It is hard to speak with a tracheostomy tube in situ. There are certain tracheostomy tube accessories that enables the patient to speak with the tube in place. One such accessory is the speaking valve. It is a button like equipment placed on the outer hub of the tracheostomy tube. These valves are one-way valves that can be attached to the outer end of the tracheostomy tube. These valves allow air to enter through the tube and exit through the mouth and nose. This will enable the patient to speak without needing to use the finger to block the tracheostomy tube in order to generate speech.
Image showing speaking valve attached to tracheostomy tube
When the valve is properly positioned the patient will inhale through the tracheostomy and when they exhale, the valve is forced shut causing air to pass around the tube to exit via vocal cords thereby vibrating it. For this to happen there should be some space for air to escape between the tracheostomy tube and the tracheal lumen. If cuff is used then it should carefully be deflated in order for the patient to speak. If the cuff is not deflated then the patient will not be able to exhale.
Patients who can be provided with speaking valve include:
1. Adult patients on tracheostomy (even those patients who are on mechanical ventilation).
2. Patients who are awake
3. Patients who are relaxed and responsive
Contraindications of speaking valve include:
1. Patients with severe upper airway obstruction
2. Patients with risk of aspiration
3. Patients with diminished cognitive status
4. Patients who are unable to tolerate cuff deflation
5. Patients on foam cuffed tracheostomy tubes
6. Patients who vomit
Procedure to be followed for placing one-way speaking valve:
The airway should be cleared of all secretions.
The patient should be placed comfortably in a chair or in a high Fowler position. This ensures optimal diaphragmatic movement and expansion. The tracheostomy tube should be a non-fenestrated one. If fenestrated tube is in place then an inner tube with fenestra at the same place as that of the outer tube is introduced. In order to avoid trapping secretions within the fenestra suction should not be applied to patients on fenestrated tracheostomy tubes. The patient should be encouraged to cough and clear all the secretions.
If the patient is using a cuffed tube then the cuff should be deflated or else the patient could suffocate if the speaking valve is introduced. Deflation can always be checked by inspecting the pilot balloon which would be in a collapsed state.
Patient’s ability to exhale during cuff deflation should be checked for by placing a stethoscope over the patient’s neck for listening to air lead sound during respiration. If air leak sound is not heard then speaking valve should not be used at all.
On auscultation over the neck after cuff deflation, if escaping air sound is heard then the speaking valve is placed over the outer hub of the tracheostomy tube. It should snugly fit without being too tight. Oxygen can also be administered as usual through the tracheostomy tube. Ventilator settings needs to be adjusted to factorize the increased airway resistance these valves are known to cause.
Since some amount of positive pressure needs to be used to open the valve for air entry, some patients may not tolerate it. They would take some time to get used to this process. Time for acclimatization should be allowed for such patients.
Image showing how speaking valve works