The inability to communicate verbally can be extremely frustrating and upsetting a patient. Following initial formation of the tracheostomy, the patient may have a period of being nursed with the cuff up if they require mechanical ventilation. As the patient weans from the ventilator and the stoma becomes established, the cuff can be intermittently deflated and a speaking valve attached. In addition to restoring the patient's voice, the presence of a speaking valve helps to restore a more normalized physiology for respiration, can enhance swallowing, promotes the clearance of secretions through the mouth, and facilitates weaning and decannulation (Sutt et al. [265]). The speaking valve trial should be discussed and agreed by the multidisciplinary team, with a clear plan regarding how long and how often the speaking valve should be in place in a 24‐hour period.

Depending on why the tracheostomy has been formed and the status of the patient, they may cope with having the cuff down and a speaking valve may be attached fairly quickly and for long periods of time. Some may actually feel their breathing is easier and prefer this set‐up. It can, however, cause a significant increase in a patient's work of breathing, and some patients with a large tube or narrow trachea may find it difficult to cope with the speaking valve due to reduced airflow around the tube (Bonvento et al. [28]). In this situation, consider downsizing the tracheostomy tube or changing it to an appropriate tube with a fenestrated inner cannula (Morris et al. [167]).

The patient will be able to tolerate having the cuff down and the speaking valve on for the prescribed length of time. The presence of the speaking valve will aid communication and facilitate weaning.

The procedure should always be explained to the patient and verbal consent gained. The patient should be counselled prior to the procedure and warned that their breathing may feel very different and that they may cough considerably when the cuff is deflated initially.

If required, the patient should be repositioned to ensure their comfort and allow easy access to the tracheostomy tube. Prior to the cuff being deflated, the patient should be encouraged to cough and clear secretions. Suction may also be required. If a patient has a subglottic port, secretions should be aspirated using a 10 mL syringe prior to the cuff being deflated (Morris et al. [167]).