Understanding Communication Challenges and Solutions for Tracheostomy Patients

In this episode of the Tracheostomy Education Podcast, Dr. Jerry Gentile and Nicole DePalma discuss the various communication options available for patients with tracheostomy tubes. They explore the anatomy of normal voicing, the impact of tracheostomy on communication, the consequences of communication barriers, and the different methods to facilitate communication, including nonverbal strategies and leak speech. The conversation emphasizes the importance of effective communication in healthcare settings and the need for tailored approaches to meet individual patient needs. This is part 1 of 2.  

Transcript

Nicole (00:01.29)
Hi, this is Tracheostomy Education Podcast. I'm here with Dr. Jerry Gentilli. We will be discussing communication options for patients with tracheostomy. Let's get started.

Jerry (00:12.642)
Hi Nicole, how are you?

Nicole (00:13.908)
Good, what's going on?

Jerry (00:15.906)
Same old. So today we're talking about communication. So before we get into patients with tracheostomy, can you discuss how normal voicing is achieved?

Nicole (00:30.506)
Sure. All right, so yeah, it's important to understand what normal voicing is and the anatomy in order to really understand what happens once the tracheostomy tube is placed. So speech is really produced with several parts of the body working together that shape the sounds of the voice. So voice is produced by the vibration of the vocal folds. Vocal folds is just the technical term for vocal cords.

The lungs are also really important. That's what helps to generate airflow for voicing. So we take a deep breath and the air kind of flows into the lungs to be able to produce some voicing. And when it's time to speak on exhalation, the air from the lungs builds under the vocal folds until the pressure kind of blows those vocal folds apart and results in vibrations. So that occurs by means of a phenomenon known as the Venturi effect.

As air passes through a constriction or venturi, it kind of speeds up and creates this suction effect. That suction draws in the mucosa from each vocal fold, which meet together in the middle, only to be pushed aside by more air from the lungs. And that kind of creates this cycle of a mucosal wave. So that is actually what leads to the sound, that vibration of the

of the vocal folds that we call voice. So these sounds are then shaped by the tongue, the lips, the soft palate, the hard palate to form speech. And the regularity of that mucosal wave is really essential to be able to produce a normal voice. There's different things that we could do in order to get the voice louder, for example, by creating by the pressure of the air that's blown past the vocal folds. So a more

forceful expulsion of air from the lungs raises that pressure. And you also kind of need a tensing of the vocal folds as well.

Nicole (02:38.378)
Then there's pitch. So pitch is created by lengthening and shortening of the vocal folds. So when you lengthen the vocal folds, that raises the pitch. And then hoarseness. When you hear a patient with a hoarse or a breathy voice, that means maybe something's happening with the vocal folds. So maybe there's an irregularity of the mucosal waves such as

Jerry (02:49.816)
That was a good one.

Nicole (03:06.814)
with a vocal fold peresis or paralysis where the vocal folds not moving adequately, or maybe there's something on the vocal fold like a nodule or a polyp or a cyst. So that's not allowing the vocal folds to come to midline. so air is kind of passing through those vocal folds. Oftentimes with intubation, we have injuries that can happen.

to the vocal folds and that can affect the voice and it can affect the swallowing as well. So we always want an ENT consult when that happens where there's a change in voice and we want to know what the cause of that is.

Jerry (03:48.696)
So let's say a baritone singer would have very short vocal chords.

Nicole (03:51.146)
Mm.

Yes, they would shorten them to produce that voicing.

Jerry (03:58.008)
Okay. So how does a tracheostomy impact communication?

Nicole (04:05.138)
All right, so when a trach tube is placed, it's placed in the neck, usually at the second or third tracheal rings. And that is below the level of where the vocal folds are. So usually when the initial trach tube is placed, it's placed with a cuffed tracheostomy tube. That cuff is a balloon-like structure at the end of the trach tube, and we can inflate and deflate that cuff, but usually it's inflated

upon the initial insertion because the purpose of that cuff is to maintain the air that's delivered from the ventilator to the lungs. So it may be necessary to keep that cuff of the trach tube inflated so all the air is delivered from the ventilator and can go to the lungs and then

back to the ventilator on exhalation to be kind of measured and monitored. And that's like the simple way of saying it. I'm sure there's a more technical version of that, but

Jerry (05:07.69)
Yeah, but the bottom line is what you just said. Once we deliver a title volume, we want to make sure we can measure the return volume.

Nicole (05:10.739)
Yeah.

