Journal of Medical Speech-Language Pathology

Volume 21, Number 4, pp. 309318

Copyright 2014 by Plural Publishing, Inc.
Optimizing Communication in
Mechanically Ventilated Patients
Vinciya Pandian, Ph.D, RN, ACNP-BC
Percutaneous Tracheostomy Service
The Johns Hopkins Hospital
Baltimore, MD
Christine P. Smith, M.S., CCC-SLP
Speech-Language Pathology
The Johns Hopkins Hospital
Baltimore, MD
Therese Kling Cole, M.A., CCC-SLP
Speech-Language Pathology
The Johns Hopkins Hospital
Baltimore, MD
Nasir I. Bhatti, M.D., M.H.S.
Otolaryngology Head-Neck Surgery
The Johns Hopkins Hospital
Baltimore, MD
Marek A. Mirski, M.D., Ph.D.
Anesthesia Critical Care Medicine
The Johns Hopkins Hospital
Baltimore, MD
Lonny B. Yarmus, D.O.
Interventional Pulmonary
The Johns Hopkins Hospital
Baltimore, MD
David J. Feller-Kopman, M.D.
Interventional Pulmonary
The Johns Hopkins Hospital
Baltimore, MD
310 JOURNAL OF MEDICAL SPEECH-LANGUAGE PATHOLOGY, VOL. 21, NO. 4
INTRODUCTION
Verbal communication greatly affects peoples au-
tonomy and is directly related to how they perceive
their quality of life (Hess, 2005). The need for effec-
tive communication is heightened during critical
illness. Critically ill patients requiring mechanical
ventilation often need an endotracheal tube or a
tracheostomy tube. When a patient is intubated,
communication is often accomplished through fa-
cial expressions, gestures, and/or writing, depend-
ing on the persons neurological status and seda-
tion level (Batty, 2009). However, these simple
modes of communication are not always effective
and can often result in frustration for the patient
(Patak et al., 2006).
A benefit of tracheostomy over an endotracheal
tube is that it may facilitate the ability to communi-
cate by mouthing words. Additionally, when a person
receives a tracheostomy tube, several methods used
to elicit phonation can be utilized, including the use
of a one-way speaking valve, leak speech, and digital
occlusion. All of these methods require toleration of
cuff deflation (Astrachan, Kirchner, & Goodwin, Jr.,
1988; Batty, 2009; Hess, 2005; Nomori, 2004). Unfor-
tunately, some critically ill mechanically ventilated
patients cannot tolerate cuff deflation despite their
ability to maintain arousal and to initiate meaning-
ful communication. Uniquely designed tracheostomy
tubes are available that enable speech and do not
require cuff deflation. These talking tracheostomy
tubes are rarely used because of a general lack of
awareness among care providers.
The purpose of this article is to: (1) describe the
types of talking tracheostomy tubes available, (2)
present four case studies of critically ill patients
who benefited from these tubes, (3) discuss their
advantages and disadvantages, propose patient
selection criteria, and (4) provide practical recom-
mendations for medical care providers.
TYPES OF TALKING TRACHEOSTOMY
TUBES (NOT REQUIRING CUFF DEFLATION)
Shiley

Cuffed Fenestrated
Tracheostomy Tubes
Shiley

Cuffed Fenestrated Tracheostomy Tubes

(Covidien, Boulder, CO) have an opening on the
superior aspect of the tube that allows airflow to
the upper airway. If a patient requires mechanical
ventilation, large volumes of air are needed to com-
pensate for the loss of air via the fenestrated port.
Tracheal mucosa may get entrained into the fenes-
tration, increasing the risk for granulation tissue
formation and tracheal stenosis.
Blom

