Above cuff vocalisation: A novel technique for communication in the ventilator-dependent tracheostomy patient

Abstract

A significant proportion of patients admitted to intensive care units require tracheostomies for a variety of indications. Continual cuff inflation to facilitate mechanical ventilatory support may mean patients find themselves awake, cooperative and attempting to communicate but unable to do so effectively. Resulting frustration and anxiety can negatively impact upon care. Through participation in the Global Tracheostomy Collaborative, our unit rapidly implemented novel techniques facilitating communication in such patients. In carefully selected and controlled situations, the subglottic suction port of routinely available tracheostomy tubes can be used to deliver a retrograde flow of gas above the cuff to exit via the larynx, facilitating speech. The resulting above cuff vocalisation is described in detail for five general ICU patients at our institution, highlighting the benefits of multidisciplinary care and the increasingly important role of the speech and language therapists in the critically ill.

Full text

Original Article
Above cuff vocalisation: A novel
technique for communication in the
ventilator-dependent tracheostomy
patient
Brendan McGrath
1
, James Lynch
1
, Mark Wilson
2
,
Leanne Nicholson
2
and Sarah Wallace
2
Abstract
A significant proportion of patients admitted to intensive care units require tracheostomies for a variety of indications.
Continual cuff inflation to facilitate mechanical ventilatory support may mean patients find themselves awake, cooperative
and attempting to communicate but unable to do so effectively. Resulting frustration and anxiety can negatively impact
upon care. Through participation in the Global Tracheostomy Collaborative, our unit rapidly implemented novel tech-
niques facilitating communication in such patients. In carefully selected and controlled situations, the subglottic suction
port of routinely available tracheostomy tubes can be used to deliver a retrograde flow of gas above the cuff to exit via
the larynx, facilitating speech. The resulting above cuff vocalisation is described in detail for five general ICU patients at
our institution, highlighting the benefits of multidisciplinary care and the increasingly important role of the speech and
language therapists in the critically ill.
Keywords
Tracheostomy, communication, vocalisation, rehabilitation of speech and language disorders
Introduction
Tracheostomies are used as artificial airway devices in
around 10% of all mechanically ventilated intensive
care unit (ICU) admissions in the UK, with exact
numbers dependent on the local case mix and to
some extent, local practice.
1–6
One of the advantages
of tracheostomy is that patients can have reductions
or cessation of sedative medication, but may find
themselves in a situation where they are alert, yet
still dependent on positive pressure ventilatory sup-
port. This almost universally requires an inflated
tube cuff in order to deliver the pressure generated
by the ventilator to the lungs, although increasingly
it is recognised that patients can be ventilated and
indeed weaned successfully with increasing periods
of cuff deflation.
7
For the majority of these patients who remain sig-
nificantly ventilator-dependent or have a substantial
aspiration risk that prevents cuff deflation, the contin-
ued presence of the inflated cuff by necessity ‘seals off’
the upper airway, preventing effective oral communi-
cation. Critical care nursing, medical and allied health
staff are familiar with attempts to communicate non-
verbally with patients in this situation by lip-reading,
facial expressions, gestures, attempted writing, typing
or the use of communication boards, ranging from
simple charts through to complex interactive devices.
At present, these interactive systems are often impre-
cise, cumbersome, costly and prone to breakage.
8,9
The nature of critical illness means that patients are
often fatigued, with subtle peripheral myopathies and
with limb movements further hampered by peripheral
vascular or monitoring devices, resulting in frustrat-
ing attempts at communication for staff, relatives and
most importantly, the patient.
10,11
The effect on psy-
chological well-being, delirium and depression of
emerging from sedation and finding yourself unable
1
Acute ICU, University Hospital South Manchester, Manchester, UK
2
Speech & Language Therapy, University Hospital South Manchester,
Manchester, UK
Corresponding author:
Brendan McGrath, Acute ICU, University Hospital South Manchester,
Southmoor Road, Wythenshawe, Manchester M23 9LT, UK.
Email: brendan.mcgrath@manchester.ac.uk
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to speak, swallow or communicate are unknown but
likely to be additive to the well-documented adverse
effects of critical illness.
7,12,13
Frustration, anger and
low mood can lead to withdrawal from interaction
with family and carers and reduced participation in
treatment, rehabilitation and the recovery process.
14
The role of experienced critical care speech and lan-
guage therapists (SLT) as part of the multidisciplinary
ICU team is key in attempting to overcome commu-
nication barriers.
