In the previous section on communication options, we reviewed different types of ways an individual with tracheostomy may speak such as mouthing words, writing, communication boards, electrolarynx, assistive technology, leak speech, finger occlusion, talking tracheostomy tubes, speaking valves and flap valves.
Here we will review the different types of speaking valves on the market for patients with tracheostomy tubes and the differences between them. Each individual resident is different and one valve may be more appropriate than another based on patient comfort, benefits and goals.
Passy-Muir Tracheostomy and Ventilator Swallowing and Speaking Valves (PSMV)
This Passy-Muir Tracheostomy & Ventilator Swallowing & Speaking Valve is often referred to the shortened name of Passy-Muir Valve or by the acronym PMV or PMSV. PMV is the term for prolonged mechanical ventilation and therefore if an acronym is used PMSV is preferred to reduce confusion.
The Passy-Muir Valve was invented by David Muir. David had muscular dystrophy and required a tracheostomy and mechanical ventilation. He was unable to speak. In a time of frustration, he invented the Passy-Muir Valve, which has provided thousands of voices to individuals with tracheostomy and mechanical ventilation all over the world.
The Passy-Muir Valve is the only bias-closed position no -leak speaking valve on the market. It is important to understand the design behind which the biased closed position works in order to understand the unique benefits that result.
Passy-Muir has developed several models that are available. The PMV™ 005 (white), PMV™ 007 (aqua), PMV™ 2000 (clear) and the PMV™ 2001 (purple) which all can be used on both individuals spontaneously breathing with tracheostomy or those with mechanical ventilation and fit with any tracheostomy tube with a universal 15mm hub. The PMV 2020 is designed for individuals with metal Jackson tracheostomy tubes with the improved inner cannula.
The PMV™ 005 is the original version and has mostly been replaced with the PMV™ 2000. Both these valves are designed for individuals in a home environment as they are lower profile. The PMV™ 007 and 2001 are for use in an institutional setting to alert staff that the speaking valve is in place or for color preference in a home environment. The PMV 007 can be used with disposable ventilator tubing for ventilator application. The PMV™ 005, 2000 and 2001 require rubber non-disposable tubing to fit securely in-line for ventilator application. All Passy-Muir Valves have the same bias-closed position design. The Passy-Muir Valve has independently been found to produce the best speech quality, as reported by listeners and participants (Leder, 1994).
The closed position “no leak” design of the PMVs promotes the establishment of a more normal “closed respiratory system.” These valves are designed in a biased-closed position and offer less work of breathing. There is no air leakage out of the PMV during expiration. Instead, all of the exhaled air is directed around the tracheostomy tube, up through the vocal cords, and then out through the oral and nasal cavities. Since the PMV remains closed except when the patient inspires, a column of air is trapped within the valve and tracheostomy tube which acts as a buffer to resist the movement of secretions up the tracheostomy tube and onto the valve.
Due to the unique closed-position, the Passy-Muir Valve offers benefits that other speaking valves do not provide.
Open Position Speaking Valves
Open position speaking valves are one way valves that open to allow inspiration to occur through the tracheostomy tube, but require reverse airflow from exhalation to close the membrane of the valve. This air leakage during exhalation can permit secretions to travel up into the tracheostomy tube and onto the valve. Inability of an open position valve to seal completely negates any benefit other than to restore voice for the tracheostomized patient and may provide some ability to cough and expel secretions through the upper airway. Examples of open position valves include Shikani Speaking Valves, Shiley Phonate, Tracoe Phon Assist, and Montgomery Speaking Valve.
Shikani Speaking Valves™ (SSV)
Shikani Speaking Valves™ are another option for individuals with tracheostomy to use to produce speech. The valve is smaller and more discreet then the Passy-Muir Valve. The SSV uses a unique ball design and a strategically placed chamber. There is a slight tilted ramp that guides the ball toward the front of the chamber with expiration. The ball moves towards the back of the chamber due to the act of inspiration and then the ball is redirected to the front of the chamber with expiration. The expired air moves the ball to allow speech to travel through the upper airway, taking the path of least resistance.
The patient can vary the position of the valve (valve “up” or valve “down”) by rotating it 180°, which allows the ball to be seated in the proximal part of the chamber.
Valve up (12 o'clock)
This is the valve "up" position with the notch and green line are facing up. Upon resting breathing, this allows airflow in and out of the tracheostomy as if there were no valve in place at all. When the patient speaks, the ball is pushed up to close the frontal opening, thus redirecting airflow through the upper airway for speech.