Nicole (05:15.752)
Right. So that is, you know, often the case during, you know, the acute disease process, the patient really needs that cuff inflated. And once the patient stabilized, then sometimes we can think about deflating the cuff of the tube or even when they're off the vent. And sometimes some places do this when they're on the ventilator as well, changing to a cuffless tracheostomy tube. It's very not uncommon in the United States, but that is something that people do as well.

But when it's inflated, we're essentially bypassing the upper airway during breathing. So again, air goes from the ventilator into the tracheostomy tube to the lungs and then back from the lungs through that tracheostomy tube and they breathe like that. So there really little to no air is escaping around that cuff and through the upper airway. And remember,

You need airflow through the upper airway and through the vocal folds to produce voicing. So since there's no airflow through the vocal folds, the individual is not able to produce voicing. they're left, aphonic is the word that you use that means no voicing. So they might be able to mouth, you know, move their lips and mouth words, but no voicing is really achieved if that cuff is

you know, mostly inflate it. So a communication assessment really should begin even before the procedure when there's a non-emergent trach tube in place just to like allow the patient to fully understand, you know, those things and what's going to happen to their voice so they don't wake up for the procedure and they're like, what's going on? And then a speech language pathologist, they're typically trained in finding the most advantageous communication method for patients with trachs.

Jerry (07:12.056)
So do you know how much volume is required to go over the vocal cords to be able to phonate? Or maybe like a leader flow?

Nicole (07:17.546)
It's actually not that much.

Jerry (07:26.722)
because we have fenestrated trachs, right? And I was always curious to know how much volume needs to go through the chords to phonate or if you would measure it in a volume or you would measure it in a liters per minute.

Nicole (07:44.72)
It's a good question. I don't know the exact amount, but it is a very small amount I know of volume that's required to create sound. So.

Jerry (07:57.688)
Well, I would think it wouldn't be that high considering that they're during the expiratory phase, they're breathing around a deflated cuff, right? So how much of the volume is actually going through the trach verse going around the deflated cuff and up through the upper airway?

Nicole (08:16.03)
You're talking about when they're on the ventilator, how much volume do they, mean, they could be off the vent, right? And they, need to be able to produce the, so it doesn't really have to do with the vent delivered. would have to do with how much volume they're able to, yeah, generate. I could look it up and I'm not even finding it when I do a Google search. So.

Jerry (08:21.314)
Yeah, either way.

Jerry (08:36.686)
Yeah, it was just a question because I sometimes when we have patients on pressure support will deflate the cuff so they can phone it. Not completely, but enough to move air around the cuff. So I'm assuming it's not a lot of volume.

Nicole (08:51.764)
Here we go, it's actually, we would say you need a minimum subglottic pressure of around two to three centimeters of water.

to result in vocal fold vibration. So it's in pressure, it's in subclotic pressure, when they've actually measured the pressure in an open tracheostomy tube and Roxanne Diaz-Gross measured that pressure to be zero when that trach tube is in an open position. So obviously they're not able to generate that pressure to cause the vocal folds to vibrate. So, yeah.

Jerry (09:33.664)
Yeah, so it is. It's a small volume. OK, OK. So what are some of the consequences of not being able to communicate?

Nicole (09:35.484)
It's a small volume.

Nicole (09:48.178)
Yeah, so as you can imagine, right, not being able to verbalize can be super frustrating for the patient. And it's not only frustrating for patients, but also the people providing care for that patient. So the family members, the nurses, the therapists, you know, trying to just understand what that patient's trying to say. mean, just imagine not being able to speak for one day, Jerry, would you even be able to

do it for an hour. no way. So I've had patients who weren't able to speak for years, literally one lady in particular that I remember from Barlow, was not, they never tried at the other facilities for, and she was trached for seven years. So we got her on an inline speaking valve.

Jerry (10:18.316)
Me? Yes. Yes. I don't like to talk. Yes.

Nicole (10:46.186)
and then we actually were able to get her eating and even weaned off the ventilator all within a few months. just, you know, attempting this, even though, you know, you might have a patient, well, they've never, they haven't been able to do it for years. It doesn't mean they can't. It just means maybe nobody's tried. The inability to effectively communicate with medical staff and other care providers, you know, if they're an acute illness, maybe they aren't

able to even understand what their illness is, participate in their medical decision-making, ask questions, know, be really, they're not able to really be active in their treatment process. End-of-life patients, you can think of those types of patients that are not able to really say what they want or need at the end of their life. It's really important. So communication's really, really particularly critical in healthcare environments where miscommunication can lead to a misdiagnosis.

or delayed medical treatment. Patients, a lot of times, obviously, they're reporting frustration, fear, powerlessness, and anxiety. I think a lot of times, you know, if a patient can't speak, sometimes the nurses or whoever, you know, they don't look at the patient like a human sometimes, right? They're just this thing laying on a bed.

