What is the recommended speaking valve for a patient with a tracheostomy tube?

Shiley Tracheostomy Tube Speaking Valve

The Shiley speaking valve is one of three widely recognized one-way speaking valves recommended for tracheostomy patients, alongside the Passy-Muir and Montgomery valves, and should be strongly considered for all patients who meet specific safety criteria. 1

Available Speaking Valve Options

The American Thoracic Society identifies three primary one-way speaking valves used in clinical practice: 1

• Passy-Muir valve (Passy & Passy, Inc., Irving, CA)
• Shiley speaking valve (Shiley Inc., Irving, CA)
• Montgomery valve (Boston Medical Products, Westboro, MA)

All three valves function as one-way ventilation devices that restore more normal airflow through the upper airway, enabling speech and improving swallowing safety. 1, 2

Mandatory Safety Criteria Before Valve Placement

Before placing any speaking valve, including the Shiley valve, verify all six safety criteria are met: 1, 3

• Tracheostomy tube size must not exceed two-thirds of the tracheal lumen (unless using a fenestrated tube)
• Medical stability is confirmed
• Cuff deflation tolerance without aspiration
• Some vocalization ability with the tracheostomy occluded
• Patent airway above the tracheostomy site
• Secretions are not thick

The cuff must be deflated or the patient must have a cuffless tube to allow air passage through the vocal cords for phonation. 1, 4

Clinical Benefits and Mechanism

Speaking valves provide significant advantages beyond just enabling speech: 1, 3

• Restores subglottic pressure by allowing exhaled air to pass through the vocal cords and upper airway rather than escaping through the tracheostomy tube 4, 2
• Reduces aspiration risk in all patients studied, with improvement across liquid, semisolid, and pureed consistencies 2
• Improves swallowing safety by creating positive subglottic pressure that helps clear residual material from the larynx 4
• Enables understandable speech that is far superior to breathy, uncoordinated speech with an open tube 1, 3

Implementation Algorithm

Follow this stepwise approach for speaking valve placement: 3, 5

1. Ensure medical stability and adequate respiratory status
2. Verify airway patency above the tracheostomy
3. Deflate the cuff or transition to cuffless tube when patient no longer requires positive pressure ventilation 1, 4, 5
4. Downsize tube if needed to ensure it does not exceed two-thirds tracheal lumen 1, 6
5. Trial the speaking valve with close monitoring
6. Assess speech quality and patient tolerance
7. Evaluate swallowing safety with and without the valve in place 1

Timing Considerations

Recent evidence suggests accelerated placement may be beneficial: 7

• Speaking valve placement within 24 hours of percutaneous tracheostomy is feasible and safe
• Patients receiving accelerated placement (≤24 hours) tolerated longer speaking valve trials compared to standard timing (≥48 hours): median 65 minutes versus 15 minutes 7
• Seven patients in the accelerated group were decannulated before hospital discharge versus only one in the standard group 7

Critical Pitfalls to Avoid

Never place a speaking valve with an inflated cuff - this creates a closed system that prevents exhalation and can cause respiratory distress or death. 1, 4

Do not leave an open tracheostomy tube without an HME, speaking valve, or cap - this increases aerosolization risk and reduces protective airflow through the upper airway. 1, 4

Avoid finger or chin occlusion as the primary method - speaking valves provide more effective and consistent occlusion. 1

Mandatory Speech Pathology Consultation

All patients with a tracheostomy should be referred to speech pathology services immediately, regardless of diagnosis, age, or expected duration of the tracheostomy. 1, 3

The speech pathologist should ideally be contacted before the tracheostomy surgery to arrange family consultation and should evaluate both communication abilities and swallowing function, as these are interdependent. 1, 3

Alternative Communication Methods

For patients who cannot tolerate speaking valves due to severe medical complications or thick secretions, offer augmentative communication options: 1

• Sign language
• Augmentative communication devices
• Manual language boards/books
• Electrolarynx

However, these are less desirable than normal speech enabled by speaking valves. 1