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Speaking Valve

Original Editor - Angeliki Chorti Top Contributors - Angeliki Chorti and Ewa Jaraczewska  

Introduction

Example of a speaking valve.

A speaking valve, also known as a voice or speech valve, is a one-way ventilation valve that is connected with the tracheal tube at the front of the tracheal cannula. [1] This device is commonly used in patients who have lost their vocal ability because of tracheostomy [2] to help them speak naturally.

Tracheostomy is often needed in critically ill patients to safeguard their airway. [3] A number of conditions may require tracheostomy, such as respiratory problems, high level spinal cord injuries, neuromuscular disorders. These conditions may lead to the inability of the patient to manage secretions and protect the airway, cause upper airway obstruction, or may require long-term respiratory/ ventilator support. [4] Tracheostomy may be indicated over long-term intubation because it may be better tolerated by patients, it's easy to clean and manage, it does not require for the patient to be sedated, and promotes quicker ventilator independence. [4] However, despite advantages there are also shortcomings. [4] Tracheostomy may affect breathing, swallowing, sense of smell, and an important drawback is also the inability of the patient to communicate vocally. [4] Return of voice is essential for tracheostomised patients and effective communication has been linked with better mood, self-esteem, better medical decision making and quality of life for these patients. [5]

The speaking valve is one of many developed rehabilitation strategies for reducing the adverse effects and improving communication in patients with tracheostomy. [6] The speaking valve works by allowing inspiration but closes when the air goes out in expiration. During exhalation, the valve remains closed and this makes sending the air to the vocal chords and larynx possible.

These valves can be used in spontaneously breathing [7] or ventilator-dependent [8] patients, and are suitable for adult [6] and neonatal and pediatric cases. [9] Therefore, they can be used in any tracheostomy size, with the only prerequisite being that the tube must have the universal 15mm connector. [10]

The speaking valve was originally introduced by Toremalm in 1967. [2] Since then, its wide clinical use has led to the development of various applications.

Types of Speaking Valves

Open Position Speaking Valves

The Open Position Speaking Valve is a one-way valve that opens during inspiration to allow air to get to the tracheostomy tube, but needs airflow to get back in exhalation to close the membrane of the valve. The inability of the valve to completely seal may cause air leakage during exhalation and thus, there is a risk of secretions moving up into the tracheostomy tube and onto the valve. This open position design may be suitable for patients who can not tolerate closed position designs (such as the Passy-Muir Valve below) and can not exhale through the upper airway. Examples of open position valves include Shikani Speaking Valves, Shiley Phonate, Tracoe Phon Assist, and Montgomery Speaking Valve.  [10]

For more on open position speaking valves you can refer to the information below. This information provide instructions on how these valves are used, but always make sure you check with the company for specifics and updates on product use.

For the Shikani Speaking Valve:

[11]

For the Shiley Phonate Valve:

[12]

For the Tracoe Phon Assist I:

[13]

For the Montgomery Speaking Valve:

Boston Montgomery Speaking Valve Manual

Closed Position Speaking Valves

Passy-Muir Valve

The Passy-Muir swallowing and speaking valve (PMSV) or Passy-Muir Valve (PMV) is the most widely known valve due to its biased closed position no-leak speaking feature. [14][15] The PMSV was invented by David Muir. David had muscular dystrophy and was unable to speak because he required tracheostomy and mechanical ventilation to breathe. You can watch a video on how the PMSV is designed to work below:

[16]

Other Speaking Valves

Modifications to the closed position types of speaking valves have been developed to meet patients' needs and circumstances. For example, some drill a small hole at the side of the PMV to allow part of the exhalation to take place in tracheostomised children. [17]

Some speaking valves are built-in devices that may allow for neck breathers to speak. For example, the Trachphone and Freevent Dual Care are Heat and Moisture Exchanger (HME) devices that combine vocal and pulmonary functions in tracheostomy patients that have compromised upper airway function. [18] HMEs are passive devices that filtrate and release the heat and humidity of a patient's exhaled air to the next inspiration, thus conserving functions that are not provided by upper airways. [19] Patients with laryngectomy may also use HMEs with built-in speaking functions (e.g. Provox Life). [20]

Criteria for Patient Selection

The following requirements need to be met in order for a patient to be candidate for a speaking valve:

  • Tracheostomy in situ
  • Tolerance of cuff deflation
  • Sufficient oral air leak
  • Awake, alert, responsive patient who attempts to communicate verbally
  • Haemodynamic stability (minimal vasopressor requirements)

