LitAlert #51
Implementation of above-cuff vocalization after Tracheostomy Is feasible and associated with earlier speech
Despite previous evidence demonstrating the safety and benefits of above-cuff vocalization (ACV) in mechanically ventilated patients, there's a lack of research on the hospital-wide adoption of ACV-capable tracheostomy tubes. This observational pre–post study aimed to assess the feasibility and impact of implementing an ACV protocol using ACV-capable tracheostomy tubes and its impact on patient speech, addressing the need for a standardized approach in ACV implementation. The median time-to-speech decreased significantly from 13 days before the intervention to 9 days after the intervention. However, there was no significant difference in the number of patients who achieved speech within 60 days between the pre- and post-intervention groups. Of the 83 patients that achieved speech in the post-intervention group, 28.9% did so through ACV. No major complications were observed during ACV use. Routine ACV implementation post-tracheostomy is feasible, safe and results in earlier speech, aiding communication in critically ill patients.
Safety and feasibility of above cuff vocalization for ventilator-dependent patients with tracheostomies
Temporary tracheostomy is a common procedure in ICU patients, typically necessitating inflated cuffs that inhibit vocalization. However, subglottic suction tubes such as the Smith-Medical 'Blue Line Ultra SuctionaidTM' allow retrograde gas flow above the cuff, enabling vocalization and potentially improving communication and psychological well-being in ventilated patients. This study investigated the ability of ICU patients to produce audible speech through above cuff vocalization (ACV), while assessing ACV safety and its potential advantages for communication, secretion management, and swallowing. ACV was successfully achieved in eight out of 10 patients and was used for a median duration of 15 minutes in 9 episodes over three days. Additionally, improvements were observed in unstimulated dry cough, swallow frequency, and aspiration ratings. In conclusion, effective ACV was feasible in ICU patients and could help them communicate in a safe and effective way.
Evidence for above cuff vocalization in patients with a Tracheostomy: A systematic review
Above cuff vocalization (ACV) was introduced in the mid-1960s and restores laryngopharyngeal airflow in tracheostomy patients, potentially improving communication, swallowing, and quality of life. A systematic evaluation of its effectiveness, safety, and acceptability is lacking. This systematic review aimed to assess implementation of ACV in clinical settings, effectiveness and safety of ACV, and the acceptability of ACV. The review found 13 studies with a high level of variability in study design and outcomes measures. The studies were of low quality, with most displaying a high risk of bias. Positive effects on communication, swallowing, cough response, and quality of life were reported, with limited use of objective measures. Overall, there is a lack of evidence regarding the acceptability, effectiveness, safety, or optimal implementation of ACV. Due to the insufficient and varying quality of evidence the authors of this systematic review were unable to provide recommendation regarding optimal implementation of ACV in a clinical setting. Future research should prioritize meticulous documentation of ACV delivery methods and incorporate a standardized set of core outcome measures.
What’s new in reducing the impact of tracheostomy on communication and swallowing in the ICU
Approximately 14% of ventilated intensive care unit (ICU) patients undergo tracheostomy, affecting communication and swallowing by blocking laryngo-pharyngeal airflow. This Editorial aims to summarize recent research on one-way valve (OVW) and above-cuff vocalization (ACV), two important techniques used for restoring communication and swallowing in tracheostomized patients. Evidence on OWVs showed that they can be used safely in ventilated patients and that although early vs late application of OVW has been shown to shorten time to decannulation, its wrongful application may also lead to serious adverse events, such as gas trapping and asphyxiation. For ACV, evidence was similarly scarce. A single randomized controlled trial on ACV application showed positive outcomes in quality of life, including speech score, and moderate patient independence and satisfaction. A systematic review on ACV highlighted the limited and poor quality of evidence, alongside variations in clinical practice. Subsequent qualitative studies and HCP surveys further highlighted the subjective and uncertain nature of ACV, leading to poor implementation, diverse practice, and opinions on its utility. The Editorial concludes that OWVs and ACV can be used in ventilated patients to restore laryngo-pharyngeal airflow and improve subglottic pressure, but further research is needed to optimize early interventions and enhance patient outcomes.
Above cuff vocalization (ACV): A scoping review
Mechanically ventilated ICU patients cannot speak because of the inflated tracheal tube cuff. Today ICU patients are more aware and awake and their inability to communicate through speech can cause anxiety and makes it difficult for HCPs to understand the patient, which could affect the safety and quality of critical care. Above cuff vocalization (ACV) could potentially enable speech in patients relying on a tracheostomy tube with an inflated cuff. This scoping review aimed to assess the safety and efficacy of ACV on speech and quality of life (QOL) for patients dependent on a cuffed tracheostomy. 88% of the patients included could speak with either an audible voice or whisper with ACV. Furthermore, ACV improved voice related QOL (V-RQOL) and QOL in mechanically ventilated patients (QOL-MV). There were multiple minor complications and two serious adverse events described, the latter was due to incorrect application of the method and incorrectly placed tracheostomy. The authors concluded that ACV improved communication for patients relying on a cuffed tracheostomy. However, improvements in V-RQOL and QOL-MV had very low quality of evidence.
Benefits and options for voice restoration in mechanically ventilated intensive care unit patients with a tracheostomy
A recent Cochrane review found insufficient evidence to advise clinicians on the best timing, suitability, and selection of communication options for ICU patients undergoing mechanical ventilation with a tracheostomy. In this opinion piece, Speech and Language Therapists (SLT) based in the United Kingdom (UK) working in critical care provide a comprehensive overview of the array of techniques available to restore a patient's natural voice. One-Way Valve (OWV) in-line with ventilatory tubing is the most natural way to speak for patients ventilated via a tracheostomy. It facilitates speech by redirecting exhaled air around the deflated cuff, enabling use of the larynx for speech. Above Cuff Vocalization (ACV) on the other hand, restores airflow via the patient's upper airway, by connecting an external retrograde gas supply to the subglottic drainage port line of the tracheostomy tube. ACV is a great alternative for patients that are not yet suitable for cuff deflation. Other alternatives, although less preferred in UK ICUs, are specialist tracheostomy tubes that have a speech inner cannula. When verbal communication is not an option, augmentative and alternative communication options (AAC) such as mouthing, gesture, writing, picture or word charts, and eye-gaze systems could be valuable. The SLTs key recommendations were that it takes a multidisciplinary team to ensure safe and timely restoration of voice. Furthermore, the first choice for voice restoration should be to restore the patient's natural way of speaking by using an OWV-line with cuff deflation. The next best alternative is ACV with cuff inflation when cuff deflation is delayed or limited.
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