Evaluation of the Electrolarynx in the Short-term Hospital Setting

Evaluation of the Electrolarynx in the Short-term Hospital 8etting* Jack] Adler, M.D., F.C.c.P.;t andJoanne Zeides, M.S.+

We evaluated the effectiveness ofthe electrolarynx as a communication tool in the short-term hospital setting with 22 tracheostomized patients. Following an initial training peclod, we found that 14 of22 patients achieved good results in communicating with the electrolarynx, three patients had fair results, and Bve patients had poor results. There were no differences in success rates for older or younger patients

or for men or women; we could not correlate specmc disease diagnosis with success or failure. The instrument could be effectively cleaned at the bedside. With the exception of patients who are severely confused or who have undergone extensive head and neck surgery, all tracheostomized patients can be considered candidates for this method of communication.

Caring fur sick patients becomes much more difficult when those patients are unable to communicate. A variety of communication techniques have been attempted with the intubated or tracheostomized patient. A patient who has a small tracheostomy cannula in place can usually phonate, that is, produce sound by vibrating the vocal cords, by being taught to occlude the tracheostomy tube while speaking. However; patients with larger tracheostomy tubes are generally not able to produce voice due to the loss of subglottal air pressure during exhalation. We have recently used a neck type electrolarynx in the shortterm hospital setting as a communication tool for patients with tracheostomies; our evaluation of its use in 22 patients is reported.

patient was then given specific instructions in the assisted use ofthe device. Initially, emphasis was placed on proper positioning of the unit flat on the neck and on the use of slO\1v, precise, exaggerated articulatory movements. The speech pathologist held each of three different electrolarynx models (Servex, Aurex-Neovox, and Western Electric 5-C) at various positions on the patients neck, seeking maximal intelligibility as assessed when the patient counted, repeated single words, and said his name and address. In so doing, the speech pathologist along with the patient and any other listeners present, determined which device produced the most intelligible speech. The patient was then instructed in self placement of the unit, articulation, and coordination of the "on" switch with articulation. He was encouraged to listen carefully to his speech production and to modify placement and articulation patterns as needed to produce maximal intelligibility. The patient was asSisted, if necessary, in placing and using the electrolarynx appropriately with gradually decreasing cues provided by the speech pathologist until the patient was holding and using the device as independently as possible. The speech pathologist returned on a daily basis to monitor each patients use ofthe electrolarynx, providing additional instruction as needed. After an interval of three to ten days, ~e effectiveness ofthe electrolarynx was then assessed. Patients were judged to have a good result if they, their families, and staffreported that the patients were able to communicate effectively with little or no assistance. Patients who reported that they used the unit occasionally or reqUired a great deal of assistance were judged to have a fair result. Those patients whose communication abilities did not improve with the instrument were considered to have a poor result. In our initial selection of patients, we excluded patients whose mental status was not conducive to effective communication with the electrolarynx. However, changes in mental status occurred in some of our patients during their hospitalization. In order to assess the effect of change in mental status on communication, we classified patients into three categories; (1) normal, (2) mild to intermittent confusion, (3) severe confusion. The speech pathologist cleaned the electrolarynx with sterile alcohol swabs before and after each session with a patient. Once cleaned and dried, a sterile cotton swab dipped in a sterile normal saline solution was placed over the instrument and then streaked onto a blood agar culture plate. Nine instruments from three different manufacturers were checked in this fashion.