[21]

Efficacy/Effectiveness

The effect of speaking valves on vocalisation or speech, ventilator weaning and tracheal intubation / extubation, and their role on aspiration and swallowing function, patient mobility and quality of life have been assessed in a 2022 review about the clinical utility and future direction of these devices. [1]

A systematic review is also on the way examining the efficacy of speaking valves in adult patients with tracheostomy. [6]

Speaking Valves and Vocalisation

The effect of the PMV on vocalisation and speech has been examined in a small case series study on ventilator-dependent adult patients. [8] PMV use resulted in better speech intelligibility, speech flow, less speech hesitancy, and improved speech time in patients. [8] Early of a speaking valve reduced the number of days to speech recovery for ventilator-dependent patients in controlled studies. [22][23] Improvements in phonation were not successful in severe pulmonary disease (adequate ventilation is not guaranteed with the cuff deflated) and laryngopharyngeal problems due to neuromuscular disease. [24]

In children, a review of 12 studies indicated that more attention has been paid to tolerance/successful use of speaking valves in children with a tracheostomy than to the impact on phonation. [25] When there is an upper airway obstruction, a retrospective study showed that drilling a small hole at the side of the PMV reduced transtracheal pressure and as result, making vocalisation possible by allowing some exhalation to take place in tracheostomised children. [17] This method is described in a 2009 paper by Brigger & Hartnick. [26]

Speaking Valves and Weaning

Speaking valves have been studied for assessing and managing airway function before and during weaning in tracheostomy patients. [27] Closed versus open tracheostomy tubes and speaking valves have helped restore subglottic pressure and as a result, improve positive end-expiratory pressure, oxygenation / ventilation, swallowing and secretion management.[28] For ventilator-dependent patients with neuromuscular disease, they have demonstrated similar speech quality and respiratory comfort as low level PEEP. [29] Unfortunately, despite their physiological benefits, more research is needed to investigate their clinical benefits in pediatric [30] and adult patients. [31] Speaking valves may not influence time to wean or whether complications may happen, but still, they are associated with better satisfaction and experience of the tracheostomised patient. [32]

Speaking Valves and Aspiration / Swallowing

The facilitation of expiration with the use of a speaking valve may be important for the breathing swallowing interaction. [7] When the air flows towards the upper airway after swallowing, it helps liquid or food particles that moved towards the trachea during swallowing to be removed. Speaking valves help restore this function, but swallowing and its synchronisation with breathing may depend on other factors too. [1][7]

Speaking Valves and Patient Mobility /Quality of Life

The use of speaking valves improved daily mobility by means of the Perme Intensive Care Unit Mobility Score in patients who tolerated them for at least 30 minutes. [33]Return of voice was connected to better patient reported self-esteem, cheerfulness, ability to be understood by others; these outcomes may also have an impact on quality of life, although definite associations are still missing. [5][34]

Timing

The timing of the decision to place a speaking valve relies on the patient’s status, and the timing of tracheostomy. In theory, speaking valve placement is feasible withing 24 hours after tracheostomy, [35] but some may prefer to wait more depending on circumstances.

Staff Requirements

Speaking valve placement usually requires the coordinated work of a specialised multidisciplinary team that should be usually in place for tracheostomy care too, consisting of medical and nursing staff (e.g. pneumonologists, ENT doctors), speech-language therapists, and respiratory care physiotherapists (always check local and state requirements for competency training), even dieticians and psychologists. [36] The team may also provide information to the patient and family about the use and maintenance of the device, as well as ensure that patients and their carers practice until proficiency is reached.

Safety

Speaking valves are relatively safe to use in tracheostomy patients as long as there are proper procedures, assessment and monitoring in place. [27] Two important factors when establishing the safety of speaking valves: [37]

  1. Anatomical integrity of the upper airway (i.e. area above tracheostomy)
  2. Space between tracheostomy cannula and cuff, and its management

Upper Airway Patency

Upper airway patency is an crucial element when considering using speaking valves. [38] It depends on the balance between forces opening the airway (i.e. dilating muscles) and forces that contribute to getting the airway closed (i.e. negative airway pressure). [39] A common way of assessing upper airway patency is tube occlusion but not all patients can tolerate this procedure. A prospective observational study on the safety and efficacy of a one-way speaking valve concluded that it is safe for patients who reach a threshold of 2 h. Other authors suggest that being able to wear a speaking valve > 12h is an indication of upper airway patency. [27] Repeated evaluations of the patient's condition are required to ensure safety and to avoid problems caused by various life-threatening conditions. [27]

