Clinical Focus

Preserving Oral Communication in Individuals

With Tracheostomy and Ventilator Dependency

Donna C. Tippett
Arthur A. Siebens
Good Samaritan Hospital, Baltimore
Johns Hopkins University, Baltimore

How to preserve oral communication in preserve oral communication without sacrificing

patients with tracheostomy is the primary focus
of this paper. We review the approaches
applicable to patients who breathe indepen-
dently and to patients who depend on coupling
to a ventilator. For the former, valving the
tracheostomy cannula to provide inspiration
through the cannula and expiration through the
larynx is often practical and effective. For the
latter, deflating the cuff, which is often inflated
to seal the cannula in the trachea, may
alveolar ventilation. Our experiences with these
patient populations are reviewed together with
an exposition of valving and cuff deflation.
Although the literature includes references to
these practices, it also suggests that their
recognition is restricted. Our own experiences
justify confidence in the effectiveness of these
compensations for the communication impair-
ments which result from tracheostomy with or
without ventilator dependency.

T
racheostomy is performed for severely impaired FIGURE 1. Sites of neuromuscular pathology identified with
respiratory function of the pharynx and larynx as tracheostomy with or without ventilator dependency.
well as for ventilating patients who cannot breathe
independently. In both instances, oral communication is
sacrificed unless special measures are taken toward its
preservation. A review of the literature is not reassuring
that concern for preserving oral communication is a
priority. This paper presents the populations for which
tracheostomy is beneficial, discusses the characteristics of
tracheostomy tubes, and describes the use of valves and
cuff deflation to promote oral communication.

Populations
Tracheostomy is frequently performed for patients who
have neuromuscular diseases, some of which render the
patient incapable of independent breathing. Lesions may be
in the: (a) central nervous system (e.g., brain stem
infarction, trauma to the spinal cord) (Zejdlik, 1983); (b)
peripheral nervous system (e.g., amyotrophic lateral
sclerosis, Guillain-Barré syndrome) (Gracey, McMichan,
Divertie, & Howard, 1982; Moore & James, 1981; Ropper
& Kehne, 1985; Ropper, Wijdicks, & Truax, 1991; Sivak,
Cordasso, & Gipson, 1983; Sivak, Gipson, & Hanson,
1982); (c) neuromuscular junction (e.g., botulism,
myasthenia gravis) (Gracey, Divertie, & Howard, 1983); or
(d) muscle (e.g., muscular dystrophy) (Bach, Alba,
Pilkington, & Lee, 1981) (Figure 1). Pathology that is not

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TippettAssociation
• Siebens 55
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 primarily neuromuscular may also lead to tracheostomy as FIGURE 2. Tracheostomy cannula with cuff inflated.
in the instance of obstructive airway disease, surgery of the
head and neck, adult respiratory distress syndrome, and
injuries that result in instability of the chest wall.
In 1985, there were 48,000 temporary tracheostomies
(ICD-9 31.1) and 6,000 permanent tracheostomies (ICD-9
31.21, ICD-9 31.29) (Pokras, 1987). In 1986, the preva-
lence of ventilator-dependent patients was estimated to be
2.8 per 100,000 in the United States (Make, Dayno, &
Gertman, 1986). More recently, the American Association
for Respiratory Care (AARC) commissioned the Gallup
Organization of Princeton, New Jersey, to conduct a survey
documenting the number of chronic ventilator-dependent
individuals in the United States. In December 1990, 300
respiratory care department managers and 100 pulmonary
physicians were interviewed by telephone. Based on these
interviews, it was estimated that there are 11,419 chronic
ventilator-dependent patients being treated in hospitals in
the continental United States at any given time (American
Association for Respiratory Care, 1991).
Ventilator dependency can be prolonged even for
patients who are weaned eventually. For example, in
patients with Guillain-Barré syndrome, mean duration of
ventilator dependency ranged from 37 to 63 days (Gracey FIGURE 3. Inspiration and expiration when a patient is
coupled to a mechanical ventilator with an inflated
et al., 1982; Moore & James, 1981; Ropper & Kehne, tracheostomy cuff; air enters the lungs when air pressure in
1985; Ropper et al., 1991); in patients with myasthenia the ventilator exceeds pressure in the lungs and escapes from
gravis, duration of ventilator dependency ranged from 1 to the lungs when lung pressure exceeds pressure in the
32 days (Gracey et al., 1983). ventilator or room.
Thus, the tracheostomy populations are sizable, their
etiologies are diverse, and the durations of ventilator
dependency are substantial.

