Communicating with conscious and mechanically ventilated critically ill patients: a systematic review

Using the appraisal outlined, the overall methodological quality varied from poor to moderate; score 9–35 out of 42, median 17 (see Additional file 2). Overall the studies were small, with only two reporting an a-priori sample size calculation [12, 29]. Only six studies used measurement tools with statistical assessment of reliability and validity, the majority used a subjective assessment. Only four studies used comparator interventions [12, 28‐30]. All studies had significant limitations in their design. There was a moderate to high risk of bias in the studies included in this review.

A communication board for intubated patients consists of icons and pictures representing basic needs. This was used with three studies, one retrospective cohort and two quasi-experimental studies [12, 17, 30]. The first study, by Stovsky et al. (1988) [30], stated that a planned communication with a picture board (comprised of 22 pictures with words) increased patient satisfaction, measured with the visual analog scale on satisfaction with communication, in the early postoperative intubation period after cardiac surgery (p = 0.05). Of the patients, 70 % (n = 14) asked for items not indicated on the board [30]. The other two studies used a two-sided board with the alphabet, a picture of the human body, and a pain scale combined with sentences [17] or illustrations [12]. In the retrospective study by Patak et al. (2006) [17], the majority (97 %; n = 28) of patients reported in the structured interviews that the communication board would have been helpful in communicating effectively during mechanical ventilation and it would have decreased their frustration level (29.8 % vs 75.8 %, p < 0.001). The study by Otuzoğlu and Karahan(2014) [12] stated that for 77.8 % (n = 35) the illustrated communication material was beneficial for communication between the medical staff and the intubated patients. Of the patients in their intervention group, 91.1 % (n = 41) used the alphabetical part of the board. Advantages mentioned by all three studies were an increased efficiency and speed of communicating, decreased frustration, and quicker expression of patients their needs [12, 17, 30].

Currently there are six types of specialized talking tracheostomy tubes available to allow communication with an inflated cuff [49]. The Portex Trach-Talk [36, 39, 42] and Communi-Trach I [42, 56] were used with four case series. The Portex BLUSA Tracheostomy Tube was reported in one article with four case reports [49]. These tracheostomy tubes have an additional lumen above the cuff through which air can flow into the larynx to facilitate verbal communication. Intelligible speech, measured by a subjective assessment of improvement of speech, was created in 100 % (n = 20) [39] and 74 % (n = 14) [36] using the Portex Trach Talk, in 90 % (n = 18) with the Communi-Trach I [56], and in 79 % (n = 15) using the Portex Trach-Talk and the Communi-Trach I (both or one of them were used) [42]. With the BLUSA tube, all patients (n = 4) achieved adequate phonation [49]. It took an average of 2.1 days (Portex “Talk”) [39] and 5.6 days (Communi-Trach I) [56] before adequate voice intensity for intelligible speech was produced.

The second option, reported in two case series, is the Blom Tracheostomy Tube which incorporates two separate valve mechanisms, through which all of the ventilator-delivered inspiratory air is directed to the lungs and the expiratory air can escape via fenestrations to the upper airway to allow phonation [37, 40]. With the Blom Tracheostomy tube, 90 % (n = 9) [37], measured with a subjective assessment, and 100 % (n = 23) [40], assessed with the Assessment of Intelligibility of Dysarthric Speakers, were able to achieve intelligible speech. In the study by Leder et al. (2013) [40], the time to audible voicing was 6.60 min. In both studies some of the subjects were also able to converse over the telephone [37, 40]. In the study by Kunduk et al. (2010) [37], two subjects (20 %) experienced clinically important oxygen saturation decreases (<90 %). The other study with the Blom Tracheostomy Tube showed no significant differences (p > 0.05) in oxygen saturation [40].

The EL is a battery-powered handheld device which is pressed onto the skin of the neck to transmit the vibrated electronic sound into the oropharyngeal cavity, where the user modulates it to create speech via articulation [57]. We retrieved seven studies on usage of the EL in the ICU setting, of which five were case series [31, 33, 43, 44, 46] and two were case reports [47, 50]: 72 % (n = 57) of all subjects had a tracheostomy. Results showed successful communication, by creating intelligible speech, with the EL in patients with a tracheostomy in all of the case series: 86 % (n = 19) [31], 100 % (n = 8) [33], 80 % (n = 5) [43], 100 % (n = 2) [44], and 79 % (n = 15) [46]. Creating intelligible speech with the EL in intubated patients was observed for 50 % (n = 2) [46] and 46 % (n = 6) [44]. One study reported the use of an EL with a nasotracheal tube, of which 50 % (n = 2) had good results, meaning good value of the EL as a means of communication [46]. All but one of the studies measured the success of the EL with a subjective assessment of improved communication. Tuinman et al. (2015) used the self-developed Electrolarynx Effectivity Score. Both case reports reported successful use of the EL in creating intelligible speech with an intubated [47] and tracheostomized [50] patient. In the study by Ewing (1975) [33], the EL was the most preferred by the patients (n = 8) and staff (n = 32) over other available basic communication methods (lip movement, sign language, and writing). In the case series of Summers (1973) [43], clear intelligible speech was produced after 15–30 min of instruction in 60 % (n = 3) and 1–2 hours in 40 % (n = 2) of patients.

