A practical approach to
tracheostomy tubes and
ventilators
Alison McKee, MS CCC-SLP
University Specialty Hospital, Baltimore MD
Department of Rehabilitation Services
Heather Starmer, MA CCC-SLP
Johns Hopkins University, Baltimore, MD
Department of Otolaryngology – Head and Neck Surgery
Learner objectives
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Discuss different communication options for
tracheotomized and ventilator dependent
patients
Demonstrate understanding of basic ventilator
settings and their implications on speech
Discuss evidence regarding the benefits of voice
restoration
Describe ways to initiate an in-line ventilator
speaking valve program
Introduction to trachs
Indications and types
Indications for tracheostomy
 Prolonged
mechanical ventilation
 Acute or chronic airway obstruction
 Retention of pulmonary secretions
 Sleep apnea
Tracheostomy
Anatomy of a trach tube
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1. Faceplate
2. Hub
3. Outer Cannula
4. Pilot line/pilot
balloon
5. Cuff
1
2
3
5
4
Trach tubes (cont.)

Shiley
– Plastic with white face
plate
– Can be cuffed or
cuffless
1 – obturator
2 – inner cannula
1
2
Trach tubes (cont.)

Portex
– Plastic tube
– Clear or white
faceplate
– Blue pilot balloon
Trach tubes (cont.)
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Bivona aircuff
TTS (tight to shaft)
cuff hugs outer
cannula
Trach tubes (cont.)

Bivona fomecuff (red
pilot balloon)
– Used when unable to
maintain seal with
standard cuff
– Reduces risk of
damage from overinflation of cuff
– Passive cuff inflation
– Cannot be used with
speaking valves
Trach tubes (cont.)

Extra length
– Used primarily with
bariatric patients to
ensure proper
ventilation
– Made by most trach
manufacturers
Trach tubes (cont.)

Bivona/Portex talking
trach
– Used for
communication with
patients who require
cuff inflation
– Delivery of nonpulmonary air between
the inflated cuff and
the vocal folds
Trach tubes (cont.)

Fenestrated trachs
– Designed to allow
communication when
on vent
– Problematic due to
malpositioning of
fenestrates
– Rarely used
Trach tubes

Jackson (metal)
– Used for non-vent
patients
– Cuffless model only
Tracheostomy speaking
valves
Nature of the problem
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Diversion of airflow away from larynx
Inadequate subglottic pressure to cause vocal
fold vibration
The solution
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Re-establish airflow
through the larynx
Substitute alternative
vibration source if
larynx is not
accessible
Speaking Valve Function
 Patient
can continue to breath in through
the trach tube
 Exhalation is then redirected up through
the trachea – creating a closed system
 Promotes a more “normal” respiratory
pattern for breathing and expelling
secretions
Currently prevalent speaking valves

Passy Muir Speaking Valve – Biased closed valve
–
–
–
Perceptually best quality voice
Fewest clinically relevant mechanical problems
Reduced effort required to initiate voice
(Zajac et al. Journal of Speech, Language, and Hearing Research 1999;
Leder. Journal of Speech and Hearing Research 1994)

