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Speaking Valves (3.46)

Speaking Valves (3.46) - Policies, Clinical, UWHC Clinical, Department Specific, Respiratory Care Services, Airway Care

3.46

3.46 Speaking Valves
Category: UWHC Patient Care Policy
Effective Date: July 1, 2017
Version: Revision
Manual: Respiratory Care Services

I. PURPOSE:
A speaking valve is a one way valve designed for communication for patients with a
tracheostomy. The use of a speaking valve may assist with improving swallow function due to
subglottic pressure restoration in pharynx/trachea, reducing occurrence of laryngeal penetration
and aspiration, improving secretion management, improving smell and taste, facilitating muscle
training and potential weaning from ventilator and tracheostomy tube.

A one way valve allows gas flow to enter the artificial airway when the patient generates a
negative inspiratory pressure of less than 2cmH20. The valve begins to close at the end of the
inspiratory cycle, providing a positive seal. Gas flow cannot escape through the artificial airway
and therefore is directed through the vocal cords and out of the upper airway. This allows
phonation to occur, and may decrease the work of breathing. (Normal upper airway inspiratory
pressures are negative 7 to negative 15 CmH20).

II. CONTRAINDICATIONS:
A. Laryngectomy
C. Bilateral vocal cord paralysis in the adducted position
D. Tracheostomy tubes with inflated cuffs

III. POLICY:
A. All patients will be assessed by the Respiratory Care Practitioner (RCP).
B. Therapy will be provided in accordance with a provider’s order.
C. Patients who have not passed their swallow study must have MD approval.
D. Patients must be under supervision when wearing this device, unless they can physically
remove the valve if it were to stop functioning properly.
1. RCP and RN will be present during initial trials.
2. AFCH requires a Speech Language Pathologist present during initial trials.
3. Once tolerance of speaking valve has been determined, RCP does not need to be
present during the duration; only during initiation and discontinuation while on a
ventilator.
4. Once care providers have been trained and signed off on home mechanical ventilation
and speaking valve utilization, they may do a speaking valve trial on their own
without RCP and/or RN present.
E. If patient transitions from an ICU to home ventilator, patient will require new evaluation for
tolerance of speaking valve in-line with ventilator with the RCP. Respiratory Therapy
F. Initial trials must be monitored with telemetry or pulse oximetry.
G. Trial will be 30 minutes or as tolerated.
1. AFCH defines mechanical ventilator initial trials as 3 trials; each 30 minutes in
length.

2. Success of initial trials will designate patient tolerance and no longer require RT to be
during duration of the speaking valve trial.
3. In AFCH, speaking valve trial will be held during the speech session to allow the
Speech Language Pathologist to evaluate the appropriateness of the utilization of the
speaking valve.
H. If patient is on a PEEP ≥ 12 cm H20 may not be able to use the speaking valve since the loss
of positive pressure may increase work of breathing due to airway collapse.
I. If the speaking valve should become sticky, noisy, vibrate, or cause increased resistance on
inspiration prior to or after two months, the speaking valve should be replaced.

IV. EQUIPMENT:
A. Speaking valve with adapters (see related link)
B. Syringe for cuff deflation
C. Suction equipment
D. Manual resuscitator

