Voice therapy exercises after tracheostomy tube removal
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Voice Therapy After Tracheostomy Tube Removal
Post-decannulation voice rehabilitation focuses on restoring phonation, respiratory support for speech, swallowing coordination, and laryngeal muscle function. The approach is guided by a Speech-Language Pathologist (SLP) and is tailored to the underlying reason for tracheostomy (ICU/ventilator weaning, head/neck surgery, airway obstruction, trauma, etc.).
Why Voice Is Affected After Tracheostomy
Tracheostomy disrupts normal airflow through the larynx. While the tube is in place, exhaled air bypasses the vocal cords, leading to:
- Vocal fold disuse and muscle atrophy
- Reduced subglottic air pressure needed for phonation
- Altered proprioceptive feedback from the larynx
- Potential vocal fold paralysis (especially after prolonged intubation or surgery)
- Desensitization of supraglottic structures
- Dysphagia from disrupted laryngeal elevation and airway protection reflexes
(Cummings Otolaryngology, block24 - Postoperative Management Issues)
Pre-Decannulation: Bridging to Voice
These are done while the tube is still in situ - they prepare the larynx for post-tube voice work:
| Technique | Purpose |
|---|---|
| Cuff deflation trials | Allows exhaled air to pass over vocal cords; reintroduces phonation |
| Finger occlusion of the tube | Patient briefly covers the tube opening, redirecting airflow upward through the larynx to permit voice |
| Passy-Muir Speaking Valve (PMV) | One-way valve on the trach tube; closes on exhalation, directing airflow up past the vocal cords for continuous phonation without manual occlusion |
The PMV is considered the gold standard pre-decannulation voice tool. It also improves swallowing, smell, and taste, and facilitates tube weaning.
Phase 1: Immediately Post-Decannulation (Days 1-7)
The stoma is still closing; subglottic pressure may be reduced and vocal folds are deconditioned.
1. Breath Support Exercises
- Diaphragmatic (costo-diaphragmatic) breathing: Patient places hands on lower ribs, practices slow deep inhalation with lateral rib expansion, then controlled exhalation. Builds subglottic pressure foundation for phonation.
- Sustained exhalation with resistance: Blow through a straw into water (bubble technique), creating back-pressure that encourages vocal fold adduction.
- Pursed-lip breathing: Prolongs exhalation, trains breath control for speech phrasing.
2. Easy Onset Phonation
- Gentle /h/ initiation before vowels (e.g., "haaah", "heeee") to avoid pressed/hard glottal attacks that strain healing vocal folds.
- Aim for relaxed, breathy onset first, then gradually firm it up.
3. Humming
- Produces gentle vibration across the vocal tract, stimulates mucosal wave, reduces edema.
- Start with sustained /m/ hum, then move through pitch levels.
Phase 2: Vocal Fold Strengthening (Weeks 1-4)
4. Sustained Vowel Phonation
- Sustain /a/, /e/, /i/ for increasing durations (start with 3-5 seconds, build to 10-15 seconds).
- Focus on steady airflow, not forcing.
- Monitor for voice breaks, breathiness, or compensatory tension.
5. Pitch Glides
- Glide smoothly from low to high pitch and back on a vowel or /m/.
- Restores full pitch range and identifies any areas of vocal fold stiffness or paralysis.
6. Loudness Variation
- Crescendo/decrescendo on a sustained vowel.
- Trains dynamic range of the voice; important for conversational volume control.
7. Resonance Exercises
- Forward placement: hum with lips together, feel vibration in lips and face.
- Semi-Occluded Vocal Tract Exercises (SOVTEs): phonation through a narrow tube or straw, lip trills, tongue trills - these load the vocal tract and reduce collision forces on the vocal folds while encouraging efficient phonation.
Phase 3: Functional Voice and Speech (Weeks 2-8)
8. Syllable and Word Drills
- Repeat consonant-vowel (CV) pairs: "ba-ba-ba", "ma-ma-ma", "la-la-la".
- Progresses to CVC words, then phrases, then sentences.
- Target articulatory precision and connected speech phrasing.
9. Phrasing and Breath Management
- Mark breath groups in a reading passage; practice pausing at phrase boundaries rather than mid-phrase.
- Gradually increase phrase length between breaths.
10. Prosody and Intonation
- Practice question vs. statement intonation patterns.
- Read aloud with deliberate pitch variation to restore natural speech melody.
Swallowing Exercises (Concurrent with Voice Therapy)
Dysphagia and dysphonia commonly coexist post-tracheostomy because the larynx serves both functions.
- Mendelsohn maneuver: Patient swallows and voluntarily holds the larynx elevated at peak height for 2-3 seconds before allowing it to drop - improves hyolaryngeal excursion and upper esophageal sphincter opening.
- Shaker (head lift) exercise: Supine, lift only the head to see feet, hold for seconds, repeated sets - strengthens suprahyoid muscles.
- Effortful swallow: Squeeze all swallowing muscles as hard as possible - improves posterior tongue base contact and pharyngeal pressure.
- Tongue strengthening: Push tongue against tongue depressor, side-to-side range of motion, tongue-to-palate squeezes.
- Laryngeal elevation exercises: Voluntary throat clear, hard swallow, pitch glides to end range - promotes laryngeal mobility.
(PMC3040585 - Speech Therapy Rehabilitation)
Special Considerations
| Situation | Modification |
|---|---|
| Unilateral vocal fold paralysis (common after prolonged intubation or neck surgery) | Compensatory posturing (head turn toward paralyzed side), vocal fold augmentation/injection may be needed before exercises are effective |
| Subglottic/tracheal stenosis | Voice therapy deferred until airway is adequate; focus on breath support post-dilation |
| Head/neck cancer + trach | Voice outcomes variable depending on extent of resection; ENT and SLP coordinate closely (Sabiston Textbook of Surgery, block15) |
| Laryngeal/tracheal stenosis post-trach | Compromise among voice, airway, and swallowing goals (Cummings Otolaryngology, block13) |
| Elderly or ICU patients | Begin with passive range of motion, muscle stimulation (NMES if indicated), then gentle active exercises |
Alarming Signs Warranting Reassessment
- Voice that does not improve after 4-6 weeks of therapy
- Progressive worsening of breathiness or hoarseness
- Aspiration symptoms (coughing/choking with liquids or solids)
- Stridor (may indicate restenosis)
- Globus sensation or worsening dysphagia
These warrant laryngoscopy to assess vocal fold mobility, mucosal integrity, and rule out restenosis or granuloma formation.
Team Approach
Post-tracheostomy voice rehabilitation is best delivered by:
- SLP - primary therapist for voice and swallowing exercises
- Otolaryngologist/ENT - laryngoscopic assessment, management of fold paralysis or stenosis
- Respiratory therapist - coordination of breathing and weaning
- Pulmonologist - for ventilator-dependent or complex airway patients
- Physiotherapist - respiratory muscle strengthening, postural support for phonation
Progress is typically gradual - most patients regain functional voice within 4-8 weeks post-decannulation, though this varies significantly by underlying cause, duration of tube dependence, and patient age.
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