This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. dysphagia assessment and a more consultative role (Martino et al. 2014). Dysphagia assessment occurs in a range of clinical contexts where there are concerns about a patient's swallowing ability, including acute and critical care, outpatient departments, rehabilitation units, and community settings.

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To conduct an international survey to investigate the use of above cuff vocalization (ACV) and how practice and opinion differs. Design: Observational, cross-sectional online survey. Setting: Critical care, acute, rehabilitation, long-term care, and community. Participants: Health care professionals involved in tracheostomy care or weaning (N=243). Interventions: Not applicable. Main Outcome Measures: Tracheostomy management, prevalence, personal experiences and opinions, and barriers to use. Quantitative data were reported descriptively, and content analysis was conducted with qualitative data. Results: The survey was completed by 243 health care professionals from 9 professional groups and 25 countries, with most responses from the United Kingdom (54%) and speech and language therapists (55%). ACV was used in 39% of services (n=93). Sixty percent (n=50/83) of health care professionals with direct experience of ACV had used it with <10 people. Implementation of ACV varied widely concerning procedures, contraindications, safety processes, professionals involved, competencies, staff training, delivery, and outcome measures. The top benefits were communication (n=76/93; 82%), mood (n=62/93; 67%), and laryngeal sensation (n=49/93; 53%). Complications included discomfort (n=54/93; 58%) and strained vocal quality (n=39/93; 42%). Barriers to ACV implementation included lack of knowledgeable staff (n=92/238; 39%) and lack of access to training (n=73/238; 31%). Conclusions: ACV uptake varies internationally with no standardized approach to ACV delivery. Diversity of opinions on approaches and benefits exist. Serious complications are infrequent, but minor complications are common. Future research is needed to establish optimal ACV implementation to maximize benefits and minimize risks.