How do you communicate with a patient who has a tracheostomy tube in?

Depends. Sometimes I try to read their lips. Other times I give them a piece of paper and pen for them to write or I'll write out the alphabet and have them spell each word by pointing to it. Takes a bit of patience, but the patients appreciate you taking the time to understand them.

A pictograph works well though not all the time available also pen and paper works well. Ive even had patients communicate with me on the cell phone by just typing the text in.