Under normal circumstances, the respiratory system supplies the aeromechanical drive that allows the vocal folds, tongue, lips, and other structures to create the sounds of speech. Although a simplification, this drive can be understood as the tracheal pressure. Usually this pressure is exquisitely and actively controlled by muscles of the chest wall. When speech is produced with ventilator support, however, the ventilator and the respiratory system must work together to produce the pressure that drives speech production. In most cases, this pressure is markedly different from that of normal speech production. As a result, the act of speaking can be challenging for patients, and they often require assistance from their pulmonologists, respiratory therapists, and speech-language pathologists. The views presented here are that patients should be enabled to speak whenever possible, and that ventilator-supported speech can often be improved by using interventions such as those described in this chapter.
Communication is critical to maintaining good quality of life. Communication is the key to being able to express needs, participate in social activities, and retain control over important life decisions.1–5 It can be especially important in intensive care or during end-of-life care.6,7 There are many ways to communicate, but of these, speech is the fastest and most convenient. It works in the dark and across telephone lines, and it conveys meaning and emotions through words and tone of voice (i.e., pitch, loudness, quality, and timing).
Patients who are ventilator-supported often complain of speech problems, especially unwanted pauses and inadequate loudness.8 This is illustrated in the following quotation,9 which comes from a patient who was asked, “Do you have any problems with your speech?” Note that the pauses between phrases were 3 to 4 seconds (• = 1 second), and that some words were produced without voice (shown in parentheses). To appreciate the severity of the speech problem, this quotation should be read aloud with timed pauses:
“Yes •••• Um, getting cut (off) •••• people interfering with me ••• trying to finish my sentences (for me) •••• that’s the most frustrating (part).”
Fortunately, it is nearly always possible to improve ventilator-supported speech. The following quotation comes from the same patient, after she received speech interventions. Pauses were reduced to approximately 1 second, and the amount of speech per breath increased by approximately 50%.
“Since I’ve been able to talk better • I’ve par- participated in talking with more people and • and in conversation instead of just doing the listening • and talking as little as possible • I’ve joined in and, and • I don’t know, I’ve just been part of a group more • Very few people try to finish my sentences now and • second guess what I’m going to say • It’s, it’s helped a lot.”
Speech comprises the tones, hisses, pops, and buzzes that are the acoustic representation of ...