Shikani Speaking Valve design 12 o’clock- 15:27- 15:48
Valve down (6 o'clock)
This is the valve in the "down' position with the notch and green line facing down. When the valve is in this position, the ball automatically moves forward, closing the frontal opening. Inhalation directs the ball posteriorly to allow airflow through the tracheostomy tube and into the lungs. Exhalation pushes the ball back to the closed position, to redirect airflow through the upper airway.
Shikani Speaking Valve design 6 o’clock- 16:24-17:06
Some patients may be more comfortable when the valve is in an alternative position, such as 3 o’clock or 9 o’clock.
Shikani speaking valves are considered open position valves, resulting in some air leaking out of the valve on expiration. The benefit of air leakage is that there is less resistance, making it easier to breathe on exhalation. The drawback is that there will be a loss of positive airway pressure so that the cough reflex will not be as strong and subglottic pressure would escape through the tracheostomy tube, which is important for swallowing. An open position design may benefit individuals who do not tolerate the biased closed-position design of the Passy-Muir Valve.
Since there is leakage of airflow during exhalation when using the Shikani Speaking Valve, it is possible to simultaneously use an HME device. The Shikani HME™ functions as an artificial nose and is designed to restore some of the essential respiratory functions which are lost when the breathed air is directed away from the nose. In particular, the Shikani HME™ filters airborne environmental particles from air inhaled by the patient with a tracheostomy; it retains moisture and heat from air that is exhaled out of the lungs; and upon re-inhalation, it filters, humidifies, and warms air returned to the lungs.
Shiley™ Phonate Valve
The Shiley™ Phonate Valve is an open position, one way valve designed for use on alert, awake tracheostomy patients who breathe spontaneously. This valve is not compatible for individuals on mechanical ventilation. Compared to finger occlusion, it reduces hygiene and infection concerns. One model is available with a built in nipple port for the addition of supplemental oxygen.
The Shiley™ Phonate Valve opens on inhalation to allow airflow to the lungs. Exhalation is required to force the membrane of the valve to the closed position. Therefore, some air escapes out the tracheostomy tube at the end of inspiration and during exhalation which may allow secretions to build inside the tracheostomy tube. A flip top lid was designed to allow for secretion removal and cleaning of the Shiley™ Valve.
Tracoe phon assist I
The Tracoe phon assist I is an open position speaking valves for individuals with tracheostomy, breathing spontaneously. It is not compatible for patients on mechanical ventilation. The valve has a silicone membrane which closes during exhalation at a fast occlusion time (25 ms), to redirect airflow through the upper airway. There are two side openings to adjust the air flow resistance individually. When the valve is turned to allow for an opening in the side, airflow will escape both through the upper airway as well as through the tracheostomy tube on exhalation. Therefore by increasing the side openings, there will be less resistance and easy breathing with the valve in place. The more closed the valve, the more airflow is directed through the upper airway. There is an oxygen supply port to provide supplemental oxygen.
Tracoe phon assist comes in both bright orange for improved visibility as well as in white.
Montgomery® Speaking Valves
Montgomery® Tracheostomy Speaking Valve
The Montgomery® Tracheostomy Speaking Valve is an open position, one way valve designed for use on awake tracheostomy patients who breathe spontaneously. The valve is not to be used for individuals on mechanical ventilation. The valve provides one-way airflow using a thin silicone diaphragm that opens on inspiration and closes on expiration. An exclusive feature of this valve is a “cough-release” mechanism, eliminating valve or tube dislodgment as a result of coughing or excessive airway pressure.
Montgomery® Ventrach™ Speaking Valve
Montgomery® Ventrach™ Speaking Valve is an open position, one way valve designed for individuals on mechanical ventilation. It provides airflow through the membrane of the speaking valve on inspiration and closes on expiration to redirect airflow through the vocal folds and upper airway. Significant air loss has been demonstrated during exhalation, when the valve should be closed (Zajak et al, 1999).
Speaking valves allow patients with tracheostomy the opportunity to produce speech naturally. Exhaled air is redirected around the tracheostomy tube and deflated cuff (if present), through the vocal folds and upper airway. The cuff of the tracheostomy tube must always be completely deflated (if present) or the patient will be unable to breathe. The Passy-Muir Valve is the only bias-closed position valve which provides additional benefits. The Passy-Muir Valve and Montgomery Ventrach may be used in-line with mechanical ventilation.
See ventilator application of speaking valves for more information.
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Leder SB. Perceptual rankings of speech quality produced with one-way tracheostomy speaking valves. J Speech Hear Res 1994;37:1308-12
Zajak, D, Fornataro-Clerici, L, Shoop, R. Aerodysnamic Characteristics of speaking valves. J Speech Hear Research 1999; 42; 92-100.