Chest
Volume 124, Issue 4, October 2003, Pages 1512-1521
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Clinical Investigations in Critical Care
Clinical Ventilator Adjustments That Improve Speech

https://doi.org/10.1378/chest.124.4.1512Get rights and content

Study objectives

We sought to improve speech in tracheostomized individuals receiving positive-pressure ventilation. Such individuals often speak with short phrases, long pauses, and have problems with loudness and voice quality.

Subjects

We studied 15 adults with spinal cord injuries or neuromuscular diseases receiving long-term ventilation.

Interventions

The ventilator was adjusted using lengthened inspiratory time (Ti), positive end-expiratory pressure (PEEP), and combinations thereof.

Results

When Ti was lengthened (by 8 to 35% of the ventilator cycle), speaking time increased by 19% and pause time decreased by 12%. When PEEP was added (5 to 10 cm H2O), speaking time was 25% longer and obligatory pauses were 21% shorter. When lengthened Ti and PEEP were combined (with or without reduced tidal volume), their effects were additive, increasing speaking time by 55% and decreasing pause time by 36%. The combined intervention improved speech timing, loudness, voice quality, and articulation. Individual differences in subject response to the interventions were substantial in some cases. We also tested high PEEP (15 cm H2O) in three subjects and found speech to be essentially identical to that produced with a one-way valve.

Conclusions

These simple interventions markedly improve ventilator-supported speech and are safe, at least when used on a short-term basis. High PEEP is a safer alternative than a one-way valve.

Section snippets

Materials and Methods

We studied 15 subjects with spinal cord injuries or neuromuscular diseases (Table 1 ), who lived in extended-care facilities or at home. Thirteen subjects received ventilation with volume-controlled positive pressure and produced speech with the tracheostomy tube cuff deflated or with a cuffless tracheostomy tube (either fenestrated or unfenestrated). All but one subject (subject 2) routinely maintained a deflated cuff throughout the waking hours. Four subjects (subjects 2, 5, 7, and 13)

Results

Speech improved in 12 of our 15 subjects with one or more of the interventions. Results of successful interventions are presented below according to type. Unsuccessful cases are considered separately thereafter.

Discussion

These interventions improved speech, especially when used in combination. Also, the application of high PEEP was found to be as effective as a one-way valve.

ACKNOWLEDGMENTS

We thank the medical staff at New England Sinai Hospital and Rehabilitation Center, West Roxbury Veterans Administration Medical Center, Posada del Sol Health Care Center, and John C. Lincoln Hospital, especially Dr. Lawrence Hotes, Dr. Leonard Ditmanson, and James Ruf, RRT. We also thank Marie Duggan, RRT, for her assistance in data collection; Robert Chase, RRT, for helping us use the stoma seal he developed; and those who helped with data analysis and other aspects of the study, most notably

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    Drs. Banzett and Brown are currently affiliated with the Pulmonary and Critical Care Unit, Massachusetts General Hospital, Boston, MA.

    Support was provided by National Institute on Deafness and Other Communication Disorders grants DC-03425 and DC-01409.

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