Communication

The Importance of Communication

Communication is the sharing of experiences, events, ideas and feelings through verbal (sounds, words, sentences) and non verbal (body movement, tone of voice, touch) channels
Communication permits us to interact as human beings. It serves a number of functions including controlling, sharing of feelings, informing, understanding, imagining and sustaining social relationships
In the medical setting, communication is an important skill required in order for the patient to give informed consent about their treatment
Patients requiring a tracheostomy are acutely ill and disabled. The effects of the drug treatments along with the acute nature of their medical condition may render them unable to breath for themselves and require an ICU admission, they may have a degree of physical weakness. Although this is a temporary situation and many patients may make a good recovery, the psychological effects can be long lasting. One of the most difficult things for a patient to cope with, is the inability to communicate. Communication difficulties are also associated with increased length of stay on ICU due to patient’s inability to participate in goal setting, treatment and end of life decisions.
Where appropriate, the patient/relatives should be informed, before the tracheostomy procedure, that they might be unable to create a voice while the tracheostomy tube is in place, as air is no longer passing through the vocal cords (a patient information sheet is recommended). They should be reassured that it is expected that the voice will return once the tube is removed or manipulated (except when a laryngectomy has been performed) and the nursing, medical staff and relatives will provide the patient with alternative means of communication until then.
Communication serves to meet many patient needs including “social interaction, information giving, reassurance, discussion of feelings, advice and counselling” ¹
“The purpose of communication for critically ill patients is to help them maintain their identity as well as psychological, structural, personal and social integrity” ¹
The psychological status of the patient must be considered as they may be unable to speak and will often be anxious in the hospital environment.
The role and responsibility of the Speech and Language Therapist is as a communication specialist is to facilitate communication and to ensure equitable communication and person time for all patients. Initial assessment of the tracheostomised patient usually occurs within the critical care setting, so the patients medical status needs to be taken into consideration and assessment needs to be functional and adaptable to the patient’s needs.

Non verbal communication – Methods to consider

Lip reading

Ask the patient to exaggerate their lip movements. Encourage use of short but complete sentences in order to make the message clearer. Look for key words to aid your understanding. This will require adequate oro-motor ability.

Facial expression and gestures

Concentrate on facial and body expressions which will add extra information to the patient’s “mouthed” words.

Coded Eye Blink or Hand Gesture

Instruct the patient to blink once for “yes” and twice for “no” in response to your questions. Alternatively consider thumbs up for “yes” and down for “no”, or any clear hand movement that the patient can achieve.

Alphabet Board, Picture Board and Phrase Books

Laminate A4 sheets displaying the alphabet in large letters, or simple pictures depicting basic activities/needs (e.g. drink, toilet…). These systems can be supplemented by a list or book of useful phrases for the patient (e.g. “Please call my husband”). Communication boards can be individualised for each patient by the Speech & Language Therapist.²

Electronic Larynx and Electronic Communication Aids

It is necessary for the Speech & Language Therapist to assess the patient for use of one of these aids, and then, if appropriate, advise the patient, family, carers and staff on its use. Use of these aids requires the patient to develop an adequate level of skill, therefore may not be suitable for short term use.

Verbal communication – Methods to consider

Manipulation of the Tracheostomy Tube for Communication

Voice production may be achieved in patients with a tracheostomy tube by using one or more of the following:

Cuff Deflation

Deflation of the cuff of the tracheostomy tube will allow air to pass into the upper airway on expiration. Phonation will be achieved as air is directed into the larynx, however the strength of the voice may be weaker as some air will pass out of the open tracheostomy.