Montgomery Speaking Valve – Biased open
valve
– Good to use for patients with mild upper airway
obstruction due to cough release mechanism
Passy Muir Speaking Valve
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Four different styles
1.
2.
3.
4.
PMV 2001
PMV 005
PMV 007 (vent)
PMV 2000 (low
profile)
1
1
1
2
3
4
Montgomery Speaking Valve
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2 different styles
1. Tracheostomy valve
2. Ventilator valve
1
2
Speaking Valves
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Primary benefit
– Communication
 Successful restoration of verbal communication in vented and
trach dependent patients
 Patient reported improvement in psychosocial functions and
emotional status
 Improvements noted in adults as well as pediatric patients
(Manzano et al. Critical Care Medicine 1993;
Passy et al. Laryngoscope 1993;
Hull, et al. Pediatric rehabilitation 2005)
Speaking Valves
 Secondary
benefits (Passy Muir only)
– Swallowing
 Reduced occurrence of laryngeal
penetration/aspiration
 Reduced amount aspirated
(Suiter, McCullough, & Powell. Dysphagia 2003;
Stachler, Hamlet, Choi, & Fleming. Laryngoscope 1996;
Dettlebach, Gross, Mahlmann, & Eibling. Head and Neck 1995)
Speaking valves
 Secondary
benefits (Passy Muir only)
– Secretion management
 Subjective patient report of reduced oral and nasal
secretions (Passy et al. Laryngoscope 1993)
 Reduced secretion production over 24 hour period
(Lichtman and Birnbaum. Journal of Speech and Hearing Research
1995)
– Olfaction (Lichtman and Birnbaum. Journal of Speech and Hearing
Research 1995; Passy et al. Laryngoscope 1993)
Speaking valves
 Secondary
benefits (Passy Muir only)
– Vent weaning/decannulation
(Fukumoto, Ota, & Arima. Critical Care Resuscitation 2006)
Speaking Valve Candidacy
 Can
be used with trach patients on and off
the vent
 Pt should be awake, alert, and attempting
to communicate
 Airway patency – trach size/# of
intubations
 Can be used for decannulation purposes in
patients who are not communicative
Contraindications for speaking
valve use
 Cuff
inflation
 Fome cuff trach
 Thick, copious secretions
 Total laryngectomy
 Laryngeal masses, stenosis, inadequate
patency of upper airway
Communication restoration in the
trach patient
– Assess size and type of tracheostomy tube
 Patients with Fome cuff trachs are not candidates
for speaking valves secondary to passive inflation
of cuff
 Larger diameter trachs may result in inadequate
airflow through the upper airway (ideal size of
trach is 2/3 size of tracheal lumen)
 Specialty trachs can be utilized for abnormal
airways (e.g. extra length, double cuff, stoma cuff,
TTS)
Speaking Valve Assessment
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Verify and record baseline vital signs
Slowly deflate cuff (~1cc at a time) and monitor
pt’s vitals and work of breathing
Suction patient if necessary
Verify voice by digital occlusion of trach
Apply speaking valve and monitor for changes in
voice, vitals, or work of breathing
Advance time of use as tolerated
Communication options
for ventilator dependent
patients
First steps
 Assess
size and type of tracheostomy tube
 Determine reason for trach/vent
dependence
 Assess vent settings and recent weaning
course
 Discuss patient status with respiratory
therapist and pulmonary team
Ventilator modes
 Assist
control (AC) – Machine does all the
work. If the pt attempts to trigger a
breath the vent will deliver the volume
predetermined by the vent setting at the
preset rate
 Pressure Regulated Volume Control
(PRVC), adjusts pressure delivered during
each breath to ensure target volume
 Used in the most compromised pulmonary
patients
Ventilator modes (continued)
 Synchronized
Intermittent Mandatory
Ventilation (SIMV) – Vent will deliver a
predetermined number of breaths per
minute at a certain volume. If pt initiates
breaths, those breaths will be at the pt’s
spontaneous volumes
 Used in beginning of weaning
Ventilator modes (continued)
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Continuous Positive Airway Pressure (CPAP)- Pt
determines how many breaths per minute will be
taken. No preset volumes are presented to the
patient. Pt is given continuous positive air
pressure to maintain integrity of gas exchange
at alveoli.
Weaning step before trach collar
Ventilator modes (continued)
 Pressure
support – Can be utilized with
other vent modes to provide pressure
support to overcome resistance from vent
tubing. Pressure support is to minimize
respiratory muscle fatigue.
Ventilator settings
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Rate – Predetermined, minimum number of
breaths per minute which will be delivered to the
patient.
Tidal volume – The volume of air delivered with
every mechanical breath.
Pressure support - The pressure delivered with
each inspiration.
Positive end expiratory pressure (PEEP) –
Positive pressure which is present at the end of
expiration
Fraction of inspired oxygen (FI02) – percentage
of oxygen delivered with each breath.
Vent setting implications for verbal
communication
 Tidal
volume – Patients who require high
tidal volumes may have more difficulty
with cuff deflation due to difficulty
compensating for loss of volume and
inability to adjust tidal volumes above a
certain level.
 Some pulmonologists feel that patients
