Bier, Jacqueline APRN, MA; Hazarian, Leon RN, BSN; McCabe, Donna RN, GNP, MA; Perez, Yaquelin RN, BSN
A SPEAKING VALVE can give a voice to a patient with a tracheostomy, enhancing his psychological well-being and encouraging him to participate in his care. In this article, we'll describe your role in helping a patient learn to use a speaking valve. For details on tracheostomy tubes and how they affect your patient, see How a Speaking Valve Works.
The speaking valve is a buttonlike piece of equipment that is placed on the outer hub of the tracheostomy tube. The one-way valve opens to let air in through the tracheostomy when the patient inspires. The valve closes during expiration, causing the air to follow the normal route of expiration and permitting speech.
Candidates for a speaking valve include adults with a tracheostomy (including mechanically ventilated patients) who are awake, relaxed, and responsive and who meet the assessment criteria specified by the valve manufacturer.
Patients who aren't eligible for a speaking valve include those who have severe upper airway obstruction or aspiration risk, tenacious or copious secretions, decreased cognitive status, severe medical instability, or inability to tolerate cuff deflation. The speaking valve can't be used with other kinds of artificial airways, such as endotracheal tubes, or with foam-filled cuffed tracheostomy tubes, which must be plugged to keep the cuff from reinflating.
Once the primary care provider determines that a patient is a suitable candidate for a one-way speaking valve, you may be responsible for placing the valve, If so, verify the primary care provider's prescription for a valve application and check the order for other instructions, such as special monitoring or testing or changes to ventilator settings during valve use.
Assess your patient's condition. He should be alert, relaxed, and free from respiratory complaints. His vital signs should be stable. Explain all the steps of the process so he knows what to expect.
Perform a baseline assessment of his vital signs; Spo2; level of consciousness; work of breathing, including use of accessory muscles and respiratory rate; skin color; type and amount of secretions; ability to tolerate cuff deflation; airway patency; and ventilator settings (if applicable).
Placing the one-way speaking valve
To place the speaking valve, start with the patient positioned comfortably in a chair or in high Fowler's position for optimal diaphragmatic movement and expansion. Then follow these steps:
* Ensure clear airways. Encourage your patient to cough to clear secretions; suction his tracheostomy tube and mouth.
* If the order specifies using a one-way speaking valve with a fenestrated tracheostomy tube, change the tracheostomy tube's inner cannula. (The inner and outer cannulas must be fenestrated.) A fenestrated tube has openings that allow another route of exhalation. To avoid trapping secretions, don't suction a patient with a fenestrated inner cannula.
* If the patient has a cuffed tracheostomy tube, deflate the cuff; otherwise, the patient can suffocate. Inspect the pilot balloon on the side of the outer tube. If this balloon is deflated, the cuff should be deflated.
* Evaluate the patient's ability to exhale during cuff deflation by placing your stethoscope over the patient's neck and listening for an air leak during respiration. If you don't hear an air leak, you shouldn't place a one-way speaking valve and should notify the patient's primary care provider.
* If you hear adequate aeration, place the speaking valve over the outer hub of the tracheostomy tube. It should fit snugly without being tight. Assess for phonation.
* Administer oxygen as ordered via the tracheostomy tube.
If the patient is on a mechanical ventilator, adjust the settings as prescribed by the primary care provider.
During the first use of the speaking valve, assess the patient frequently until a regular pattern of use is established. Monitor vital signs and the other clinical parameters in your baseline assessment. If the patient's status deteriorates, remove the speaking valve immediately and provide appropriate therapy. The patient may require suctioning during valve use. He can use the valve again once his airways are clear.
Each patient's ability to use the one-way speaking valve differs. The positive pressure that the valve produces in the trachea takes some getting used to, and some patients may tolerate only brief trials of the valve initially. The different pressure will become more familiar to him in time.
Teach the patient and family to be aware of changes in the patient's breathing patterns while using the speaking valve. Explain that the voice produced through the speaking valve may be deeper and hoarser than the voice he had before the tracheotomy. If his larynx was injured during the surgical procedure, scar tissue affecting voice quality could be present. In addition, the placement of the tracheostomy tube in relation to the vocal cords will affect his voice.
If the patient's airways are clear and he's having trouble breathing while using the valve, remove the valve and notify the patient's health care provider. Try to relieve the patient's anxieties about breathing and adequate air supply. Explain that while he's using the speaking valve, he'll feel changes in air pressure in the upper airway. Make sure he isn't alone and is monitored and within your visual range during initial use of the speaking valve. Ideally, he'll eventually be able to tolerate the valve during all waking hours.
Teach him not to leave it on while he's asleep or use it when he's sleepy.
Maintaining clear airways for the patient using the speaking valve is key. If he can't cough up secretions, assess him periodically and suction him as needed. Assess the consistency of secretions; thick, tenacious secretions increase the risk of airway obstruction via mucus plugging. Tell him not to use the speaking valve during these times.
Aspiration is a risk for all patients with tracheostomies, but one study found that this risk may actually decrease when a patient uses a speaking valve. Monitor your patient carefully and watch for signs and symptoms of aspiration, including changes in secretion production, fever, and change in mental status.
Teach the patient to clean the valve daily or as needed with warm water and mild, fragrance-free soap. Rinse the valve thoroughly, let it air-dry, and replace it in its storage container.
Talking it up
Proper use of a one-way speaking valve can improve the quality of life for people requiring tracheostomy tubes, even if they need mechanical ventilation. By understanding how speaking valves work and what your patient needs to know to use one, you can improve his ability to communicate with his loved ones and caregivers.
How a speaking valve works
A tracheostomy provides an artificial airway, but air no longer passes through the upper trachea and oropharynx unless the tube is cuffless, the cuff is deflated, or a speaking valve is used, as in the illustration. Lack of airflow through the upper airway reduces pharyngeal and laryngeal tone and sensation and prevents effective glottic closure.
Cuffed tubes usually are used in acute care and for mechanically ventilated patients. When the cuff is inflated, air must pass through the tracheostomy tube to enter and exit the lungs. Because air no longer passes over the vocal cords, speech isn't possible.
An uncuffed tube may permit limited speech, if enough air circulates around the tube to permit the patient to say a word or two. However, speaking with an uncuffed tube increases the patient's work of breathing.
At New York University Medical Center in New York City, Jacqueline Bier is director of nursing in the medical/neurology service, Leon Hazarian is a staff nurse I in the medical unit, Donna McCabe is nurse-manager of the acute care medical unit, and Yaquelin Perez is a staff nurse in the medical unit.
SELECTED WEB SITES
Passy-Muir, Inc., http://www.passy-muir.com
American Association for Respiratory Care, http://www.aarc.org
American Speech-Language-Hearing Association, http://www.asha.org
Last accessed on August 12, 2004.
Britton, D., et al.: “The Use of Speaking Valves with Ventilator-Dependent and Tracheostomy Patients,” Current Opinion in Otolaryngology & Head and Neck Surgery. 9(3):147–152, June 2001.
Elpern, E., et al.: “Effects of the Passy-Muir Tracheotomy Speaking Valve on Pulmonary Aspiration in Adults,” Heart & Lung. 29(4):287–293, July 2000.
Happ, M.: “Communicating with Mechanically Ventilated Patients: State of the Science,” AACN Clinical Issues
. 12(2):247–258, May 2001.
© 2004 Lippincott Williams & Wilkins, Inc.