Review paper|Articles in Press

Augmentative and alternative communication tools for mechanically ventilated patients in intensive care units: A scoping review

Published:February 09, 2023DOI:



      The aim of this scoping review was to understand the extent and type of evidence on augmentative and alternative communication tools used with mechanically ventilated patients in the intensive care unit.

      Review method used

      This scoping review was conducted using Arksey and O'Malley's methodological framework, followed by PAGER (Patterns, Advances, Gaps, Evidence for practice and Research recommendations) framework to provide a structured approach to analysis of reviews.

      Data sources

      In December 2021, six electronic databases—CENTRAL, CINAHL, Embase, Medline (Ebscohost), PyscINFO, and Web of Science—were searched. Searches were supplemented with hand searching of reference lists of included studies.

      Review methods

      Studies were selected according to inclusion and exclusion criteria. Full-text review was completed by two independent authors, with any disagreement resolved by consensus or with consultation with a third reviewer. A table was developed to extract key information from the eligible studies. The Mixed Methods Appraisal Tool and Supporting the Use of Research Evidence checklist were used to quality appraise the selected primary research and reviews, respectively.


      Twenty-three studies (19 primary studies and four reviews) were included in the review. Findings highlighted five main patterns: (i) Co-designing of the augmentative and alternative communication tools; (ii) Patients' and healthcare professionals' training needs on augmentative and alternative communication tools; (iii) Implementation of validated communication assessment algorithms; (iv) Amalgamate several communication methods/approaches; (v) Technical competency required for high-technology augmentative and alternative communication tools.


      Both low- and high-technology augmentative and alternative communication tools are widely used for mechanically ventilated patients in intensive care units, but there is a need for systematically assessing the communication needs and implementing communication interventions to promote meaningful patient-centred clinical outcomes.


