Patient Centered CareFeasibility of the electrolarynx for enabling communication in the chronically critically ill: The EECCHO study
Introduction
All critically ill patients receiving mechanical ventilation experience a period of inability to speak when consciousness is regained due to the presence of an endotracheal or tracheostomy tube [1]. The inability to speak has a particularly profound impact for chronically critically ill (CCI) patients, who for the most part, are medically stable, conscious, and receiving minimal to no sedation, yet experience a protracted intensive care unit (ICU) stay [2]. Chronic critical illness is variably defined, however generally refers to patients requiring mechanical ventilation for a minimum of seven days, experiencing relative clinical stability, and who are generally tracheostomized. Inability to speak is one of the most frequent and distressing recollections of the ICU [3, 4]. Recognized consequences of speech incapacity are: significant emotional distress including anxiety, panic, anger, agitation, and loss of control; unrecognized pain; sleeplessness; and difficulty diagnosing depression and delirium [5, 6]. Anxiety associated with inability to speak can exacerbate pain [7] and may impede successful weaning from mechanical ventilation [8]. Other deleterious consequences include increased use of physical restraint, self-extubation and line removal, and injury to self and healthcare professionals due to agitation associated with inability to communicate [9]. Patient's inability to speak also creates stress and frustration for family members [10] and healthcare professionals [11, 12].
Communication impairment during hospitalization is a modifiable risk factor for adverse events and therefore has implications for care quality and patient safety [9]. Accreditation organizations have mandated demonstration of reasonable efforts to establish alternative communication strategies for patients unable to speak [13]. Progressive cuff deflation enables airflow through the vocal cords, nose and mouth with use of strategies including in-line speaking valves, digital occlusion and capping enable speech in tracheostomized patients. Despite the well-recognized deleterious consequences of speech incapacity, few studies have identified effective communication strategies that enable speech for CCI patients unable to tolerate cuff deflation due to secretion issues yet wishing to establish meaningful communication. Mouthing words, the most common approach, is often difficult to understand and subject to misinterpretation [14]. Reduced fine motor skills and impaired cognition, commonly experienced by CCI patients, impair ability to write or use communication boards or software applications. Patients may be less able to cope with these unfamiliar methods during periods of extreme physical stress and significant emotional/psychological distress such as experienced during protracted ICU admission [15]. Other communication options for promoting speech during mechanical ventilation and cuff inflation include speaking tracheostomy tubes that use either an independent gas source such as the Portex® Trach-Talk™ Blue Line® Tracheostomy Tubes (Smiths Medical, Dublin, OH) or that directs exhaled gas into the upper airway to promote airflow upwards through the larynx such as the Blom® Tracheostomy Tube (Pulmodyne, Indianapolis, IN).
The electronic artificial larynx, or electrolarynx, developed to facilitate post-laryngectomy communication in the 1940s [16], transmits electronic sound source vibrations through soft tissue, either at the neck at the level of the glottis, the cheek, or via an oral adaptor. Speech is created through movement of articulators including the lips, tongue, and jaw [17]. Following publication of two case studies that highlighted the ability of the electrolarynx for establishing speech in mechanically ventilated patients [17, 18], we sought to evaluate, using previously validated objective tools, the feasibility of the electrolarynx to produce intelligible and comprehensible speech for CCI patients with a tracheostomy and unable to tolerate cuff deflation. Secondary objectives were to measure anxiety, communication ease, and satisfaction before and after electrolarynx training as well as explore barriers and facilitators to electrolarynx use.
Section snippets
Study design, setting, and participants
We conducted a prospective single group feasibility study in three units: a specialized weaning centre and an ICU at a large community teaching hospital, and an ICU at a tertiary academic hospital in Toronto, Canada. Our study sample comprised patients admitted to a participating centre with a tracheostomy in situ due to prolonged mechanical ventilation and unable to tolerate cuff deflation for >1 h. Additional inclusion criteria were: (1) alert, awake, and able to follow simple commands; (2)
Cohort characteristics and outcomes
From Jan 2015 to Dec 2016, we recruited 24 tracheostomized patients, one participant per month on average, with a consent rate of 57.5%. Most (63%) were male and admitted for medical reasons (58%); mean age was 62 years (Table 1). The cohort had a median (IQR) ventilation duration of 66 (27–66) days and an ICU length of stay of 93 (38–140) days. Of the 24 participants, 15 (62.5%) were successfully decannulated, and 3 (12.5%) died during their unit admission.
