When do you order a Passy-Muir (speaking) valve for patients with tracheostomies?

When to Order a Passy-Muir Speaking Valve for Tracheostomy Patients

Immediate Referral and Consultation

All patients with a tracheostomy should be referred to speech-language pathology services immediately, regardless of diagnosis, age, or expected duration of the tracheostomy, and a one-way speaking valve trial should be initiated as soon as safety criteria are met. 1

The American Thoracic Society identifies speaking valves as the gold standard for enabling speech in tracheostomy patients because they redirect exhaled air through the vocal cords and upper airway rather than allowing it to escape through the tracheostomy tube. 1

Safety Criteria That Must Be Met Before Ordering

Before ordering or trialing a Passy-Muir valve, verify the patient meets all of the following safety criteria: 1

• Cuff deflation tolerance: The patient must tolerate having the tracheostomy cuff deflated without respiratory distress or aspiration 2, 1
• Medical stability: No acute respiratory compromise or hemodynamic instability 1
• Patent upper airway: The airway above the tracheostomy must be open and unobstructed 1
• Adequate secretion management: Secretions cannot be excessively thick or copious 2, 1
• Some vocalization ability: Patient should demonstrate some ability to vocalize when the tracheostomy is manually occluded 1
• Appropriate tube size: The tracheostomy tube should be smaller than the airway caliber to allow adequate air leak 2

Clinical Timing for Valve Placement

Order the Passy-Muir valve once the patient successfully weans off mechanical ventilation and can tolerate cuff deflation or transition to a cuffless tube. 2

The specific clinical sequence is: 2, 1

• Patient successfully weaned from mechanical ventilation (no longer requiring positive pressure support)
• Cuff deflated or transitioned to cuffless tracheostomy tube
• Patient considered low-risk for requiring re-intubation or mechanical ventilation
• Heat-moisture exchanger (HME) with viral filter placed when not using speaking valve
• One-way speaking valve or capping initiated to facilitate speech and prompt weaning

Assessment Protocol Before Ordering

The speech-language pathologist must evaluate: 1

• Oral mechanism examination: Assess vocal cord function and upper airway patency
• Swallowing ability: Evaluate aspiration risk with cuff deflation
• Cognitive status: Ensure patient can cooperate with valve use
• Respiratory status: Confirm adequate respiratory reserve and secretion clearance

Additional Benefits Beyond Speech

Speaking valves provide critical physiologic benefits beyond communication: 2, 1

• Improved swallowing safety: Creates positive subglottic pressure that helps clear residual material from the larynx 3
• Reduced aspiration risk: Restores translaryngeal airflow and protective airway mechanisms 3
• Decreased aerosolization: An open tracheostomy without HME, speaking valve, or cap increases viral particle expulsion risk 2
• Enhanced quality of life: Enables normal speech development in children and communication in adults 2, 1

Common Pitfalls to Avoid

Do not attempt speaking valve placement if the patient cannot manage oral secretions, as this predicts aspiration and requires instrumental swallowing evaluation first. 3

Do not use speaking valves with an inflated cuff, as this creates a closed system that prevents exhalation and can cause respiratory distress or barotrauma. 2

Do not delay referral to speech-language pathology until the patient is "ready" for decannulation—early consultation optimizes outcomes. 1

For pediatric patients with upper airway obstruction who cannot tolerate standard Passy-Muir valves due to excessive transtracheal pressures (>10 cmH₂O), drilling a small 1.6-mm hole in the valve side creates a pressure relief port that enables phonation while maintaining safety. 4

Monitoring During Valve Use

During initial trials, monitor for: 5

• Respiratory distress: Dyspnea, increased work of breathing
• Oxygen desaturation: Maintain SpO₂ ≥95% 2
• Excessive transtracheal pressure: Should not exceed 10 cmH₂O in pediatric patients 4
• Inability to exhale: Indicates upper airway obstruction requiring valve removal

Two healthcare professionals should be present during initial valve application to ensure immediate response to complications. 5