So patients with communication disorders do have a higher rate of medical complications and errors, increased risk of preventable adverse events, and that's from J.Co. And those adverse events can lead to poorer patient outcomes, unnecessary suffering, dissatisfaction, longer hospital stays, extra healthcare spending each year. And if you're...

a hospital in the United States and you're trying to get joint commission accreditation, you have to adhere to their standards to ensure that healthcare providers communicate appropriately and effectively with patients. having some kind of communication method with this patient, with patients is, you know, actually mandated and it's a patient, right? But it's also our ethical responsibility. We need to reestablish communication.

Nicole (13:05.179)
reestablishing that communication for patients with cuffed trachs has a significant effect on the patient's quality of life. There have been studies that show that. And also for patients who are pediatrics, these patients have never produced voicing in their life. They were maybe intubated right away and then they got a trach tube. So there's a lot of developmental risks for young children with trachs.

don't get to explore making sounds, their parents have never heard them coo or babble. They might have limited social interactions. That's critical to their development of language. Caregivers do they have shown studies have shown caregivers tend to talk less to children who cannot communicate. And they're at risk for delays if the if therapeutic interventions not initiated. So a lot of

you know, definitely a lot of consequences to not being able to communicate.

Jerry (14:08.952)
Well, I would think that, you know, a small kid, four, five, six years old. I don't know how they would be intubated, or tricked on a vent and not being able to communicate with their parents or their siblings. That must really be tough. I mean, an adult, they can, you know, you can talk to them and tell them, look, you know, you can't speak on the vent right now.

Nicole (14:28.158)
Yeah, all right.

Jerry (14:36.642)
because the cuff is inflated, there's no air going through the upper airway. And I think an adult would be, while difficult, think they have the ability to understand what's going on and understand the situation much better than like a four-year-old or a six-year-old, where you would tell them the same thing. They wouldn't understand that. They just want to talk to their mother or father or siblings. And I could see that being really difficult.

Nicole (15:05.934)
Yeah. And look, there's obviously the length of time to that this, you know, if it's an adult and it's an acute thing and it's just going to be maybe a few days or whatnot that they're not able to produce voice saying, yeah, I get that. Like breathing always comes first. But

Jerry (15:28.046)
Now you can't communicate if you're dead,

Nicole (15:30.346)
Right, but you know, once they're medically stable, then I think we really need to look at, well, I'm talking about oral communication options. Obviously, we always want them to try to communicate maybe with nonverbal communication options like we'll get into, but yeah, we'll discuss some of both of those things.

Jerry (15:53.002)
Okay. What are the options to improve communication for patients with tracheostomy?

Nicole (15:59.594)
Yes. So, so there are a few, there's, there's the nonverbal options, which I was, which I was just talking about, like gesturing, you know, the patients who are hitting, you know, their bedside table with the suction catheter, the head nodding, the writing, if they're able to use of communication boards, alphabet boards and picture boards and augmentative communication. So,

Jerry (16:14.52)
Yeah, I'm really bad at charades.

Nicole (16:28.328)
These methods can be tailored to meet individualized patient needs. And then there's oral communication. So there's electrolarynx, fenestrated trach tubes, leaked speech, tracheal occlusion, speaking valves, caps, and talking trach tubes, or you can call it above the cuff vocalization. And we're gonna get into each of those.

Jerry (16:42.58)
speech.

Jerry (16:54.978)
Well, let's talk about that leak speech for a second. You know, as an RT, we do not like deflating cuffs, especially if it's a non-subglottic trick. It's because you run the risk of all the secretions that are pooled above the cuff. As soon as you deflate the cuff, it flushes all those bacteria-laden secretions into the sterol lower airway. So my question would be...

Is it worth speaking verse possibly causing a VAE from deflating the cuff and allowing the aspirate into the sterile lower airway?

Nicole (17:43.036)
All right, so you bring up a good question with the aspiration debate, right, with the cuff.

Jerry (17:52.482)
because you and I have both seen, and I'm sure you have, I know I definitely have, where as soon as you deflate the cuff, the patient starts to cough right away.

