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Speech Therapy

The Speech and Language Therapist’s (SLT) role is to maximise a patient’s ability to communicate consistently and effectively with the people around them. The Speech and Language Therapist, therefore, has a key role within the tracheostomy team, as the tracheostomy tube can impact on the patient’s ability to communicate.

NORMAL HEAD AND NECK ANATOMY
Figure 1 The Anatomy Of The Head And Neck Demonstrating The Path Of Airflow.



THE IMPACT OF THE TRACHEOSTOMY TUBE ON COMMUNICATION
The presence of the tracheostomy tube within the trachea can impact on a patient’s ability to communicate.

Loss or reduction of voice production
A tracheostomy tube can mean that all or some of the air gets diverted away from the upper airway and out through the tracheostomy tube. This can result in an absent or weak voice due to the inflated cuff (figure 3 )or insufficient air passing above the tube (figure 4).





The vertical movement of the larynx during speech alters the length of the vocal cords resulting in pitch variation. The following aspects of a tracheostomy tube can alter pitch by restricting the elevation of the larynx:

  • An oversized tube- restricting movement of the tube, airflow and the larynx.
  • The weight of equipment attached to the tube can tether laryngeal movement.
  • An inflated cuff and more significantly an over inflated cuff can restrict laryngeal movement

THE ASSESSMENT OF THE TRACHEOSTOMISED PATIENT’S COMMUNICATIVE ABILITIES
The assessment of the tracheostomised patient needs to be functional and adaptable to all levels and aspects of each individual's changing communicative abilities.

Assessment needs to answer the following questions:

  • What are the patient’s communicative needs?
  • What is the patient’s current pattern of alertness?
  • Are they already communicating?
  • If so, how and is it effective?
  • Do they have a method of attracting someone’s attention?
  • Do they have a consistent yes/no response?
  • What is their level of cognition? E.g. Is it sufficient to use a communication aid?
  • What are the patient’s physical/motor abilities? E.g. oro-motor movement, eye movement, limb movement, has their dominant hand been affected?
  • What are the patient’s current linguistic abilities? E.g. are their receptive or expressive language skills within normal limits?
  • Who are the patient’s main communication partners?

This information will then be used to assess which mode or combination of modes would be the most suitable and efficient communication option.

COMMUNICATION OPTIONS
The ultimate goal is to restore the patient’s ability to communicate verbally, consistently and effectively. This goal is seldom achieved immediately and alternative communication options may need to be considered to substitute or support verbal communication.

The communication options available to the tracheostomy patient are:

  • Verbal communication- uses natural voice production e.g. speaking valve.
  • Oral communication- requires sufficient oro-motor skills, without the use of natural voice production e.g. mouthing.
  • Non-Oral/Non-Verbal communication- does not require natural voice or oro-motor movements e.g. writing or a letter chart.

Combinations of all of these options are likely to be used in the majority of tracheostomised patients throughout the weaning process.

VERBAL COMMUNICATION OPTIONS eg speaking valve
Contraindications For Use:

  • Unable to tolerate cuff deflation.
  • Patient unable to produce voice.
  • Upper airway obstruction.
  • Unstable medical/respiratory status.
  • Insufficient oro-motor function to produce intelligible speech.
  • Severe language or cognitive impairment that affects the patient’s ability to use language to communicate effectively.

The One Way Speaking Valve
The one way speaking valve attaches to the hub of the tracheostomy tube, altering the path of expired air and providing the potential to produce voice.

The One Way Speaking Valve works in the following way:

  • Air is inspired through the tracheostomy tube.
  • On exhalation the valve shuts and the expired airflow is redirected passed the tube and/or through the fenestration, into the upper airway allowing voice production. (figure 5).



Figure 5 A Drawing To Demonstrate How The One Way Speaking Valve Alters The Respiratory Pattern

N.B The cuff must be deflated prior to fitting the speaking valve. If the cuff remains inflated the valve will allow the person to breathe in, but will prevent them breathing out (figure 6).



ORAL COMMUNICATION OPTIONS eg mouthing
Contraindications For Use

  • Insufficient oro-motor function to produce intelligible speech.
  • Severe language or cognitive impairment that may affect the patient’s ability to use language to communicate effectively.

NON-VERBAL/NON-ORAL COMMUNICATION OPTIONS eg writing
Contraindication for use

  • Severe language or cognitive impairment that may affect the patient’s ability/ desire to use language to communicate effectively

Summary
The Speech and Language Therapist’s (SLT) role is to maximise a patient’s ability to communicate consistently and effectively with the people around them. Ultimately, the patient is the pivotal member of the Tracheostomy Team and their capacity to communicate with the people around them is paramount to their care, psyche and general well being.

It is therefore essential that their communication needs and abilities are identified and maximised at the very outset of their care.