Tracheostomy tubes – communication options

How does having a tracheostomy tube affect voice and speech?

Voice occurs when the stream of air that comes from the lungs passes through the vocal cords as we exhale. The airstream is modified by the vibrating vocal cords as the air passes through, thereby producing sound, which is then modified again in our mouth and nose to make the different sounds of speech when we talk. Speech and voice may be affected when a child has a tracheostomy tube because it re-routes all or some of the airstream away from the vocal cords.

How do infants communicate?

Infants communicate with us through a variety of ways. They can use vocalisation, crying, facial expressions and eye contact and gestures (when their motor skills develop). We call these ‘infant cues’. Until infants and young children start to use words to communicate, these infant cues are their form of communication.

As some children with tracheostomy tubes cannot cry or produce voice, it is vital to look for other infant cues, so that we know how they are feeling. Infants often use a variety of cues, called ‘clusters’. Examples include:

Cues indicating that your child is hungry:
Suck-searching behaviour (rooting), sucking on hands or fists, fussing or crying, having a flexed body position, calming down when being held in a feeding posture (in your arms), looking at the parent, breast, bottle or food and being in a hunger posture, such as upper arms close to the chest, elbows flexed tightly, forearms raised and hands (open or fisted) held under the chin.

Cues indicating that your child is full:
Falling asleep, slack lip seal around the breast/bottle, lack of facial expression, decreased muscle tone, arms extended along sides, legs extended, extended relaxed fingers, decreased sucking, gurgling and cooing or talking, pulling away from the breast/bottle and pushing away the bottle.

Cues indicating that your child is sleepy:
Decreased muscle tone and drooping eyelids, grimacing or screwing up eyes, fussing or grizzling, rubbing eyes with fists, snuggling or nuzzling when being held.

Cues indicating that your child is in pain:
A flushed face, grimacing, a cry expression, tense body, back-arching or pushing back, arms and legs either splayed out tightly or bunched in a foetal position (curled up). Infants may also rub/pull ears or rub ears on sheet/bed (ear ache) or chew on material, objects or fists (teething) or may be constantly irritable and grizzly.

How can I help my infant learn to communicate?

Always maintain eye contact with your baby. Use lots of facial expression, gestures, and short sentences, speak clearly and slowly, and repeat words often. Make sure your child’s ears are regularly checked to ensure they can hear properly and do not have an ear infection. Talk and read regularly to your child.

What are other communication options for children who are learning to talk or talking?

Voice and speech options

Finger occlusion of the tracheostomy tube: Your ENT or speech pathologist will advise you on your child’s readiness for this. Do not attempt it unless advised it is safe. Putting a clean finger on the child’s tracheostomy tube for short periods of time when the child wants to speak can stop air from escaping from the tracheostomy tube and re-divert air through the neck, past the vocal cords and out of the mouth. Your child will need to have enough space around the tube and no obstruction in their throat to allow the air to re-route out of the mouth. They may learn to cover their tracheostomy tube with their chin or finger when talking.

A tracheostomy speaking valve: A tracheostomy speaking valve is a one-way valve that allows your child to breathe in through the tracheostomy tube, and out through their nose and mouth. Refer to fact sheet 3.

Fenestrated tracheostomy tubes: Fenestrated tracheostomy tubes (for older children) have an opening in the tube which allows air to pass through the vocal cords. These are rarely used for young children.

An above cuff-line tracheostomy tube: This type of tube is for older children. It has a line attached to the tracheostomy tube and an opening above the level of the cuff which allows air from an outside source to be pumped into the airway and then passes through the vocal cords to provide voice.

Non-speech options

Gesture: Use of gesture, either natural gestures or gestures that are part of a formal sign language, is encouraged for children with tracheostomy tubes – especially for pre-linguistic children who haven’t learnt to say real words yet. It doesn’t matter whether a young child has a voice; gestures and signing assist in promoting the child’s early language development – both understanding and producing language.

Augmentative communication devices (AAC): Children with tracheostomy tubes can use other forms of communication such as real objects, object boards, picture boards or folders, writing boards, and eye gaze frames. High tech voice output devices can be used for children who might have a physical impairment or for those who are unable to use their hands.

What is a total communication approach?

This approach is often recommended for infants and young children with tracheostomy tubes. It combines the use of facial expressions, gestures, speech and AAC to promote learning and using speech and language to communicate. Infants and young children often learn better when several forms of communication are used.

Who should I contact to talk about my child’s communication development

You can contact your local speech pathologist to discuss where to best access services for your child. The speech pathologist will assess your child’s communication development in the context of any cognitive, sensory, physical or environmental factors that may affect your child, and then recommend the best form/s of communication for your child at their stage of development.

For more information

See these other fact sheets in our Tracheostomy tubes series:
Tracheostomy tubes (general information)
Tracheostomy tubes: Feeding, eating and drinking
Tracheostomy tubes: Using a speaking valve

Contact us

Speech Pathology Department Queensland Children’s Hospital
t: 07 3068 2375
e: LCCH-Speech@health.qld.gov.au

ENT Clinical Nurse Consultant / Clinical Nurse Queensland Children’s Hospital
t: 07 3068 1379
e: CHQ_CNC-ENT@health.qld.gov.au

Resource No: FS290. Developed by the Speech Pathology Department, Queensland Children’s Hospital. Updated: November 2017. All information contained in this sheet has been supplied by qualified professionals as a guideline for care only. Seek medical advice, as appropriate, for concerns regarding your child’s health.