Fenestrated Tracheostomy Tube

Use of a fenestrated tracheostomy tube also allows air to pass into the upper airway on expiration, thus producing voice. It is essential to remove a non fenestrated inner cannula if in-situ. The fenestration needs to be patent, as in some occasions the fenestration is in contact with the tracheal wall, thereby not allowing airflow through the fenestration. Re-adjustment of the patient’s head/ shoulders can be attempted to unblock the fenestration

Downsizing of Tracheostomy Tube

Use of a smaller tracheostomy tube will allow increased passage of air between the tube and the tracheal walls on exhalation but it will also increase the work of breathing as the resistance to air flow is increased. This will therefore need to discussed with the MDT.

Intermittent Finger Occlusion

Intermittently occluding the tracheostomy tube with a gloved finger will allow for effective voicing in many patients. To use this technique the patient should ideally be able to tolerate cuff deflation, but if not must have a fenestrated tracheostomy tube (with fenestrated inner cannula) in place.

One Way Speaking Valve

One-way speaking valves can be used very effectively with tracheostomised and ventilator dependent patients. Use of a one way speaking valve is dependent upon the patient’s ability to tolerate cuff deflation³.

Portex® Orator one-way speaking valve

This type of speaking valve has a one-way mechanism where the valve opens on inspiration, allowing air to enter the airway via the tracheostomy, however closes on expiration, forcing air into the upper airway and larynx to allow for phonation.

“Passy Muir” tracheostomy and ventilator speaking valves

For the patient who is ventilator dependent and can tolerate cuff deflation, the “Passy-Muir” valve should be considered.³

Talking tracheostomy tube

Patients unable to tolerate cuff deflation, (eg. ventilated patient), should be considered for use of a vocalaid tracheostomy tube. Air from an external source is delivered above the cuff to allow airflow through the larynx for phonation. This may allow the tracheostomised patient to communicate verbally, however as the airflow is reduced, voice may be weak.

Portex® Vocaloid / Suctionaid Blue Line Ultra® tracheostomy tube

The Speech & Language Therapist will be able to provide information and advice on achieving the most appropriate communication system for the individual patient.

Box 8.1 Procedure for using a One Way Speaking Valve – Self ventilating patient

Action

Rationale

The patient must have SpO₂ levels monitored using a pulse oximeter

To obtain the patient’s correct baseline status

Where possible the patient must fully understand the procedure and its mechanism, explanation is therefore essential

To reduce the anxiety of the patient which influence the success of the voice production

If using a non-fenestrated tube the cuff must be deflated (see fig 8.4a and 8.4b) (medical agreement should be obtained) and the inner cannula should be removed if not fenestrated

If the cuff is inflated when using a non-fenestrated tube, air is unable to pass through the vocal cords and a voice cannot be produced. The patient’s respiration will be compromised

If humidified oxygen or air is required, this can be placed over the speaking valve in the normal manner

To mantain consistent environment for the patient throughout the assessment

Once the speaking valve is in place, instruct the patient to breathe in (via the tracheostomy tube) and blow out gently through the mouth

The patient will not be used to normal breathing, especially if the tracheostomy tube has been in place for some time

Being trial attempts at phonationby asking the patient to say “ah” or count from “one” to “five”

Automatic speech such as counting is often easier for the patient than spontaneous speech

If the patient’s voice sounds “wet” or “gurgly” ask them to cough and clear secretions

Any secretions present that may affect voice clarity

Monitor carefully and liaise with the other team members regarding the weaning plan (see section 11.0)

Remove the speaking valve if:

Respiratory difficulty occurs
SpO₂ levels decrease
The patient becomes fatigued
The patient requests it

Always refer to the Speech & Language Therapist’s advice in the medical and nursing notes and the weaning plan.

If indicated, remove the speaking valve at the end of the trial period, re-inflate the tracheostomy tube cuff using the MOV technique, checking cuff pressure.

Clean and dry the speaking valve according to manufacturers guidelines and store in a named sealed container.

Document all actions on the weaning plan.

To ensure effective communication amongst the multidisciplinary team.