15
Endotracheal and tracheostomy tubes that have
the ability to drain subglottic secretions via dedicated
additional ports are increasingly recognised as one of
the effective components of strategies to reduce venti-
lator-associated pneumonias.
16
Through participation
in an international tracheostomy quality improve-
ment project (The Global Tracheostomy
Collaborative (GTC), www.globaltrach.org) our hos-
pital collaborated with colleagues from the
Tracheostomy Review And Management Service
(TRAMS) team, based at Austin Healthcare,
Melbourne, Australia. Some of TRAMS’s work is
with high spinal injury patients, and they were using
the same Smiths Medical (Ashford, Kent, UK) Blue
Line Ultra Subglottic Suction (SGS) tracheostomy
tubes that are in routine use on our ICU in
Manchester, UK. TRAMS were using the SGS port
in an innovative way to allow speech for patients who
were fully ventilated. The GTC QI project supports
rapid adoption of international best practices and led
to us quickly sharing protocols and experience in this
technique. By directing a retrograde flow of gas via
the SGS tube to exit above the cuff, patients can the-
oretically vocalise, with the technique described as
above cuff vocalisation (ACV), as demonstrated in
Figures 1 and 2. We describe a case series of the
innovative use of the SGS port of tracheostomy
tubes to facilitate communication in five general
ICU patients. Our patients were awake, cooperative
and attempting to communicate, but were unable to
do so effectively due to the requirement for continu-
ally inflated tracheostomy tube cuff for ongoing mech-
anical ventilatory support.
Case reports
Case 1
A 76-year-old man with a history of asthma and
Parkinson’s disease was admitted to hospital with
shortness of breath, confusion and suspected infective
exacerbation of asthma. He quickly developed Type 2
respiratory failure due to Influenza A and was trans-
ferred to ICU for invasive ventilation. He deteriorated
further and required partial extracorporeal CO
2
removal using a HemolungÕRAS (ALung
Technologies, Pittsburgh, US). After seven days of
intubation he was tracheostomised and was already
showing signs of critical illness myopathy. Three
days later he was referred to SLT, alert but confused
and unable to follow commands. He was noted to
have pulmonary oedema, remaining on ventilator
pressure support of 23 cm H
2
O with the cuff inflated.
He demonstrated occasional cuff leak and a whisper
voice whilst attempting to mouth words. Two days
later he was much more cooperative but high ventila-
tor pressure support precluded cuff deflation or speak-
ing valve trials. Although he had audible upper
airway secretions, none were retrieved on SGS. With
consent, ACV was trialled and he was able to phonate
at 5 l/min flow rate with an audibly wet, breathy voice
quality rated 2 on the Therapy Outcome Measure for
Voice Impairment scale (TOMS, see Table 1).
17
This
represented an improvement from TOMS 0 without
ACV. His speech was intelligible and although his
voice was not ‘normal’ it was sufficient to enable
him to speak audibly. Nursing staff and SLT contin-
ued with regular 5 min spells of ACV in order to facili-
tate communication with staff, family and visitors for
a further three days until he began to tolerate cuff
deflation and his wean progressed rapidly to decannu-
lation two days later. In addition to the benefits of
communication and laryngeal sensitivity, effects on
swallowing were observed during fibreoptic endo-
scopic evaluation of swallowing (FEES).
18
Without
ACV, he silently aspirated secretions and oral fluids
but with ACV, aspiration became overt with an active
cough response. The laryngeal airflow not only
revived vocal fold vibration producing voice but
also appeared to improve glottic closure reflexes.
19
Case 2
A 41-year-old man with severe Chronic Obstructive
Pulmonary Disease (COPD) following smoking and
cannabis use was admitted to hospital for a double
lung transplant. He remained sedated and invasively
ventilated via an oral endotracheal tube for 12 days
post-transplant, requiring veno-arterial and veno-
venous extra-corporeal membrane oxygenation (VA
and VV ECMO) for eight days of this period. He
was tracheostomised at day 12 and sedation was
reduced and stopped by day 14. Ventilator weaning
was very prolonged due to critical illness myopathy,
pleural effusions and anxiety and he required contin-
ual cuff inflation to facilitate positive pressure sup-
port. By five weeks post-transplant, he was getting
frustrated with mouthing words and he was referred
to SLT for communication and swallowing assess-
ment. SLT performed an ACV trial and he achieved
audible voice, easily scoring a TOMS 4. On FEES he
was observed to have a sluggish left vocal cord but
this hardly impacted on voice quality. He continued
to use ACV for four further days communicating very
effectively until cuff deflation was established and he
was decannulated a few days later. At times he was
observed to burp which may have been a consequence
of ACV airflow causing aerophagia.
