How to understand speech in a stroke patient with a tracheostomy (tracheal tube)?

Facilitating Speech in a Stroke Patient with Tracheostomy

Consult a speech-language pathologist immediately and trial a one-way speaking valve (such as Passy-Muir, Shiley, or Montgomery valve) after ensuring the patient meets safety criteria, as this is the most effective method to enable understandable speech in tracheostomy patients. 1

Immediate Action: Speech Pathology Consultation

• All patients with a tracheostomy should be referred to speech pathology services regardless of diagnosis, age, or expected duration of the tracheostomy. 1
• The speech pathologist should evaluate both communication abilities and swallowing function, as these are interdependent in stroke patients with tracheostomy. 1
• This consultation is critical for stroke patients who may have both mechanical (tracheostomy-related) and neurological (stroke-related) communication impairments. 1

Primary Solution: One-Way Speaking Valve

Speaking valves are the gold standard for enabling speech in tracheostomy patients because they allow exhaled air to pass through the vocal cords and upper airway rather than escaping through the tracheostomy tube. 1

Mechanism of Action

• Without occlusion of the tracheostomy tube, most air escapes through the tube, making speech very breathy and difficult to coordinate with respiration. 1
• One-way speaking valves open during inspiration (allowing air in through the tracheostomy) and close during expiration (forcing air up through the larynx and vocal cords). 1
• The most widely used valves are Passy-Muir, Shiley speaking valve, and Montgomery valve. 1

Safety Criteria Before Using Speaking Valve

Before trialing a speaking valve, verify the patient meets ALL of the following criteria: 1

• Tracheostomy tube size does not exceed two-thirds of the tracheal lumen (or a fenestrated tube is used) 1
• Medical stability 1
• Ability to have the cuff deflated without aspiration 1
• Some ability to vocalize with the tracheostomy occluded 1
• Patent airway above the tracheostomy 1
• Secretions are not thick 1

Critical Pitfall to Avoid

• Never use a speaking valve with an inflated cuff - this can cause complete airway obstruction and respiratory arrest. 1
• The cuff must be deflated to allow air to pass around the tube and through the upper airway. 1

Alternative Communication Methods

If the patient does not meet criteria for a speaking valve (common in acute stroke with severe medical complications), use these alternatives: 1

• Sign language or gestures 1
• Augmentative communication devices (electronic communication boards) 1
• Manual language boards/books (picture or letter boards) 1
• Electrolarynx 1
• Finger or chin occlusion of the tracheostomy tube (less effective than speaking valves but possible for brief communication) 1

Tube Considerations for Speech

• The tracheal cannula must not exceed two-thirds the lumen of the anatomical trachea OR must be fenestrated to allow adequate air leak around the tube for speech production. 1
• Fenestrated tubes have openings that allow air to pass through the tube wall into the upper airway. 1
• If the tube is too large relative to the trachea, downsizing may be necessary before speech is possible. 1

Assessment Protocol

The speech pathologist should evaluate: 1

• Oral mechanism examination including vocal cord function 1
• Swallowing ability (stroke patients often have dysphagia that affects both safety and speech coordination) 1
• Cognitive status (stroke-related cognitive deficits may impact communication beyond mechanical issues) 1
• Respiratory status (adequate respiratory drive and lung function are needed for speech) 1

Swallowing Evaluation Importance

• Perform swallowing evaluation with the cuff both inflated and deflated if using a cuffed tube. 1
• Evaluate with and without the speaking valve to assess any changes in swallowing pattern. 1
• This is critical because aspiration risk may change with valve use, and stroke patients are at high baseline risk for aspiration. 1

Practical Implementation Steps

1. Ensure medical stability and adequate oxygenation 1
2. Verify airway patency above the tracheostomy (no significant upper airway obstruction from stroke-related edema or other causes) 1
3. Deflate the cuff (if present) and monitor for aspiration risk 1
4. Downsize tube if needed to ensure it occupies less than two-thirds of tracheal diameter 1
5. Trial speaking valve under supervision with pulse oximetry monitoring 1
6. Assess speech quality and patient tolerance 1
7. Evaluate swallowing safety with valve in place 1

Expected Outcomes

• Speaking valves offer significant advantages and should be strongly considered for all patients who meet safety criteria. 1
• Patients who successfully use speaking valves typically have improved communication quality compared to alternative methods. 1
• Better communication correlates with improved quality of life and may facilitate rehabilitation participation in stroke patients. 1