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        • Xin-Xing J.
        • Yang J.
        • Xiao-Xin L.
        A systematic review on voiceless patients' willingness to adopt high-technology augmentative and alternative communication in intensive care units.
        Intensive Crit Care Nurs. 2021; 63
        • Khalaila R.
        • Zbidat W.
        • Anwar K.
        • Bayya A.
        • Linton D.M.
        • Sviri S.
        Communication difficulties and psychoemotional distress in patients receiving mechanical ventilation.
        Am J Crit Care. 2011; 20: 470-479
        • Freeman-Sanderson A.
        • Morris K.
        • Elkins M.
        Characteristics of patient communication and prevalence of communication difficulty in the intensive care unit: an observational study.
        Aust Crit Care. 2019; 32: 373-377
        • Holm A.
        • Karlsson V.
        • Nikolajsen L.
        • Dreyer P.
        Strengthening and supporting nurses' communication with mechanically ventilated patients in the intensive care unit: development of a communication intervention.
        Int J Nurs Stud Adv. 2021; 3: 1
        • Modrykamien A.M.M.D.
        Strategies for communicating with conscious mechanically ventilated critically ill patients.
        Bayl Univ Med Center Proc. 2019; 32: 534-537
        • Rotondi A.J.
        • Chelluri L.
        • Sirio C.
        • Mendelsohn A.
        • Schulz R.
        • Belle S.
        • et al.
        Patients' recollections of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit.
        Crit Care Med. 2002; 30: 746-752
        • Carruthers H.
        • Astin F.
        • Munro W.
        Which alternative communication methods are effective for voiceless patients in intensive care units? a systematic review.
        Intensive Crit Care Nurs. 2017; 42: 88-96
        • ten Hoorn S.
        • Elbers P.W.
        • Girbes A.R.
        • Tuinman P.R.
        Communicating with conscious and mechanically ventilated critically ill patients: a systematic review.
        Crit Care. 2016; 20: 333
        • Zaga C.J.
        • Berney S.
        • Vogel A.P.
        The feasibility, utility, and safety of communication interventions with mechanically ventilated intensive care unit patients: a systematic review.
        Am J Speech Lang Pathol. 2019; 28: 1335-1355
        • American Speech-Language-Hearing Association (ASHA)
        Augmentative and alternative communication.
        2021 ([online]. Available at:) ([cited 2022 April 13])
        • International Society for Augmentative and Alternative Communication
        What is AAC?.
        ([online]. Available from:) ([cited 2022 May 20])
        • Rustam J.S.
        • Kongsuwan W.
        Communication in patients with ventilation support: an integrative review.
        Songklanagarind J Nurs. 2017; 37: 25-31
        • Vincent Jl
        Communication in the ICU.
        Intensive Care Med. 1997; 23: 1093-1098
        • Holm A.
        • Dreyer P.
        Use of communication tools for mechanically ventilated patients in the intensive care unit.
        Comput Inf Nurs. 2018; 36: 398-405
        • Szilágyi A.K.
        • Diószeghy C.
        • Fritúz G.
        • Gál J.
        • Varga K.
        Shortening the length of stay and mechanical ventilation time by using positive suggestions via MP3 players for ventilated patients.
        Interv Med Appl Sci. 2014; 6: 3-15
        • Salem A.
        • Ahmad M.M.
        Communication with invasive mechanically ventilated patients and the use of alternative devices: integrative review.
        J Res Nurs. 2018; 23: 614-630
        • Holm A.
        • Viftrup A.
        • Karlsson V.
        • Nikolajsen L.
        • Dreyer P.
        Nurses' communication with mechanically ventilated patients in the intensive care unit: umbrella review.
        J Adv Nurs. 2020; 76: 2909-2920
        • Pina S.
        • Canellas M.
        • Prazeres R.
        • Lopes J.
        • Marcelino T.
        • Reis D.
        • et al.
        Augmentative and alternative communication in ventilated patients: a scoping review.
        Rev Bras Enferm. 2020; : 73
        • Dithole K.
        • Sibanda S.
        • Moleki M.M.
        • Thupayagale-Tshweneagae G.
        Exploring communication challenges between nurses and mechanically ventilated patients in the intensive care unit: a structured review.
        Worldviews Evid Based Nurs. 2016; 13: 197-206
        • Karlsen M.M.W.
        • Ølnes M.A.
        • Heyn L.G.
        Communication with patients in intensive care units: a scoping review.
        Nurs Crit Care. 2019; 24: 115-131
        • Arksey H.
        • O'Malley L.
        Scoping studies: towards a methodological framework.
        Int J Soc Res Methodol. 2005; 8: 19-32
        • Levac D.
        • Colquhoun H.
        • O'Brien K.K.
        Scoping studies: advancing the methodology.
        Implement Sci. 2010; 5: 1-9
        • Bradbury-Jones C.
        • Aveyard H.
        • Herber O.R.
        • Isham L.
        • Taylor J.
        • O'Malley L.
        Scoping reviews: the PAGER framework for improving the quality of reporting.
        Int J Soc Res Methodol. 2021; : 1-14
        • Tricco A.C.
        • Lillie E.
        • Zarin W.
        • O'Brien K.K.
        • Colquhoun H.
        • Levac D.
        • et al.
        PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation.
        Ann Intern Med. 2018; 169: 467-473
        • Nasraway Jr., S.A.
        • Jacobi J.
        • Murray M.J.
        • Lumb P.D.