The Problems of Cuff Inflation

A cuff is commonly inflated to seal the tracheostomy
tube in the trachea. This prevents aspiration of some
foodway contents into the airway. Although flow of air to
and from the lungs through the cannula is unaffected by the
inflated cuff, flow through the larynx, pharynx, mouth, and
nasal passages cannot occur and phonation is sacrificed
(Figure 2). In the instance of the ventilator-dependent
patient, the inflated cuff affords leak-free coupling of the
ventilator to the lungs (Figure 3). Breathing in this “closed” interfere with blood flow to the tracheal cartilages suffi-
system is controlled by adjusting ventilator settings to be cient to cause necrosis and softening (tracheomalacia). The
compatible with normal concentrations and partial pressures tracheal lumen may be narrowed by granulation tissue and
of oxygen and carbon dioxide in arterial blood. the scarring that follows damage to the wall. A communi-
Cuff inflation is attended by a number of drawbacks in cation between tracheal and esophageal lumens
addition to those pertaining to oral communication. The (tracheoesophageal fistula) may occur, a circumstance
inflated cuff forms an imperfect seal against aspiration of under which food may enter the airway and/or air enter the
fluid boluses and secretions; contributes to desensitization foodway. The avoidance of these problems is a salient
of the trachea and larynx, thereby interfering with protec- advantage of cuff deflation and cuffless cannulas.
tive coughing; and can bulge posteriorly through the
membranous portion of the trachea to compress the
esophagus (Betts, 1965; Cameron, Reynolds, & Zuidema,
Preserving Oral Communication in
1973; Feldman, Deal, & Urquhart, 1966; Leverment, Individuals With Tracheostomy Who
Pearson, & Rae, 1976; Weber, 1974). Moreover, secretions Breathe Independently
pool above the cuff in the proximal trachea and larynx, Preserving oral communication for the patient with a
resulting in inflammation of these tissues (Siebens, Tippett, tracheostomy requires that air flow through the larynx
Kirby, & French, 1993). The integrity of the tracheal wall during expiration. A cuff must be deflated or absent, and
may be lost if cuff pressure and duration of inflation the cannula must be occluded during expiration (Figure 4).