METHOD

Patients selected for study were adults who had recently undergone tracheostomies, usually for ventilator management or tracheobronchial toilet. (At our institution, we manage ventilator patients with an endotracheal tube for several weeks before proceeding to tracheostomy.) Although these patients were often quite sick and in the intensive care unit, their medical status was stable and their neurologic status intact enough to enable them to communicate. Excluded from the study were all patients who were obviously inappropriate candidates for communication training, eg, comatose patients. All patients had a standard cuffed tracheostomy tube in place; as these patients required ventilatory support, the cuffon the tracheostomy tube remained inflated at the time electrolarynx use was initiated. To the best of our knowledge, none of these patients had previous speech impainnents. At the bedside, the speech pathologist clinically evaluated the patients ability to follow instructions and to articulate, that is, to produce specific speech sounds by moving the oral structurestongue, lips, jaw, palate, and cheeks in coordinated, precise sequences. The purpose and use of the electrolarynx were explained and demonstrated to the patient, family, and nursing stafI The

*From the Brookdale Hospital Medical Center, Brooklyn. tChief: Pulmonary Section; Associate Professor Clinical Medicine. *Senior Speech Pathologist Manuscript received Ma.r 13; revision accepted September 5.

Reprint requut8: Dr. Adler, Brookdale Hospital, Brooklyn 11212

RESUIIS

Over 24 months, we studied 22 patients: 15 women and seven men ranging in age from 35 to 78 years. CHEST I 89 I 3 I MARCH, 1986

407

Table I-Summary of Clinical Information and Outcome Age

Sex

Diagnosis

Device

38

F F F F F F F F F M M M M F F F F F F M M M

COPD COPD COPD COPD COPD COPD COPD COPD COPD COPD COPD COPD COPD Hypopharyngeal Ca Neck Ca Thyroid Ca Lung Ca Multiple sclerosis

Servox Servox West Elect Servox Servox West Elect Servox Servox Servox West Elect Servox Servox Servox West Elect Servox West Elect Aurex Servox West Elect Servox Aurex Aurex

41

56

61

64

67 71 76 76

53

61

66

70

35

61 74

77 43

55 46

57 78

Guillian-Barre

Brainstem CVA CVA, COPD Bilateral vocal

cord paralysis 2°

Duration

Assessment

Ultimate Disposition

2 Weeks

Good Good

Achieved phonation Achieved phonation Achieved phonation Died Achieved phonation Died Achieved phonation Too confused Achieved phonation Achieved phonation Became unmotivated Refused further attempts Achieved phonation Became too weak Refused therapy Achieved phonation Became too weak Became too weak Became unmotivated Severely dysarthric Too confused Died

5 Weeks 7 Weeks

Fair

Good Good

8 Weeks

4 Weeks 3 Weeks 3 Weeks 1 Week 4 Weeks 2 Weeks 2 Weeks 3 Weeks 2 Days 4 Weeks 3 Days 8 Weeks 4 Weeks 6 Weeks 10 Weeks 2 Weeks 8 Weeks 10 Weeks

Good Fair Poor Poor

Good Good Fair

Good Good Poor

Good Good

Good Good Poor Poor

Good

to mets. Ca. to cervical area

Table 1 summarizes pertinent clinical data and outcome of these patients. Their diagnoses included 13 patients with chronic obstructive pulmonary disease (COPD), two patients with cerebral vascular disease, five patients with cancer of the head or neck, and one patient each with Guillain-Barre syndrome and multiple sclerosis. The initial assessment indicated that 14 patients had a good result, three patients a fair result, and five patients a poor result. The ultimate disposition of these patients revealed the following: nine patients achieved phonation; three patients died; two patients refused further therapy; two patients became discouraged and ceased using the unit; two patients' confusion and one patient's dysarthria prevented effective use. Table 2 presents the impact of mental status on electrolarynx use. All patients who became severely confused had poor results. However; two of those patients who were intermittently confused were able to communicate effectively, and nearly all patients with normal mental status were able to use the device Table 2-ClaaijictJtion of BeaultIJ According to Mental Statuti