Tracheostomy Tube
The Blom

Tracheostomy Tube (Pulmodyne, Indi-

anapolis, IN) has a thin polyvinyl chloride cuff and
a fenestration. It can be used with either a stan-
dard nonspeech cannula or a speech cannula. The
speech cannula will allow air to flow to the upper
airway through a strategically placed fenestration
Purpose: To describe the types of talking tracheostomy tubes available, present
four case studies of critically ill patients who used a specialized tracheostomy tube to
improve speech, discuss their advantages and disadvantages, propose patient selection
criteria, and provide practical recommendations for medical care providers.
Methods: Retrospective chart review of patients who underwent tracheostomy in 2010.
Results: Of the 220 patients who received a tracheostomy in 2010, 164 (74.55%)
received a percutaneous tracheostomy and 56 (25.45%) received an open tracheostomy.
Among the percutaneous tracheostomy patients, speech-language pathologists were
consulted on 113 patients, 74 of whom were on a ventilator. Four of these 74 patients
received a talking tracheostomy tube, and all four were able to speak successfully while
on the mechanical ventilator even though they were unable to tolerate cuff deflation.
Conclusions: Talking tracheostomy tubes allow patients who are unable to tolerate-
cuff deflation to achieve phonation. Our experience with talking tracheostomy tubes
suggests that clinicians should consider their use for patients who cannot tolerate cuff
deflation.
Key Words: mechanically ventilation, speech, communication, talking tracheostomy
tube, and quality of life
OPTIMIZING COMMUNICATION IN MECHANICALLY VENTILATED PATIENTS 311
located above the cuff. The inflated cuff prevents
the fenestration from contacting the tracheal mu-
cosa. Inspiratory pressure causes the valve flap at
the level of the fenestration to close so that all in-
spiratory air goes to the lungs. During exhalation,
expiratory pressure allows opening of the fenes-
tration to permit exhaled air to flow to the upper
airway to achieve phonation. One of the benefits of
this talking tracheostomy tube is that it provides
a hands-free means of communication.
Portex

Trach-Talk Blue Line

Tracheostomy Tubes
The Portex

Trach-Talk Blue Line

Tracheostomy
Tubes (Smiths Medical, Dublin, OH) have an addi-
tional lumen above the cuff through which air can
be administered to facilitate verbal communication.
One particular issue that we have encountered with
this type of tracheostomy tube is that the thumb
port cannot be detached for suctioning and clearing
out secretions trapped in the lumen. If speech lu-
men becomes clogged, the whole tracheostomy tube
would need to be replaced to have a functional tube
for speech. The inner cannulas are corrugated, po-
tentially increasing the risk of mucus plugging and
difficulty in clearing secretions. In addition, because
these inner cannulas are not reusable, health-relat-
ed costs for patients and families can be higher.
Bivona

Mid-Range Aire-Cuf

and Fome-Cuf

Tracheostomy
Tubes with Talk Attachment
Bivona

Mid-Range Aire-Cuf

and Fome-Cuf

Tra-
cheostomy Tubes with Talk Attachment (Smiths
Medical, Dublin, OH) include a lumen above the cuff
to direct compressed air through the upper airway to
achieve vocalization. Similar to the Portex

Trach-
Talk Blue Line

Tracheostomy Tubes, these tra-

cheostomy tubes speech lumen can also become
clogged because the thumb port is not detachable
for cleaning or suction use. The air cuff can later be
deflated for transitioning to speaking valve use. It is
important to note, however, that the foam cuff can-
not be deflated for use with a speaking valve.
Portex

Blue Line Ultra

Suctionaid
(BLUSA) Tracheostomy Tubes
The BLUSA cuffed tracheostomy tube (Smith Med-
ical, Dublin, OH) (Figure 1) features an additional
lumen located above the cuff that can be dedicated
for suction and/or speech. This particular tracheos-
tomy tube was used in the four case studies report-
ed here. The BLUSA has a 15-mm hub for transi-
tion to a speaking valve if the patient progresses to
cuff deflation.
Table 1 lists the distinguishing characteristics of
the various talking tracheostomy tubes.
Figure 1. Portex