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 The patient can occlude the hub of the cannula intermit-
tently with a finger. The hygiene of this practice is ques-
tionable at times, however, and bimanual tasks cannot be
performed simultaneously with speaking. A unidirectional
valve coupled to the hub of the cannula can accomplish the
equivalent of finger occlusion without its drawbacks. Such
valves are open during inspiration and closed during
expiration, forcing air through the larynx. A variety of
these valves are described in the literature and are summa-
rized below.
In 1968, Toremalm constructed a plunger-type, one-way
valve with a moving membrane on a piston. In 1972,
Emery adapted a flap valve from an Ambu bag to make a
speaking valve. Tucker developed a tracheostomy tube that
incorporated within its lumen a metallic flap hinged from
the sides of the tube so that airflow during inspiration
rotated the flap to an open position and during expiration to
a closed position (Dedo, 1990). Cowan in 1975 adapted an
Improved Jackson speaking-aid tracheostomy tube to
prevent complete closure of the valve during expiration
and still allow phonation for a patient with a post-diphthe-
ritic laryngeal and tracheal stenosis. Four years later, Saul
and Bergstrom (1979) described a straight tracheal cannula
with a two-way valve that could be rotated to allow
inspiration only or inspiration/expiration.
More recently, French, Siebens, Kummell, Kirby and
Eisele (1984) developed a simple ball valve. Its operation
is shown schematically in Figure 5. Figure 5A shows the
valve at rest. When the patient inhales (Figure 5B), the
inspiratory stream blows the ball back, allowing air to enter
freely through the port. The ball is stopped from entering
the cannula by a wire stop. On expiration (Figure 5C), the
ball seals the port, forcing airflow through the larynx.
Adaptations of French et al.’s (1984) Hopkins valve are
designed to fit either an Improved Jackson metal or Shiley
plastic tracheostomy cannula.
FIGURE 4. When the tracheostomy cannula is occluded, air
flows around the deflated cuff and through the larynx during
both inspiration and expiration.
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French, Kummell, and Siebens (1991) compared the
advantages and disadvantages of the Hopkins ball valve
with the Passy-Muir flap valve (Passy, 1986). The Passy-
Muir valve was invented by David Muir, a 23-year-old
man with quadriplegia secondary to muscular dystrophy. It
consists of a centrally supported membranous flap
mounted in a plastic housing. Its resting position is closed
and the flap is blown open during inspiration. This valve
attaches to cannulas that incorporate a universal 15-mm
fitting. Inspiratory resistance was less with the ball valve.
Closing pressure was slightly lower with the flap valve
inasmuch as this valve is closed in its resting position.
Additionally, the ball valve is smaller, more easily con-
cealed, more durable, and easier to clean. Both valves can
be applied by the patient, the flap valve more easily than
some of the adaptations of the ball valve. If one removes
the inner cannula from a Shiley #6 tube (inner diameter =
7.0 mm; outer diameter = 10.0 mm) and attaches a ball
valve to the outer cannula, resistance to inspiratory flow
compares with the resistance when the tube is used without
a valve and the inner cannula is in place, the usual circum-
stance. Such technical information is generally lacking
from descriptions of a given valve. An additional reference
in which technical information is cited, however, is
Toremalm (1968). The closing pressure of his plunger-type
valve is 2 cm water, a disadvantageous characteristic
inasmuch as this value is four times that of the ball valve.
FIGURE 5. Ball valve at rest (A), during inspiration (B), and
during expiration (C).
Tippett • Siebens 57
 A special rendition of the Hopkins valve was designed FIGURE 6. Speaking tracheostomy cannula.
to accommodate an individual who could neither tolerate
valving with every breath nor reach her cannula for
elective finger occlusion (Lynch, Tippett, French, &
Siebens, 1990). She was a 25-year-old woman who
presented with bilateral paresis of the shoulder and elbow
flexor muscles, and bilateral vocal fold abductor paralysis
(vocal folds were fixed at midline) secondary to acute
intermittent porphyria, a metabolic defect in the liver that
