Tracheostomized patients are benefiting from speaking valves through improved diets and restoration of the natural physiology of the airways, which improve cough mechanisms and manage secretions

Prior to the introduction of speaking valves in 1985, communication options for intubated or tracheostomized patients were limited. Speaking by means of finger occlusion of the tracheostomy tube was common, but if patients had limited or no use of their hands or were ventilator-dependent, physicians simply accepted that these patients could not speak at all. Pediatric patients were often taught a form of sign language, which usually presented mixed results. Speech-language pathologists were rarely used to assist this patient group, and education about the effects, both mental and physical, of long-term tracheostomy was nearly nonexistent.

The invention of speaking valves began to change the long-term scenario for ventilator-dependent and tracheostomized patients. Speaking valves come in two basic models: open and closed-position. One manufacturer of the closed-position valve states that it improves swallowing and may reduce aspiration and that the same degree of airway protection does not exist with the open valve. The closed-position valve allows the buildup of subglottal air pressure, which allows patients to swallow easily and safely.

Using speaking valves can restore patients’ sense of taste and smell, increase their appetites, and improve their diets. Valves can also restore the natural physiology of the airways, thus improving cough mechanisms and managing secretions.

Case 1
A child born with bilateral vocal cord paralysis due to an in utero stroke was started on a closed-position speaking valve at the age of approximately 24 months. Theoretically, the patient should not have been able to use a speaking valve because the vocal cords were paralyzed in an adducted position. Upon initial examination, experts doubted whether the child could use the speaking valve successfully. The patient’s mother was trained to use the valve, and mother and child worked together with a dedicated speech pathologist. Initially, the patient would use the valve for a few seconds during each session in the hope that airflow past the vocal cords would stimulate movement. After 1 year, the patient was able to wear the valve all day. The child progressed from receiving only tube feedings and being unable to speak, to eating and talking normally.

Case 2
A man in his 30s suffered a C1/C2 fracture while surfing and was permanently paralyzed. Like many high spinal cord injury patients, he tended to shy away from using a speaking valve because he experienced normal uneasiness upon hearing air escape when the cuff was deflated—a required action when using a speaking valve. After a few months of practice, encouragement from his respiratory care practitioners, and reassurance from his wife and friends, he is now able to use the speaking valve during all waking hours. He has also resumed motivational speaking and a leadership role in youth ministry.

When patients begin to use speaking valves, family members are frequently surprised to hear patients’ natural voices when they regain speech function. Since the speaking valve allows air to move between the vocal cords, the sound produced by the valve is the natural voice of the patient.

According to clinicians, the benefits of speaking valves should not be underestimated. Besides giving significant physical benefits, the valves also provide an enormous psychological boost as patients regain a sense of freedom and a certain amount of control over their care situation. It is not uncommon to witness a patient who had been apathetic and frustrated to become animated and involved when speech has been restored. In addition, physicians and respiratory care practitioners sometimes find it easier to wean ventilator-dependent patients when they are successfully using a speaking valve.

The timing of the decision to place a speaking valve varies depending on the patient’s condition, and the timing of tracheostomy. Just as physicians may order a tracheostomy for a ventilator-dependent patient anywhere from 1 to 3 weeks after intubation (depending on the hospital or region), the time to introduce a speaking valve varies as well.

Theoretically, the valve can be introduced 48 to 72 hours after tracheostomy, but many physicians prefer to wait until the patient has been moved out of the intensive care unit (ICU), either to another area of the hospital or to a long-term care facility. Some experts call this the ICU mentality, in which the primary goal in the ICU is to save lives, and luxuries like communication can come later. However, given the psychological boost provided by the use of a speaking valve, perhaps caregivers should consider putting the tracheostomy patient on such a device much sooner.

Just as other muscles in the body that are not used will atrophy, so do vocal cords and oropharyngeal muscles. Therefore, utilizing speaking valves will enhance stimulation to these muscles and maintain an adequate tone for swallowing, communicating, and the ability to tolerate cuff deflation.

A team consisting of a physician, speech-language therapist, and respiratory care practitioner can work together to promote use of the speaking valve with tracheostomized and long-term ventilator-dependent patients—even within the ICU—when appropriate.

The team may assist patients in learning how to use the device, as well as encourage patients and their families to practice until proficiency is achieved. The physical and psychological rewards will likely lead to a significant improvement in patient outcomes.

Valerie Kellogg, RRT, AAS, MA, MBA, is a contributing writer for RT Magazine.