Above cuff vocalisation: A novel technique for communication in the ventilator-dependent tracheostomy patient

Abstract

A significant proportion of patients admitted to intensive care units require tracheostomies for a variety of indications. Continual cuff inflation to facilitate mechanical ventilatory support may mean patients find themselves awake, cooperative and attempting to communicate but unable to do so effectively. Resulting frustration and anxiety can negatively impact upon care. Through participation in the Global Tracheostomy Collaborative, our unit rapidly implemented novel techniques facilitating communication in such patients. In carefully selected and controlled situations, the subglottic suction port of routinely available tracheostomy tubes can be used to deliver a retrograde flow of gas above the cuff to exit via the larynx, facilitating speech. The resulting above cuff vocalisation is described in detail for five general ICU patients at our institution, highlighting the benefits of multidisciplinary care and the increasingly important role of the speech and language therapists in the critically ill.

Keywords: Tracheostomy; communication; rehabilitation of speech and language disorders; vocalisation.

Figure 1.

Tracheostomy tube in situ with subglottic suction ports and tubing indicated. Left-hand figure demonstrates the usual removal of secretions by aspiration. Right-hand figure demonstrates the flow of gas to the upper airways via the larynx when additional gas flow is directed into the subglottic port.

Figure 2.

One of the patients described with cuffed Blue Line Ultra Subglottic suction Tracheostomy tube in situ with the cuff inflated. The green oxygen tubing is connected to the subglottic suction port via the clear open valve (arrow), occluding which will facilitate ACV (with permission).

Figure 3.

Gas flows through correctly positioned tracheostomy tubes: Left-hand figure shows a cuff-inflated tube with gas flow excluded from the upper airway. Centre figure shows gas flow in ‘leak speech’, with the cuff deflated (or not present). Gas flows via the tracheostomy tube, but also a small amount via the upper airways. Right-hand figure shows increased airflow via the upper airways by adding a fenestration to the tracheostomy tube.