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Table 1 Characteristics of the included studies (n = 31)

From: Communicating with conscious and mechanically ventilated critically ill patients: a systematic review

Author, year Study design and sample size Intervention type Study population (tracheostomized; intubated) Measures Main findings
Otuzoğlu, 2014 [12] Quasi-experimental
– no randomization
– control group (n = 90)
Communication board Orally intubated patients after cardiac surgery Question forms for assessment:
communication experiences during intubation period, and evaluation of communication process
Communication board was helpful (77.8 %; n = 35) and partially helpful (22.2 %; n = 10)
In the control group 35.6 % (n = 16) had difficulties with the communication, in the treatment group 2.2 % (n = 1)
Patak, 2006 [17] Retrospective study (n = 29)
– no control group
Communication board Patients with mixed diagnosis. Type of intubation unknown Structured interview with 13 questions, self-developed: level of frustration without and if a communication board had been available Frustration in communication would have been lower if a communication board had been offered (29.8 % vs 75.8 %; p < 0.001)
97 % (n = 28) perceived that a communication board would have been helpful in communicating effectively
Stovsky, 1988 [30] Quasi-experimental
– no randomization
– control group (n = 40)
Communication board Orally intubated patients after cardiac surgery Open-end patient interview
Satisfaction questionnaire
Visual analog scale on satisfaction with communication
A planned communication with the board increased patient satisfaction (t = 2.09, n = 35, p = 0.05)
68 % (n = 27) in both groups stated that learning a communication technique before surgery was beneficial
Kluin, 1984 [36] Case series (n = 19) Speaking tube Portex “Talk” Tracheostomized patients with mixed diagnosis Subjective assessment of improved communication 74 % (n = 14) acquired intelligible speech, 16 % (n = 3) had fluctuating function due to problems with secretions or mental status, 11 % (n = 2) were unsuccessful
Kunduk, 2010 [37] Case series (n = 10) Speaking tube Blom Speech Cannula Tracheostomized patients with mixed diagnosis Success in phonation (e.g., sentence length and volume)
Subjective satisfaction
90 % (n = 9) achieved sustained audible phonation and were very satisfied with the device and their speech quality
Leder, 2013 [40] Case series (n = 23) Speaking tube Blom Speech Cannula Tracheostomized patients with mixed diagnosis Voice intensity levels, obtained using a digital sound level meter
Assessment of Intelligibility of Dysarthric Speakers (AIDS)
All participants achieved audible voicing
Speech intelligibility scores improved from 80 % to 85 % (p = 0.03)
Time to audible voicing was 6.60 min (SD 5.81)
Leder, 1990 [39] Case series (n = 20) Speaking tube Portex “Talk” Tracheostomized patients with mixed diagnosis Voice intensity levels, obtained using a digital sound level meter
Subjective assessment by SLP
Significant greater voice intensity over ambient room noise at 5 l/min, 10 l/min, and 15 l/min (all p < 0.001)
All subjects demonstrated adequate voice intensity for conversational speech intelligibility
Leder, 1989 [38] Case series (n = 20) Speaking tube Communi-Trach I Tracheostomized patients with mixed diagnosis See Leder, 1990 [39] Significant greater voice intensity over ambient room noise at 5 l/min, 10 l/min, and 15 l/min (all p < 0.01)
90 % (n = 18) demonstrated adequate speech
Mitate, 2015 [48] Case report (n = 1) Speaking valve (Vocalaid) Ventilator-dependent tetraplegic Subjective assessment of improved communication Talked 10 min with Vocalaid, with fatigue (inadequate for communication).