Blue Line Ultra

Suctionaid (BLUSA) tracheostomy

tube.
312 JOURNAL OF MEDICAL SPEECH-LANGUAGE PATHOLOGY, VOL. 21, NO. 4
METHODS
After obtaining Institutional Review Board ap-
proval, we performed a retrospective analysis of
prospectively collected data. Included in the study
were patients who had received a tracheostomy in
2010 at an academic tertiary care center. These
patients received standardized pre- and postop-
erative care from a dedicated tracheostomy team
composed of credentialed operators, anesthesiolo-
gists, a dedicated tracheostomy nurse practitioner,
nurses, respiratory therapists, and speech-lan-
guage pathologists (Pandian, Nguyen, Mirski, &
Bhatti, 2008; Pandian et al., 2011; Pandian et al.,
2012). Case studies of four patients who received
a BLUSA cuffed tracheostomy tube are presented
to provide an understanding of the role of special
tracheostomy tubes in patients who cannot toler-
ate cuff deflation. We used Stata 11.0 software to
analyze our data. Percentages are reported for all
variables.
RESULTS
Figure 2 gives a statistical overview of the 220
patients who received a tracheostomy in 2010. As
shown, 164 (74.55%) received a percutaneous tra-
cheostomy and 56 (25.45%) received an open trache-
ostomy. Speech-language pathologists (SLP) were
consulted on 113 (68.90%) patients who received
a percutaneous tracheostomy. Of the patients who
were evaluated by SLP, 74 were mechanically ven-
tilated at the time of that consult. Among these
mechanically ventilated patients, 29 demonstrated
tolerance of the in-line speaking valve during the
first trial, and 6 required additional follow-up ses-
sions to achieve tolerance of the speaking valve.
Four mechanically ventilated patients did not
pass the in-line speaking valve trial and received a
BLUSA tracheostomy tube for speech.
CASE STUDIES
To elaborate on both the benefits of and issues aris-
ing from the use of BLUSA tubes, we report our
experience with these four patients who succeeded
in verbal communication.
Case 1
A 45-year-old Indian man, who received bilateral
orthoptic lung transplant for progressive inter-
stitial lung disease, developed respiratory failure
secondary to diaphragmatic paralysis and pneu-
monia. A tracheostomy was performed for chronic
ventilator dependence. He was unable to tolerate
cuff deflation while receiving mechanical ventila-
tion as he had a high level of anxiety despite ex-
tensive education about the process involved with
cuff deflation and Passy Muir speaking valve use,
music therapy, and pharmacologic management. A
size 8.0 BLUSA was placed, and the patient was
able to achieve a hoarse vocal quality on 5 liters
of air initially. However, during a later session, he
began to develop a strained vocal quality in an at-
tempt to control airflow by tensing his vocal folds.
Vocal function exercises were effective in reducing
the strained vocal quality. Changing from an 8.0-
TABLE 1. Characteristics of Talking Tracheostomy Tubes
D
e
f
l
a
t
a
b
l
e