is inherited as an autosomal dominant trait and is marked
by increased production and urinary excretion of
porphobilinogen and porphyrin precursor. The modified
Hopkins valve was controlled by a camera shutter release
mechanism that the patient manipulated with her thumb
and forefinger to maintain the valve in an open position
during breathing at rest. Elective depression of the shutter
release allowed the ball to fall forward, occluding the valve
and forcing airflow through the larynx.
In our setting, the evaluation of an individual’s candi-
dacy for valving is conducted collaboratively with the
physician, nurse, speech-language pathologist, and
respiratory therapist. Initially, speech components are
assessed with particular attention to the respiratory and
laryngeal mechanisms. The cannula is down-sized if
necessary to ensure that it does not entirely fill the tracheal
lumen. A session is conducted during which a caregiver
performs intermittent cannula occlusion only during
expiration using a gloved finger. Respiratory and Jahrsdoerfer, 1987), allow speech throughout the whole of
phonatory qualities are assessed (e.g., respiratory rate, the respiratory cycle (Safar & Grenvik, 1975; Whitlock,
shortness of breath, inspiratory stridor, effortful exhalation, 1967) and do not require adjusting ventilator output
altered voice quality). If the session is judged to be settings (Safar & Grenvik, 1975).
successful, use of the valve is approved. Tolerance is However, these speaking tracheostomy cannulas present
determined empirically by monitoring respiration, voice numerous problems: secretions interfere with airflow
quality, and the patient’s subjective assessment of comfort. through the small openings above the cuff; the cannula is
Alternatively, contraindications to valving are identified, difficult to position so that these openings are unob-
for example, obstructions to expiratory airflow resulting structed; voice quality is altered; speaking is dependent on
from either narrowing of the trachea or full or partial a caregiver and a source of compressed gas; and air may
occlusion of the glottis (e.g., bilateral vocal fold paralysis leak around the stoma with an objectionable gurgling
in the medial position). Additional efforts are made to sound (Gordan, 1984; Kluin, Maynard, & Bogdasarian,
determine if valving is possible if the patient’s clinical 1984; Leder, 1990; Leder & Astrachan, 1989; Leder &
characteristics change, for example, improvement in voice Traquina, 1989; Sparker et al., 1987). For these reasons,
quality. we have experienced limited success using speaking
tracheostomy cannulas in the rehabilitation population.
Preserving Oral Communication in Although these tubes can serve a useful purpose (Blom,
1988), their inherent disadvantages often preclude their use
Individuals With Tracheostomy Who over the long term.
Are Coupled to Ventilators Given the drawbacks and undesirable side effects
A “speaking tracheostomy cannula” offers one solution associated with cuff inflation as well as the disadvantages
for restoring oral communication despite dependence on associated with speaking tracheostomy cannulas, we have
mechanical ventilation through a cuffed cannula (Figure 6). advocated cuff deflation to restore oral communication for
Air for speech is supplied independently of ventilation by the ventilator-dependent individual with a tracheostomy
a compressed air source such as an oxygen supply. When (Tippett & Siebens, 1991). During the inspiratory phase,
the air control port is occluded, air from the source air delivered from the ventilator flows through the cannula
escapes through small openings above the inflated cuff and both into the lungs and through the glottis (Figure 7).
flows through the larynx, enabling the individual to speak. Phonation occurs during inflation of the lungs (inspiration),
Such cannulas were first developed by R. J. L. Whitlock a paradox when compared to the usual circumstance in
(1967) to facilitate communication for those patients who which phonation occurs during deflation (expiration). The
were unable to write due to paralysis or limb injuries. proportions of tidal volume used for speech and for
These tubes rely on an individual’s own oropharyngeal ventilation vary with glottic resistance, which is under
mechanism (Sparker, Robbins, Nevlud, Watkins, & volitional control by the patient. When the glottis is

