Why cuffed tracheostomy tube

Inspect new trach tube for leaks while pushing air into balloon. If cuff does not leak, remove the air from it completely. Put obturator into trach tube. Lubricate the balloon with a water-based lubricant.

Insert the new trach tube. Remove obturator. Connect the ventilator tubing. Reattach the syringe to the balloon. To reduce the risk of tracheal injury, cuff management should include careful inflation technique to the minimal occlusion volume MOV , followed by monitoring of inflation volume and cuff pressure.

The cuff pressure should be maintained between cmH 2 O, but preferably at the bottom end of this range, in order to minimize the risks of both tracheal wall injury and aspiration. Regular monitoring of cuff pressure is recommended at every shift hourly , after any tracheostomy-related intervention, after any change in the cuff volume or upon development of an air leak. These tubes are usually used for patients who can protect their own airway, have an adequate cough reflex and most importantly can manage their own secretions.

They remove the risk of tracheal damage caused by inflation of the cuff, may aid swallowing and communication with the concomitant use of a speaking valve. However, a speaking valve can only be used in patients who have airflow through their pharynx into their nose and mouth. Uncuffed tracheostomy tubes are frequently used for patients being cared for in the community or a hospital ward.

A dual cannula uncuffed tube is preferred for safety and comfort as removal of the inner cannula for cleaning is not traumatic to the patient. Some tubes have low profile openings to make the tube more discreet. Tracheostomy tubes are available in both standard and longer lengths.

Standard length tubes are generally designed to accommodate patients with normal airway anatomy. However, the length and angulation of standard design tracheostomy tubes may be too short and unsuitable for some critical care patients, risking complications.

You can reuse it after cleaning it thoroughly. Cuffless Tube with Disposable Inner Cannula Click picture to enlarge Used for patients with tracheal problems Used for patients who are ready for decannulation Save the decannulation plug if the patient is close to getting decannulated. Patient may be able to eat and may be able to talk without a speaking valve. Cuffed Tube with Reusable Inner Cannula Click picture to enlarge Used for patients with tracheal problems Used for patients who are ready for decannulation Save the decannulation plug if the patient is close to getting decannulated.

Patient may be able to eat and may be able to speak without a speaking valve. Fenestrated Cuffed Tracheostomy Tube Click picture to enlarge Used for patients who are on the ventilator but are not able to tolerate a speaking valve to speak There is a high risk for granuloma formation at the site of the fenestration hole.

There is a higher risk for aspirating secretions. It may be difficult to ventilate the patient adequately. Fenestrated Cuffless Tracheostomy Tube Click picture to enlarge Used for patients who have difficulty using a speaking valve There is a high risk for granuloma formation at the site of the fenestration hole.

Metal Tracheostomy Tube Click picture to enlarge Not used as frequently anymore. Many of the patients who received a tracheostomy years ago still choose to continue using the metal tracheostomy tubes. Patients cannot get a MRI. One needs to notify the security personnel at the airport prior to metal detection screening. Request an Appointment Adult Patients Already a Patient?

Traveling for Care? The ventilator is normally flow-cycled during pressure support ventilation. In the presence of a leak through the upper airway, the ventilator may fail to cycle appropriately and thus result in a prolonged inspiratory phase. Although this would usually be considered undesirable, it might facilitate speech. Prigent et al 54 reported that pressure support with PEEP and the cuff deflated resulted in an increase in inspiratory time during speech, and this improved speech duration during both the inspiratory and expiratory phases.

This occurred with minimal effect on gas exchange parameters. Prigent et al 53 found that text reading time, perceptive score, intelligibility score, speech comfort, and respiratory comfort were similar with PEEP and with a speaking valve. During speech with PEEP at 5 cm H 2 O, 6 of the 10 patients had no return of expiratory gas to the expiratory line and therefore had the entire tidal volume available for speech.

Tracheostomy tubes are available in a variety of sizes and styles. It is important for RTs, physicians, speech-language pathologists, nurses, and others caring for patients with a tracheostomy tube to understand these differences and select a tube that appropriately fits the patient.

The ability to speak is an important aspect of the quality of life for patients with a tracheostomy. A variety of techniques to achieve this are available for either mechanically ventilated or spontaneously breathing patients. Ms Altobelli has no relationships to disclose. Dean, a controversy at our institution between the ENT [otolaryngology] surgeons and the general surgeons who also place trachs is, at the time that a patient is ready to go to an uncuffed tube, whether we should use a stainless steel Jackson or an uncuffed anything else.

We have Shileys at our institution, so we commonly use an uncuffed Shiley. Our ENT surgeons commonly propose that the stainless steel Jackson tubes are the best at reducing granulation tissue and reaction in the airway. The difficulty we have is if that patient, at some point, requires any kind of positive pressure or a little bit of bag assistance, where the adapter to the tracheostomy tube is problematic.

We end up with all sorts of jerry-rigged adapters at the bedside. I had a slide about metal trach tubes that I took out because I thought nobody uses them anymore. Are they commercially available?