with tidal volumes greater than 800 are
not candidates for cuff deflation/inline
PMV
Vent setting implications for verbal
communication
 PEEP
– The PMV adds ~2 cm of PEEP.
PEEP >7 can lead to barotrauma. Patients
receiving >5 of PEEP at baseline may
need to have the vent adjusted for the
added PEEP from the PMV.
 Pressure support – As with PEEP, high
airway pressures can lead to barotrauma.
In general, patients with PS >10 are not
candidates for inline PMV.
Vent setting implications for verbal
communication
 FI02
– Patients with higher oxygen
requirements often do not tolerate cuff
deflation due to inability to compensate.
Generally speaking, patients with FI02
>60% don’t do well with cuff
deflation/inline PMV.
Vent setting implications for verbal
communication
 Rate
– Again, patients with higher
respiratory rate requirements are less
likely to adjust to changes in ventilation.
Generally speaking, patients with set rates
of >16 may not do well with cuff
deflation/inline PMV.
Other considerations
 Peek
airway pressures – Patients with
baseline peak airway pressures >40 are
not candidates for inline PMV secondary to
risks of barotrauma (as measured at rest,
not during phonation attempts or
coughing)
 Secretions – Patients with excessive
secretions may not be able to tolerate cuff
deflation or inline PMV.
Verbal communication options for
vent dependent patients
 Leak
speech/cuff deflation
 Inline Passy Muir Valve
 Talking trach tubes
 Electrolarynx
Leak speech/cuff deflation
 Requires:
- Intact or relatively unimpaired
articulators
- Fairly stable pulmonary status
- Patent upper airway
- Functional vocal fold mobility
 Contraindications:
- High oxygen requirements
- High tidal volumes
Leak speech assessment
 Consult
with pulmonary or respiratory
departments to determine pt stability
 Verify and record vent settings
 Verify and record baseline vital signs
 Suction orally and via trach if necessary
 Slowly deflate cuff (~1cc at a time) and
monitor pt’s ability to phonate as well as
pt’s VS and WOB – suction again if needed
Leak Speech Assessment cont.
 Disable
low minute volume alarm.
 Monitor pt 1:1 during initial trial and
discontinue if HR or RR increase, if SaO2
decreases, if pt has severe and intractable
coughing, or if the pt c/o excessive SOB.
 Advance time gradually according to
tolerance
Keep in mind with leak speech
 Vent
settings, particularly tidal volume and
pressure support will impact the pt’s voice
production.
 If pt is unable to achieve any voice
(particularly if low minute volume does not
alarm at all), suspect excessive trach size.
Keep in mind with leak speech
cont.
 Tidal
volumes may be adjusted to assist
with voice production.
 ENT consultation if persisting
dysphonia/aphonia.
Inline PMV
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Requires:
- Intact or relatively unimpaired articulators
- Fairly stable pulmonary status
- Patent upper airway
- Functional vocal fold mobility
- Good tolerance of cuff deflation
Contraindications:
- High oxygen requirements
- High tidal volumes
- High PEEP
- High pressure support
Inline PMV assessment
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Consult with pulmonary or respiratory
departments to determine pt stability
Coordinate with RT for initial evaluation
(recommend assessment of tolerance of cuff
deflation prior to initial inline PMV trials)
Verify and record baseline vent settings
Verify and record baseline vital signs
Suction orally and via trach if necessary
Slowly deflate cuff (~1cc at a time) and monitor
pt’s ability to phonate as well as pt’s VS and
WOB –suction if necessary
Inline PMV assessment cont.
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Disable low minute volume alarm.
Monitor pt 1:1 during initial trial and discontinue
if HR or RR increase, if SaO2 decreases, if pt has
severe and intractable coughing, or if the pt c/o
excessive SOB.
Advance time gradually according to tolerance
Problems you may encounter
 Problem:
Good vital signs but poor
phonation
Solutions:
1. RT can make vent adjustments
including increasing tidal volume or PEEP
2. ST can focus on maximizing respiratory
support for phonation through traditional
voice therapy techniques
3. ENT can assess for glottic closure issues
Problems you may encounter
 Problem:
Severe coughing
Solutions:
1. Revert back to cuff deflation trials to
desensitize the upper airway
2. Keep cuff deflated throughout the day
for greater desensitization
3. Do short, intermittent PMV applications
until pt becomes used to airflow
Problems you may encounter
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Problem: Good VS with cuff deflation but
inability to tolerate inline PMV
Solutions:
1. Most likely issue is inadequate upper airway
patency – recommend ENT consult
2. Anxiety may also contribute to this scenario, if
voice is excellent but pt with increased HR/RR,
try relaxation techniques and short, intermittent
PMV applications
Developing an in-line
protocol
Protocols and Procedures
 Obtain
access to/create PMV policy and
procedure (see handout)
 Determine responsible parties – SLP, RT,
pulmonologist and nursing
 Determine selection criteria – See previous
slide on speaking valve candidacy
 Meet with appropriate committee to
review draft and determine approval
process
Determine responsible parties

