Reply: Speaking Valve Placement: Use Manometry and Downsizing.

From the Authors:

Tracheostomy tube manometry is a promising approach for assessing patients’ candidacy for speaking valves, capping, downsizing, and decannulation. We are grateful to Dr. Johnson for sharing his insight and data regarding this objective measure. Using tracheostomy tube manometry to assess inspiratory and expiratory intratracheal airway pressures is straightforward and efficient, providing valuable quantitative data that can guide care decisions. Although this approach is not widely used in the intensive care unit (ICU) setting, it may complement other assessments of preparedness for speaking valve placement. It may also help identify patients that will tolerate tracheostomy tube downsizing and/or readiness for decannulation as shown in patients in a long-term acute care hospital (1).

An open question is whether the predictive value of manometry observed in patients in a rehabilitation setting will be reliable in ICU patients soon after tracheostomy. Additional limitations to the study by Johnson and colleagues are the retrospective design, absence of a control group, and lack of data regarding time from tracheostomy to speech valve trials. Our study investigated placement of speech valves in mechanically ventilated patients within 24 hours of the initial tracheotomy surgery, a window during which the postoperative recovery from a procedure and residual sedation differs markedly from that during rehabilitation. In addition, in the ICU setting, tracheostomy tube manometry may have less of a role, as a decrease in expired tidal volume (i.e., ventilator delivered vs. returned) during cuff deflation demonstrates adequate or inadequate airflow to the upper airway.

Although using a single measure to determine candidacy for speech valve placement is attractive, tube manometry does not obviate the need for a comprehensive speaking valve evaluation. Patients undergoing tracheostomy placement are often deconditioned and remain dependent on ventilator support for adequate gas exchange. Such patients frequently only tolerate brief speaking valve trials, and the assessment of tolerance requires a speech-language pathologist at the bedside. As respiratory function, secretion management, and mental status improve, patients may tolerate longer trials of speaking valve. In this setting, tube manometry may provide important guidance in determining when a smaller tracheostomy tube is needed or a cuffless trach is possible. In addition, tube manometry may also be informative in patients with a low Glasgow Coma Score who are unable to communicate respiratory discomfort.

In future studies, including tracheostomy tube manometry may provide a quick and objective assessment of candidates for early speaking valve intervention. However, we suggest this measurement be used to supplement other important assessments of a patient’s readiness rather than replacing a comprehensive evaluation by a trained speech-language pathologist.

Last, although we only briefly addressed capping and decannulation during our study, further research is needed to determine if earlier speaking valve use expedites decannulation. Several studies (2, 3) have provided guidelines for capping, and tracheostomy tube manometry could be used to further refine such algorithms. We thank Dr. Johnson for illuminating the potential role of tracheostomy tube manometry in this population.