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 FIGURE 7. Inspiration and expiration when a patient is FIGURE 8. Relationship between glottic aperture and inflation
coupled to a mechanical ventilator with a deflated cuff. of the lungs during the inspiratory cycle in a patient coupled
to a ventilator; glottis is open on the left and closed or
narrowed on the right.

narrowed, more of the tidal volume is delivered to the

lungs. When there is little laryngeal resistance, inflation of
FIGURE 9. Velum and tongue “fall” against the posterior
the lungs diminishes (Figure 8). Thus, the patient becomes pharyngeal wall in the supine position (right figure) narrowing
a participant in the regulation of inspiration by varying the pharyngeal opening and increasing resistance to airflow.
glottic aperture. During expiration, alveolar air escapes
through both the cannula into the ventilator tubing and
through the glottis (Figure 7).
Resistance to airflow during sleep is not actively
modulated by volitional control of the larynx. It is modu-
lated, however, by the combined resistance of four valve-
like apertures: the lips, the tongue-palate appositions, the
velopharyngeal wall, and the glottis of the relaxed larynx.
In the supine position (the usual position for the ventilator-
dependent individual during sleep), the pharynx offers
greater resistance to flow than in the sitting position
because the velum and tongue “fall” toward the posterior
pharyngeal wall (Figure 9), narrowing retrolingual cross-
sectional area of the pharyngeal airway by approximately
50% of its area measured prone (Weller, Siebens,
Marshall, Tippett, & Kirby, 1995). him to carry on his business over the telephone from his
Prentice and his colleagues (1989) proposed that home.” In the study of Bach and Alba (1990), 91 of 104
communication and airway clearance of ventilator- patients were adequately ventilated with deflated cuffs or
dependent patients be synchronized primarily with expira- cuffless tubes 24 hours per day; 10 were converted to
tion rather than inspiration. A one-way valve was used to noninvasive alternatives of ventilatory support and 3
obstruct tracheostomy outflow into the ventilator after the continued with cuff inflation. Respiration parameters were
lungs had been filled during inspiration. It is unclear within normal limits (i.e., arterial blood gas, daytime
whether this approach achieves more effective phonation oxygen saturation, end-tidal PCO2). Tippett and Siebens
and clearance of the upper airway than cuff deflation alone. (1991) studied 5 ventilator-dependent, cognitively intact
It is clear, however, that such valving is unnecessary for individuals with glottic control. We documented that cuff
effective oral communication, upper airway clearance, and deflation is compatible with safe ventilation, preserves oral
prevention of aspiration. communication, and, additionally, can be used to restore
There are precedents for using cuff deflation with oral alimentation. There are multiple other citations in the
patients who have a neurogenic basis for their ventilatory literature in which references are made to the use of cuff
insufficiency. Safar and Grenvik (1975) used this tech- deflation and cuffless tubes to facilitate oral communica-
nique in 1960 during the Maryland poliomyelitis epidemic. tion (Bach et al., 1981; Blom, 1988; Duggan & Dory,
In 1973, Auchingloss and Gilbert described the use of 1990; Heffner, Miller, & Sahn, 1986; Kinnear &
“leaking connections” between tracheostomy tubes and Shneerson, 1985; O’Donohue, Giovannoni, Goldberg,
fixed-cycle, volume-limited ventilators with 5 patients. Keens, Make, Plummer, & Prentice, 1986; Sivak et al.,
Successful cuff deflation was also reported with a 37-year- 1983; Zejdlik, 1983).
old man who had amyotrophic lateral sclerosis (Lehner,
Ballard, Figueroa, & Woodruff, 1980) and with 16
ventilator-dependent patients, one of whom had poliomy- Authors’ Experience
elitis (Make, Gilmartin, Brody, & Snider, 1984). The latter Since 1988, we have had experiences with 16 ventilator-
patient’s speech was considered “excellent and allowed dependent patients ranging in age from 18–80 years (Table

