Tracheostomy tubes speech

Different auxiliary methods of administration can be used in conjunction with nebulizers to deliver aerosol to the patient [144]. A mouthpiece may be inserted in the mouth or a face mask may be attached tightly to the face. A large-bore inlet adapter attaches tubing from the nebulizer outlet to the mouthpiece or mask. It is possible to compensate for exhaled aerosol without increasing resistance to prevent condensation. A face tent fits more loosely around the patient s mouth, allowing speech. The latter arrangement is frequently used with ultrasonic nebulizers. A tracheostomy mask may be fitted to the patient s tracheostomy tube directly and requires a T-shaped adapter. Environmental chambers are used to enhance therapy and include incubators, pediatric croup tents, and hoods. 

The choice of size, shape, and composition of the tube should be individualized. Tracheostomy tubes and cannulae for home use are made of plastic or silicon. Silicone tubes are more flexible than PVC tubes and may offer a better fit. To allow for connection to the ventilator, the tube must extend at least 2 to 3 cm beyond the stoma, but should be situated no closer than 2 cm from the carina. The tube curvature should be such that the tube is in the center of the tracheal lumen rather than impinging on the tracheal wall—to avoid damage to the tracheal wall and to avoid problems with ventilation, comfort, and speech. 

Careful patient selection prevents unsafe levels of alveolar hypoventilation with subsequent hypoxemia and hypercapnea, especially if the tidal volume leakage is >20%. Any compensatory increase in respiratory rate and shortened expiratory time, attributable to the air leakage, may aggravate dynamic hyperinflation, especially among patients with airflow obstruction (15). Ventilator-supported speech has been reported in patients with neuromuscular diseases (NMD) and intact bulbar function (16-19). The physiologic characteristics that enable this population to tolerate ventilator-supported speech include little or no decrease in chest wall or lung compliance and the absence of airflow obstmction. Therefore, patients with NMD may be ventilated with a deflated or cuffless tracheostomy tube accepting the modest compromise in alveolar ventilation (16,20-22). Patient populations, such as those with chronic obstructive pulmonary disease may be able to tolerate cuff deflation for short periods provided there is adequate supervision. 

Few, if any, patients with NMD should be left to develop unexpected ventilatory failure as appropriate assessment, self-management education, and follow-up will identify disease progression and risk of respiratory complications. When ventilatory failure occurs, tracheostomy tubes can be avoided, for the most part, irrespective of the degree of ventilator dependence, with the exception of those with insufficient bulbar-innervated musculature for speech, deglutition, and airway protection. Those with indwelling tracheostomy tubes should be offered decannulation as part of their rehabilitation, irrespective of the extent of their respiratory muscle failure. The only exceptions to this therapy are patients with advanced bulbar ALS or those with rare facioscapulohumeral muscular dystrophy, who lose all bulbar-innervated muscle function and aspirate saliva to the extent of Sao2 remaining below 95% (13). 

Esteban A, Anzueto A, Alia I, et al. How is mechanical ventilation employed in the intensive care unit An international utilization review. Am J Respir Crit Care Med 2000 161(5) 1450-1458. Hess DR. Facilitating speech in the patient with a tracheostomy. Respir Care 2005 50(4) 519-525. Bach JR, Alba AS. Tracheostomy ventilation. A study of efficacy with deflated cuffs and cuffless tubes. Chest 1990 97(3) 679-683. 

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