Application of one-way speaking valves in adult tracheostomy patients: the time should be earlier

One-way speaking valves (OWV) can be used in tracheostomy patients. Their design enables inhalation via the tracheostomy tube due to an open diaphragm, that closes immediately before or during exhalation, thus restoring normal physiological exhalation pathways. This mechanism provides multiple physiological and psychological benefits, including enabling voice, re-establishes subglottic pressure, enhances peak expiratory flow rate, improved swallowing, and reduced aspiration risk [1, 2]. Additionally, OWV reestablish physiological expiratory positive pressure, which strengthens respiratory muscles, enhances lung capacity, and supports early mobilization [3].

Unlike intubated patients, adult tracheostomy patients experience asynchronous weaning and decannulation processes, often requiring a stepwise approach [4]. Accordingly, the timing of OWV intervention can be divided into three distinct phases: during mechanical ventilation, during a trial of unassisted or spontaneous breathing, and after successful weaning. While most studies focus on the use during spontaneous breathing or after successful weaning, research on its application during mechanical ventilation remains relatively limited [5, 6]. This comment aims to emphasize the importance of early initiation of OWV use and its potential to accelerate weaning and decannulation, and to provide criteria for early use and clinical practice considerations.

The use of OWV during mechanical ventilation not only offers unique advantages compared to their application during trials of unassisted/spontaneous breathing or after successful weaning but also demonstrates comparable safety [7]. Sutt et al. demonstrated through electrical impedance tomography that the use of OWV in mechanically ventilated patients significantly increased end-expiratory lung impedance without inducing regional hyperinflation, meanwhile, oxygen saturation and end-tidal carbon dioxide remained stable, and respiratory rate significantly decreased during OWV use [8, 9]. These findings provide physiological evidence for the use of OWV in line with the ventilator circuit in mechanically ventilated patients. Research by Freeman-Sanderson et al. demonstrated that under specific conditions early intervention with OWV in the ventilator circuit during mechanical ventilation significantly accelerates voice recovery, enhances communication and patient satisfaction, improves psychological health, and facilitates earlier decannulation in tracheostomy patient [10]. Additionally, a randomized controlled trial (RCT) compared the early use of OWV (within 12 ~ 24 h post-percutaneous tracheostomy) with standard use (48 ~ 60 h post-percutaneous tracheostomy. The study found that patients in the early intervention group tolerated the valve for longer periods and achieved higher decannulation rates at discharge [11]. These findings confirm that the use of OWV during mechanical ventilation can be initiated as early as 48 h post-tracheostomy, or even sooner under appropriate clinical conditions.

To ensure both safety and effectiveness, specific clinical and respiratory criteria must be met for the use of OWV during mechanical ventilation, with cuff deflation being the primary criterion, as it ensures proper airflow through the tracheostomy tube during exhalation [10, 11]. Patients should demonstrate spontaneous breathing capability, effective ventilator triggering, and adequate gas exchange without requiring high levels of ventilatory support to maintain oxygenation. Key respiratory parameters in these studies include PEEP ≤ 10 cmH₂O, FiO₂ < 60%, peak inspiratory pressure < 40 cmH₂O, SpO₂ > 90% [10, 11]. The criterion of PEEP ≤ 10 cmH₂O was set to exclude patients with PEEP-dependent hypoxemia, while the threshold of peak inspiratory pressure < 40 cmH₂O was chosen to avoid selecting patients with severe airway spasm or obstruction. However, these parameters may vary based on individual patient needs and the available literature. We acknowledge that these criteria still require further research to refine and better understand their optimal application. Additional conditions include stable clinical status, consideration of an adequate level of consciousness and ability to participate, unobstructed upper airway anatomy, tolerance of cuff deflation, and sufficient airway protective ability. We strongly recommend that patient screening for OWV use be conducted through a multidisciplinary team assessment, involving speech therapists, respiratory therapists, intensivists, bedside nurse and other relevant specialists. Furthermore, close monitoring and management are essential to assess patient tolerance to the speaking valve and ensure safety during its use.

When applying a OWV in mechanically ventilated adult tracheostomy patients, it is crucial to understand the pathways of ventilation. During inspiration, the ventilator delivers support, with part of the inspiratory tidal volume entering the patient’s lungs and another portion escaping through the gap between the deflated cuff and the airway via the upper respiratory tract [12]. Consequently, compared to situations without a OWV, the use of an inline OWV may require additional compensation for inspiratory tidal volume or inspiratory pressure.

During expiration, when the OWV remains closed, most ventilators may register the expiratory tidal volume as zero. This requires managing low expiratory tidal volume and low expiratory minute ventilation alarms. Some ventilators provide the option to adjust alarm thresholds or switch to inhaled tidal volume monitoring to prevent these alarms. Therefore, it is important to verify these settings based on the specific ventilator model and features before clinical use.

We propose that OWV should be utilized as early as clinically feasible in tracheostomy patients, even during mechanical ventilation. Despite promising findings, further high-quality evidence is required to establish standardized guidelines for early application of OWV.

Not applicable.

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Author notes

1. Shi-Min Zhang, Yi-qi Qian and Yaxiaerjiang·Muhetaer have contributed equally to this work.

Authors and Affiliations

1. Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, No. 180 Fenglin Road, Xuhui District, Shanghai, 200032, China

   Shi-Min Zhang, Yi-qi Qian, Yaxiaerjiang Muhetaer, Min-jie Ju & Kai Liu

2. Department of Critical Care Medicine, Shanghai Geriatric Medical Center, Shanghai, 200032, China

   Yaxiaerjiang Muhetaer

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Supervision: Kai Liu, Min-jie Ju; Writing—original draft: Shi-ming Zhang; Yi-qi Qian; Yaxiaerjiang·Muhetaer; Writing—review & editing: Kai Liu, Min-jie Ju;

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Zhang, SM., Qian, Yq., Muhetaer, Y. et al. Application of one-way speaking valves in adult tracheostomy patients: the time should be earlier. Crit Care 29, 210 (2025). https://doi.org/10.1186/s13054-025-05425-4

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• Received: 15 January 2025

• Accepted: 20 April 2025

• Published: 23 May 2025

• DOI: https://doi.org/10.1186/s13054-025-05425-4

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