Nicole (18:01.958)
And I totally have seen that and I don't think that's a bad thing. I think the cough reflex is a very good thing so that our patient can actually go ahead and clear that airway of those secretions. So now they have their protective mechanism, which was given to us to be able to protect our airway from secretions going down the wrong.

Jerry (18:26.734)
But they're coughing because of that flush of bacteria-laden secretions into that sterile lower airway the minute you deflate that cuff.

Nicole (18:35.322)
Right. So like we talked about before, the purpose of the cuff is for positive pressure ventilation. The purpose is not for preventing aspiration. Now on an endotracheal tube, then yes, the purpose of the cuff also prevents aspiration because it's that trachea, that endotracheal tube is bypassing through the vocal folds and that patient does not

vocal like that renders the vocal folds you know they're not able to utilize them essentially because the endotracheal tube is through it but with a trach tube you have the vocal folds above the level of the trach tube so now you have that protective mechanism to assist with you know reducing the risk of aspiration so actually they found that cuff deflation

Jerry (19:10.99)
splits them. Right.

Nicole (19:33.3)
Patients with cuffed, the cuff deflated, once, mean, these were patients who were off the ventilator, but it's still an important study. So patients who had the cuff deflated weaned quicker from mechanical ventilation and had less respiratory infections and pneumonias compared to patients who they left the cuff inflated. So ultimately you are trying to reduce pneumonias and not just, you know,

aspiration, so not just like material going into the airway or trying to reduce pneumonia. And that study found that pneumonias were reduced when the cuff was deflated. So we have our patient, if they have a good protective mechanism, they're able to cough, then that is clearing, it's a good thing they're able to clear their secretions and prevent pneumonias.

Jerry (20:23.406)
So you would suggest that it's done on patients that have good cough mechanisms, not patients that are sedated or patients that have neuromuscular disease or...

Nicole (20:28.968)
Yes.

No.

No, yeah. Well, neuromuscular disease is kind of very broad, but there are patients that have a good cough, even if they have a neuromuscular disease.

Jerry (20:44.726)
or say traumatic quads or something like that.

Nicole (20:49.45)
Those, yeah, those might be a little bit more difficult to deflate the cuff on, for sure. You might want to use the subglottic suction for those patients. But again, you still would have to probably take out the trach and then you still have to deflate the cuff to put the new trach in. But I do love subglottic trachs, yes. Do you want to get into non-verbal communication first?

Jerry (20:58.295)
Okay.

Jerry (21:08.14)
So, okay. Yeah. So I was just going to say, let's talk about, nonverbal communication.

Nicole (21:16.558)
Sure, okay, so nonverbal communication. have, let's see, we have, it's, you know, it's very common, you know, there's low technology. those types of communication things, you know, you're not using batteries or electronics. There's writing and dry erase boards. That's very like,

Jerry (21:28.502)
I'm assuming it's quite popular, quite popular with the tracheostomies patients.

Nicole (21:46.332)
low cost solution, right? But for a patient, a lot of times that's great that the patient's able to write, but that's limiting because you wouldn't just want to, people want to talk. You don't want to have to write everything. takes a lot of time to get the message out. But there's, they also might be too weak to write. That's another thing. There's also communication boards that provide

know, pictures or symbols they can point to, need suctioning, I could point to like, I want a blanket, whatever it is, you can kind of individualize those pictures as well for the patient. But again, that depends on physical ability. Maybe they're not able to utilize their hands, maybe they're completely paralyzed, or they're just not able to really point very well. Users can...

you know, use different body parts, use light pointers, eye gaze, or a head and mouth stick. They can also maybe we're scanning the message and the patient kind of blinks when they we tell them, is it this is it this and then they kind of blink when they get to the correct message, you can do it that way. But you know, there's a limit in the number of messages that that patient can communicate when it's a board there's

You can also use an alphabet board though that might be able to supplement communication. Yeah. Yeah. Imagine a patient that maybe they can't use their hands and now you're trying to use an alphabet board so they can actually say what they want, not just a couple of images or pictures. Maybe it's nothing on that board that they want to say. So now you're having to go through the alphabet, A, B, C, D,

Jerry (23:12.034)
That must be really slow though, right? Slow communication.

Jerry (23:37.038)
I'd say forever. Well, can't they use something like Stephen Hawking's had that thing they moved his eyes.

Nicole (23:37.31)
They blinked. Yeah. Yeah.