20
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Case 3
A 76-year-old lady with a background of COPD,
hypertension, presbycusis (age-related hearing loss)
and non-insulin dependent diabetes underwent a left
upper lobectomy for lung carcinoma. She had a failed
extubation post-operatively and was re-intubated then
tracheostomised two days later. Within five days she
was awake but intermittently drowsy and was attempt-
ing to communicate by mouthing words with variable
intelligibility. She was too confused and agitated to lip-
read or use writing or picture/word charts and had
unreliable yes/no head nod and shake responses.
Following SLT assessment, an ACV trial was agreed,
given her high ventilation requirements and need for
cuff inflation. On 3 and 5 l/min flow rates she achieved
audible whisper but no voice and airflow sounded tur-
bulent and restricted. Despite this, her speech became
more intelligible over the following two days, commu-
nication interactions became easier and no desaturation
or respiratory distress occurred. Her hearing impair-
ment did impact but she benefitted from communica-
tion partners writing down conversation.
Because of her limited voice, we considered a poten-
tial problem with upper airway patency and ACV was
stopped. However, FEES was not carried out as cuff
deflation followed quickly and swallow function was
assessed by SLT as safe. With cuff deflation, she toler-
ated the speaking valve poorly and experienced
ongoing dysphonia (gruff, strained voice). This
prompted ENT assessment and the vocal folds were
visualised and found in a paramedian position and
weak, confirming the signs observed. She was decan-
nulated 10 days later and her dysphonia gradually
improved, suggesting causation as likely intubation
trauma and recurrent laryngeal nerve trauma during
thoracic surgery.
21
Upper airway obstruction is a
likely contraindication for using ACV although further
research is needed on the optimal timing and use of
endoscopy for establishing this prior to trials.
Case 4
A 41-year-old man with community-acquired pneu-
monia was admitted to ICU following deterioration
requiring intubation and ventilation but developed
acute respiratory distress syndrome necessitating VV
ECMO for 34 days. He was previously fit and well,
but profoundly deaf since birth, resulting in him com-
municating as both a deaf speaker and sign language
user. He developed severe critical illness myopathy
related to high dose steroids and was unable to use
his upper limbs or even lift his head off the pillow. He
Figure 1. Tracheostomy tube in situ with subglottic suction ports and tubing indicated. Left-hand figure demonstrates the usual
removal of secretions by aspiration. Right-hand figure demonstrates the flow of gas to the upper airways via the larynx when additional
gas flow is directed into the subglottic port.
Figure 2. One of the patients described with cuffed Blue Line
Ultra Subglottic suction Tracheostomy tube in situ with the cuff
inflated. The green oxygen tubing is connected to the subglottic
suction port via the clear open valve (arrow), occluding which
will facilitate ACV (with permission).
McGrath et al. 3
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was tracheostomised following 11 days of intubation
and was totally ventilator dependent. Once awake he
was attempting to communicate by mouthing words
and was referred to SLT for communication and swal-
lowing advice. He had bulbar signs of myopathy redu-
cing his intelligibility and was becoming increasingly
frustrated and angry with his communication difficul-
ties, impacting his compliance with nursing and med-
ical care. Since cuff deflation was impossible due to a
ventilator pressure support of 25 cm H
2
O, a trial of
ACV on 6 l/min was carried out and produced a com-
pletely normal voice at the first use within a few min-
utes (TOMS 5). ACV was subsequently performed
every day for 5 min spells to facilitate communication
with staff and relatives. A small amount of secretions
were removed by SGS each time and a communica-
tion partner was required to occlude the airflow port
but otherwise no difficulties were encountered. He
continued to use ACV for the next month as tolerance
of cuff deflation remained poor despite sprint weaning
and he sustained a strong, loud voice. Interestingly, he
was initially totally aphagic due to myopathy of swal-
lowing musculature and prolonged cuff intubation
and inflation but his swallow function improved
quicker than anticipated. It is postulated but not clin-
ically proven as yet, that the repeated airflow on ACV
facilitated re-sensitisation of the larynx, improving
airway protection and swallow strength.