        in collaboration with the members of the Task Force of the American College of Critical Care Medicine of the Society of Critical Care M, the Sedation, analgesia, and neuromuscular blockade of the critically ill adult: revised clinical practice guidelines for 2002.
        Crit Care Med. 2002; 30
        • Jacobi J.
        • Fraser G.L.
        • Coursin D.B.
        • Riker R.R.
        • Fontaine D.
        • Wittbrodt E.T.
        • et al.
        Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult.
        Crit Care Med. 2002; 30: 119-141
        • Tsuruta R.
        • Fujita M.
        Comparison of clinical practice guidelines for the management of pain, agitation, and delirium in critically ill adult patients.
        Acute Med Surg. 2018; 5: 207-212
        • Vincent J.-L.
        • Shehabi Y.
        • Walsh T.S.
        • Pandharipande P.P.
        • Ball J.A.
        • Spronk P.
        • et al.
        Comfort and patient-centred care without excessive sedation: the eCASH concept.
        Intensive Care Med. 2016; 42: 962-971
        • Peters M.D.
        • Godfrey C.
        • McInerney P.
        • Baldini Soares C.
        • Khalil H.
        • Parker D.
        Scoping reviews.
        Joanna Briggs Institute Reviewer's Manual. 2017: 408-446
        • Hong Q.N.
        • Fàbregues S.
        • Bartlett G.
        • Boardman F.
        • Cargo M.
        • Dagenais P.
        • et al.
        The mixed methods appraisal tool (MMAT) version 2018 for information professionals and researchers.
        Educ Inf. 2018; 34: 285-291
        • Specialist Unit for Review Evidence (SURE)
        Questions to assist with the critical appraisal of systematic reviews.
        2018 ([online]. Available at:) ([cited 2022 April 8])
        • Hosseini S.-R.
        • Valizad-Hasanloei M.-A.
        • Feizi A.
        The effect of using communication boards on ease of communication and anxiety in mechanically ventilated conscious patients admitted to intensive care units.
        Iran J Nurs Midwifery Res. 2018; 23: 358
        • Maringelli F.
        • Brienza N.
        • Scorrano F.
        • Grasso F.
        • Gregoretti C.
        Gaze-controlled, computer-assisted communication in intensive care unit: "speaking through the eyes.
        Minerva Anestesiol. 2012; 79: 165-175
        • Otuzoğlu M.
        • Karahan A.
        Determining the effectiveness of illustrated communication material for communication with intubated patients at an intensive care unit.
        Int J Nurs Pract. 2014; 20: 490-498
        • Rathi R.
        • Baskaran M.
        Communication board satisfaction among clients on mechanical ventilator.
        Int J Nurs Educ. 2015; 7: 216-221
        • Vignesh S.
        • Parimala L.
        • Kalabarathi S.
        Effectiveness of high-tech communication board on patients response and level of satisfaction among mechanical ventilated patients.
        Int J Res Pharm Sci. 2020; 11: 86-90
        • Ertürk Yavuz M.
        • Gürsoy A.
        Computer-based communication tool provides effective communication for non-speaking patients: a quasi-experimental study.
        Clin Nurs Res. 2021; 10547738211038638
        • Duffy E.I.
        • Garry J.
        • Talbot L.
        • Pasternak D.
        • Flinn A.
        • Minardi C.
        • et al.
        A pilot study assessing the spiritual, emotional, physical/environmental, and physiological needs of mechanically ventilated surgical intensive care unit patients via eye tracking devices, head nodding, and communication boards.
        Trauma Surg Acute Care Open. 2018; 3e000180
        • Happ M.B.
        • Roesch T.K.
        • Garrett K.
        Electronic voice-output communication aids for temporarily nonspeaking patients in a medical intensive care unit: a feasibility study.
        Heart Lung. 2004; 33: 92-101
        • Koszalinski R.S.
        • Tappen R.M.
        • Viggiano D.
        Evaluation of speak for myself with patients who are voiceless.
        Rehabil Nurs. 2015; 40: 235-242
        • Rodriguez C.S.
        • Rowe M.
        • Koeppel B.
        • Thomas L.
        • Troche M.S.
        • Paguio G.
        Development of a communication intervention to assist hospitalized suddenly speechless patients.
        Technol Health Care. 2012; 20: 519-530
        • Rose L.
        • Istanboulian L.
        • Smith O.M.
        • Silencieux S.
        • Cuthbertson B.H.
        • Amaral A.C.K.-B.
        • et al.
        Feasibility of the electrolarynx for enabling communication in the chronically critically ill: the EECCHO study.
        J Crit Care. 2018; 47: 109-113
        • Ull C.
        • Hamsen U.
        • Weckwerth C.
        • Schildhauer T.A.
        • Gaschler R.
        • Waydhas C.
        • et al.
        Approach to the basic needs in patients on invasive ventilation using eye-tracking devices for non-verbal communication.
        Artif Organs. 2022; 46: 439-450
        • Albayram T.
        • Yava A.
        The determination of the efficiency of visual communication cards developed for the purpose of communication with the intubated patients in the intensive care unit of cardiovascular surgery.
        Turkiye Klinikleri J Cardiovasc Sci. 2020; 32: 103-115
        • Johnson E.
        • Heyns T.
        • Nilsson S.
        Nurses' perspectives on alternative communication strategies use in critical care units.
        Nurs Crit Care. 2022; 27: 120-129
        • Nilsen M.L.
        • Sereika S.M.
        • Hoffman L.A.
        • Barnato A.
        • Donovan H.
        • Happ M.B.