A
i
r

C
u
f
f
F
o
m
e

C
u
f
f
L
u
m
e
n

a
b
o
v
e

t
h
e

c
u
f
f
S
u
c
t
i
o
n

a
b
o
v
e

t
h
e

c
u
f
f
D
e
t
a
c
h
a
b
l
e

t
h
u
m
b

p
o
r
t
F
e
n
e
s
t
r
a
t
i
o
n
I
n
n
e
r

c
a
n
n
u
l
a
R
e
q
u
i
r
e

a
i
r

f
o
r

s
p
e
e
c
h
Portex Blue Line Ultra Suctionaid (BLUSA) x x x x x x
Bivona Mid-Range Aire-Cuf x x
Bivona Fome-Cuf x x
Blom Tracheostomy Tube x x x x
Portex Trach-Talk Blue Line x x x
Shiley Cuffed Fenestrated x x
OPTIMIZING COMMUNICATION IN MECHANICALLY VENTILATED PATIENTS 313
mm to a 9.0-mm BLUSA resulted in a better seal
around the cuff to maintain better intrathoracic
pressures. With the 9.0-mm BLUSA, he was able
to phonate with only 4 liters of air. He used the
BLUSA as his primary means of communication
with family and staff for months until he passed
away. Using a BLUSA allowed the patient to
achieve meaningful communication, while decreas-
ing the anxiety associated with cuff deflation.
Case 2
A 54-year-old Caucasian man presented with a
history of progressive lymphoproliferative disor-
der status post several rounds of chemotherapy
and bone marrow transplant. His disease course
was complicated by severe graft versus host dis-
ease, and he was admitted for worsening pulmo-
nary infiltrates. Despite broad spectrum antibiotic
and antifungal therapy, he progressed to acute
respiratory distress syndrome and required intu-
bation. He eventually received a tracheostomy for
prolonged ventilator dependence and was unable
to tolerate cuff deflation for a speaking valve. He
had a life partner who took care of him around the
clock. They wanted to communicate during the
patients terminal days. The tracheostomy team
placed a BLUSA for verbal communication. This
patient was not strong enough to raise his arm to
occlude the thumb port. However, his partner was
very helpful and occluded the thumb port for him
to communicate. Although the patient was not able
to carry on lengthy conversations, the BLUSA pro-
moted his quality of life by allowing him to express
his basic needs and emotions such as pain, anxiety,
thirst, and other discomforts.
Total
Tracheostomies
2010
(n = 220)
Speech and
Language
Pathologists
Consulted
(n = 113)
Speech and
Language
Pathologists not
Consulted
(n = 51 )
Percutaneous
Tracheostomies
n = 164 (74.55%)
Open Surgical
Tracheostomies
n = 56 (25.45%)
Speech and
Language
Pathologists
Consulted
(n = 52)
Speech and
Language
Pathologists not
Consulted
(n = 4)
Vented
(n = 74)
Vented
(n = 18)
Speaking Valve Trial
Passed Initial Trial = 29
Did not pass initial, but passed later = 6
Did not pass initial or later trials = 4
Speaking Valve Trial
Passed Initial Trial = 2
Did not pass initial, but passed later = 1
Did not pass initial or later trials = 2
Blueline Suctionaid (BLUSA)
(n = 4)
Figure 2. Tracheostomy statistics.
314 JOURNAL OF MEDICAL SPEECH-LANGUAGE PATHOLOGY, VOL. 21, NO. 4
Case 3
A 25-year-old Caucasian woman who was diag-
nosed with type 2 neurofibromatosis at age 14 and
underwent multiple bilateral vestibular schwan-
noma resections with residual left facial weak-
ness and deafness in the left ear presented after
a suboccipital craniotomy that was complicated by
sacrifice of the right facial nerve, right vocal fold
paralysis, severe oropharyngeal dysphagia, severe
gastroesophageal reflux disease, and new onset
deafness in the right ear. After weaning from the
mechanical ventilator failed, a tracheostomy tube
was placed. A 4.0 tracheostomy tube was eventu-
ally was chosen because of her anatomy and inabil-
ity to achieve phonation with a 6.0 cuffed tracheos-
tomy tube. Although was able to vocalize with the
use of a speaking valve, achieving efficient ventila-
tion and suctioning were difficult with the smaller
tracheostomy tube. She could not hear her own
voice, but she was motivated to achieve phonation
for ease of communication with staff, family, and
her boyfriend. The tracheostomy team placed a
BLUSA to enable verbal communication.
Soon after the placement of the BLUSA, she
weaned to requiring only nocturnal ventilator sup-
port. During the daytime when she could tolerate
cuff deflation, she was unable to achieve adequate
phonation with the BLUSA secondary to air leak-
age around the stoma despite trying multiple air-
flow settings. As her condition improved, she was
able to achieve hoarse vocal quality with cuff de-
flation and digital occlusion, which had not been
possible with a traditional tracheostomy tube of
similar size. The BLUSA tubes have a smaller
outer diameter and larger inner diameter than
do our institutions standard Shiley tracheostomy
tubes. The larger inner diameter permits adequate
ventilation and suctioning, whereas the smaller
outer diameter allows upper airway airflow with
digital occlusion and speaking valve use. She was
diagnosed with severe flaccid dysarthria with ap-
proximately 10% intelligibility. She continued to
use digital occlusion intermittently to produce 1-
or 2-word utterances with poor intelligibility while
tolerating cuff deflation. A month later, she stopped
using digital occlusion for speech, preferring text
messaging and typing for communication. She was
diagnosed with severe depression. Augmentative
alternative communication assessment was rec-
ommended. Over the course of time, the BLUSA
was no longer suitable for her because of deficits
in cranial nerves V and VII that impaired articula-
tion, true vocal fold motion impairment, deafness,