Ventilated Patients

Patients in need of mechanical ventilation will have to connect the valve with the tracheal cannula as well as the ventilator tube, to allow patient vocalisation when using the ventilator. It is also necessary to adjust the ventilator to the appropriate ventilator usage parameters. [1]

Speaking Valves and Cuff Management

One of the most important thing to remember when using speaking valves is that they should never be used when the cuff is inflated in the cuffed tube. [40] This action may have serious consequences for a patients' life, since the individual can not breathe out when the tracheostomy is cuffed and inflated and the speaking valve prevents an alternative outlet for the air. This dangerous overpressure, leading to severe complications or even patient’s death, has been addressed by creating a biomimetic speaking valve which includes an integrated overpressure valve automatically opening when reaching critical pressure levels and a whistle to alert medical staff. [41]

However, some tracheostomy tubes allow the option of vocalisation with the cuff inflated or deflated. This is due to the fact that these tracheostomy tube shafts are fenestrated. Fenestrated tracheostomy tubes have one or more small openings that allow more airflow through the upper airway compared to the non-fenestrated inner cannulas, giving some ability to the patients to speak even with inflated cuffs. [42] This alternative option for patients who can not tolerate one way speaking valves may be linked with risks such as granulation tissue formation, tracheomalacia, and tracheal stenosis. [42]

Before placement, suctioning of airway and oral secretions should be performed to ensure that the airway is clear before deflating the cuff. Ideally, the patient should be sitting instead of lying down to avoid secretions getting back to the lungs. Respiratory status and vital signs should be monitored in the early stages to examine tolerance and comfort of the speaking valve. Once the patient is ok with cuff deflation, the placement of the speaking valve can be made. Again, signs of valve intolerance should be carefully monitored. If the patient is able to tolerate the speaking valve, attempts to vocalise can start with automatic speech e.g. counting, and at later stages proceed to spontaneous communication.

The UK National Tracheostomy Safety Project has a video providing safety information and appropriate procedures for people using speaking valves:

[43]

Contraindications and Poor Tolerance

The use of a speaking valve is contraindicated when the patient is not stable medically and is unconscious, during sleep, there is an oral intubation or metal tracheostomy tube, cannot tolerate full cuff deflation (e.g. high risk or frequent aspiration, thick unmanageable secretions) or there is airway obstruction that does not permit vocalisation during exhalation (e.g. laryngeal stenosis). [21] Common reported reasons for poor tolerance are low oxygen saturation, coughing, respiratory distress (Borg dyspnea scores 4-10 or respiratory rate increase > 20%), and fatigue. [27] Table 1 describes reported causes for respiratory difficulty.

Table 1. Causes of respiratory difficulty when using speaking valves
Mucosal Oedema
Grannulation Tissue Hyperplasia
Vocal Cord Paralysis
Abnormal Breathing Patterns
Excessive Upper Airway Secretions
Oversized tracheostomy tube
Anxiety
Improper positioning of tracheostomy tube
Decrease in SatO2 < 90%

[27]

FAQs

  1. I have an adult patient with a high risk of aspiration. Is it safe to deflate the cuff when using the Passy-Muir speaking valve? Cuff inflation does not necessarily ensure that the patient will not aspirate. [44] In fact, there is some evidence that deflating the cuff may reduce aspiration when compared to keeping the cuff inflated when using PMVs in adults.[45] [46] Deflating the cuff is necessary when using closed position speaking valves to prevent air trapping and lethal side-effects. Assessment of the patient and appropriateness to use a PMV should precede any decisions about the patient's management. Before you use the valve, perform suctioning of airway to clear oral secretions and place the patient in a sitting position instead of lying. Monitor your patient's respiratory status and vital signs to check for tolerance and comfort.
  2. I have the fenestrated tube in my patient's tracheostomy. How can I do airway suctioning to clear secretions? When suctioning through a fenestrated tube, make sure that the non-fenestrated inner cannula is in place, so that the suctioning catheter does not damage trachea tissue. Both are usually delivered to the patient in the same package. [47]
  3. I have deflated the cuff gradually with a 10 ml syringe and I am carrying out suction at the same time on my patient. I have checked the airflow in my patient's mouth and it looks ok. What should I look for when checking for signs that the speaking valve is not tolerated? When deflating the cuff, vital signs should be stable and the patient should not report or indicate fatigue. Intolerance may derive from various reasons and may include signs such as increased anxiety, dyspnea, tachypnoea>35 breaths/ min from baseline, tachycardia >20 beats/min from baseline, hypoxia, hypercapnia, loud expiratory wheeze and continuous coughing. If this occurs, you need to re-inflate the cuff. [48]

