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Using a Speaking Valve While on a Ventilator

George Barnes, MS, CCC-SLP

March 4, 2022



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.

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


George Barnes, MS, CCC-SLP
Course: #10056Level: Intermediate1 Hour
  'Gave me confidence to work with trachs more'   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.

20Q: Velo-Cardio-Facial Syndrome (VCFS)
Presented by Karen J. Golding-Kushner, PhD, CCC-SLP, ASHA Fellow


Karen J. Golding-Kushner, PhD, CCC-SLP, ASHA Fellow
Course: #8700Level: Intermediate1 Hour
  'very detailed explanations and "real world" examples of how to teach these skills to parents/clients'   Read Reviews
This course describes the characteristics of Velo-cardio-facial syndrome that are of the greatest relevance to SLPs: those that affect feeding, speech and language. Best practice for intervention is also explained.

20Q: Pediatric Voice Disorders: Diagnostic and Treatment Approaches
Presented by Susan Baker Brehm, PhD, CCC-SLP, Barbara (Derickson) Weinrich, PhD, CCC-SLP, Lisa Nelson Kelchner, PhD, CCC-SLP, BCS-S


Susan Baker Brehm, PhD, CCC-SLPBarbara (Derickson) Weinrich, PhD, CCC-SLPLisa Nelson Kelchner, PhD, CCC-SLP, BCS-S
Course: #8972Level: Introductory1 Hour
  'Voice clients are infrequent in school settings'   Read Reviews
This course provides the practicing speech-language pathologist with information on special considerations in the treatment of children with voice disorders. The various causes of voice disorders are discussed as well as the treatment of specific types of disorders.

20Q: Evaluation and Treatment of Speech/Resonance Disorders and Velopharyngeal Dysfunction
Presented by Ann W. Kummer, PhD, CCC-SLP


Ann W. Kummer, PhD, CCC-SLP
Course: #8729Level: Intermediate1 Hour
  'This, combined with Dr'   Read Reviews
Children with speech and resonance disorders (hypernasality, hyponasality, and cul-de-sac resonance) and/or nasal emission present challenges for speech-language pathologists (SLPs) in all settings. This article will help participants to recognize resonance disorders and the characteristics of velopharyngeal dysfunction, and provide appropriate management.

Respiratory Muscle Strength Training and Speech-Language Pathologists: Part 1
Presented by Denise Dougherty, MA, SLP


Denise Dougherty, MA, SLP
Course: #9282Level: Intermediate1 Hour
  'This applies to almost every patient I work with'   Read Reviews
This is Part 1 of a two-part series. This course will provide an overview of respiration and why respiratory muscle strength training is important. Appropriate diagnoses for patient referral, including COVID-19, will be examined, as well as evidence for use of respiratory muscle strength training. (Part 2 - Course 9283)

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