depression, and decreased motivation.
Case 4
A 40-year-old African American man with amyo-
trophic lateral sclerosis presented for an elective
tracheostomy for prolonged mechanical ventilation.
A 6.0 cuffed tracheostomy tube was placed. After
tracheostomy, he was evaluated for inline speak-
ing valve tolerance but had increased peak inspira-
tory pressures and failed speaking valve trials. His
speech was characterized as moderate spastic-flac-
cid dysarthria. Intelligibility was better with airflow
to the upper airway than with lip reading alone, and
therefore a BLUSA was placed. Three liters of air
were administered via the blue line. He was able to
achieve intelligible phonation with the assistance of
a communication partner (speech-language patholo-
gist or nursing aid). The communication partner had
to occlude the thumb port for him as he had upper
extremity weakness and was unable to occlude it
himself. Although the device enabled the patient to
speak, he had thick secretions, and suction catheters
were too large for the BLUSAs inner cannula, mak-
ing suctioning difficult. Change to an 8.0 BLUSA im-
proved the ease of suctioning and decreased airflow
requirement from 3 to 2 liters. In addition, he report-
ed increased comfort. However, over the course of
time, he demonstrated trapping of air below the vo-
cal folds because of vocal fold spasms. Vocal function
exercises were beneficial in reducing laryngeal spas-
ticity and improving vocal quality. He was able to
successfully use the BLUSA for short conversations
with family and friends while he continued to use
his augmented communication device (DynaVox Ey-
eMax, DynaVox Mayer-Johnson, Wollaston, UK)
for speaking engagements and work-related tasks.
DISCUSSION
Patients who have high positive end-expiratory
pressure requirements on the ventilator are at risk
for atelectasis (collapse of alveoli), arterial-alveolar
shunting (good blood supply but poor ventilation),
and desaturation after sudden loss of the end-expira-
tory pressure upon cuff deflation. Although talking
tracheostomy tubes can help with phonation in pa-
tients who are unable to tolerate cuff deflation while
on the ventilator, they are rarely used, perhaps be-
cause providers are unaware of their benefits.
Few reports have explored the use of BLUSA
tracheostomy tubes for verbal communication (Hu-
sain, Gatward, & Harris, 2011; Leder & Traquina,
1989; Safar & Grenvik, 1975), likely because the
device was initially designed for suctioning of sub-
OPTIMIZING COMMUNICATION IN MECHANICALLY VENTILATED PATIENTS 315
glottic secretions, unlike other talking tracheosto-
my tubes, to decrease the incidence of ventilator-
associated pneumonias (Coffman, Rees, Sievers, &
Belafsky, 2008; Dezfulian et al., 2005; Lacherade et
al., 2010). To our knowledge, this is the first paper
to describe the use of BLUSA to improve speech.
We have found that the BLUSA has numerous
advantages over traditional talking tracheostomy
tubes: (1) the speech lumen diameter is larger, (2)
the inner cannula is not corrugated, and (3) the
thumb port can be disconnected and the speech lu-
men can be flushed with saline for patency.
Advantages
No Interruption of the Function
of the Mechanical Ventilator
As cuff deflation and changes to ventilator set-
tings are not required, the volume of air entering
the lungs and exiting will remain similar to that of
a person not using a speaking valve. BLUSA tra-
cheostomy tubes have a unique cuff texture that
is supposed to allow a better seal in the trachea,
resulting in continuous and accurate monitoring of
tidal volumes (Safar & Grenvik, 1975).
Airway Hygiene
Generally, airway hygiene is better with trache-
ostomy than endotracheal tubes. In addition, the
BLUSA allows intermittent suctioning of secre-
tions in the subglottic region via the blue line. This
suction, in turn, can prevent flow of aspirated se-
cretions into the lungs and decreases the risk for
pneumonitis or ventilator-associated pneumonia.
This benefit is especially important for patients
who have poor glottic function and cannot protect
their airway from oropharyngeal secretions.
Patient Safety
Patients who use inline speaking valves while they
are mechanically ventilated have limited time for
communication given that monitoring by experi-
enced staff is necessary for safety. However, with
BLUSA tubes, if patients are able, they can occlude
their thumb port and communicate at their conve-
nience even in the absence of experienced staff. Pa-
tients do not have to wait for the medical staff to de-
flate the cuff and provide monitoring. Even if they
are unable to occlude the thumb port, their com-
munication partner (family member/friend) can oc-
clude it for them without waiting for medical staff.
Increased Inner Diameter While
Outer Diameter Remains Small
A decrease in inner diameter of the tracheostomy
tube can result in large increases in airway re-
sistance. Compared to most of the commercially
available standard tracheostomy tubes, the inner
diameter of the BLUSA is larger while the outer
diameter is similar. This design prevents the in-
crease in airway resistance associated with trache-
ostomy tubes that have a smaller inner diameter.
The design also promotes ease of suctioning with-
out having to increase the outer diameter of the
tracheostomy tube.
Comfort
The cuff is made of plasticized poly-vinyl chloride
using a Soft Seal