Incorrect
Speaking valve used in the presence of an inflated cuff preventing exhalation

Correct
Speaking valve with cuff deflated

Box 8.2 Procedure for using a Passy Muir Speaking Valve (PMV) inline with ventilator

Action

Rationale

Obtain medical agreement prior to commencing procedure

Patient needs to be medically stable and weaning from mechanical ventilation, in order to ensure that patient is safe to tolerate cuff deflaction and ventilator adjustments.

Where possible the patient must fully understand the procedure and it’s mechanism, explanation is therefore essential

To reduce the anxiety of the patient which can influence the success of the voice production

Look for evidence of reduced airway patency – Patient history, bronchoscopy results, ABGs

Ideally the patient should be on a pressure support of ≤ 15 – 18 cmH₂O and no ≥ 8cmH₂O of PEEP

To ensure minimum ventilator support is required

Check RR/HR/SpO₂

To ensure within normal limits for the patient

Determine potential changes to ventilation modes and O₂ therapy

To allow for air leak within the ventilator system

Suction orally and via trache tube prior to cuff deflation

To ensure minimum residual secretions during procedure

Cuff deflation procedure
Slowly deflate cuff while carrying out synchronous suction. Check for airflow at mouth
Know your ventilator
It is best to use the NIV mode on your ventilator while using the passy muir valve

To ensure that cuff deflation is tolerated. Signs of intolerance:

Increased coughing
Increased respiratory rate
Respiratory effort
Need for suction increases
SpO₂ levels decrease

If signs of intolerance are observed, please remove valve, re-inflate cuff and do not proceed any further without further reassessment

Once the patient is tolerating cuff deflation insert the passy muir valve into the ventilator circuit as close to the trache as possible

Assess patients ability to phonate

To ensure supraglottic airflow. Remove the speaking valve if:

Respiratory rate / effort increases
Heart rate rises
SpO₂ levels decrease
Patient experiences distress / discomfort
No supraglottic airflow
Weak / breathy / hoarse voice
Inspiratory / expiratory stridor
The patient requests it

If the patient’s voice sounds “wet” or “gurgly” ask them to cought and clear secretions

Any secretions present may adversely affect voice clarity

Monitor RR / Sats / WOB carefully and liaise with the other team members regarding the weaning plan

Remove the speaking valve if:

Respiratory difficulty occurs
SpO₂ levels decrease
The patient becomes fatigued
The patient requests it

If indicated, remove the speaking valve at the end of the trial period, re-inflte the tracheostomy tube cuff if indicated using the MOV technique, checking the cuff pressure with a manometer

Clean and dry the speaking valve according to manufacturer’s guidelines and store in the box provided by manufacturer with the patients name on it

Document all actions on the weaning plan

To ensure effective communication amongst the multidisciplinary team

If the initial trial is successful and it is agreed to continue with its use please place te aqua marine sticker provided in the speaking valve pack onto the pilot balloon line which states that when this valve is used the cuff must be deflated first

Contradictions for speaking valve use

Inability to tolerate full cuff deflation
Airway obstruction
Unstable medical/pulmonary status
Laryngectomy
Severe anxiety/cognitive dysfunction
Anarthria
Severe tracheal/laryngeal stenosis
End stage pulmonary disease

If communication is particularly difficult or further advice is needed, please contact the Speech & Language Therapy department.

References

Ashworth P, Kegan C (Eds) (1985) Interpersonal Skills in Nursing Research and Applications Croom Helm London
Boardmaker for Windows. (2001) Mayer-Johnson U.S.A.
Dikeman KJ, Kazandjian MS (1995) Communication and Swallowing Management of Tracheostomy and Ventilator-Dependent Adults San Diego Singular Publishing Group, Inc
Prentice W, Baydur A. (1989) Passy Muir Tracheostomy Speaking Valve on Ventilator-
Mason M, Watkins C. (1992) Protocol for Use of the Passy-Muir Tracheostomy Speaking Valves The European Respiratory Journal Aug 29-Sept 3