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Using a Speaking Valve While on a Ventilator

George Barnes, MS, CCC-SLP

March 4, 2022

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Question

Can a speaking valve be used while a patient is still on the ventilator?

Answer

While more complicated and possibly at a higher risk to the patient, a speaking valve can be successfully placed on a patient while they are still ventilator dependent. A patient who is on the ventilator cannot be considered for a cuffless tracheostomy tube and may not be appropriate for a tracheostomy tube downsize either. This means the patient’s tracheostomy tube may take up a large area of tracheal space needed for adequate upper airflow with the speaking valve. The most dangerous scenario that can occur is if the patient’s cuff is left inflated after the speaking valve is placed. With an inflated cuff, the patient will not be able to exhale any air around the tracheostomy tube to the upper airway, keeping all air below the level of the cuff and suffocating the patient. If pursued, a speaking valve trial in-line with the patient's ventilator tubing should be done under a clearly defined, facility mandated protocol and only after appropriate IDT discussions occur for medical clearance. Lastly, respiratory therapy should be present for this evaluation and should be trained and skilled in the various settings and alarms that will need to be adjusted. 

There are several signs that indicate a patient is not tolerating the speaking valve. Those signs include reports of difficulty breathing, anxiety, or inability to speak. Further, the SLP may see changes in the patient’s cardiopulmonary status (e.g. a drop in oxygen saturation or an increase in respiratory or heart rate). Visible fatigue may also be observed in the form of the patient inadvertently using accessory muscles to support adequate lung ventilation. The SLP may also notice that the patient is unable to phonate. This may be due to an issue in airway patency, breath support, or vocal fold function. Backpressure when removing the speaking valve may indicate that the upper airway is not patent (obstructed) (Lichtman, 1995). Any signs that the patient is unable to tolerate the speaking valve should be an alarm to remove the speaking valve as restricted upper airway airflow may result in respiratory insufficiency or failure (Prigent et al., 2011). The SLP may suction, reposition, and re-educate the patient before reattempting the speaking valve. If these strategies are unsuccessful and a tracheostomy tube downsize has already been completed, further consideration of respiratory insufficiency and/or upper airway obstruction should be pursued with the assistance of the pulmonologist and ENT.

Refer to the SpeechPathology.com course, 20Q: Beyond the Swallow: Tracheostomy Tube and Ventilator Management, for more information on the various questions that may arise for the medical SLP involved in the care of patients with tracheostomy and/or mechanical ventilation.


george barnes

George Barnes, MS, CCC-SLP

George Barnes MS CCC-SLP has developed an expertise in dysphagia with a focus on diagnostics in the medically complex population through his dedication to a variety of medical settings. George yearns to make education useful, research clinical-focused, and quality care accessible. His coaching program with FEESible Swallow Solutions supports SLPs with the guidance they need to reach their clinical and career goals. He co-founded a mobile FEES service to bring the highest quality assessment to the patient's bedside. His webinars bridge research and patient care. George strives to go beyond the swallow in dysphagia management by looking at the whole patient which is evident in his work on a pneumonia risk calculator. With a passion for food and a deep appreciation for the joy and connection it gives to our lives, he has dedicated his life to helping others enjoy this simple, but deep-rooted pleasure.


Related Courses

20Q: Beyond the Swallow - Tracheostomy Tube and Ventilator Management
Presented by George Barnes, MS, CCC-SLP
Text

Presenter

George Barnes, MS, CCC-SLP
Course: #10056Level: Intermediate1 Hour
  'The question and answer style made it easy and clear to read/follow'   Read Reviews
This course addresses the various questions that may arise for the medical SLP involved in the care of patients with tracheostomy and/or mechanical ventilation. Topics include causes of respiratory failure, consequences of tracheostomy/ventilation, risk management related to intervention, and considerations for assessment and treatment of swallowing and communication, including the use of speaking valves.

Eating Again After Extubation: A Case Study
Presented by George Barnes, MS, CCC-SLP
Video

Presenter

George Barnes, MS, CCC-SLP
Course: #10582Level: Intermediate1 Hour
  'Good presentation'   Read Reviews
Key factors related to respiratory failure and oral intubation, including levels of respiratory support and effects of intubation on the larynx and swallow, are reviewed in this course. A decision-making framework for creating evidence-based, individualized plans of care is described within the context of a case study.

Eating Again After Trach/Vent: A Case Study
Presented by George Barnes, MS, CCC-SLP
Video

Presenter

George Barnes, MS, CCC-SLP
Course: #10638Level: Intermediate1 Hour
  'The course included several medical complexities and charts to assist with the decision-making process'   Read Reviews
The research and theoretical framework behind trach/vent management, including elements of decision-making and risk assessment and management, are described in this course. A complex case study of resuming oral intake in a patient with trach/vent is presented to provide an in-depth look at real-world application of this information.

Breathe, Speak, Eat: What the SLP Needs to Know About Respiratory Failure
Presented by George Barnes, MS, CCC-SLP
Video

Presenter

George Barnes, MS, CCC-SLP
Course: #10445Level: Introductory1 Hour
  'This course was easy to follow! The instructor did a great job outlining the topics and breaking down how respiration relates to swallowing'   Read Reviews
This is Part 1 of a two-part series. Respiratory disease, respiratory failure, oral intubation, effects of intubation on the larynx and the swallow, and dysphagia management are discussed in this course. Risk factors and salient features of dysphagia after extubation are described in order to help clinicians effectively evaluate and treat their patients.

Breathe, Speak, Eat: What the SLP Needs to Know About Trachs and Vents
Presented by George Barnes, MS, CCC-SLP
Video

Presenter

George Barnes, MS, CCC-SLP
Course: #10461Level: Introductory1 Hour
  'Provided excellent information regarding the roles an SLPs plays with this population and provided excellent information for SLPs working with this population or wanting to work with this population'   Read Reviews
This is Part 2 of a two-part series. An overview of tracheostomy tube and mechanical ventilator management, including their effects on airflow, speech and swallowing, is provided in this course. Discussion includes speaking valves, common challenges, and ways to improve outcomes in this complex patient population.

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