cuff design with reduced bulk

that is more compliant and decreases the amount
of pressure it applies on the tracheal wall while
maintaining good seal within the trachea com-
pared to traditional commercially available tra-
cheostomy tube cuffs (Young & Blunt, 1999). This
construction can decrease the risk for tracheal wall
ischemia and/or granulation tissue formation.
Ease of Use
Once initial evaluation is completed, patients us-
ing BLUSA do not require frequent follow-up to
evaluate tolerance because of the creation of two
separate circuitsone for speech and one for ven-
tilation. BLUSA does not require extensive train-
ing for staff, patients, or family as is common with
high tech augmentative communication devices or
in-line speaking valves.
Decrease Anxiety
Up to 35% of critically ill individuals undergoing
prolonged mechanical ventilation experience in-
creased anxiety (Hofhuis et al., 2008; Li & Puntillo,
2004; Samuelson, 2011; Treggiari et al., 2009). Pa-
tients levels of anxiety can be lessened if they are
able to adequately communicate with their care-
givers, family, and friends (Batty, 2009; Lindgren
& Ames, 2005). Patients using BLUSA are able
to communicate at their convenience, thereby de-
creasing anxiety as shown in Case 1. Communica-
tion can also provide a sense of autonomy in that
these patients can participate in their ICU care
decision-making process.
316 JOURNAL OF MEDICAL SPEECH-LANGUAGE PATHOLOGY, VOL. 21, NO. 4
Improvement of Quality of Life
Being able to verbally communicate can improve
how a person perceives his or her quality of life
(Hess, 2005).
Potential Problems and Practical Solutions
Speech Lumen Occlusion
Occasionally, the speech lumen can become occlud-
ed with secretions that are pooled in the subglottic
region above the tracheostomy cuff, thereby pre-
venting the airflow required for phonation. The oc-
clusion can be remedied by slowly aspirating with
a 20-cc syringe for as long as necessary to remove
subglottic secretions. If resistance is met on aspira-
tion, it may be necessary to flush/irrigate the line
with air or sterile normal saline (5 mL 10 mL) via
20-cc syringe, and immediately aspirate the line
to clear. It is normal for some irrigation fluid to
exit the stoma area. If the occluded line cannot be
cleared, it may be necessary to replace the BLUSA.
In addition, we avoid placing a BLUSA as the ini-
tial tracheostomy tube in order to prevent bloody
secretions from clogging the speech port. The BLU-
SA can be placed during the