Tippett • Siebens 59
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 TABLE 1. Characteristics of ventilator-dependent patients the secretions that usually pool above the cuff. The tidal
regarding oral communication and cuff deflation at hospital volume was increased to compensate for the glottic leak
admission and discharge.
created by cuff deflation. The inspiratory phase of ventila-
tion was prolonged to optimize phrase length. Background
Oral Cuff
Pt. # Age Sex Diagnosis Communication Deflation
noise was minimized to capitalize on auditory cues
relevant to the patient and ventilator functions. The patient
Adm D/C Adm D/C was taught to speak during the output phase of the ventila-
1 40 F ALS Ya Y N Y tor cycle by using such cues as listening, observing
2 59 M SCI Ya Yb N Y
outward displacement of the chest, and sensing inflation of
the lungs. Adduction of the vocal folds was facilitated by
3 21 M DMD N Y N Y
instructions to “tighten your throat,” “hold your breath” or
4 70 M GBS N Yb N Cuffless
“push down.” The three criteria essential to success were
5 34 M ACM N Yb N Y cognition compatible with learning, laryngeal control
6 57 F AMD N Yb N Y sufficient for varying glottic resistance volitionally, and
7 74 F PSP N N Y Y most importantly, acceptance of the premise that cuff
8 18 F SCI N Y N Y inflation may be unnecessary.
9 24 M BMD N Y N Y
10 80 F SCS Ya Yb N Y Acknowledgments
11 23 M SCI N Y Y Y The authors are indebted to Nancy Hayter and Arnold Dent of
12 29 M SCI Ya Y N Y the Department of Respiratory Care, Good Samaritan Hospital,
13 66 M SCI Ya Y N Y Baltimore, Maryland, for their particular interest in restoring oral
14 75 M BDP N Y N No tube
communication to patients with tracheostomy and ventilator
dependency. The contributions of numerous nurses and therapists
15 24 M SCI Ya Y N Cuffless in the rehabilitation medicine program and the consultation of
16 42 M CHB N Y N Y James Heroy, Stephen Sellinger, and Howard Steiner are also
acknowledged with gratitude. Joseph French was invaluable by
a = speaking tracheostomy tube; b = Hopkins speaking valve virtue of designing the Hopkins speaking valve, and Nell Kirby in
providing them. The patience and skill of Linda Zeigenfuse in
preparing this manuscript was appreciated greatly.
1). There were 5 women and 11 men. Their diagnoses
included amyotrophic lateral sclerosis, spinal cord injury, References
Duchenne muscular dystrophy, Guillain-Barré syndrome,
Arnold-Chiari malformation, acid maltase deficiency, American Association for Respiratory Care. (1991). A study of
chronic ventilator patients in the hospital. Dallas: AARC.
progressive supranuclear palsy, Becker’s muscular Auchingloss, J. H., & Gilbert, R. (1973). Mechanical aid to
dystrophy, spinal cord stenosis, bilateral diaphragmatic ventilation in the home: Use of volume-limited ventilator and
paralysis, and cervical hemangioblastoma. leaking connections. American Review of Respiratory Disease,
At admission, 10 patients were not communicating 108, 373–375.
orally, and 6 communicated using speaking tracheostomy Bach, J. R., & Alba, A. S. (1990). Tracheostomy ventilation: A
cannulas. At discharge, 10 of the 16 patients remained study of efficacy with deflated cuffs and cuffless tubes. Chest,
ventilator-dependent. Of these 10, 8 were communicating 97, 679–683.
orally via cuff deflation and 1 tolerated a cuffless tube Bach, J. R., Alba, A., Pilkington, L. A., & Lee, M. (1981).
(patient 15). Another did not achieve successful oral Long-term rehabilitation in advanced stage of childhood onset,
communication because of cognitive/language deficits and rapidly progressive muscular dystrophy. Archives of Physical
Medicine and Rehabilitation, 62, 328–331.
severe dysarthria. Six patients progressed to ventilator Betts, R. H. (1965). Post-tracheostomy aspiration. New England
independence. Hopkins ball valves were applied to the Journal of Medicine, 273, 155.
cannulas of 5 of the 6. In summary, only 2 of the 16 Blom, E. D. (1988). Alternative methods of communication for
patients used cuff deflation when admitted. At discharge, intubated patients in critical care. Indiana Medicine, 81, 398–
13 practiced cuff deflation when awake, 2 used cuffless 400.
tubes and 1 had been decannulated. Cameron, J. L., Reynolds, J., & Zuidema, G. D. (1973).
These ventilator-dependent patients were taught to use Aspiration in patients with tracheostomies. Surgery, Gynecol-
cuff deflation using strategies that we have published ogy and Obstetrics, 136, 68–70.
previously (Tippett & Siebens, 1991). First, the anatomy Cowan, D. L. (1975). Laryngeal and tracheal stenosis: An
and physiology of respiration, the position of the cannula, adapted speaking-aid tracheostomy tube. Journal of
Laryngology and Otology, 89, 531–534.
and the relationship between airway and foodway were Dedo, H. H. (1990). Tracheotomy. In Surgery of the larynx and
reviewed. A 3-dimensional model showing anatomical trachea (pp. 81–110). Philadelphia: BC Decker, Inc.
structures in a sagittal exposure was most helpful. Duggan, M., & Dory, A. E. (1990, September). Speech for the
Cannulas were down-sized to a number six (Jackson or ventilator dependent patient. Poster session presented at the
Shiley) when necessary to assure low resistance flow Annual Convention of the American Association of Spinal
around the cannula in the tracheal lumen. The trachea was Cord Injury Nurses, Las Vegas, NV.
suctioned immediately on initial cuff deflation to remove Emery, F. M. (1972). Speaking valve for attachment to a