Mouthstick stylus fixed on maxilla made communication possible with a communication board and an iPad touchscreen
Pandian, 2014 [49] 4 case reports (n = 4) Speaking tube BLUSA cuffed tracheostomy tube Tracheostomized patients with mixed diagnosis Subjective assessment of improved communication All achieved adequate phonation. One used it as his primary means of communication, the others only for short sentences to express their basic needs. With two cases someone else had to occlude the thumb port needed for phonation
Sparker, 1987 [42] Case series (n = 19) Speaking tube Portex “Talk” and Communi-Trach I Tracheostomized patients, mainly with spinal cord fracture Assessment of intelligibility with the AIDS (n = 5)
Subjective assessment SLP (n = 19)
All patients were able to speak, 79 % (n = 15) utilized the device effectively for communication
Adler, 1986 [31] Case series (n = 22) Electrolarynx neck type Tracheostomized patients with mixed diagnosis Subjective assessment of improved communication by SLP (good, fair, or poor) 64 % (n = 14) achieved good results 14 % (n = 3) achieved fair results, 23 % (n = 5) achieved poor results
Ewing, 1975 [33] Case series (n = 8) Electrolarynx 1 neck type; 1 intra-oral type Tracheostomized patients with unknown diagnosis Daily written evaluation
Patient and staff questionnaire to determine quality, ease of use, and preference for device
EL was preferred by both patients and staff over other communication methods (lip movement, sign language, writing)
EL was: most comfortable, easiest to use, and clearest for self-expression
Girbes, 2014 [47] Case report (n = 1) Electrolarynx neck type Orally intubated man after lung surgery Subjective assessment of improved communication EL enabled the patient to immediately produce intelligible speech
Shimizu, 2013 [50] Case report (n = 1) Electrolarynx neck type Tetraplegic tracheostomized patient Subjective assessment of improved communication The patient gradually became better able to speak fluently and could be understood on the first day of EL use
Summers, 1973 [43] Case series (n = 5) Electrolarynx neck type Tracheostomized patients with mixed diagnosis Subjective assessment of improved communication 80 % (n = 4) was able to produce clear, intelligible speech 20 % (n = 1) was able to speak, but quite poorly
Easy to learn how to use the device
60 % (n = 3) manipulated EL on the neck themselves
Tuinman, 2015 [44] Case series (n = 15) Electrolarynx Mixed diagnosis. Oral tube (n = 13) and tracheostomy (n = 2) A developed five-point Electrolarynx Effectivity Score (EES) EL was effective or very effective (EES 4 and 5) with 40 % (n = 6). For two patients it improved lip-reading (EES 3)
The intra-oral type was used successfully in one patient
Wu, 1974 [46] Case series (n = 27) Electrolarynx neck type Diagnosis unknown. Oral (n = 4) and nasal tube (n = 4), tracheostomy (n = 19) Subjective evaluation of improved communication (excellent, good, or failure) 70 % (n = 19) reported “excellent” or “good” results
All excellent results came from tracheostomized patients
Both nasotracheal and orotracheal intubated patients (n = 8) reported 50 % “good” results
Happ, 2004 [34] Case series (n = 11) “High-tech” AAC 2 VOCAs:
– MessageMate
– DynaMyte
Mixed diagnosis Oral tube (n = 7) and tracheostomy (n = 4) Communication Methods Checklist
Revised Ease of Communication
Scale (ECS)
Semi-structured interviews
ECS measurements showed significantly less difficulty with communication after device use (t > 2.62; n = 11, p = 0.047)
73 % (n = 8) used VOCAs with minimal assistance and instruction
Happ, 2005 [35] Case series (n = 10) “High-tech” AAC 2 VOCAs:
– MessageMate
– DynaMyte
Tracheostomized patients following surgical procedures for head or neck cancer – Revised ECS
– Semi-structured interviews
– Questionnaires
VOCAs were used in 17 % (n = 8) of total observed events.
60 % of the messages were completed without assistance
ECS scores showed less difficulty communicating with the VOCA (mean 19.8) in comparison with control group (mean 22.5)
Etchels, 2003 [32]
MacAulay, 2002 [54]
Case series (n = 19) “High-tech” AAC ICU-Talk communication computer Mixed diagnosis. Oral tube (n = 13) and tracheostomy (n = 6) ICU-Talk Project:
Nurse Questionnaire
Relative Questionnaire
Patient Questionnaire
16 % (n = 3) remembered using it and found it useful
Summary findings nurse questionnaires:
12 % used it as a first means of communication
44 % said ICU-Talk assisted with patient care
72 % said that the patient did stop using ICU-Talk
Garry, 2016 [51] Pilot prospective study (n = 12)
– no control group
“High-tech” AAC
eye-tracking device
The Tobii C12 eye-tracking computer
Mixed diagnosis. Oral tube (n = 3), tracheostomy (n = 8), self-maintained (n = 1) Psychosocial Impact of Assistive
Devices Scale (PIADS)
All patients were able to communicate basic needs to nursing staff and family. Positive mean overall impact score (PIADS = 1.30; n = 12, p = 0.004), and in mean scores for each PIADS domain: competence = 1.26, adaptability = 1.60, and self-esteem = 1.02 (all n = 12, p < 0.01)
Koszalinski, 2015 [52] Pilot observational study (n = 20)
– no control group
“High-tech” AAC
Speak for Myself Computer Pad Software Application
Mixed diagnosis.
