Safety and feasibility of above cuff vocalisation for ventilator-dependant patients with tracheostomies

Introduction: Temporary tracheostomy is commonly used in patients admitted to intensive care units. Cuffed tubes prevent laryngeal airflow, preventing vocalisation. Sub-glottic suction tubes such as the ‘Blue Line Ultra Suctionaid™’ are used primarily to remove sub-glottic secretions, but retrograde gas flows via the suction port can facilitate above cuff vocalisation. The aims were to assess whether patients could achieve an audible voice using above cuff vocalisation, to demonstrate the safe use of the Blue Line Ultra Suctionaid™ tracheostomy tube for above cuff vocalisation, and to assess potential benefits of above cuff vocalisation for communication, secretion management and swallowing. Methods: Our study (Reference 15/NW/0464, IRAS 178997) recruited adult intensive care unit patients who were alert, able to participate in an above cuff vocalisation trial and dependent on an inflated Blue Line Ultra Suctionaid™ cuff for ventilatory support. Consenting participants underwent fibreoptic endoscopic assessment of swallow by experienced Speech & Language Therapy staff with and without above cuff vocalisation. Clinical and fibreoptic endoscopic assessment of swallow, assessment of voice quality, swallowing and secretion management were recorded and scored. Median differences between paired observations and scores were analysed with and without above cuff vocalisation. Adverse events were identified by follow up fibreoptic endoscopic assessment of swallow and patient accounts. Results: Ten patients completed the study. Above cuff vocalisation was used for a median of 15 min, during a median of nine episodes, over a median of three days. Above cuff vocalisation resulted in an audible voice in eight of the 10 patients, during 66 out of 91 above cuff vocalisation attempts. There improvements in unstimulated dry cough and swallow frequency and aspiration ratings measured by fibreoptic endoscopic assessment of swallow. No complications were reported or observed in 66 attempts with only one episode terminated prematurely. Conclusions: Above cuff vocalisation can achieve effective, safe, well-tolerated vocalisation in ventilator-dependant intensive care unit patients. Above cuff vocalisation has the potential to aid earlier, more effective communication and may improve laryngeal function and rehabilitation.