Feasibility and patient acceptability outcomes
Overall mean (SD) intelligibility
Discussion
We conducted this feasibility study to examine the ability of the electrolarynx to enable speech for tracheostomized patients unable to tolerate cuff deflation using rigorous methods and validated objective tools. We demonstrated the electrolarynx did enable intelligible and comprehensible speech in some participants. However, we did not achieve our feasibility end-points with an overall intelligibility score of 45% and comprehension difficulty score of 6.4. Intelligibility and
Conclusion
In this feasibility study, we demonstrate that the electrolarynx may improve speech intelligibility and comprehensibility, particularly when the communication partner is able to visualize the participant's face, in some, but not all tracheostomized patients. Importantly, the electrolarynx improved perceived ease of communication and reduced anxiety from the patient perspective. Further studies are required to explore combinations of communication adjuncts that are most effective for improving
Financial disclosure
This study was support by a grant from the Michael Garron Hospital Community Based Research Fund and a Seed Grant from Sigma Theta Tau International. The two electrolarynx devices used for the study were supplied free of change by Beckwith Voice Supplies and ATOS Medical who had no role in the study design, data collection, interpretation of results, or writing of the manuscript.
Conflict of interest statement
The authors have no conflicts of interest to declare.
Acknowledgements
We would like to thank the unit staff that assisted with conduct of the study protocol as well as research staff including Liz Lee, Hoda Moin, Niki Farrow, Julie Min, Glen Enright, and Sarah Brennenstuhl (statistician).
References (34)
- et al.
Psychological wellbeing, health related quality of life and memories of intensive care and a specialised weaning centre reported by survivors of prolonged mechanical ventilation
Intensive Crit Care Nurs
(2014) - et al.
Communication interaction in ICU: patient and staff experiences and perceptions
Intensive Crit Care Nurs
(2006) - et al.
Communication boards in critical care: patients' views
Appl Nurs Res
(2006) Factors related to the emotional responses of intubated patients to being unable to speak
Heart Lung
(1998)- et al.
Validity of the Faces Anxiety Scale for the assessment of state anxiety in intensive care patients not receiving mechanical ventilation
J Psychosom Res
(2008) - et al.
Effect of a multi-level intervention on nurse-patient communication in the intensive care unit: results of the SPEACS trial
Heart Lung
(2014) - et al.
Vagal withdrawal and psychological distress during ventilator weaning and the related outcomes
J Psychosom Res
(2017) - et al.
Enhancing the communication of suddenly speechless critical care patients
Am J Crit Care
(2016) - et al.
Transitions in the communication experiences of tracheostomised patients in intensive care: a qualitative descriptive study
J Clin Nurs
(2015) - et al.
Patients' experiences of being mechanically ventilated in an ICU: a qualitative metasynthesis
Scand J Caring Sci
(2015)
Communication difficulties and psychoemotional distress in patients receiving mechanical ventilation
Am J Crit Care
Patients' experiences of being in an intensive care unit: a select literature review
Am J Crit Care
Exacerbation of pain by anxiety is associated with activity in a hippocampal network
J Neurosci
Pain assessment is associated with decreased duration of mechanical ventilation in the intensive care unit: a post hoc analysis of the DOLOREA study
Anesthesiology
Impact of patient communication problems on the risk of preventable adverse events in acute care settings
CMAJ
Use of augmentative and alternative communication strategies by family members in the intensive care unit
Am J Crit Care
Nurse and patient interaction behaviors' effects on nursing care quality for mechanically ventilated older adults in the ICU
Res Gerontol Nurs
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2021, International Journal of Nursing Studies AdvancesCitation Excerpt :Another review concludes that communication interventions with mechanically ventilated patients are feasible, have utility and are safe (Zaga et al., 2019). Some studies have tested communication with single AAC interventions that may improve communication, e.g. low-tech tools (Hosseini et al., 2018; Otuzoğlu and Karahan, 2014), high-tech devices (Garry et al., 2016; Koszalinski et al., 2020; Rodriguez et al., 2016; Rose et al., 2018) and staff communication training (Dithole et al., 2017; Radtke et al., 2012). In the SPEACS trial, a multi-component intervention was designed that consisted of basic communication training and additional AAC training for nurses.