What is Above Cuff Vocalization in Tracheostomy Patients?

Anja Fischer, Speech-Language Pathologist, shares her clinical expertise on the use of ACV in tracheostomized patients.

Above Cuff Vocalization or ACV is a technique which can restore airflow to the upper airway through application of an external flow of medical gas via the subglottic port of certain tracheostomy tubes. Understanding the importance of proper technique and patient selection when utilizing ACV is essential to ensuring safe and successful implementation.

Anja Fischer is a Speech-Language Pathologist working in Munich, Germany in both a neurological-psychiatric hospital and independently. She obtained her FEES certification in 2023 and is currently pursuing a degree at the FOM in Munich with a focus on marketing and digital media. Anja is a member of the Society for Dysphagia in Germany and the Dysphagia Working Group in Munich which she participates in to engage in professional exchange, deepen her knowledge about the latest developments in the field of dysphagia/tracheostomy tube management, and provide herself with valuable networking opportunities with colleagues and specialists to jointly promote innovative approaches to patient care. For many years, Anja’s focus has been on the care of patients with a tracheostomy tube both in the hospital and outpatient setting. In her current position, she utilizes ACV nearly every day with patients. We talked with Anja to learn more about ACV and which benefits she has seen patients experience from its use.

Can you define Above Cuff Vocalization and provide a general understanding of what it is?

Above cuff vocalization (ACV) refers to a technique which can allow a tracheostomy patient to speak. The vocal folds are located above the cuff of the tracheostomy tube. Air passes through the subglottic suction port, exits above the cuff, then travels up to the vocal folds. ACV allows for limited phonation in the presence of a cuffed tracheostomy tube with a subglottic suction aid and facilitates communication for individuals undergoing mechanical ventilation.

What type of patient is Above Cuff Vocalization appropriate for?

I use ACV with patients who are awake and able to cooperate. These patients have a cuffed tracheostomy tube that cannot be deflated due to ventilation or other causes and therefore have no chance of communicating verbally. I also use it in a weakened form with less airflow to improve pharyngeal sensitivity in patients who are not awake or interactive and cannot tolerate a deflated cuff for the same reasons. I’ve found ACV particularly beneficial in patients with delirium.

Who would ACV not be appropriate for?

I find it unsuitable for patients who are very sensitive, tend to become stressed easily, and show physically defensive behavior due to ACV attempts. You should also check beforehand that there is no upper airway obstruction and that the subglottic suction is functional. It should also be kept in mind that ACV should not be a substitute for deflating the cuff, meaning it should be used as a supportive tool or if there is not an option for cuff deflation. In addition, it should not be performed on newly created tracheostomies.

Can you describe in a detailed step-by-step approach how to perform ACV with a patient?

The general procedure for ACV is that beforehand, the patient's current status and condition is assessed and discussed with the nursing staff and/or doctors if necessary. If there are no contraindications, it is important to explain to the patient in advance (regardless of the patient's condition) what you are doing and what the procedure will be like. The secretions above the cuff are then removed using subglottic suction. The ACV adapter is connected to a thumb port and the air supply. Next, the patient is informed that some air will pass above the cuff and then he/she may be able to speak. It is best to start with a very small flow of air supply, approximately 1 liter/min and increase to a maximum of 5 liter/min if indicated and tolerated. From my experience, increasing the flow is not usually necessary and is usually sufficient at 2-3 liter/min.

What kind of complications have you experienced with ACV and how do you manage them?

So far, I have only very rarely experienced complications and when I have, it was more of an unfamiliar feeling that the patients reported or a coughing sensation, which was resolved when the oxygen supply was stopped, or flow reduced. Sometimes the patients are also confused when they hear their voice, as it sounds different than normal.

What benefits have you seen patients experience from the use of ACV?

I see a lot of advantages with ACV. In some of our patients, pharyngeal sensitivity improves, and patients are provided with a way to speak and communicate which is also important for nursing staff, doctors, and relatives to have the opportunity to communicate with the patient. Furthermore, I would say that it has been an effective tool in patients with delirium. I have also recently started using it with patients with dysphagia to reduce aspiration and improve swallowing through pharyngeal stimulation.

Any recommendations in this educational material are a general guide for best practice, to be implemented by qualified healthcare professionals subject to clinical judgement and availability of healthcare resources.

The information presented should not be considered medical advice for specific conditions. A patient’s individual circumstances and preferences should always be considered and clinical practice should be in accordance with the principles of protection, participation and partnership.