All electronic AAC devices described in the nine studies had common topics about basic communication needs in the ICU on the main screens (e.g., emergency, pain, and emotions) [19, 32, 34, 35, 41, 45, 51‐54]. Two case series reported the use of voice output communication aids (VOCAs), which are a subset of handheld AAC devices with which patients touch a word–picture icon on a keypad to produce a prerecorded voice message [34, 35]. VOCAs were used in 17 % [35] and 27 % [34] of observed communication events, and in both studies all patients were able to successfully generate valid messages. In 70 % [34] and 94 % [35] of the observed communication events, more than one method of communication was applied (e.g., gesture, mouthing words, head nods, and writing).

The computerized AAC devices are specialized computers that contain a database of prestored phrases or pictorials. The selected phrases are voiced by a speech synthesizer [19, 32, 41, 51‐53]. The LiveVoice computer of the pilot study by Miglietta (2004) [53] uses various control devices for navigation through the menus; infrared eye-blink detector, touch buttons, or a touch-sensitive screen. Over 90 % of the patients felt that the system assisted them in obtaining their needs (pain management, hygiene, comfort, and anxiety). Of the hospital staff, 96 % (n = 42) felt that the LiveVoice improved patient care; this was not further specified. The pilot study by Rodriguez (2012) [19] used a multifunctional computer with touch buttons and a touch-sensitive screen. Ten patients (91 %) were satisfied with use of the device, measured with the Patient Satisfaction and Usability Instrument, and showed the ability to independently use the device from day 1. The use of the ICU-Talk communication computer was reported as a case series by Etchels et al. (2003) and MacAulay et al. (2002) [32, 54]. Of the patients who remembered using the computer, 16 % (n = 3) found it useful for creating conversations. Of the nurses, 44 % said the ICU-Talk assisted with patient care. The pilot study by Koszalinski et al. (2015) [52] with the Speak for Myself Computer Pad stated that 95 % (n = 19) thought the device was helpful for communication and it decreased frustration levels. The ‘intelligent’ keyboard of van den Boogaard and van Grunsven (2004) [45] scored more highly on ease of use (63 %) and satisfaction (88 %) compared with the alphabetical letter board. The gaze-controlled system of Maringelli et al. (2013) [41] improved significantly (p < 0.001) the ability to communicate basic needs and necessities, and decreased the level of anxiety remarkable. The eye-tracking device of Garry et al. (2016) [51] gave all of the patients the ability to communicate basic needs and had a positive psychosocial impact.

Dowden et al. (1986) [28, 55] described the use of AAC strategies for 50 temporarily nonspeaking ICU patients. The oral approaches (e.g., EL, speaking valve) and fine motor approaches (e.g., communication board) were the most recommended techniques. The most successfully served patients were those who were able to use several approaches simultaneously (70–82 % communication needs met). Reasons for intervention failure were decreased cognitive status (51 %), patient’s rejection of the intervention type (27 %), and decreased motor control (20 %).

The SPEACS trial by Happ et al. (2014) [29] measured the impact of two levels of interventions on communication interactions between nurses and intubated ICU patients (n = 89). They conducted a three-phase clinical trial: (1) usual care; (2) basic communication skills training; and (3) additional training in electronic AAC devices. Use of an AAC was 0.84 % (Phase 1), 0.51 % (Phase 2), and 6.31 % (Phase 3). The results demonstrated an increase in communication frequency in one ICU setting for both intervention groups (Phase 1 vs 3, p < 0.0001; and Phase 1 vs 2, p < 0.0001). The Phase 3 intervention added significant improvements to patients’ perceptions about communication ease (p < 0.01). No device limitations were mentioned.

Patients using the communication boards were orientated without changes in mental status, able to see well enough to read the prints, and had no linguistic problems [12, 17, 30]. Two out of three studies used orally intubated patients after cardiac surgery [12, 30]. Difficulties with the use of the different communication boards were that the board contained too much information [17]. Certain needs and requirements of the patients were lacking on the board [12]. Also, optimal positioning of the board presented difficulties [30].

All tracheostomized patients in which the talking tracheostomy tubes were used were cognitively intact without upper-airway obstruction and had intact muscular function for articulation. Patients had mixed diagnoses [36‐40, 42, 48, 49]. Common causes of malfunctioning of the tube included occlusion of the air vent ports, cuff leaks, and kinking of the airflow line tubing. One case report, also using a tracheostomy tube with additional lumen (Vocalaid), stated that it was inadequate for communication due to fatigue after a few minutes and discomfort [48].

The EL was used in patients with mixed diagnosis, intact cognition, and articulatory function [31, 33, 43, 44, 46, 47, 50]. Difficulties in using the EL were due to trouble of understanding the EL voice in the beginning and the unnatural voice quality. In four of the studies, some patients needed assistance in positioning of the device [31, 33, 44, 50].

High-tech communication interventions were used by patients who were cognitive able to communicate and follow simple commands [19, 32, 34, 35, 41, 45, 51‐53]. In six studies patients needed to have some muscle power to use the device [19, 32, 34, 35, 45, 52]. Gaze-controlled and eye-tracking devices were used in paralyzed or physically limited patients with intact visual acuity [41, 51, 53]. Primary barriers to using the VOCAs were poor device positioning, deterioration of motor and/or cognitive function, and unfamiliarity of healthcare professionals with the use of the VOCA [34, 35]. Barriers to using the computerized AAC devices were fatigue, insufficient muscle power or coordination of the upper extremities, and reduced attention span or sedation [19, 32, 41, 45, 51‐53].

To construct the algorithm we used the patient characteristics and the results which are presented in this systematic review. As a starting point we used the algorithm published by Williams in 1992 [27]. Through discussion, in the aforementioned working group, a hierarchy of assessment tasks to facilitate assessment and selection of communication methods was determined. The algorithm is shown in Fig. 2.