They are still available. They are reusable tracheostomy tubes, and they actually go back to the OR [operating room] and get sterilized for future additional use. They come in a sterile autoclave package. We have some that have been recycled numerous times. I just didn't know we could get new ones. Our practice is similar to yours. If we go to an uncuffed trach tube, we use a Shiley or a Portex uncuffed with the standard mm connector. If we are concerned that the patient might have to go back on the ventilator, we consider a tight-to-shaft cuff.

Another challenge we have is our tracheal stoma patients. Those patients who are not ventilated are fine since they have a large tracheal stoma, but when they need mechanical ventilation, finding the proper trach size, placement, and the correct balloon that doesn't require too much pressure to keep it within the airway.

Any tips and tricks regarding optimal tracheostomy tubes for patients with a chronic tracheostomy stoma? Generally, what we've done is use a size 6 Shiley or something like that. It generally takes a smaller tube, and other than that, I don't think we've done anything out of the ordinary. One problem with this approach is the length of the cuff and the fact that the permanent stoma is generally closer to the carina than a typical temporary tracheostomy stoma.

Even with a smaller tube, you've got a long cuff in the stoma, which may be at or in the bronchus after placement. These tubes also come in various sizes, including very small diameters, but are the same length as traditional ETTs.

You can cut and shorten the length of an MLT tube to take advantage of the shorter cuff. Another tube that can be used in a stoma is the wire-wrapped or armored tube. These have a slightly shorter cuff, are very flexible, impossible to kink, but cannot be cut to shorten them. Another disadvantage is they also include a high-pressure cuff, which is not desirable for long term use. So, you're saying you could use one of the adjustable flange Bivona tubes, for example.

I've not used tracheostomy tubes in permanent stomas. I've used the traditional ETTs because they are flexible, conform to the tracheal anatomy, and have short cuffs, at least in the two I mentioned. I'm more familiar with their cuff sizes, and there are a variety of different sizes available to choose from without special ordering. The armored tube, at least from some manufacturers, does have a higher pressure cuff; that's one downside of using it. Or somebody gets pneumonia after having had surgery and then develops respiratory failure and requires mechanical ventilation.

Again, it's the issue that, if you put a regular size trach in, the tip might be in the right main bronchus. The regular sizes are usually too long because the tracheal stoma is farther down on the trachea. But using a smaller diameter tube is also a shorter tube, and that's an issue we see sometimes as we're downsizing trach tubes. The tube gets downsized to make more room around the tube so that the patient can use the upper airway, and then the tube is butting against the posterior tracheal wall because it's a short tube.

To answer your previous question on metal tubes, I just did a computer search. Dean, one other question. In your team approach for downsizing and decannulation, do you have tips regarding whether it's logical or not logical to do an endoscopy and really evaluate the glottis before you consider tracheostomy downsizing or decannulation?

We do not do that regularly. The thing that RTs [respiratory therapists] will do is to use a manometer and measure the tracheal pressures. If we downsize the trach tube and we're still getting high pressures and the patient is not tolerating the speaking valve or the cap, the next step would be to do the endoscopy to look at the upper airway pathology.

What happens frequently is a surgeon puts in a tracheostomy, the patient comes back to the ICU, you measure the cuff pressure when they're returning from the OR with a fresh tracheostomy, and it's 50 cm H 2 O. What is your approach to a patient with a fresh tracheostomy and a high cuff pressure? First of all, to make sure it really needs to be 50 cm H 2 O. Sometimes, it's 50; we lower it to 25, and it's okay. But you're assuming we lower it to 25 and it leaks, so then what do we do?

We could try to reposition the tube, or we get the surgeon involved because that may require an upsize of the trach tube. It's a fresh trach, I would have the surgeon there. Lena, I'll defer to you as the surgeon in the group. What would you do? I would say we'd go to the bedside first to troubleshoot and figure out whether we put the wrong size trach in or whether it is not large or long enough. But I think we would also look carefully at the ventilator settings as well.

We're ventilating with low pressures: could we do anything to modify and lower the V T [tidal volume]? Yes, if you need to change it out, you need to change it out. Again, we do both our open and percutaneous tracheostomies bedside and in the ICU, so the patient doesn't need to go anywhere to further evaluate all issues. Sometimes, the cause of high cuff pressure seems to be a problem of fit, where the cuff is sitting eccentrically in the trachea. I guess the question is how do you know whether you need a long proximal limb or a long distal limb?

How do you react to the patient with severe tracheomalacia who may need a large volume of air in the cuff? Sometimes, it's positional, as you point out, and you can try to reposition the trach tube. But if the issue is that the tube is not positioned well in the trachea, maybe it needs to be a longer tube, maybe there is tracheal pathology. I think then you need to put a bronchoscope in and take a look. In the patient series we reported, 1 the way that trach tube malpositions were identified was bronchoscopy.

Can I explore the concept of your trach team a little more? If you need a trach tube change before the 5-d mark, where you said you're reasonably comfortable doing it at the bedside, how do you do that? In everybody, first, and then in somebody with a difficult airway? The approach is we have a group of RTs who are our trach team therapists; an RT sees these patients every 4 h around the clock.

