Capping

The cap generally comes packaged with the tracheostomy tube however additional caps may be available if the packaged cap is not available.  The color of the cap may be white or red.  The purpose of the cap is to allow the individual to use the respiratory muscles and allows the use of the upper airway.  Generally individuals who are ready to be weaned may use a cap.

Facilitating Speech with Tracheostomy Tube

The loss of speech can be addressed through three techniques.

Finger Occlusion

The easiest technique is for the patient to use their finger to occlude the trach.  The cuff on the tracheostomy tube must be deflated first.  This technique is dependent on the patient’s coordination.

Cap

The cap fits directly over the 15mm adaptor of the tracheostomy tube and usually comes in the same package as the tracheostomy tube.

The cap occludes the tracheostomy so all airflow passes by the tracheostomy tube in the trachea and past the vocal cords.  An important note must be made about the procedure to cap a tracheostomy tube:  The tracheostomy tube cuff MUST be deflated before capping.

Warning!

Air trapping is a sign that the patient is intolerant to the cap.  Air trapping occurs when a patient is unable to coordinate their breathing and they prematurely self occlude their airway with their vocal cords.  A remaining volume of air remains in the lungs during the subsequent breaths.  Over time a large volume of air is trapped in the lung.  Removing the cap releases this volume of air.  You will hear a “whooshing” sound from the tracheostomy tube when you remove the cap.  This confirms that you have released the pressure in the lungs.

Speaking Valve

A speaking valve is a one-way valve (i.e. Passy-Muir Valve) that allows airflow into the lungs  during inhalation but closes on exhalation to direct airflow past the vocal cords.  The speaking valve is attached to the tracheostomy tube directly.  A speaking valve can be tricky for patients to get used to and coaching and short practice times are essential for success.  The speaking valve can be used with or without mechanical ventilation. It is essential that the cuff is deflated before placement of the speaking valve.

Cuff down Without a Speaking Valve

There is another option for patients that doesn’t require additional equipment to facilitate speech.  If the tracheostomy tube cuff is deflated entirely and the mechanical ventilator is properly set the patient can use a portion of the inspired air for speech.

Incremental adjustments to the PEEP, tidal volume, and inspiratory time facilitate this method of speech.  It is quite possible that if the ventilator is set with a continuous flow, typically with higher PEEP, the patient may be able to speak continuously without pause.  Again, alarm adjustments should be made due to the loss of a portion of the mechanical breath.

Generally speaking, patients who are not mechanically ventilated have sufficient respiratory muscle strength to generate enough flow to vocalize.

Guidelines

• Saturations may also drop so it is important to use a pulse oximeter for the first few trials.
• Suction the patient before placing the speaking valve or red cap.
• Remain at the bedside to assess the patients’ readiness and also to assess their oxygen saturations and assist with instruction and coaching.
• Patient tolerance when on the speaking valve varies between individuals.
• Consider requesting a speech therapist or respiratory therapist to be available to assist.

WARNING!

Always assess the patient when placing a cap or speaking valve to make sure the cuff on the tracheostomy tube is deflated.  Even if you are 100% sure that the cuff is deflated, one should always re-check.  Use a syringe to deflate the cuff.  This will ensure that the patient does not suffocate due to negligence of leaving an inflated cuff and occluding the tracheostomy tube.