60 American Journal of Speech-Language Pathology • Vol. 4 • No. 2 May 1995

Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 10/17/2020, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
 tracheostomy tube. British Medical Journal, 2, 466.
Feldman, S. A., Deal, C. W., & Urquhart, W. (1966). Distur-
bance of swallowing after tracheostomy. Lancet, 1, 954–955.
French, J. J., Kummell, J., & Siebens, A. A. (1991). Adapting
the “Hopkins speaking valve” for use with a Shiley cannula.
Proceedings of the 14th Resna Conference, 376–378.
French, J., Siebens, A., Kummell, J., Kirby, N., & Eisele, J.
(1984). Preserving communication and airway clearance in
tracheostomized children and adults. Archives of Physical
Medicine and Rehabilitation, 65, 651.
Gordan, V. (1984). Effectiveness of speaking-cuffed
tracheostomy tube in patients with neuromuscular diseases.
Critical Care Medicine, 12, 615–616.
Gracey, D. R., Divertie, M. B., & Howard, F. M. (1983).
Mechanical ventilation for respiratory failure in myasthenia
gravis: Two-year experience with 22 patients. Mayo Clinic
Proceedings, 58, 597–602.
Gracey, D. R., McMichan, J. C., Divertie, M. B., & Howard,
F. M. (1982). Respiratory failure in Guillain-Barré syndrome:
A 6-year experience. Mayo Clinic Proceedings, 57, 742– 746.
Heffner, J. E., Miller, K. S., & Sahn, S. A. (1986).
Tracheostomy in the intensive care unit Part I: Indications,
technique, management. Chest, 90, 269–274.
Kinnear, W. J. M., & Shneerson, J. M. (1985). Assisted
ventilation at home: Is it worth considering? British Journal of
Disorders of the Chest, 79, 313–351.
Kluin, K. J., Maynard, F., & Bogdasarian, R. S. (1984). The
patient requiring mechanical ventilatory support: Use of the
cuffed tracheostomy “talk” tube to establish phonation.
Otolaryngology–Head and Neck Surgery, 92, 625–627.
Leder, S. B. (1990). Verbal communication for the ventilator-
dependent patient: Voice intensity with the Portex “talk”
tracheostomy tube. Laryngoscope, 100, 1116–1121.
Leder, S. B., & Astrachan, D. I. (1989). Stomal complications
and airflow line problems in the Communi-Trach I cuffed
talking tracheostomy tube. Laryngoscope, 99, 194–196.
Leder, S. B., & Traquina, D. N. (1989). Voice intensity of
patients using a Communi-Trach I cuffed speaking
tracheostomy tube. Laryngoscope, 99, 744–747.
Lehner, W. E., Ballard, I. M., Figueroa, W. G., & Woodruff,
D. S. (1980). Home care utilizing a ventilator in a patient with
amyotrophic lateral sclerosis. Journal of Family Practice, 10,
39–42.
Leverment, J. N., Pearson, F. G., & Rae, S. (1976). A mano-
metric study of the upper oesophagus in the dog following
cuffed-tube tracheostomy. British Journal of Anaesthesia, 48,
83–89.
Lynch, C. Q., Tippett, D. C., French, J. J., & Siebens, A. A.
(1990). Tracheostomy and upper extremity paresis: Restora-
tion of oral communication. Asha, 32, 181.
Make, B., Dayno, S., & Gertman, P. (1986). Prevalence of
chronic ventilator-dependency. American Review of Respira-
tory Disease, 133(4, part 2), A167.
Make, B., Gilmartin, M., Brody, J. S., & Snider, G. L. (1984).
Rehabilitation of ventilator-dependent subjects with lung
diseases: The concept and initial experience. Chest, 86, 358–
365.
Moore, P., & James, O. (1981). Guillain-Barré syndrome:
Incidence, management and outcome of major complications.