first tracheostomy
tube change, once the stoma has formed.
Self-Occlusion
Patients who have upper extremity weakness or
discoordination may not be able to independently
occlude the thumb port to facilitate phonation.
Usually, when a patient communicates, there will
be someone in the room to whom the patient will be
talking (communication partner). The communica-
tion partner (staff, family, caregiver, or significant
other) must be educated on assisting the patient
with occlusion of the thumb port. Signs/education-
al pamphlets may be placed in the room to educate
the communication partner on this task.
Vocal Cord Injury
There is a potential risk for vocal fold injury caused
by dry air moving up through the airway through
the vocal folds. Attaching a humidifier to the air
that is administered via the speech lumen can al-
leviate this problem. Hyperadduction of the vocal
folds in response to high airflow is also a risk. It
is important to identify the minimum airflow re-
quirement to elicit phonation to avoid hyperadduc-
tion. Tippett recommends the use of 4 to 7 liters
of air to achieve phonation (Tippett & Vogelman,
2000). In our experience, in persons of small stat-
ure, 2 liters of air may be sufficient. It is also cru-
cial that the air/oxygen is not administered via the
speech lumen if the patient has an upper airway
obstruction as the air /oxygen supply may result in
pressure building up in the subglottic space (Smith
Medical, 2007).
Poor Vocal Quality
Sometimes patients can achieve phonation but
their vocal quality may not be optimal, perhaps
because of dry airway, hyperadduction, underly-
ing vocal fold pathology, or upper airway obstruc-
tion. It is vital to assess the integrity of the vocal
folds or upper airway patency and consult otolar-
yngologists to perform upper airway laryngoscopy
to identify any underlying pathology.
Poor Tubing Connection
In our experience, achieving a secure connection
between the thumb port and the oxygen tubing is
often difficult. Extra effort by pushing and twisting
may be needed to ensure a tight and secure connec-
tion. Some clinicians use adhesive tape to secure
the connection. It is necessary to assess the thumb
port frequently to monitor the connection.
Disposition Issue
Many home health care agencies do not provide
medical air that is required for phonation with
the BLUSA. Oxygen can be used instead to enable
speech with a BLUSA.
Abdominal Distention
The mechanical ventilator administers breaths
without impacting the speech circuit; however, the
amount of air administered via the speech lumen
potentially could be swallowed when the mouth is
closed and cause abdominal distention. It is impor-
tant to make sure airflow is turned off when the
patient is not pursuing communication. If medical
air is administered continuously, it is important to
ensure that the thumb port remains unoccluded.
Line Misidentification
Given that BLUSA is rarely used, clinicians may not
be aware of the unique parts of a talking tracheos-
OPTIMIZING COMMUNICATION IN MECHANICALLY VENTILATED PATIENTS 317
tomy tube. As a result, they might have difficulty dif-
ferentiating between the pilot balloon and the speech
lumen. We recommend clearly labeling the pilot bal-
loon and the speech lumen to avoid medical error.
Subcutaneous Emphysema
According to the manufacturers guidelines, the
speech lumen should never be used for speech in a
freshly formed stoma as the air intended for speech
may leak through the stoma preventing speech but
causing subcutaneous emphysema (Smith Medical,
2007). It is most likely safer to place a BLUSA for
speech during the first tracheostomy tube change
rather than the initial placement.
Selection of Patients for BLUSA
On the basis of our experience, we propose that pa-
tients who fit the following criteria are eligible for
a BLUSA.
1. Patients who require prolonged mechanical
ventilation but cannot tolerate cuff deflation.
2. Patients who are awake, alert, and attempting
to communicate.
3. Patients who are able to manipulate the thumb
port or have a communication partner who is
able to assist with use of the device.
4. Patients with sufficient motor speech and
language capabilities to produce functional
communication.
5. Patients without upper airway obstruction.
6. Patients with an established stoma.
Role of the Speech-Language Pathologist
The speech-language pathologist (SLP) plays an
important role on the interdisciplinary team, serv-
ing as an advocate for both the communication
and swallowing needs of a patient with a tracheos-
tomy. As the level of care for this patient popula-
tion has evolved and expanded beyond the acute
medical setting to rehabilitation and long-term
care facilities as well as the community setting,
the SLP must obtain the necessary training to pro-
vide services in this area. The American Speech-
Language-Hearing Association has identified clear
guidelines, knowledge, and skills to achieve profi-
ciency in management of this population (Ameri-
can Speech-Language-Hearing Association, 1993).
The evaluation of communication for a patient
with a tracheostomy tube typically begins with
determining a patients candidacy for speaking
valve use. If a patient cannot tolerate a traditional
speaking valve, the SLP may assist with trouble-
shooting and identification of alternate communi-
cation options, including the placement of a talking
tracheostomy tube. The SLP often initiates discus-
sion with the medical team about a patients prog-
nosis and plan of care before suggesting a talking
tracheostomy tube. There must be consideration of
a patients weaning potential, cognition, and physi-
cal and psychosocial issues. The selection criteria
proposed in this paper may be used as a reference.
Once the talking tracheostomy tube is placed, the
SLP will make recommendations for optimal air-
flow settings for voicing and provide education to
the patient, family, and team to ensure proficient
use of the new tracheostomy. Vocal function exer-
cises will be needed by many patients as part of
their treatment. Evaluation and treatment for this
patient population is dynamic, and the SLP pro-
vides ongoing support for troubleshooting barriers
to communication that may arise.
CONCLUSION
Talking tracheostomy tubes enable phonation in
patients who are unable to tolerate cuff deflation.
To our knowledge, this paper is the first to discuss
the use of BLUSA for verbal communication. Selec-
tion criteria proposed in this paper will enable cli-
nicians to identify appropriate patients. Although
we are limited in how far we can extrapolate from
our 4 case studies, our findings suggest the value
of a wider use of BLUSA and support the need for
further research into its benefits for certain pa-
tients. Prospective studies comparing the different
types of talking tracheostomy tubes incorporating
a larger sample size are required to further explore
the benefits of these tracheostomy tubes. Our expe-
rience with BLUSA suggests that clinicians should
consider the use of talking tracheostomy tubes for
patients who cannot tolerate cuff deflation.
Address correspondence to Vinciya Pandian, Tra-
cheostomy Nurse Practitioner, Percutaneous Trache-
ostomy Service, The Johns Hopkins Hospital, 600 N.
Wolfe Street, Meyer 8-140, Baltimore, MD 21287.
email: vpandia1@jhmi.edu
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