19
Case 5
A 30-year-old homeless man sustained 45% burns to
face, neck, both arms and hands following a fire in his
tent. He was previously well with a background of
alcohol and substance abuse. He was admitted to
the burns unit 24 h after the event after being found
by a passer-by. In addition to dermal burns, he pre-
sented with stridor, hoarseness, periorbital oedema
and underwent a difficult intubation. Bronchoscopy
revealed inhalation burns to the posterior tongue,
pharynx, glottis, vocal cords and trachea with soot
andsloughinthepharynxandlarynx.Hewas
sedated and ventilated and repeat bronchoscopy
showed minimal laryngeal oedema but carbonaceous
sputum. He had a failed extubation at day 8 but was
successfully extubated onto high-flow nasal cannula
oxygenatday10,andassessedbySLTregularlyover
the following week. He was drooling, with a weak
voice, unsafe swallow and agitation. At day 20, he
was re-intubated and tracheostomised due to respira-
tory failure, high sputum load and secretion aspir-
ation. He was ventilated with the cuff inflated for a
further week and found communication extremely
frustrating, increasing his agitation and non-compli-
ance with treatments. Bronchoscopy and ENT
fibreoptic nasendoscopy showed significant improve-
ment in laryngopharyngeal inhalation injury and it
was decided to trial ACV in order to facilitate com-
munication. He was unable to achieve voice (TOMS
0) and secretions were propelled up into the orophar-
ynx stimulating a cough and swallow. Minimal bene-
fit was perceived from ACV and cooperation was
limited, which extended to all therapeutic communi-
cation strategies suggested by SLT. He remained
aphonic and severely dysphagic following decannu-
lation five days later. Repeat FEES demonstrated
poor glottic closure, epiglottic and vocal fold
oedema and silent aspiration of secretions and oral
intake as a result of intubation and inhalation
trauma. He was discharged with a percutaneous
endoscopic gastrostomy and remained aphonic due
to a permanently altered larynx. This case illustrates
the need for cooperation and intact laryngeal func-
tion for ACV to be successful, although in such com-
plex cases options for communication are very
limited.
Table 1. Therapy outcome measure for voice impairment.
Score Description
0Severe persistent aphonia
Unable to phonate. Does not phonate
1Consistent dysphonia
Occasional phonation. May be dysphonic with aphonic episodes
2Moderate dysphonia
Can phonate but frequent episodes of marked vocal impairment occurring
3Moderate/mild dysphonia
Less frequent episodes of dysphonia (e.g. occurs some time each day/or slight persistent ‘huskiness’)
4Mild dysphonia
Occasional episodes of dysphonia occurring
5No dysphonia
Appropriate modal voice consistently used
Source: Adapted from Enderby.
17
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Videos of some of these patients using ACV
(with appropriate permissions) and animations
describing the flow of gas are available via the
Health Foundation website at www.health.org.uk/
blog/giving-voice-critically-ill-patients-literally.
Discussion
We have described how verbal communication is pos-
sible in typical ICU patients in a carefully controlled
and directly supervised environment using Blue Line
Ultra SGS tracheostomy tubes in common use. We
are not the first group to describe the successful use
of additional airflow to facilitate ACV in specialist
populations, but have recognised the potential appli-
cation of this technique as part of the armoury of
communication aids available to the general ICU
population managed with tracheostomies. The
following is a brief overview of related techniques to
facilitate oral communication in the tracheostomy-
ventilated patient.
In order to achieve adequate voice, a subglottic
(tracheal) pressure of a least 2 cm H
2
O is required
as a minimum, with tracheal pressures of 5–10 cm
H
2
O described during normal speech with flows of
50–300 ml/s (3–18 l/min).
22,23
Whilst it is not possible
to replicate these physiological conditions in the
patient with a cuffed tracheostomy, strategies exist
to allow the patient enough glottic airflow to vocalise.
These can be considered as scenarios and systems
where the cuff remains inflated or the cuff is at least
partially deflated. In practice, different options may
be appropriate for patients at different stages of
their critical illness.
Cuff deflation
For a patient to tolerate cuff deflation, they must have
an appropriate secretion load and adequate clearance,
be at an acceptable risk of aspiration into the airway
and have adequate respiratory mechanics to be able to
tolerate the reduction in positive pressure support.
Speech can be achieved by simple cuff deflation,
assuming that there is enough space between
the outer tracheostomy tube and the trachea for ade-
quate flows of exhaled gas to pass, that the larynx
is functional and that the upper airways are patent.
This method of vocalisation is often referred to as
‘leak speech’. Using a fenestrated tracheostomy tube
system may increase the amount of gas passing
through the larynx. Fenestrated tubes or cuff deflation
effectively divert gas flow away from the patients
lungs, which in most cases will reduce the effectiveness
of ventilation (Figure 3). Specific ventilator
strategies and ventilators that will tolerate and com-
pensate for such volume loss can be used in this
situation.