Resources

Speaking Valves from Tracheostomy Education

Passy-Muir Competency Form Template an example for documenting clinicians' knowledge and skills for placement of one-way speaking valves

Example of a Tracheostomy Competency Framework including speaking valves in its core skills

Example of a clinical protocol and education requirements of SLPs for speaking valve placement

Speech-Generating Device Evaluation template by the American Speech-Language-Hearing Association

Example of key documentation and procedures for PMV in the NHS.

References

  1. ↑ 1.0 1.1 1.2 1.3 Lian S, Teng L, Mao Z, Jiang H. Clinical utility and future direction of speaking valve: A review. Front Surg. 2022 Sep 8;9:913147.
  2. ↑ 2.0 2.1 Toremalm NG. A tracheotomy speech valve. Laryngoscope. 1968 Dec;78(12):2177-82.
  3. ↑ Cheung NH, Napolitano LM. Tracheostomy: epidemiology, indications, timing, technique, and outcomes. Respir Care. 2014 Jun;59(6):895-915; discussion 916-9.
  4. ↑ 4.0 4.1 4.2 4.3 Lais G, Piquilloud L. Tracheostomy: update on why, when and how. Curr Opin Crit Care. 2025 Feb 1;31(1):101-107.
  5. ↑ 5.0 5.1 Freeman-Sanderson AL, Togher L, Elkins MR, Phipps PR. Quality of life improves with return of voice in tracheostomy patients in intensive care: An observational study. J Crit Care. 2016 Jun;33:186-91.
  6. ↑ 6.0 6.1 6.2 Duan D, Cui W, Liu W, Xie J. Application of speaking valves in adult patients with tracheostomy: a protocol for a systematic review and meta-analysis. BMJ Open. 2024 Jul 27;14(7):e086415.
  7. ↑ 7.0 7.1 7.2 Prigent H, Lejaille M, Terzi N, Annane D, Figere M, Orlikowski D, Lofaso F. Effect of a tracheostomy speaking valve on breathing-swallowing interaction. Intensive Care Med. 2012 Jan;38(1):85-90.
  8. ↑ 8.0 8.1 8.2 Passy V, Baydur A, Prentice W, Darnell-Neal R. Passy-Muir tracheostomy speaking valve on ventilator-dependent patients. Laryngoscope. 1993 Jun;103(6):653-8.
  9. ↑ Zabih W, Holler T, Syed F, Russell L, Allegro J, Amin R. The Use of Speaking Valves in Children With Tracheostomy Tubes. Respir Care. 2017 Dec;62(12):1594-1601.
  10. ↑ 10.0 10.1 Tracheostomy Education. Speaking Valves. Available from: https://tracheostomyeducation.com/speaking-valves [accessed 13/9/2025]
  11. ↑ Health Products for you. The Shikani Speaking Valve - Instructional Video for Patients. Available from: https://www.youtube.com/watch?v=M049PKA6FRA&t=25s [accessed 24/9/2025]
  12. ↑ Medtronic Minimally Invasive Therapies Group. Speaking and phonation: Shiley™ flexible tracheostomy tubes. Available from: https://www.youtube.com/watch?v=not7kipbFzc [accessed 24/9/2025]
  13. ↑ TRACOE medical International. TRACOE Product Video - The TRACEOE phon assist I. Available from: https://www.youtube.com/watch?v=UvtBKghnLiA [accessed 24/9/2025]
  14. ↑ Passy V. Passy-Muir tracheostomy speaking valve. Otolaryngol Head Neck Surg. 1986 Sep;95(2):247-8.
  15. ↑ Kaut K, Turcott JC, Lavery M. Passy-Muir speaking valve. Dimens Crit Care Nurs. 1996 Nov-Dec;15(6):298-306.
  16. ↑ PassyMuir. PassyMuir Valve Design. Available from: https://www.youtube.com/watch?v=9yn5ekGJ0Qw&t=7s [accessed 13/9/2025]
  17. ↑ 17.0 17.1 Buckland A, Jackson L, Ilich T, Lipscombe J, Jones G, Vijayasekaran S. Drilling speaking valves to promote phonation in tracheostomy-dependent children. Laryngoscope. 2012 Oct;122(10):2316-22.
