The Impact of Multiple Intubations on Voice Change

The Impact of Multiple Intubations on Voice Change: A Case Study

The Impact of Multiple Intubations on Voice Change: A Case Study

Millions of individuals worldwide are affected by voice disorders, which can have an impact on people of different ages. Consequently, these disorders can significantly affect an individual’s quality of life, resulting in a decrease in their social circle, potential depression, and overall well-being. However, there is hope, as with early detection and proper professional support, these negative effects can be mitigated.
Thus, the current study aimed to emphasize the effectiveness of teletherapy as a treatment modality for voice therapy. Begin to be aware of the loudness of your voice in different situations (e.g. when talking to a peer, or a family or in larger gatherings). Monitor your loudness to suit the situation. Try to stop the use of loud voices too often or for long durations of time.

Treatment for voice disorder

Notably, the results of the study demonstrated significant improvements in both qualitative and quantitative measures, pointing to overall progress in the treatment of voice disorders. Moreover, the study found that teletherapy represented a feasible and effective alternative to traditional in-person therapy, making it particularly beneficial for individuals who face accessibility challenges or discomfort with in-person therapy sessions.
The prevalence of heart failure increased, which is a crucial global health concern that affects  breathing, the larynx, and even the quality of speech (Reddy et al;2021). It is common practice for individuals undergoing cardiac surgery to have a controlled intubation of their trachea in the operating room. Following the procedure, patients are transferred to the ICU where they receive mechanical ventilation and have their tracheal tube removed. However, a percentage of these patients, ranging from 2 to 13%, may require reintubation following the removal of the tracheal tube.
The intubation of the trachea is a crucial measure that can save the lives of critically ill patients (Parker et al.,2020). Two known complications include subglottic stenosis and posterior glottic stenosis, both of which can result in significant patient morbidity. In critically ill patients requiring airway protection and ventilatory support, tracheal intubation may be necessary. The presence of an endotracheal tube can cause inflammation, fibrosis, and scarring, which can lead to stenosis in the laryngotracheal region, including subglottic stenosis and posterior glottic stenosis (PGS).


If patients require ongoing intubation and ventilatory support beyond seven days, a tracheostomy may be performed to facilitate weaning from mechanical ventilation and reduce the occurrence of fibrotic laryngotracheal complications. It is important to note that tracheal intubation is a life-saving measure for critically ill patients (Davidson et al., 2021). Yamanka et al. (2009) reported that the occurrence of hoarseness following endotracheal intubation ranges from 14% to 50% but is typically temporary. In a retrospective analysis of 3,093 patients who underwent endotracheal intubation during anesthesia, hoarseness was observed in 49% of patients in the early postoperative period.​
The initial investigation by Liu et al. (2021) demonstrated that tele practice voice therapy was a practical and successful approach to treating self-reported voice problems in female elementary school teachers.

Method ​

A 78year old male with dysphonia from posterior glottic stenosis following prolonged intubations after coronary artery bypass graft, mitral valve replacement, and tricuspid valve repair was considered for the study. Written consent was collected from the client before the study.

The client reported voice change and difficulty in increasing the loudness. When the client continues to speak for a longer duration, he gets better voice quality for a short span of time (less than a minute) as reported.


The voice assessment conducted included both qualitative and quantitative measures. Qualitative evaluation was performed using Consensus Auditory-Perceptual Evaluation of  Voice (CAPE-V) and GRBAS (Table 2) to assess the severity of the client’s hoarse voice, which presented with asthenia and absence of aphonia. The quantitative evaluation involved aerodynamic measurements, specifically Maximum Phonation Duration (MPD) and s/z ratio (Table 1). For both measures, the duration was measured using a stopwatch, and the phonation with the longest duration was selected from three trials.

For the recording task, it  was ensured that the client was seated in a noise free room and was asked to phonate /a/ at his comfortable pitch and loudness. The patient was asked to download the pitch tuner app and record the phonation sample. Self-perception of voice quality and its effect on quality of life was assessed through VRQOL and VHI 10 where the pre-therapy scores revealed a score of 30 (VRQOL) and 11 (VHI-10).

Table1: Aerodynamic measures of the client during assessment (before voice therapy).
Pre-therapy /a/ /i/ /u/
MPD 6 sec 4 sec 4 sec
S/Z Ratio 1.5
Table 2: GRBAS Results
Pretherapy: GRBAS
Grade 3
Roughness 3
Breathiness 3
Asthenia 2
Strain 3

After the assessment, the client was advised to take voice therapy sessions. The sessions were carried out using the Zoom video conferencing platform from October to January.


The therapy sessions included vocal hygiene education and semi-occluded voice therapy, breathing exercises, warm-up, stretching, and Auditory perceptual analysis for 1 session per week for 4 months. Self-assessment protocols were conducted before the intervention and 4 months after the last intervention, and the differences before and after interventions were compared.


The progress of the therapy was measured through a comparison of pre and post-therapy samples. Qualitative evaluation was performed using Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and GRBAS (Table 3) was performed at the end of 4 months revealing a moderate hoarse voice.

Table 3: Aerodynamic measures of the client during assessment (after voice therapy).
Post-therapy /a/ /i/ /u/
MPD 16 sec 14 sec 14 sec
S/Z Ratio 1.3
Graph 1: Comparison of Pre and Post therapy MPD values

Comparison of Pre and Post therapy

*Above values are in seconds

Table 4: GRBAS Results
Post-therapy: GRBAS
Grade 2
Roughness 2
Breathiness 1
Asthenia 1
Strain 2
Graph 2: GRBAS Results Comparison

GRBAS Results Comparison

There was a significant reduction in VHI-10 and VRQOL scores by the end of 4 months

Table 5: VHI 10 & VRQOL comparison
Post-therapy Post-therapy
VHI 10 11 7
VRQOL 30 17
Graph 3: VHI 10 & VRQOL comparison

VHI 10 & VRQOL comparison

The participant reported a lot of positive feedback from his family and colleagues with significant improvements in his overall quality of life.

Discussion and conclusion:

Millions worldwide suffer from voice disorders, affecting individuals of all ages. These conditions have a profound impact on quality of life, leading to social isolation, depression, and overall well-being decline. The study aimed to highlight teletherapy’s effectiveness as a voice therapy treatment. Results showed significant improvements in qualitative and quantitative measures, indicating progress in voice disorder treatment.

Tele therapists never run out of unique activities due to the benefit of technology. Right from Speech-Language Delays in children to Aphasia in adults we have got them all covered with our unlimited online resources. These findings can revolutionize voice therapy delivery and enhance the lives of those with voice disorders.

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