24
The amount of airflow that exits via the upper air-
ways and larynx may be increased by the use of a one-
way speaking valve.
25
These valves are placed between
the ventilator and tracheostomy tube and are ‘open’
in inspiration, allowing normal ventilation of the
lungs. In expiration, however, the valve closes and
gas flow cannot exit via the lumen of the tracheos-
tomy tube. Gas must therefore pass around the tube
in the trachea to the upper airways, traversing the
larynx and potentially allowing speech. The obvious
requirements in this situation are a deflated (or no)
cuff and a patent upper airway, and significant harm
has been described when using these valves.
26
These
valves can be used with or without a ventilator,
although any ventilator must be able to compensate
for the significantly increased leakage and escape of
gas from the circuit via the upper airways.
25,27
If the
patient is able to co-ordinate respiration and move-
ment, simple digital occlusion of the tracheostomy
tube will drive expired airflow through the larynx.
Newer tubes have been described that incorporate
the one-way valve mechanism within a dedicated
‘speaking’ fenestrated inner cannula.
28
Cuff remains at least partially inflated
If the cuff cannot be continually deflated for clinical
reasons, there remain a number of options to facilitate
speech. Dedicated ‘speaking tubes’ have dynamic cuffs
whereby during inspiration, the cuff expands and pro-
vides an effective seal of the airway. The cuff deflates
in expiration and allows exhaled gas to at least par-
tially bypass the tracheostomy tube. Gas is exhaled
via both the upper airways and the tracheostomy
tube itself.
29
With a fenestrated tracheostomy tube (with an
appropriately fenestrated inner cannula in situ) gas
flow is directed partially via the upper airways from
the lumen of the tracheostomy tube. The cuff can
remain inflated. In this configuration, positive pres-
sure ventilation will be at least partially directed via
the upper airways in inspiration and exhaled gas will
similarly exit. Vocalisation is theoretically possible
therefore in inspiration and expiration. The tracheos-
tomy tube does not protect from aspiration as there
remains an open communication from the upper air-
ways into the lungs. A number of commercially avail-
able cuffed fenestrated tubes exist, and modifications
to existing tubes have also been described by fashion-
ing bespoke fenestrations to facilitate speech.
30
Tubes
with dynamic fenestrations are also commercially
available which allow the fenestrations to open in
expiration only.
31
If the cuff remains permanently inflated and the
tube is un-fenestrated, vocalisation is possible using
an additional gas supply that exits above the cuff.
There have been a number of these types of tubes
described, with ‘Speaking tracheostomy tubes with
the cuff inflated’ reported as early as 1975.
32
Other
variations on this technique were described using
single or multiple gas ports and generally reported
McGrath et al. 5
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successful quiet speech in small case series.
33–37
Because laryngeal gas flow and mechanical ventilation
of the lungs continue independently by two separate
gas supplies, this technique effectively decouples
speech and breathing. There is no loss of ventilation
during speech with this device, and the inflated cuff
reduces the risk of aspiration.
23
This classification of
vocalisation strategy has become known as ACV.
The potential for ACV in the acutely ill critical
care population
With the increasing use of SGS tubes in an attempt to
reduce VAP, many tracheostomised ICU patients will
have a device in situ that could allow attempts at
vocalisation in certain circumstances. Husain
described the use of Blue Line Ultra SGS tubes
for ACV in spinal injury patients in 2011.
38
Although this particular tube was designed for dedi-
cated aspiration of secretions from the subglottic
space, there may be advantages over some other
tubes specifically designed for ACV.
20
The ‘speech
lumen’ (SGS port) diameter is larger, the inner cannula
is not corrugated and the SGS lumen can be flushed
with saline for patency. Perhaps the biggest advantage
is that the tracheostomy tube initially inserted to facili-
tate ongoing airway maintenance can be used for
attempts at ACV without having to change the tube
for another device. This reduces the need for a specific
tube change to facilitate speech, which is a disadvan-
tage of other dedicated speaking tubes.
23
There are a number of potential limitations to the
use of ACV via a SGS or additional port for vocal-
isation. Voice quality may be limited and in our
patients voice quality was limited to little more than
a whisper in some, as reported in other series. Voice
quality may improve with higher translaryngeal gas
flows but this can be associated with a potentially
greater risk of airway injury.
37,39
If the resistance to
airflow retrograde through the stoma is less than that
through the upper airway, much of the added flow
may leak from the stomal site and not be available
for speech.
