The Speaking Valve Part 2: The Dance Floor
By George Barnes MS CCC-SLP
It's hard to imagine that so much power can be packed into such a small piece of plastic. Let's be honest, when working with patients with trachs and vents we have to be hyper-focused. They can be very sick and the stakes can be high. But with high stakes comes high reward. And no reward is higher than seeing somebody speak for the first time in weeks (if not months).
Anatomy in an Analogy
The nose, mouth, and throat (upper airways or nasopharynx) are known as “dead space” (unfair right?). The upper airways need air, heat, and moisture to function properly. By putting a hole in the lower airway (a trach) the air flows to the path of least resistance (through the trach tube). The upper airways are then like the kids without a date to the dance just sitting in the bleachers and being ignored. The lungs and the alveoli are the prom kings and queens tearing up the dance floor and getting all of the attention. But don’t worry, because the speaking valve (SV) is that cool kid who wants EVERYBODY to get involved and re-introduces the lower airway to the upper airway so they can all dance together (leaving room for the holy spirit of course).
Here are some of the most important things I investigate when seeing a patient with a trach (off the vent) for the first time. Much of this is from my clinical experience and education (hence the lack of references).
Mentation: The ideal patient is awake, alert, and responsive and we aren’t going to get very far with a patient who is unconscious. Anybody in between deserves a chance.
Medical stability: Oxygen saturation (SpO2), heart rate (HR), and respiratory rate (RR), are your most important indicators of stability. You should also check the temperature and blood pressure in your chart review. Not stable? Know your patient and talk to the respiratory team to see why they’re not stable and what direction they’re heading in. For example, you may learn that the patient’s baseline differs from the normal ranges, but remains stable.
Trach type: Smaller is better. Cuffless is best. Fenestrated? Maybe, but not for long. A fenestrated trach can allow for increased upper airflow, but increase risks such as granulation (60%) if used for longer than a couple of weeks (Pandian et al., 2019).
Initial assessment: Digital occlusion is often used to gauge the upper airflow, but a brief trial of the SV itself is cleaner and gives you more information in less time. After placement monitor the patient closely for any changes.
Problem-solving:
The airway volume and quality can tell you a lot about how the air is moving. Some takeaways from my clinical experience:
Wet? Secretions
Low volume? Poor airflow
Coughing? Secretions and/or poor airflow
Aphonia? Try taking off the valve to see if there’s back pressure (you may even hear a whoosh of air). This may be an indication that the patient is not getting proper upper airflow. No back pressure? Have them blow through a straw to see if there is air coming out. If so, refer for an upper endoscopy to see how vocal folds are moving.
Backpressure: A sign something is blocking airflow. Try suctioning, reposition the patient, and making sure the cuff is fully deflated. That didn’t help? Does the trach tube look dislodged? No? See if the trach can be downsized or made cuffless (this usually does the trick in my experience). Still not working? Have ENT take a look for potential obstruction.
Back to the dance floor
It’s amazing how much we can do for our patients through a simple change. One little piece of plastic can bring the upper and lower airways back onto the dance floor so the patient can start enjoying the music of language again. And a side benefit? Start enjoying the joy of food again. More on that next week.
Enjoy learning about clinical decision making? Consider taking our short course, Complex Decision-Making in Dysphagia Management to learn more.
Reference:
Pandian, V., Boisen, S. E., Mathews, S., & Cole, T. (2019). Are Fenestrated Tracheostomy Tubes Still Valuable? American Journal of Speech-Language Pathology, 28(3), 1019–1028. https://doi.org/10.1044/2019_ajslp-18-0187