The trach team therapists are really good at doing trach tube changes and the other technical aspects of trach care; they're also really good in their clinical judgment and know when they shouldn't try to do this by themselves. So, if it's the second or third day after the trach tube placement and the tube needs to be changed, we call the surgeon back. We don't mess with that. It becomes something that the surgical team takes care of: that's the MD on the team.

The first trach tube change is always done with somebody from the service that placed the trach tube present. If, in their judgment, they could get into trouble, they will ask for a more senior resident or attending physician to be present. After the first trach tube change, the therapists do the tube changes, and the only requirement is that there is a physician nearby. The therapists on the trach team have a lot of technical expertise, but more important is their excellent judgment and knowing when to get help.

There's some evidence in the anesthesia literature that the use of fluids in cuffs causes less postoperative sore throat and less irritation to the tracheal mucosa. Any evidence of that in the ICU population? I don't know if that's been studied. We inflate the cuffs with air unless it's the tight-to-shaft cuff. One of the issues with fluid inflation of the cuff is how would you know how much pressure the cuff is exerting against the tracheal wall?

I'm not sure how we'd measure the cuff pressure. Okay, does anybody know anything about that? I haven't seen anything in the literature.

We've measured pressures when they're filled with saline, and the pressures are actually quite high. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address. Skip to main content. Research Article Conference Proceedings. Dean R Hess. Abstract Tracheostomy tubes are used to administer positive-pressure ventilation, to provide a patent airway, and to provide access to the lower respiratory tract for airway clearance.

Introduction Tracheostomy tubes are used to facilitate the administration of positive-pressure ventilation, to provide a patent airway in patients prone to upper airway obstruction, and to provide access to the lower respiratory tract for airway clearance. Components of a standard tracheostomy tube. Tracheostomy Tube Dimensions The dimensions of tracheostomy tubes are given by their inner diameter, outer diameter, length, and curvature.

View this table: View inline View popup Download powerpoint. Table 1. Jackson Tracheostomy Tube Size. Table 2. Angled and curved tracheostomy tubes. Extra Length Tracheostomy Tubes If the tracheostomy tube is too short, the distal end can obstruct against the posterior tracheal wall Fig. Table 3. Table 4. Dual-Cannula Tracheostomy Tubes Some tracheostomy tubes are used with an inner cannula, and these are called dual-cannula tracheostomy tubes.

Table 5. Fenestrated Tracheostomy Tubes The fenestrated tracheostomy tube Fig. Fenestrated tracheostomy tube. Subglottic Suction Port Tracheostomy tubes that provide a suction port above the cuff are available. Blom tracheostomy tube. Courtesy Pulmodyne. Tracheostomy Tube Cuffs Tracheostomy tubes can be cuffed or uncuffed.

Stomal Maintenance Devices Several approaches can be used for stomal maintenance in patients who cannot be decannulated. Olympic Trach-Button. Courtesy Natus Medical. Changing the Tracheostomy Tube The tracheostomy tube may be changed to another one for a number of reasons: to reduce the size of the tube, to change the length of the tube if it is malpositioned, because it is obstructed with secretions, because it is broken eg, cuff leak , to change the type of tube, or as a routine change with a chronic tracheostomy.

Decannulation There is a relative lack of evidence to inform when a tracheostomy tube should be removed. Accidental Decannulation Of concern from the perspective of patient safety is accidental decannulation. Tracheostomy Teams Tobin and Santamaria 31 reported the impact of an intensivist-led multidisciplinary team to oversee ward management of patients with a tracheostomy. Speaking With a Tracheostomy Tube Placement of a tracheostomy decreases the ability of the patient to communicate effectively.

Spontaneously Breathing Patients With the cuff deflated or with a cuffless tube , patients or their caregivers can place a finger over the proximal opening of the tracheostomy tube to direct air through the upper airway and thus produce speech. Commercially available speaking valves. Table 6. Speaking Valve Contraindications. Mechanically Ventilated Patients The talking tracheostomy tube Fig. Talking tracheostomy tubes. Courtesy Smiths Medical. Summary Tracheostomy tubes are available in a variety of sizes and styles.

Drs Hess and Altobelli are co-first authors. References 1. Tracheostomy tubes and related appliances. Respir Care ; 50 4 : — Hess DR. Facilitating speech in the patient with a tracheostomy.

An investigation into the length of standard tracheostomy tubes in critical care patients. Anaesthesia ; 63 3 : — OpenUrl PubMed. When to change a tracheostomy tube. Respir Care ; 55 8 : — Significant tracheal obstruction causing failure to wean in patients requiring prolonged mechanical ventilation: a forgotten complication of long-term mechanical ventilation.

Chest ; 4 : — Tracheal ulceration and obstruction associated with flexible Bivona tracheostomy tubes. Anaesth Intensive Care ; 34 4 : — Tracheostomy tube malposition in patients admitted to a respiratory acute care unit following prolonged ventilation. Chest ; 2 : — Are frequent inner cannula changes necessary? A pilot study. Heart Lung ; 27 1 : 58 — Effect of inner cannula removal on the work of breathing imposed by tracheostomy tubes: a bench study.

Respir Care ; 46 5 : —