Normally speech is obtained by a steady stream of air that comes from the lungs and passes through the vocal cords. When the trach tube is inserted, most of the air bypasses the vocal cords and goes out through the tube. Some air may leak up to the vocal cords, but it may not be forceful enough to drive the vocal cords into vibration, or it may only allow enough force for very short utterances. All trach tubes should fit easily into the airway with some space around the tube. If the tube fits snugly inside the trachea, all of the exhaled air will leave the body via the tracheostomy tube and no air will be able to pass through the vocal cords. If mechanical ventilation is needed, a more “fitted” trach may be required. If the airway is very small, scarred, or has a granuloma, the patient may not be able to move enough air past the vocal cords to vocalize. If the vocal cords are scarred or paralyzed, the patient’s voice may sound hoarse or unusual. The goal is to always match the patient with the smallest trach possible. > Ways to Achieve Vocalization with a Tracheostomy Tracheostomy Questions? E-mail tracheostomysupport@jhmi.edu | 