V. PROCEDURE:
A. Review and acknowledge the provider’s order.
B. Review patient’s chart.
C. Obtain the appropriate equipment. (See related link).
D. Assess the patient to determine if the appropriate indications for therapy are present.
E. Introduce yourself to the patient and/or family. Explain the reason for the procedure.
F. Suction the patient via mouth and tracheostomy.
G. Reposition the patient for optimal breathing mechanics. Slowly deflate the tracheostomy cuff.
H. Monitor patient’s tolerance of speaking valve throughout trial by evaluating patient’s
respiratory status; looking for signs of fatigue, hemodynamic changes, and SpO2 changes.
I. When a fenestrated tube is present, insert the fenestrated inner cannula.
J. For non-ventilated patients
1. RCP or The Speech Language Pathologist will test the patency of the upper airway and
glottis functioning by occluding the trach with a clean gloved finger.
a. If patient is able to phonate, continue with procedure.
b. If patient is unable to phonate or exhale out of mouth/nose, abort procedure and
notify MD for further upper airway assessment.
2. Place the valve on the patient’s trach hub.
3. Have the patient attempt to speak.
K. For ventilator dependent patients
1. Attach the valve in line with the ventilator circuit. (see related link).
2. Monitor patient’s tolerance of speaking valve throughout trial (see V. Procedure H) as
well as Peak Inspiratory Pressure (PIP) and Tidal Volume on ventilator.
3. If peak pressures rise above allowable limits, remove speaking valve immediately.
4. Adjust ventilator settings and alarms as necessary.
a. TIDAL VOLUME: May need to compensate for volume lost by increasing tidal
volume or PIP to reach volumes achieved prior to placement of the speaking
valve. Increase tidal volume in small increments to achieve previous PIPs if
necessary. DO NOT EXCEED PRE-CUFF DEFLATION PIPs. No volume
adjustments should be needed if PIPs stay within their normal range.

b. PEEP: May need to turn off PEEP to reduce or eliminate the excessive flow and
auto-cycling created by the vent trying to maintain PEEP level with cuff leak. If
the patient is ≥ to 12 Cm PEEP, they may not be able to use the speaking valve
since the loss of positive pressure may increase work of breathing due to airway
collapse. Note: If end exp pressure climbs (stair stepping on wave form), patient
is most likely air trapping. This means there is not enough leak around the trach –
may need to reduce PEEP.
c. PRESSURE SUPPORT (PS): Patients on PS need to have the pressure support
decreased to allow the vent to cycle into exhalation. At higher PS levels, flow
may not decrease because of the leak, giving the patient a long inspiration.
Another option is to consider change to AC mode during speaking valve use.
d. ALARMS: Reevaluate all alarms for appropriate adjustments.
1. Exhaled Volume/Minute Ventilation alarms: Air is not exhaled via
ventilator circuit and back to the machine, therefore ventilator will not be
able to read any exhaled volumes
2. Pressure Alarms: Ensure sensitive disconnect and sensitive high pressure
alarms.
L. Once session is complete, remove the speaking valve and adapters if indicated and replace
with setup being used prior to speaking valve placement.
1. Return ventilator settings and alarms to their previous levels prior to valve placement.
2. Re-inflate the cuff, as indicated.
1. Unless the physician has written an order for the cuff to remain deflated during
waking hours.
2. Unless the speaking valve has been expanded and no longer limited to just speech
sessions.
M. In AFCH: after the success of the initial 3 trials for 30 minutes each, obtain an order for
frequency and duration of continued trials.
N. Bedside documentation of patient speaking valve trial.
1. CSC: Place sticker on balloon cuff and post signs above patient’s bed identifying them as
candidates for use of valve to ensure safety.
2. AFCH: Place the information on the suction card located at the head of patient’s bed .
O. Cleaning:
1. Speaking valve is to be cleaned by nursing daily.
2. Do Not Use: hot water, alcohol, peroxide bleach, autoclaving, or ethylene oxide to
clean, as it will destroy the rubber valve.
3. Using a mild soapy detergent, swish speaking valve and accessories in soapy warm
water. See instructions on inside of storage container.
4. Rinse thoroughly with sterile water. (If the valve is not totally clean of detergent, the
valve may get sticky.) Allow the valve and accessories to air dry thoroughly before
placing in closed storage container.

VI. REFERENCES:
A. Respiratory Care P&P 3.45 Tracheostomy Change and Weaning.
B. SpeakingvalveSet-ups.docx
C. www.bosmed.com

D. The Children’s Institute. (2011). Passy Muir Valve Use. Pittsburg, PA: Patricia McMellon
MA, CCC/SLP.
E. Respiratory Care P&P. (2007). Passy Muir Speaking Valve.