        Nurse and patient interaction behaviors' effects on nursing care quality for mechanically ventilated older adults in the ICU.
        Res Gerontol Nurs. 2014; 7: 113-125
        • Patak L.
        • Gawlinski A.
        • Fung N.I.
        • Doering L.
        • Berg J.
        • Henneman E.A.
        Communication boards in critical care: patients' views.
        Appl Nurs Res. 2006; 19: 182-190
        • Holm A.
        • Karlsson V.
        • Dreyer P.
        Nurses' experiences of serving as a communication guide and supporting the implementation of a communication intervention in the intensive care unit.
        Int J Qual Stud Health Well-Being. 2021; 161971598
        • El-Soussi A.H.
        • Elshafey M.M.
        • Othman S.Y.
        • Abd-Elkader F.A.
        Augmented alternative communication methods in intubated COPD patients: does it make difference.
        Egypt J Chest Dis Tuberc. 2015; 64: 21-28
        • Rose L.
        • Sutt A.-L.
        • Amaral A.C.
        • Fergusson D.A.
        • Smith O.M.
        • Dale C.M.
        Interventions to enable communication for adult patients requiring an artificial airway with or without mechanical ventilator support.
        Cochrane Database Syst Rev. 2021;
        • Manafo E.
        • Petermann L.
        • Mason-Lai P.
        • Vandall-Walker V.
        Patient engagement in Canada: a scoping review of the ‘how’ and ‘what’ of patient engagement in health research.
        Health Res Policy Syst. 2018; 16: 1-11
        • Duffett L.
        Patient engagement: what partnering with patient in research is all about.
        Thromb Res. 2017; 150: 113-120
        • Gustavsson S.M.
        • Andersson T.
        Patient involvement 2.0: experience-based co-design supported by action research.
        Action Res. 2019; 17: 469-491
        • Ward M.E.
        • De Brún A.
        • Beirne D.
        • Conway C.
        • Cunningham U.
        • English A.
        • et al.
        Using co-design to develop a collective leadership intervention for healthcare teams to improve safety culture.
        Int J Environ Res Public Health. 2018; 15: 1182
        • Slattery P.
        • Saeri A.K.
        • Bragge P.
        Research co-design in health: a rapid overview of reviews.
        Health Res Policy Syst. 2020; 18: 1-13
        • Istanboulian L.
        • Rose L.
        • Gorospe F.
        • Yunusova Y.
        • Dale C.M.
        Barriers to and facilitators for the use of augmentative and alternative communication and voice restorative strategies for adults with an advanced airway in the intensive care unit: a scoping review.
        J Crit Care. 2020; 57: 168-176
        • Bleijenberg N.
        • Janneke M.
        • Trappenburg J.C.
        • Ettema R.G.
        • Sino C.G.
        • Heim N.
        • et al.
        Increasing value and reducing waste by optimizing the development of complex interventions: enriching the development phase of the Medical Research Council (MRC) Framework.
        Int J Nurs Stud. 2018; 79: 86-93
        • Mobasheri M.H.
        • King D.
        • Judge S.
        • Arshad F.
        • Larsen M.
        • Safarfashandi Z.
        • et al.
        Communication aid requirements of intensive care unit patients with transient speech loss.
        Augment Altern Commun. 2016; 32: 261-271
        • Happ M.
        • Sereika S.
        • Garrett K.L.
        • Tate J.A.
        • DiVirgilio-Thomas D.
        • George E.
        • et al.
        Study of patient-nurse effectiveness with assisted communication strategies (speacs) in the ICU.
        Am J Respir Crit Care Med. 2010; 181
        • Radtke J.V.
        • Tate J.A.
        • Happ M.B.
        Nurses' perceptions of communication training in the ICU.
        Intensive Crit Care Nurs. 2012; 28: 16-25
        • Graham I.D.
        • Logan J.
        • Harrison M.B.
        • Straus S.E.
        • Tetroe J.
        • Caswell W.
        • et al.
        Lost in knowledge translation: time for a map?.
        J Contin Educ Health Prof. 2006; 26: 13-24
        • Valentina C.
        • Giovanna A.
        • Erika N.
        • Silvia F.
        • Maria C.G.
        • Gianfranco M.
        • et al.
        The use of blended learning to improve health professionals' communication skills: a literature review.
        Acta Biomed. 2019; 90: 17
        • Holden K.
        No longer voiceless in the ICU: speech-language pathologists and intensive care nurses help intubated patients communicate.
        ASHA Lead. 2017; 22: 40-41
        • Jansson S.
        • San Martin T.R.
        • Johnson E.
        • Nilsson S.
        Healthcare professionals' use of augmentative and alternative communication in an intensive care unit: a survey study.
        Intensive Crit Care Nurs. 2019; 54: 64-70
        • Morris A.H.
        Treatment algorithms and protocolized care.
        Curr Opin Crit Care. 2003; 9: 236-240
        • Williams M.L.
        An algorithm for selecting a communication technique with intubated patients.
        Dimens Crit Care Nurs. 1992; 11: 222-233
        • Beukelman D.
        • Mirenda P.
        Augmentative and alternative communication.
        • Khasawneh O.Y.
        Technophobia without boarders: the influence of technophobia and emotional intelligence on technology acceptance and the moderating influence of organizational climate.
        Comput Hum Behav. 2018; 88: 210-218
        • Salem A.M.
        • Ahmad M.M.
        “Be my voice” placed on augmentative and alternative communication device.
        Int J Appl Nat Sci. 2018; 7: 1-10