Speech for People With Tracheostomies or Ventilators
What is a tracheostomy?
A tracheostomy is a surgical opening in the windpipe (trachea). It is made by cutting the neck below the Adam's apple (below the vocal cords). A tube is placed in the opening, and air goes in and out through the tube instead of through the mouth and nose. For some, a tracheostomy is short-term. For others, it is long-lasting or permanent.
What happens when a person has a tracheostomy?
When a person breathes, there are structures that warm and moisten air, filter air-borne debris, and cause coughing, sneezing, smelling, tasting, and swallowing. After a tracheostomy, the air does not pass by these structures of the mouth and nose. The extra debris can cause a buildup of fluids and secretions in the lungs. These secretions often need to be cleared by suctioning through the tracheostomy tube. Problems with smell, taste, and swallowing can reduce appetite and food intake. Food and secretions can enter the lungs (aspiration) and potentially cause pneumonia or choking.
What impact does a tracheostomy have on speech?
People who have a tracheostomy cannot speak in the same way as those who do not. Air no longer passes through the vocal folds so the person cannot produce sounds easily. In some cases, the person may be able to say a few sounds but will quickly run out of air.
Family members and caregivers often become frustrated because they do not know what the person needs or wants. The person feels alone at a time when his or her life is undergoing dramatic change.
Young children with tracheostomies do not get to explore making sounds. They also may have limited social interactions that are critical to the development of language skills. Caregivers tend to talk less to children who cannot communicate. These children are then robbed of the models they need to hear so they can figure out what language is all about.
How do people with tracheostomies communicate?
There are a number of options for speaking with a tracheostomy. The tube inserted into the tracheostomy can be plain or have an inflatable cuff. When the cuff is pumped up there is a greater seal inside the throat than with plain tubes. A tight seal can allow more air to enter the lungs, but also may prevent enough air from moving through the vocal folds. This makes speech quite difficult.
People with a plain tube or who may only need the cuff inflated at certain times (e.g., during eating or sleeping) may get enough air for speech. They may also be able to produce speech by blocking the tube with their fingers or hand. Then the person can breathe through their mouth and nose and vibrate the vocal folds as they did before surgery.
These methods do not work for all people. Covering the tube may cause more resistance to breathing that some people can't handle. Bacteria from the hand or fingers may cause infection, a particularly serious situation for people with swallowing problems. Some people may not get enough air for speech without blocking the tube but may not have the awareness, muscle movement, or muscle tone to block the tube well.
A variety of valves are available that can be attached to the tracheostomy tube. These valves allow air to enter via the tube but leave by way of the mouth and nose. Use of certain valves may also have the following benefits:
- reduce secretions
- increase the sense of smell
- reduce aspiration
- facilitate tube removal in people who do not need the tracheostomy permanently
- increase the amount of oxygen in the blood
Because all valves do not produce the same quality of speech or the same benefits, a valve for a specific person should be selected based on his or her individual needs.
What impact does having a ventilator have on speech?
For some people, a tracheostomy tube alone may not be enough. The tube may need to be connected to a breathing machine (ventilator) that provides a mixture of gases for life support. People on ventilators can speak as long as the tracheostomy tube allows air to flow through the vocal folds. However, the speech patterns of ventilator users may sound different.
Because of the design of the ventilator, speech occurs when air is pushed out of the body (expiratory cycle). Then there is a long silence until the next cycle of the ventilator. During this silence, the person may lose his or her turn to talk as others fill the silence with their own speech. Listeners may also find it hard to follow the person's communication message because the normal rhythm of conversation is disrupted.
What the person says may suddenly become louder or softer. The person's voice may sound different all of a sudden. This happens because pressure in the trachea from the ventilator is not constant as it is in typical speech. The speech of people on ventilators may be improved by making simple adjustments to ventilator settings, particularly if no other problems exist besides breathing insufficiency. There is also at least one speaking valve available that can be used with a ventilator.
What do speech-language pathologists do when working with people with tracheostomies or ventilators?
A team of professionals is involved in making decisions about the care of people with tracheostomies and ventilators. In addition to the person with the tracheostomy and his or her family or caregivers, the team may consist of the following:
- respiratory therapists
- speech-language pathologists (SLPs)
The SLP will evaluate the person's thinking and language skills, oral-motor and swallowing functioning, and ability to produce voice in different situations. Whatever communication method is recommended for the person, the SLP plays a central role in making sure that the person and his or her caregivers know how to maximize communication.
Tracheostomy and ventilator use is life sustaining. Speech for patients with tracheostomies or ventilators is life enriching.
ASHA has developed guidelines for the Use of Voice Prostheses in Tracheotomized Persons With or Without Ventilatory Dependence that outline more specifics about the role of the SLP with this population. In addition, the Preferred Practice Patterns for the Profession of Speech-Language Pathology outline the common practices followed by SLPs when engaging in various aspects of the profession. The Preferred Practice Patterns for prosthetic/adaptive device assessment and intervention are outlined in Sections 28 and 29.