  18. ↑ Atos. Tracheostomy HMEs and HMEFs Literature Review 2024. Available from: https://www.atosmedical.us/download/sites/22/2024/10/MC3195-TcEN_202404-Literature-Review-Tracheostomy-HMEs-and-HMEFs.pdf [accessed 26/9/2025]
  19. ↑ Vargas M, Chiumello D, Sutherasan Y, Ball L, Esquinas AM, Pelosi P, Servillo G. Heat and moisture exchangers (HMEs) and heated humidifiers (HHs) in adult critically ill patients: a systematic review, meta-analysis and meta-regression of randomized controlled trials. Crit Care. 2017 May 29;21(1):123.
  20. ↑ Bień S, Okła S, van As-Brooks CJ, Ackerstaff AH. The effect of a Heat and Moisture Exchanger (Provox HME) on pulmonary protection after total laryngectomy: a randomized controlled study. Eur Arch Otorhinolaryngol. 2010 Mar;267(3):429-35.
  21. ↑ 21.0 21.1 NHS. Critical Care Key Documents. WAHT-KD-022 Available from: https://apps.worcsacute.nhs.uk/KeyDocumentPortal/Home/DownloadFile/2809 [accessed 28/9/2025]
  22. ↑ Sutt AL, Cornwell P, Mullany D, Kinneally T, Fraser JF. The use of tracheostomy speaking valves in mechanically ventilated patients results in improved communication and does not prolong ventilation time in cardiothoracic intensive care unit patients. J Crit Care. 2015 Jun;30(3):491-4.
  23. ↑ Freeman-Sanderson AL, Togher L, Elkins MR, Phipps PR. Return of Voice for Ventilated Tracheostomy Patients in ICU: A Randomized Controlled Trial of Early-Targeted Intervention. Crit Care Med. 2016 Jun;44(6):1075-81.
  24. ↑ Manzano JL, Lubillo S, Henríquez D, Martín JC, Pérez MC, Wilson DJ. Verbal communication of ventilator-dependent patients. Crit Care Med. 1993 Apr;21(4):512-7.
  25. ↑ Zabih W, Holler T, Syed F, Russell L, Allegro J, Amin R. The Use of Speaking Valves in Children With Tracheostomy Tubes. Respir Care. 2017 Dec;62(12):1594-1601.
  26. ↑ Brigger MT, Hartnick CJ. Drilling speaking valves: a modification to improve vocalization in tracheostomy dependent children. Laryngoscope. 2009 Jan;119(1):176-9.
  27. ↑ 27.0 27.1 27.2 27.3 27.4 27.5 Wang H, Jiang H, Zhao Z, Liu J, Zhang C. Application and safety of speaking valves in tracheostomy patients. Crit Care. 2024 Dec 18;28(1):424.
  28. ↑ Gross RD, Mahlmann J, Grayhack JP. Physiologic Effects of Open and Closed Tracheostomy Tubes on the Pharyngeal Swallow. Annals of Otology, Rhinology & Laryngology. 2003;112(2):143-152.
  29. ↑ Prigent H, Garguilo M, Pascal S, Pouplin S, Bouteille J, Lejaille M, Orlikowski D, Lofaso F. Speech effects of a speaking valve versus external PEEP in tracheostomized ventilator-dependent neuromuscular patients. Intensive Care Med. 2010 Oct;36(10):1681-1687.
  30. ↑ Chiang J, Wolter N, Syed F, Russell L, Amin R. Evaluation and initiation of speaking valves in children with tracheostomies. Chest. 2019; 156(Suppl4): A852.
  31. ↑ O'Connor LR, Morris NR, Paratz J. Physiological and clinical outcomes associated with use of one-way speaking valves on tracheostomised patients: A systematic review. Heart Lung. 2019 Jul-Aug;48(4):356-364.
  32. ↑ Whitmore KA, Townsend SC, Laupland KB. Management of tracheostomies in the intensive care unit: a scoping review. BMJ Open Respir Res. 2020 Jul;7(1):e000651.
  33. ↑ Ceron C, Otto D, Signorini AV, Beck MC, Camilis M, Sganzerla D, Rosa RG, Teixeira C. The Effect of Speaking Valves on ICU Mobility of Individuals With Tracheostomy. Respir Care. 2020 Feb;65(2):144-149.
