Restoring Voice After Tracheostomy: Communication options to support patient-centric care

The Clinical Significance of Restoring Communication

A tracheostomy tube alters normal airflow through the larynx, resulting in an inability to produce audible voice. Patients with tracheostomies frequently report frustration, fear, anxiety, isolation, and a loss of control related to their inability to speak (Foster, 2010; Tolotti et al., 2018). Qualitative studies describe communication loss as one of the most distressing aspects of critical illness, with patients expressing feelings of helplessness, panic, and despair when they are unable to make their needs known (Freeman-Sanderson et al., 2018; Volpato et al., 2025).

Restoring verbal communication is therefore a critical component of patient-centered tracheostomy care. The ability to speak has been associated with significant improvements in patient-reported self-esteem, particularly related to being understood by others (Freeman-Sanderson, 2016). Verbal communication allows patients to more fully express their thoughts, emotions, and care needs, which in turn enhances patient satisfaction and overall quality of life (Morris et al., 2015). Improved patient-reported quality of life has also been demonstrated in individuals with tracheostomies receiving mechanical ventilation when verbal communication is restored (Pandian et al., 2020), highlighting the importance of prioritizing verbal communication whenever clinically feasible.

A Clinical Framework for Patient-Centered Communication

Restoring communication is a shared responsibility of the multidisciplinary team, with speech-language pathologists playing a central role in assessment and intervention. Patients may rely on a combination of non-verbal strategies, such as augmentative and alternative communication (AAC), and verbal communication approaches. AAC strategies may include writing tools, alphabet or picture boards, gesture systems, eye-tracking devices, and electronic communication aids. When verbal communication is not yet possible, these tools should be implemented as early as possible and may be used alone or in combination with verbal approaches depending on patient condition.

Whenever possible, verbal communication should be prioritized, as it represents the most natural form of interaction. Restoring airflow to the upper airway not only enables voice but also provides important physiologic benefits, including improved secretion management and swallowing (OConnor et al. 2019; Tang et al. 2025). Upper airway airflow can be reestablished using strategies such as leak speech, speaking valves, and above-cuff vocalization, helping patients regain their voice as early as clinically appropriate.

Restoring Voice: Clinical Options and Considerations

Leak Speech
Leak speech occurs when airflow passes around the tracheostomy tube and through the vocal folds during exhalation, which may be possible with a cuffless tube or a deflated cuff, provided there is adequate airway patency and sufficient space between the tube and tracheal wall.

When audible voice is produced under these conditions, it is referred to as leak speech. Voice quality is often weak or low in volume but leak speech may provide an early opportunity for verbal communication in select patients. Tracheostomy tubes with an optimized inner-to-outer diameter ratio, such as the Tracoe Twist Plus, can help facilitate airflow around the tube and support voicing potential.

Speaking Valves
Speaking valves are devices that attach to the 15 mm connector of a tracheostomy tube. They permit inhalation through the tube and, during exhalation, the valve redirects airflow around the tracheostomy tube, through the larynx, restoring audible voice. To utilize a speaking valve, patients must have a cuffless tracheostomy tube or completely deflated cuff.

Several categories of speaking valves are available to meet varying patient needs:

• A fully occlusive speaking valve redirects all exhaled airflow through the upper airway to support phonation (e.g., Passy-Muir Speaking Valve).
• An adjustable speaking valve can be fully closed to direct all exhaled airflow through the upper airway, or it can be opened or partially opened to reduce expiratory resistance and potentially minimize air trapping (e.g., Tracoe Phon Assist Speaking Valve).
• Speaking valves with integrated heat and moisture exchangers (HME) provide both speech and humidification in a single system (e.g., DualCare Speaking Valve + HME).

Tracoe TrachPhone HME
TrachPhone is an HME with an integrated push-to-speak valve, offering an alternative method of voice restoration while maintaining humidification.

Above Cuff Vocalization (ACV)

Above Cuff Vocalization (ACV) is a voicing technique used for patients requiring an inflated tracheostomy cuff during mechanical ventilation. A tracheostomy tube with a subglottic suction port (e.g., Tracoe Twist Plus Extract) is required. Air or oxygen is introduced through the subglottic port, directing airflow into the upper airway to restore voice.

General clinical considerations for ACV:

• Preparation: Clear secretions from above the cuff before starting, explain the procedure to the patient and caregivers, ensure appropriate positioning, and connect appropriate tubing for ACV delivery.
• Airflow management: Deliver airflow through the subglottic suction line. Start with low flow (approximately 1 L/min) and adjust based on patient tolerance, keeping flows below 10 L/min. (Petosic et al. 2021; Gajic et al. 2024)
• Monitoring: Observe vital signs, patient comfort, and voicing ability throughout the procedure. Discontinue ACV if there are significant changes in status or discomfort.
• ACV should be individualized for each patient, balancing communication goals with safety and comfort.

Clinical Implications and Key Takeaways

Loss of verbal communication is one of the most distressing consequences of a tracheostomy, with profound effects on emotional well-being and quality of life. Although AAC strategies are essential when speech is not immediately possible, restoring verbal communication should be prioritized whenever clinically appropriate. Speech-language pathologists and their multidisciplinary colleagues play a critical role in actively advocating for, assessing, and implementing verbal communication strategies including leak speech, speaking valves, and above-cuff vocalization to ensure timely, patient-centered care, promote patient engagement, and optimize both clinical and psychosocial outcomes.

References:
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Freeman-Sanderson AL, Togher L, Elkins MR, Phipps PR. Quality of life improves with return of voice in tracheostomy patients in intensive care: an observational study. J Crit Care. 2016;33:186–191. https://doi.org/10.1016/j.jcrc.2016.01.012

Foster A. More than nothing: the lived experience of tracheostomy while acutely ill. Intensive Crit Care Nurs. 2010;26(1):33–43. https://doi.org/10.1016/j.iccn.2009.09.004

Gajic O, et al. Implementation of above-cuff vocalization after tracheostomy is feasible and associated with earlier speech. Am J Speech Lang Pathol. 2024;33(1):51–56.

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O’Connor L, Morris N, Paratz J. Physiological and clinical outcomes associated with use of one-way speaking valves on tracheostomised patients: a systematic review. Heart Lung. 2019;48(4):356–364. https://doi.org/10.1016/j.hrtlng.2018.11.006

Pandian V, Cole T, Kilonsky D, Holden K, Feller-Kopman DJ, Brower R, et al. Voice-related quality of life increases with a talking tracheostomy tube: a randomized controlled trial. Laryngoscope. 2020;130(5):1249–1255. https://doi.org/10.1002/lary.28211

Petosic A, et al. Above cuff vocalisation (ACV): a scoping review. Acta Anaesthesiol Scand. 2021;65(1):15–25.

Tang ZM, Peng ZY, Shi ZH, Wu HW, Chen LS, Yang ZL, et al. Enhancing swallowing function in tracheotomy patients with subglottic oxygen flow: a randomized self-controlled crossover trial. Dysphagia. 2025. https://doi.org/10.1007/s00455-025-10852-0

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Volpato E, Poletti V, Banfi P, Pagnini F. Exploring experiences and emotions in tracheostomy and laryngectomy: a systematic review. Psychol Health Med. 2025 Jul 18. https://doi:10.1080/13548506.2025.2531465