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Communicating with conscious mechanically ventilated critically ill patients: let them speak with deflated cuff and an in-line speaking valve!
Critical Care volume 21, Article number: 7 (2017)
With great interest we read the article in Critical Care by ten Hoorn et al. . We appreciate the efforts of the authors to write the first review about interventions enabling communication with critically ill patients and to develop an algorithm to select a communication technique. Their attention was focused on patients who were completely ventilator dependent. In cases where tracheotomized patients are able to tolerate cuff deflation, a spontaneous breathing trial with a one-way speaking valve is suggested in their algorithm. However, we would like to point out that this algorithm lacks an important alternative in this particular patient group.
Several studies have been reported on tracheotomized ventilator-dependent critically ill patients who are able to speak with a speaking valve in the respiratory circuit. Speech by tracheotomized ICU patients during mechanical ventilation with a deflated cuff had already been described by Manzano (Verbal communication of ventilator-dependent patients. Crit Care Med 1993;21(4):512-517). In recent years we are aware of at least three articles addressing the issue of enabling speech during weaning of tracheotomized patients off the ventilator. Egbers et al.  described their experience with a high-flow ventilator, a deflated cuff, and an in-line speaking valve. Sutt et al.  restored speech with use of an in-line speaking valve earlier compared to patients that only used a speaking valve during spontaneous breathing trials. Despite a deflated cuff, lung recruitment improved  and in-line speaking valve use is part of their standard care in prolonged weaning. In a randomized clinical trial by Freeman-Sanderson et al.  the intervention group received early cuff deflation and insertion of an in-line speaking valve during mechanical ventilation. Restoration of phonation was significantly sooner and without an increase in complications compared to standard therapy with a speaking valve and trials of spontaneous breathing .
Although it was partially beyond the scope of the literature search by ten Hoorn et al. (search closed December 2015), we would like the readers of Critical Care to draw their attention to this possibility, which has considerable potential to enable speech in tracheotomized patients who are (not yet) able to sustain longer periods of spontaneous breathing trials.
ten Hoorn S, Elbers PW, Girbes AR, Tuinman PR. Communicating with conscious and mechanically ventilated critically ill patients: a systematic review. Crit Care. 2016;20(1):333.
Egbers PH, Bultsma R, Middelkamp H, Boerma EC. Enabling speech in ICU patients during mechanical ventilation. Intensive Care Med. 2014;40(7):1057–8.
Sutt AL, Cornwell P, Mullany D, Kinneally T, Fraser JF. The use of tracheostomy speaking valves in mechanically ventilated patients results in improved communication and does not prolong ventilation time in cardiothoracic intensive care unit patients. J Crit Care. 2015;30(3):491–4.
Sutt AL, Caruana LR, Dunster KR, Cornwell PL, Anstey CM, Fraser JF. Speaking valves in tracheostomised ICU patients weaning off mechanical ventilation--do they facilitate lung recruitment? Crit Care. 2016;20:91.
Freeman-Sanderson AL, Togher L, Elkins MR, Phipps PR. Return of voice for ventilated tracheostomy patients in ICU: a randomized controlled trial of early-targeted intervention. Crit Care Med. 2016;44(6):1075–81.
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PHE and ECB are both responsible for writing, revising, and submitting this letter. Both authors read and approved the final manuscript.
The authors declare that they have no competing interests.
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See related research by ten Hoorn et al., https://ccforum.biomedcentral.com/articles/10.1186/s13054-016-1483-2
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Egbers, P.H., Boerma, E.C. Communicating with conscious mechanically ventilated critically ill patients: let them speak with deflated cuff and an in-line speaking valve!. Crit Care 21, 7 (2017). https://doi.org/10.1186/s13054-016-1587-8
- Mechanical Ventilation
- Standard Care
- Spontaneous Breathing
- Considerable Potential
- Verbal Communication