  34. ↑ Freeman-Sanderson AL, Togher L, Elkins MR, Phipps PR. Return of Voice for Ventilated Tracheostomy Patients in ICU: A Randomized Controlled Trial of Early-Targeted Intervention. Crit Care Med. 2016 Jun;44(6):1075-81.
  35. ↑ Martin KA, Cole TDK, Percha CM, Asanuma N, Mattare K, Hager DN, Brenner MJ, Pandian V. Standard versus Accelerated Speaking Valve Placement after Percutaneous Tracheostomy: A Randomized Controlled Feasibility Study. Ann Am Thorac Soc. 2021 Oct;18(10):1693-1701.
  36. ↑ Bonvento B, Wallace S, Lynch J, Coe B, McGrath BA. Role of the multidisciplinary team in the care of the tracheostomy patient. J Multidiscip Healthc. 2017 Oct 11;10:391-398.
  37. ↑ Sutt AL, Wallace S, Egbers P. Upper Airway Assessment for One-Way Valve Use in a Patient With a Tracheostomy. Am J Speech Lang Pathol. 2021 Nov 4;30(6):2716-17.
  38. ↑ Li J, Perez A, Schehl J, Albers A, Husain IA. The Association Between Upper Airway Patency and Speaking Valve Trial Tolerance for Patients With Tracheostomy: A Clinical Retrospective Study and an In Vitro Study. Am J Speech Lang Pathol. 2021 Jul 14;30(4):1728-36.
  39. ↑ Cheng S, Brown EC, Hatt A, Butler JE, Gandevia SC, Bilston LE. Healthy humans with a narrow upper airway maintain patency during quiet breathing by dilating the airway during inspiration. J Physiol. 2014 Nov 1;592(21):4763-74.
  40. ↑ Tracheostomy. NTSP Manual 2013. Available from: https://tracheostomy.org.uk/storage/files/Cuff%20management%20Vocalisation.pdf [accessed 13/9/2025]
  41. ↑ Knorr N, Auth P, Kruppert S, Stahl CA, Lücking KM, Tauber F, Speck T. Speaking valve with integrated biomimetic overpressure release and acoustic warning signal. Sci Rep. 2024 Nov 4;14(1):26655.
  42. ↑ 42.0 42.1 Pandian V, Boisen SE, Mathews S, Cole T. Are Fenestrated Tracheostomy Tubes Still Valuable? Am J Speech Lang Pathol. 2019 Aug 9;28(3):1019-1028.
  43. ↑ National Tracheostomy Safety Project. One-way speech & swallow valve. How to safely use with ventilators. Available from: https://www.youtube.com/watch?v=LdpEVf58Rso&t=777s [accessed 27/9/2025]
  44. ↑ Zanella A, Scaravilli V, Isgrò S, Milan M, Cressoni M, Patroniti N, Fumagalli R, Pesenti A. Fluid leakage across tracheal tube cuff, effect of different cuff material, shape, and positive expiratory pressure: a bench-top study. Intensive Care Med. 2011 Feb;37(2):343-7.
  45. ↑ Dettelbach MA, Gross RD, Mahlmann J, Eibling DE. Effect of the Passy-Muir Valve on aspiration in patients with tracheostomy. Head Neck. 1995 Jul-Aug;17(4):297-302.
  46. ↑ Han X, Ye Q, Meng Z, Pan D, Wei X, Wen H, Dou Z. Biomechanical mechanism of reduced aspiration by the Passy-Muir valve in tracheostomized patients following acquired brain injury: Evidences from subglottic pressure. Front Neurosci. 2022 Oct 31;16:1004013.
  47. ↑ Tracheostomy Education. Fenestrated Vs Unfenestrated Tracheostomy. Available from: https://tracheostomyeducation.com/fenestrated-vs-unfenestrated-tracheostomy/#:~:text=Do%20NOT%20use%20a%20speaking%20valve%20or%20cap,cuffless%20tracheostomy%20tube%20is%20recommended%20prior%20to%20capping. [accessed 14/9/2025]
  48. ↑ Houston Methodist St Catherine Hospital. Speaking and Swallowing Valve. [26/9/2019]. Available from: https://1.passy-muir.com/wp-content/uploads/2021/10/COE_HMCCH_10.25.19_RehabEducation.pdf [accessed 30/9/2025]
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