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