Voice Restoration: A Speaking Valve

After a tracheostomy is placed, patients often experience difficulty producing an audible voice. The interrupted airflow to the upper airway makes it difficult for the vocal cords to vibrate to produce audible sound. However, there are ways to help restore this airflow to give patients the best chance to speak. One option for voice restoration for patients with tracheostomy tubes is to use a speaking valve. A speaking valve can be utilized to help restore airflow to the upper airway. This valve allows inhalation via the tracheostomy tube but blocks exhalation (either fully or partially) via the tracheostomy tube. The exhaled air then flows around the tracheostomy tube, through the upper airway, out the mouth and nose. Restoring airflow through the upper airway can improve laryngeal sensation, which provides rehabilitation to the upper airway. This rehabilitation potential could positively affect patient speech and swallow as well as decrease aspiration risk.

The ability to restore speech for a patient with a tracheostomy has a tremendous impact on their quality of life. Improvements in phonation have been shown to occur in 76% of children with a tracheostomy tube who utilized a speaking valve. Even for children who are not able to speak (due to age or neurological condition), being able to verbalize sound or audibly cry improves the safety of the child as well as improves the quality of life of the caregivers. For both pediatric and adult patients, restoration of voice can improve the ability to express wants and needs, communicate with loved ones and the care team, minimize ICU delirium, and improve quality of life and overall outcomes.

In addition to restoring airflow, a speaking valve has other benefits, including improved swallow, restoring partial resistance to the lungs, and decreasing risk of aspiration.

Swallowing ability may be negatively impacted with a tracheostomy due to the lack of airflow into the upper airway. This results in reduced sensation and may result in disuse atrophy of muscles used for swallowing. Research indicates that a significant proportion of patients with a tracheostomy tube, up to 59%, experience aspiration. This can lead to severe medical issues, including pneumonia. Although dysphagia in this patient population is multifactorial (i.e. related to the overall condition and diagnosis), restoring airflow to the upper airway may be beneficial for some patients. Utilization of a speaking valve can help improve subglottic pressure, sensation, and cough function in this population and may reduce the occurrences of aspiration.

There are different types of speaking valves available. Some are fully closed, restoring complete exhalation through the upper airway. This complete closure may be difficult for some patients with weak respiratory musculature, issues with partial airway obstruction, or a tracheostomy tube that is taking up too much space in the airway. For those patients, a valve that allows for some escape of air to prevent air trapping may be beneficial. The Phon Assist speaking valve provides this opportunity. The Phon Assist speaking valve has two adjustable side openings to individually adjust breathing resistance per patient need. When the valve is in the open position, the patient partially exhales through the speaking valve side openings and partially exhales through the upper airway. As each patient tolerates different resistance, the Phon Assist speaking valves allows for individual patient needs and preferences to be considered.

Before placing a speaking valve, there are guidelines and safety measures to be considered. Making sure that the patient has either a cuffless tracheostomy tube or a deflated cuff is of the utmost importance. Otherwise, valve placement could lead to severe respiratory distress and suffocation. Some patients need suctioning prior to placement of a speaking valve. During the first couple of trials, consistent monitoring of the patient and vital signs should be recorded.

A speaking valve has multitude of benefits it can provide to a patient with a tracheostomy. These benefits include improved speech, decreased risk of aspiration, and safer swallowing. After a thorough assessment by a trained healthcare provider, few adverse events have been noted with the use of a speaking valve. Intolerance of a speaking valve can be related to patency of the airway, patient fatigue, and air trapping. These contraindications must be discussed prior to utilizing a speaking valve and evaluated frequently. A speaking valve is a great way to help restore airflow to the upper airway to help kickstart rehabilitation that could lead to decannulation. Speaking valves are a valuable tool for providers to utilize for their patients with a tracheostomy.

References:

Duan D, Cui W, Liu W, Xie J. Application of speaking valves in adult patients with tracheostomy: a protocol for a systematic review and meta-analysis. BMJ Open. 2024;14(7):e086415. Published 2024 Jul 27. doi:10.1136/bmjopen-2024-086415

Eichar BW, Kaffenberger TM, McCoy JL, Padia RK, Muzumdar H, Tobey ABJ. Effect of Speaking Valves on Tracheostomy Decannulation. Int Arch Otorhinolaryngol. 2023;28(1):e157-e164. Published 2023 Oct 6. doi:10.1055/s-0043-1767797

Wang, H., Jiang, H., Zhao, Z. et al. Application and safety of speaking valves in tracheostomy patients. Crit Care 28, 424 (2024). https://doi.org/10.1186/s13054-024-05217-2