Pulmonologist: Initiate consultation and
communicate any change in status that
may impact candidacy for valve use
Determine responsible parties
 Speech language pathologist: Conduct a
clinical evaluation of the PMV candidate,
dispense and apply the PMV and necessary
adaptors, develop appropriate therapeutic
goals, follow the patient’s progress, and
discontinue PMV intervention if changes in
status occur.
Determine responsible parties
 Respiratory therapist: Assess the respiratory
status of the patient, make necessary
adjustments to the ventilator after discussion
with the pulmonologist, place and remove the
PMV according to recommendations made by
the SLP, and monitor the status of the patient
during inline PMV use in conjunction with the
SLP.
Determine responsible parties

Nursing: Communicate to the SLP any
changes in patient status which may
impact candidacy for inline PMV use,
assist in monitoring the patient during
PMV once established, place and remove
the PMV according to recommendations
made by the SLP, and clean the PMV
according to SLP recommendations.
In-line protocol inclusions
 Establish
candidacy in conjunction with RT
and pulmonary
 Determine speaking valve placement
guidelines
 Identify troubleshooting tips
 Establish a discontinuation criteria
 Train and educate staff with competencies
Importance of multidisciplinary care
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Speech pathologists are experts in voice,
speech, and swallowing
Respiratory therapists are experts in trach/vent
management
Otolaryngologists are experts in airway
management
Pulmonologists are experts in pulmonary
management
Nurses are experts in the care of their patients
Good studies to cite to your
medicine colleagues
 91/104 patients able to tolerate cuff
deflation/cuffless trach while on
mechanical ventilation (Bach and Alba. Chest 1990.)
 A multidisciplinary team approach can be
used to promote a positive patient
outcome in the mechanically vented (Bell.
Critical Care Nurse 1996.)
 Cuff deflation increase vocalization
without compromising respiratory function
(Conway and Mackey. Anaesthesia 2004)
Other communication
options
Talking trach tubes
 Requires:
- Intact or relatively unimpaired
articulators
- Functional vocal fold mobility
- Relatively patent upper airway
 Contraindications:
- No major contraindications
Talking trach tubes
 Made
by both Bivona and Portex
 Allows for phonation by presentation of
non-pulmonary air between the cuff and
the vocal folds.
 Does not require cuff deflation and will not
impact ventilation of the patient.
Talking trach tube
Assessment for talking trach
tube
 Once
a patient is identified as a candidate,
trach can be changed by ENT.
 Once the trach is changed, humidified air
line should be established for the talking
trach.
Assessment for talking trach tube
cont.
 The
talking trach line is attached via
oxygen tubing to the humidified air source
and the flow should be set initially at
7L/min.
 Digitally occlude the port on the talking
trach line to administer airflow to the
upper airway and ask pt to phonate.
Troubleshooting with a talking
trach
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Problem: Air does not seem to be flowing
through.
Solution: Because the port is located right above
the cuff, secretions can clog the line. Try
flushing saline through the line and then reverse
suction through the talk line.
Problem: Excessively wet vocal quality impacting
intelligibility
Solution: Suction through the talk line to remove
secretions from above the cuff.
Troubleshooting with a talking
trach
 Problem:
Inability to get adequate voicing
Solution: May be due to inadequate
airflow. Air flow meter may vary between
5-15 L/minute. Try increasing the airflow
by 1 L/min at a time.
 Problem: Excessive coughing
Solution: Airflow may be too high. Try
reducing the airflow by 1 L/min at a time.
Also try intermittent application of air
rather than constant airflow.
Troubleshooting with a talking
trach
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Problem: Intermittent voice breaks
Solution: Because of the design of talking trachs,
patient position and trach position can interfere
with uninterrupted phonation. Try different
head postures and positions while sustaining
phonation to find the best position.
Problem: Pt complaints of throat irritation with
prolonged use
Solution: Turn air flow off when not in use to
minimize air delivery.
Electrolarynx
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For patients on the vent who are unable to
obtain restoration of laryngeal communication,
an electrolarynx can be used to restore
alaryngeal speech.
Patients do best with oral adaptors
Electrolarynx training for vent patients should
mirror what is done for laryngectomy patients
(i.e. focus on device placement, overarticulation, speaking rate).
Other non-oral options
 Communication
boards
 Writing
 Assistive/augmentative
devices
communication
Ethical Considerations
 Quality
of life issues (Markstrom et al 2002, Kaub-
 Family
and caregivers involvement (Rossi
Wittemer 2003)
Ferrario 2001)
 Coping
with long-term tracheostomy or
ventilation
Conclusions
Conclusions
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There are a number of communication options
available for tracheotomized and ventilator
dependent patients
Successful rehabilitation depends upon a
functional multidisciplinary approach
The SLP’s interventions can extend beyond basic
communication restoration
SLPs have the knowledge, passion, and
communication skills to advocate for their
patients