Type of intubation unknown
Three open-ended questions that asked if the patient users liked or disliked using Speak for Myself 95 % (n = 19) stated that Speak for Myself was helpful for communication
All but one patient said they would use Speak for Myself if hospitalized again and unable to speak
Frustration was less with Speak for Myself (better able to communicate, more in control, more power to make choices)
Maringelli, 2013 [41] Case series (n = 15) “High-tech” AAC gaze-controlled communication system Mixed diagnosis. Oral tube (n = 7) and tracheostomy (n = 8) Internally developed pre- and post-intervention questionnaires, one per each group (patients, physicians, nurses) Significant improvement in different communication domains, and a remarkable decrease of anxiety and dysphoric thought
Improved the physicians’ and nurses’ ability to understand patients’ fundamental needs and clinical conditions (p < 0.001)
Miglietta, 2004 [53] Pilot prospective study (n = 35)
– no control group
“High-tech” AAC
LifeVoice communication computer
Nonverbal acutely ill trauma patients
Type of intubation unknown
Questionnaires with graded responses (1–5) related to ease of use and perception of improvement in comfort and anxiety (days 1, 3, and 7) 94 % (n = 33) of patients were interested in continued use >90 % of patients felt the system assisted them in obtaining their needs (pain management, hygiene, comfort, and anxiety)
Hospital staff (n = 42) felt the device improved patient care (96 %) and comfort (91 %)
Rodriguez, 2012 [19] Pilot observational study (n = 11)
– no control group
“High-tech” AAC
multifunctional communication computer
Patients mainly following surgery for head or neck cancer Type of intubation unknown Usability of communication intervention form (every day)
Patient satisfaction and usability instrument (prior to discharge)
Ability to independently use the device from day 1 until completion of the study
91 % (n = 10) of the participants were satisfied with use of the device and considered its use and functions of importance
Van den Boogaard, 2004 [45] Case series (n = 9) “High-tech” AAC
“intelligent” keyboard compared with a letter board
Unknown diagnosis.
Type of intubation unknown
Patient evaluation of satisfaction, convenience of use, and amount of effort required to work with each communication aid. Nurses were required to evaluate similarly Both patients (88 % resp. 43 %) and nurses (86 % resp. 33 %) were more satisfied with the keyboard than the alphabetical letter board
Five patients (56 %) thought the keyboard was easy to operate
All patients chose to continue using it
Dowden, 1986a [28]
Dowden, 1986b [55]
Quasi-experimental
– no randomization
– no control group (n = 50)
Divers AAC:
– Oral (EL, speaking valve)
– Fine motor (communication board, memowriter)
– Limited switch (eye-scanning or single switch)
Mixed diagnosis.
Type of intubation unknown
Interview before intervention for needs assessment (list of specific communication requirements)
Interview after intervention to assess success of chosen communication aid
96 interventions were implemented with 50 patients.
Motor control capabilities of patients allowed 49 % oral approaches, 46 % fine motor approaches, and 5 % limited switch approaches
Oral approaches and fine motor approaches met an average of respectively 53 % and 68 % of their communication needs
Use of several approaches simultaneously was most successful, this resulted in an average of 70–82 % of needs met
Happ, 2014 [29] Quasi-experimental
– no randomization
– control group (n = 89)
Diverse AAC:
Phase 1: usual care
Phase 2: BCST
Phase 3: training electronic AAC and consult SLP
Mixed diagnosis. Oral tube (n = 21) and tracheostomy (n = 68) Frequency and quality of communication exchange
Success of each communication exchange on a five-point scale
Ease of communication by patient’s self-report on a five-point scale
Frequency of AAC use per exchange
AAC was used in 0.84 % (Phase 1), 0.51 % (Phase 2), and 6.31 % (Phase 3)
Increase in communication frequency in ICU Unit A (Phase 1 vs 3 (p < 0.0001); Phase 1 vs 2 (p < 0.0001))
Patients in the AAC + SLP intervention group used significantly more AAC methods (p = 0.002) and patients’ perceptions about communication ease improved (p < 0.01)
  1. AIDS (Assessment of Intelligibility of Dysarthric Speakers): tool for quantifying single-word intelligibility, sentence intelligibility, and speaking rate of adult speakers with dysarthria
  2. Revised ECS (Ease of Communication Scale): 10 Likert-type statements about perceived communication difficulty to patients who referred to a card printed in large font with response selections (0) not hard at all, (1) a little hard, (2) somewhat hard, (3) quite hard, (4) extremely hard
  3. EES (Electrolarynx Effectivity Score): five-point scale: (1) no improved intelligibility, because of insufficient mouth movement; (2) no effect, but sufficient mouth movement;
  4. (3) improved lip-reading by producing recognizable sounds; (4) effective, can speak words; (5) very effective, can make sentences
  5. PIADS (Psychosocial Impact of Assistive Devices Scale): list of 26 self-reported items to assess functional independence, well-being, and quality of life
  6. AAC augmentative and alternative communication, VOCA voice output communication aid, SLP speech language pathologist, EL electrolarynx, BCST basic communication skills training (e.g., communication board, writing)