Mental status

Good

Fair

Poor

Within normal limits Intermittent confusion Severely confused

12

2

1

408

1

Table 3-Cla8Bification of Results According to Manufacturer

Initial Assessment of Effectiveness Electrolarynx

Good

VVestern Electric Aurex Neovox Servox

5 2

Fair

Poor

2

4

1

7

Table 4-Claaification of BeaultIJ According to Patient Cooperation

Initial Assessment of Effectiveness

2

satisfactorily. Table 3 indicates that good results were achieved with all three instruments. Note that we did not systematically compare all three instruments in all patients. The data in Table 4 indicate that some patients who did not cooperate fully with the speech pathologist were still able to achieve good or fair levels of communication using the electrolarynx. There was no difference demonstrated in success rate for older or younger patients or for men or women. Except for the two patients with cerebrovascular disease who both did poorly, there was no demonstrable relationship of medical diagnosis with success or

4

Initial Assessment of Effectiveness

Patient Cooperation with Speech Pathologist

Good

Fair

Poor

Good

12

1 2

1 3

Poor

3

Electrolarynx in Short-term Hospital setting (Adler, Zeides)

failure of electrolarynx use. The results of bacteriologic studies demonstrated that a single culture from one Aurex instrument was positive for Bacillus species; all cultures taken from the eight other instruments demonstrated no bacterial growth.

DISCUSSION

The neck type electrolarynx, originally developed in

1942, has been an effective tool for patients who have undergone laryngectomy. Summers, l in 1970, was the

first to describe his experience in using the electrolarynx with five patients who had tracheostomies inserted for a brief period of time. His work was cited by a later author who agreed with Summers' conclusion, but did not add additional case material. 2 Wu, Suh, and TurndorP described using the electrolarynx with 27 intubated or tracheostomized patients; 11 of their 19 patients with tracheostomies had excellent results. Our data also indicate the usefulness of the electrolarynx in patients requiring tracheostomies. As one would anticipate, severely confused patients did not use the electrolarynx well even with assistance. However, three of five patients with mild or intermittent confusion were helped with this device. Nearly all patients who were alert and tried to communicate did benefit. One sick, intermittently confused patient in the surgical intensive care unit benefitted from his ability to communicate to a point that we noted significant improvement in his mental status. Not all patients who were able to use the electrolarynx satisfactorily continued using the device throughout their hospitalization. In some patients, medical condition deteriorated. Others became less motivated and stopped. Some achieved phonation after placement of a small metal tracheostomy tube. We did not demonstrate or detect any significant

side effects resulting from the use of the electrolarynx. Careful cleaning of the instrument at the bedside resulted in effective sterilization. The instrument requires care and maintenance, and thus, cannot be considered disposable. Nonetheless, it worked well when cared for in a routine fashion. For patients undergoing extensive surgical procedures or radiation therapy to the neck, it may not be feasible to position the electrolarynx properly, and an alternate method of communication may be required. Also, this study did not compare efficacy and safety of the electrolarynx with other methods of communication in tracheostomized patients. Currently, several other devices are available for use in such patients, and it may be of interest to undertake such a comparison in a prospective fashion. 4.5 In summary, we have evaluated the electrolarynx in a group of acute medical and surgical patients requiring tracheostomies and have found the device helpful in facilitating effective communication. With the exception of patients who are severely confused or who have undergone extensive head and neck surgery, all tracheostomized patients can be considered candidates for this method of communication. REFERENCES

1 Summers J. Use of electrolarynx in patients with temporary tracheostomies. J Speech Hear Dis 1970; 38:335-38 2 Fritzell B, Hammarberg B. Technical aids for patients with voice disorders. Scand J Rehab Moo 1976; 8:61-63 3 Wu WH, Sub C~ Turndorf H. Use of artificial larynx during airway intubation. Crit Care Moo 1974; 2:152-54 4 Blom ED, Singer MI, Harkleroad BA. Self-activated pneumatic voicing system for ventilator dependent patients. Presented at Amer Assoc Resp Therapy Convention, 1982 5 Szachowicz EH, Walsh JJ, Maisel RH. TALC tracheostomy tube: normal speech while on a ventilator. Otolaryngol Head Neck Surg 1981; 89:221

CHEST I 89 131 MARCH, 1988

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