Nicole (23:46.07)
Yes. So you can have high technology systems such as that. So where you're kind of, you know, blinking or using your hand again, it doesn't, but the way that they use that, once they touch or use their eyes to communicate to that high technology device, then that device can produce voicing for the patient. So that's usually more for patients with

severe speech and language disorders or degenerative disease like ALS, there are likely more appropriate candidates for that high communication. And there's also verbal communication options. So I mentioned the fenestrated trach tubes earlier, you were talking about this a little too. So those tubes have

you know, the holes in them to allow for airflow through the tube when a fenestrated inner cannula is in place to produce voicing. So those individuals might voice when the cuff is inflated, partially deflated or completely deflated. But a drawback of the fenestrated tube is that the positioning of those fenestrations often rub against the tracheal wall and can result in granulation tissue.

There is also a risk of subcutaneous emphysema during positive pressure ventilation. And then a non-fenestrated inner cannula should be used during suctioning so the catheter doesn't inadvertently pass through the fenestrations, which can result in trauma to the tracheal wall. And it's also just, again, you have to worry about the, you do have to possibly deflate that cuff or.

completely deflate the clefts. mean, you can get some voicing without doing that through the fenestrations though.

Jerry (25:41.079)
But you have to worry about if the patient has lot of thick secretions of those fenestration holes clogging up,

Nicole (25:49.802)
I guess then you just have like a non-finished rated trach if that happened.

Jerry (25:56.046)
It immediately become non-fenestrated. But I would assume that if the patient had thick secretions that you wouldn't want to use a fenestrated trach that it would clog up very quickly.

Nicole (26:11.754)
clog the fenestration. mean, again, I guess it would just result in them not not being able to produce voicing, but I don't know if it's a risk for you. If you feel like that's a risk for the patient.

Jerry (26:25.546)
I would think so. Yeah. Well, even if the fenestrated holes clog up, the tube will still function as a normal tube, a normal trach tube. They'll be able to breathe through it, but they just won't be able to phoning. Yeah. Now what's leak speech since we're on the topic of deflating cuffs and talking.

Nicole (26:34.6)
Right. That's what I mean. Yeah, yeah.

Nicole (26:45.29)
So yeah, so leak speech, we were talking about inflated cuffs. So with an inflated cuff, again, the trach tube prevents that airflow through the upper airway, through the vocal folds. And since those vocal folds require that airflow, those patients aren't able to produce speechings. So if the cuff is either partially or completely deflated, some airflow can

quote unquote, like leak around that tracheostomy tube and through the upper airway, through the vocal folds, hence the term leak speech. So there has to be kind of adequate space around that tracheostomy tube and around the trachea for that, you know, for that air to pass through the upper airway.

So when a patient's on mechanical ventilation, leaked speech can actually occur on both inspiration and expiration. So since speech can be sometimes clear when the ventilator delivers a breath on inspiration, individuals are sometimes taught to speak when the ventilator delivers that breath. However, that's obviously the opposite of how our normal breathing and speech patterns

are, right? We speak on exhalation. So that can result in dysphonia. Another limitation of leaked speech is that speech is often breathy and weak since airflow takes the path of least resistance and often back through the tracheostomy tube instead of through the vocal folds and upper airway. Leaked speech also, it doesn't close the system like speaking valves do.

to create a pressurized system for better voicing and swallowing. And there are some ventilator changes that can improve leak speech. There's also the ventilator alarms can go off and so that can be distraction. So you kind of want to be with a patient during leak speech. So yeah, those are kind of the positives and negatives about leak speech. And we can, you can kind of get a lot more information on like the

Nicole (29:07.388)
nitty gritty of like what ventilator settings, how to do that a little bit more on tracheostomyeducation.com. There's some communication webinar that has like the full information on all this because it's kind of a lot to get into.

Jerry (29:22.67)
What I found is that when we do do leak speech in my units that patients that have good NIFs, negative inspiratory forces, are able to actually improve their minute ventilation by pulling in additional volume on top of what we're already delivering with the ventilator. So we find that...

Nicole (29:36.521)
Mm-hmm.

Jerry (29:52.662)
these patients are actually pulling in more tidal volume around the cuff and are adding, using that additional volume to help push out and around the cuff to actually phonate, improve their phonation, improve the volume of their voice by pulling this additional volume and enforcing it around the cuff.

But again, these are patients that are usually very wienable patients who are in the weaning process and have negative inspiratory forces of say minus 40 plus.

Nicole (30:27.978)
Mm-hmm.

Nicole (30:38.89)
That's great that you're utilizing that.

Jerry (30:40.066)
Yeah. Yeah. It's very, it's very effective in improving minute ventilation as well.