A tracheostomy is a surgical procedure that creates a temporary or permanent opening, called a stoma, in the front of the neck to place a tube directly into the windpipe (trachea). This tube provides an alternative route for breathing, often needed when the upper airway is blocked or when mechanical ventilation is required for an extended period. While the tube initially alters the mechanics of breathing and speaking, various methods and devices can be used to restore verbal communication.
How a Tracheostomy Affects Speech
Normal speech production relies on air moving from the lungs, up through the windpipe, and past the vocal cords, which are located in the larynx. The exhaled airflow causes these cords to vibrate, creating the sound that is then shaped into words by the mouth, tongue, and lips. A standard tracheostomy tube is placed below the vocal cords, and its primary function is to secure the airway for breathing.
The tube diverts exhaled air directly out of the neck opening, completely bypassing the larynx and the vocal cords. Since no airflow reaches the vocal cords, the fundamental mechanism for producing sound is lost, resulting in the patient being unable to speak audibly. If the tracheostomy tube includes an inflatable cuff that seals the trachea, it entirely prevents air from leaking up toward the throat, making speech unavailable immediately following the procedure.
Restoring Voice with a Speaking Valve
The primary method for restoring verbal communication is the use of a one-way device known as a speaking valve. This small, lightweight device attaches to the outer opening of the tracheostomy tube. It fundamentally changes the direction of airflow by allowing air to be inhaled through the tube. The valve then closes automatically during exhalation.
When the valve closes, the exhaled air is redirected up around the tracheostomy tube and through the upper airway, vibrating the vocal cords. This allows the patient to produce voice and speak. For the speaking valve to function safely, the cuff on a cuffed tracheostomy tube must be completely deflated; otherwise, the blocked exhaled air would cause a serious breathing obstruction.
Beyond restoring the voice, the speaking valve offers several physiological benefits by re-establishing a closed respiratory system. It restores subglottic pressure, which is necessary for a strong cough and a more natural swallow. This restoration of pressure can also improve the patient’s ability to manage secretions and may enhance the sense of smell and taste. Successful use of a speaking valve often represents a significant step toward the eventual removal of the tracheostomy tube, known as decannulation.
Non-Vocal and Alternative Communication Methods
Alternative communication methods are necessary when a patient is not yet medically cleared to use a speaking valve or while they are building tolerance. These non-vocal techniques are often employed in the initial stages of recovery or if the patient has copious secretions. Low-tech solutions include using a simple paper and pen or a dry-erase board to write out messages.
Communication boards featuring pictures, letters, or commonly used phrases allow the patient to point to convey their needs, especially when writing is difficult. Electronic communication aids, such as tablets or dedicated speech-generating devices, can convert typed text into audible speech, offering a flexible voice. For immediate communication, a patient may use digital occlusion, manually covering the external opening of the tube during exhalation to temporarily direct air up for a short burst of speech.
The Role of Professional Speech Therapy
The successful re-establishment of communication after a tracheostomy is heavily dependent on the expertise of a Speech-Language Pathologist (SLP). The SLP conducts a thorough assessment to determine if the patient is a candidate for a speaking valve, ensuring they can tolerate full cuff deflation and have a clear upper airway. This assessment is a safety measure to prevent respiratory distress upon valve placement.
Once candidacy is confirmed, the SLP manages the initial trial and implementation of the speaking valve, guiding the patient through coordinating breathing and speaking. They also address related issues, such as dysphagia (difficulty swallowing), which is common due to reduced laryngeal elevation and sensation. The SLP provides specific exercises and techniques to strengthen the muscles involved in swallowing and speaking, ensuring rehabilitation is safe and effective.