Pre‐procedure

ActionRationale

1. 1.Show
   Discuss the possibility of a speaking valve trial with the multidisciplinary team.
   To ensure the multidisciplinary team agree to the speaking valve trial. E
2. 2.Show
   This is a clean procedure and requires the presence of two nurses.
   To ensure patient safety (NTSP [206], C).
3. 3.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [198], C).
4. 4.Show
   Cleanse hands with soap and water or an alcohol‐based handrub.
   To minimize the risk of infection (NHS England and NHSI [179], C).
5. 5.Show
   Help the patient to sit in a semi‐recumbent position with neck slightly extended.
   To ensure patient comfort and allow easy access to the neck area (NTSP [206], C).

Procedure

1. 6.Show
   Cleanse hands using an alcohol‐based handrub and apply disposable plastic apron, gloves and eye protection.
   To minimize the risk of infection (NHS England and NHSI [179], C).
2. 7.Show
   Prepare a dressing tray or trolley for the procedure. Place the speaking valve and a 10 mL syringe onto the sterile sheet.
   To ensure all equipment required is prepared prior to starting the procedure. E
3. 8.Show
   Encourage the patient to cough and suction secretions in the mouth or from above the cuff if necessary. If the tube has a subglottic port, aspirate gently using a 10 mL syringe.
   To prevent pooled secretions entering the lungs when the cuff is deflated (NTSP [206], C).
4. 9.Show
   If the tracheostomy tube is cuffed, gently deflate the cuff using a clean 10 mL syringe on expiration while simultaneously providing suction.
   Providing suction while the cuff is deflated helps to clear any secretions that remain, reducing the risk of aspiration (Morris et al. [167], C; NTSP [206], C).
5. 10.Show
   Reassure the patient as required.
   The patient may cough for a period of time after cuff deflation, which may cause them to panic and worsen their breathing. E
6. 11.Show
   Apply the speaking valve directly onto the tracheostomy tube. Ask the patient to inhale through the tracheotomy tube and exhale through their mouth.
   To encourage air to flow past the vocal cords and aid phonation. E
7. 12.Show
   Ask the patient to say ‘ah’ or count from one to five. If the patient's voice sounds wet, ask them to cough and clear secretions. If the problem persists, remove the speaking valve and ask them to cough and clear secretions again. Provide suction as required.
   Deflating the cuff can move secretions into the upper airways; these need to be cleared (Morris et al. [167], C).
8. 13.Show
   Monitor the patient closely during the speaking valve trial. Remove the speaking valve if:

   • the patient shows signs of respiratory distress
   • the patient's oxygen saturations fall
   • there is an evident wheeze or stridor
   • the patient is unable to vocalize
   • the patient looks fatigued
   • the patient requests it.
   A change in breathing or evidence of clinical deterioration requires immediate removal of the speaking valve and reinflation of the cuff (Morris et al. [167], C).
9. 14.Show
   Depending on how the patient copes with the speaking valve, make a weaning plan with the multidisciplinary team.
   To ensure a collaborative approach to weaning. E
10. 15.Show
    At the end of the speaking valve trial, re‐perform steps 2–6, then remove the speaking valve.
    As above.

    To end the speaking valve trial. E
11. 16.Show
    Use the 10 mL syringe to reinflate the cuff and check the pressure using the cuff manometer. The pressure should be between 15 and 25 cmH₂O (10–18 mmHg).
    To ensure the cuff is sufficiently inflated to prevent aspiration, but not overinflated so as to cause damage to the trachea (NTSP [206], C).
12. 17.Show
    Check that the patient is comfortable and they are at ease with their breathing.
    To ensure patient comfort. E

Post‐procedure

1. 18.Show
   Monitor the patient's respiratory status and observations/NEWS. Escalate any concerns or deterioration in condition/NEWS immediately.
   To identify any concerns or clinical deterioration early, and ensure timely escalation to senior staff if required (RCP [230], C).
2. 19.Show
   Clean the speaking valve using normal saline 0.9% and leave it to air dry. Store it in an airtight container.
   To minimize bacterial colonization and prevent infection (Everitt [75], C).
3. 20.Show
   Document how long the cuff was down and if the speaking valve was tolerated. Document any other concerns or details that may assist the multidisciplinary team.
   To communicate to the multidisciplinary team the details of the cuff‐down speaking valve trial. E