36,40
This may be less of a problem with
percutaneously formed stomas.
36
The TRAMS team
pragmatically does not recommend the use of ACV
before 72 h following new tracheostomy and limit gas
flows to 5 l/min. It should be stressed that complica-
tions should be minimised by appropriate bedside
supervision of trials of ACV by an experienced multi-
disciplinary ICU team, including an appropriately
trained SLT.
The delivery of gas flow via the SGS tube may also
cause potential problems. Dry gas or high concentra-
tions of oxygen are likely to have a drying effect on
the laryngeal mucosa and hyperadduction of the vocal
folds in response to translaryngeal airflow may occur.
Humidifying gas delivered via a small calibre SGS
tube is possible but requires modifications to existing
systems. The delivery of gas into the subglottic region
relies on a patent upper airway to decompress the
space. Gas may be swallowed or potentially be deliv-
ered into the soft tissues and cause subcutaneous
emphysema if the tube becomes displaced. Most sys-
tems have an open connector between the SGS port
and the external gas supply that requires occlusion in
order to facilitate speech. This requires a degree
of strength and co-ordination in the ICU patient, or
assistance from staff or carers, although automated
systems have been described.
35
If a closed system
were used that delivers continual flow to the subglottic
space, a (low) pressure relief valve would be a sensible
addition to the circuit. In keeping with previous
Figure 3. Gas flows through correctly positioned tracheostomy tubes: Left-hand figure shows a cuff-inflated tube with gas flow
excluded from the upper airway. Centre figure shows gas flow in ‘leak speech’, with the cuff deflated (or not present). Gas flows via the
tracheostomy tube, but also a small amount via the upper airways. Right-hand figure shows increased airflow via the upper airways by
adding a fenestration to the tracheostomy tube.
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reports, our experience suggests that several days of
ACV use may be necessary before the patient is able
to develop voice with ACV and in some patients,
voice may not be possible.
23,37,39
From our limited
observational data, there were no clear predictors of
early, successful voicing.
Finally, upper airway secretions may also interfere
with the quality of voice, and secretions above the cuff
can lead to a blocked gas flow line.
23
This problem
should be minimised by the continued use of the SGS
port for secretion clearance. We have observed anec-
dotally that the management of oral and laryngeal
secretions during ACV seemed to improve in the
two patients who underwent concomitant FEES
during a trial of ACV. This phenomenon is worthy
of further study as the flow of gas through the larynx
may facilitate the clearance of subglottic secretions.
This could be an additional benefit of ACV over
and above that benefit from earlier laryngeal recovery
after intubation that would be expected from
encouraging translaryngeal gas flow.
In conclusion, we have described how effective
verbal communication is possible in a carefully con-
trolled and directly supervised environment using
Blue Line Ultra SGS tracheostomy tubes that are in
common use amongst critical care patients. This
report also highlights the benefits of collaboration
through networks such as the GTC in driving rapid
adoption of techniques that translate immediate bene-
fits to patients. Guidelines for more widespread safe
use of these and other tracheostomy tubes should
be developed jointly between SLT practitioners and
the multidisciplinary ICU team. In addition to com-
munication benefits, the effect of ACV on secretion
management, recovery of laryngeal function, decan-
nulation times and ventilator-associated pneumonias
are currently unknown. Further detailed studies are
required to determine parameters for safe use, clarify
patient selection and techniques to ensure our patients
have the best chance of successful verbal communica-
tion during their ICU management.
Acknowledgements
The authors gratefully acknowledge the assistance of the
Global Tracheostomy Collaborative (www.globaltrach.org)
in sharing of experience and protocols regarding the
use of ACV, especially that of Mrs Tanis Cameron and
the TRAMS team, Austin Health, Melbourne
(www.tracheostomyteam.org).
Declaration of Conflicting Interests
The authors declared the following potential conflicts of
interest with respect to the research, authorship, and/or
publication of this article: This work was carried out as
part of UHSMs Health Foundation Funded ‘Shine’
Tracheostomy Quality Improvement Project.
BAM is the current European Lead of the Global
Tracheostomy Collaborative.
Funding
The authors disclosed receipt of the following financial sup-
port for the research, authorship, and/or publication of this
article: The authors have received unrestricted funding from
Smiths Medical to evaluate BLUS tubes for the purposes of
ACV in a future study.
Consent
All patients discussed in this case series have given their
written consent to publication, have been offered a draft
of the final manuscript and the Trust Cadicott Guardian
has given her written consent to publication.
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