possible only with the ETT out of the way.
• "Leak speech"-  the patient 's cuff is deflated but the ventilator remains attached, and the PEEP generates a leak through the upper airway. The resulting air flow may be quite robust, and the patient may find this somewhat uncomfortable. Additionally, one is courting disaster each time one does something that interrupts the isolation of the lower airway in a patient being weaned from tracheostomy, as the above-the-cuff secretions may be allowed to slip into the lower airway with each deflation.
• Above-the-cuff gas flow: McGrath et al (2016) describe a technique of sending about 3-5L/min of oxygen into the above-the-cuff suction port of tracheostomy devices that permit that kind of secretion clearance. The patient should be warned that you are about to do this, as the first time it is done, a whole mass of subglottic gunk is blown up into their mouth and out the nose (prepare the Yankeur in hand as you turn on the gas). The voice generated by this is a quiet whisper, but is better than nothing, and can be turned on by the patient (operating a valve) whenever they want. 
• Cuff down with speaking valve: the one way valve permits inspiration through the tracheostomy, and expiration through the upper airway, permitting speech in patients who are free from ventilator dependence but not from the tracheostomy tube itself. A valveless method of handling this is to simply show the patient how to occlude their own tracheostomy for speech. A fenestrated tracheostomy is functionally identical.