Critical Care Medicine, 9, 549–555.
O’Donohue, W. J., Giovannoni, R. M., Goldberg, A. I., Keens,
T. G., Make, B. J., Plummer, A. L., & Prentice, W. S.
(1986). Long-term mechanical ventilation: Guidelines for
management in the home and at alternate community sites.
Downloaded from: https://pubs.asha.org Iberoamericana- Instituto Universitaria on 10/17/2020, Terms of Use: https://pubs.asha.org/pubs/rights_and_permissions
Chest, 90, 1S-37S.
Passy, V. (1986). Passy-Muir tracheostomy speaking valve.
Otolaryngology–Head and Neck Surgery, 95, 247–248.
Pokras, R. (1987, April). Detailed diagnosis and procedures for
patients discharged from short-stay hospitalizations, United
States, 1985. Vital and Health Statistics, Series 30, No. 90.
DHHS Pub. No. (PHS) 87-1751. Public Health Service,
Washington, DC: U.S. Government Printing Office.
Prentice, W., Baydur, A., & Passy, V. (1989). Passy-Muir
tracheostomy speaking valve on ventilator dependent patients.
American Review of Respiratory Disease, 139, A541.
Ropper, A. H., & Kehne, S. M. (1985). Guillain-Barré syn-
drome: Management of respiratory failure. Neurology, 35,
1662–1665.
Ropper, A. H., Wijdicks, E. F. M., & Truax, B. T. (1991).
Respiratory failure. In Guillain-Barré syndrome (pp. 253–
262). Philadelphia: FA Davis.
Safar, P., & Grenvik, A. (1975). Speaking cuffed tracheostomy
tube. Critical Care Medicine, 3, 23–26.
Saul, A., & Bergstrom, B. (1979). A new permanent
tracheostomy tube: Speech valve system. Laryngoscope, 89,
980–983.
Siebens, A. A., Tippett, D. C., Kirby, N., & French, J. (1993).
Dysphagia and expiratory air flow. Dysphagia, 8, 266–269.
Sivak, E. D., Cordasco, E. M., & Gipson, W. T. (1983).
Pulmonary mechanical ventilation at home: A reasonable and
less expensive alternative. Respiratory Care, 28, 42–49.
Sivak, E. D., Gipson, W. T., & Hanson, M. R. (1982). Long-
term management of respiratory failure in amyotrophic lateral
sclerosis. Annals of Neurology, 12, 18–23.
Sparker, A. W., Robbins, K. T., Nevlud, G. N., Watkins, C.
N., & Jahrsdoerfer, R. A. (1987). A prospective evaluation
of speaking tracheostomy tubes for ventilator dependent
patients. Laryngoscope, 97, 89–92.
Tippett, D. C., & Siebens, A. A. (1991). Using ventilators for
speaking and swallowing. Dysphagia, 6, 94–99.
Toremalm, N. G. (1968). A tracheostomy speech valve.
Laryngoscope, 78, 2177–2182.
Weber, B. (1974). Eating with a trach. American Journal of
Nursing, 74, 1439.
Weller, J., Siebens, A., Marshall, T., Tippett, D., & Kirby, N.
(1995). The effect of position on cross sectional area of
pharynx. Proceedings of the Fifth International Conference on
Pulmonary Rehabilitation and Home Ventilation, 106.
Whitlock, R. M. L. (1967). A means of speaking for patients
with cuffed tracheostomy tubes. British Medical Journal, 3,
547.
Zejdlik, C. P. (1983). Promoting optimal respiratory function. In
Management of spinal cord injury (pp. 167–211). Monterey,
CA: Wadsworth Health Sciences Division.
Received March 28, 1994
Accepted October 25, 1994
Contact author: Donna C. Tippett, MA, Department of Communi-
cation Sciences and Disorders, Shock Trauma Center,
University of Maryland Medical System, 22 S. Greene Street,
Baltimore, MD 21201-1595
Key Words: tracheostomy, mechanical ventilation,
ventilator dependency, speech, communication
Tippett • Siebens 61