Tracheostomy tubes

OVERVIEW

Various types of tubes may be used to provide an airway via a stoma created surgically or using percutaneous dilation

USE

May be temporary (e.g. slow respiratory wean, gradually resolving neurological deficits) or permanent (e.g. laryngectomy)

  • airway protection
  • facilitates positive pressure ventilation
  • suctioning of secretions

DESCRIPTION

Composition

  • PVC – softens at body temperature, conforming to tracheal anatomy
  • silicone – naturally soft
  • rarely metal

Key components

  • Outer tube
  • Inner tube – fits snugly into outer tube, can be easily removed for cleaning and relief of obstruction
  • Flange – flat plastic plate attached to outer tube that lies flush against the patient’s neck and allows the tube to be secured in position; may or may not be adjustable
  • 15mm outer diameter connector
  • obturator – used during insertion, subsequently removed

Additional optional features:

  • Uncuffed – used if airway reflexes intact and requiring minimal ventilatory support
  • Cuff – inflatable air reservoir (high volume, low pressure) or self-inflating foam cuff – provides maximum airway sealing for positive pressure ventilation
  • Air inlet valve – one-Way valve that prevents spontaneous egress of the injected air
  • Air inlet line – thin tubing providing a route for air from air inlet valve to cuff
  • Pilot cuff – serves as an indicator of the amount of air in the cuff
  • Fenestrations – hole(s) situated on the curve of the outer tube to allow or enhance airflow through the vocal cords; can be used with a non-fenestrated inner cannula to prevent air leak
  • Speaking valve – occludes the tracheostomy tube during expiration only, to facilitate speech and swallowing
  • Tracheostomy button or cap (cork) – used to occlude the tracheostomy tube opening during both inspiration and expiration prior to decannulation (with cuff down)
  • Extra length – either the proximal length (e.g. if obese) or intra-tracheal length (e.g. to bypass tracheal obstruction from tracheomalacia)

METHOD OF INSERTION

  • See percutaneous tracheostomy

COMPLICATIONS

  • Complications of insertion (see Percutaneous tracheostomy)
  • Haemorrhage (see Bleeding tracheostomy)
  • tube occlusion (e.g. blood, secretions, crusts)
  • granulation tissue formation with obstruction or bleeding
  • accidental tube dislodgement/ decannulation
  • airway stenosis
  • tracheomalacia

TYPES OF TRACHEOSTOMY TUBE

Portex or Shiley (Mallinckrodt) cuffed tracheostomy tubes

  • disposable plastic tubes with an introducer and cuff
  •  have an inner cannula
  • Commonly used in patients who require a short-term airway support e.g. post- operatively or for positive pressure ventilation

Shiley cuffed/ uncuffed fenestrated tracheostomy tube

  • disposable plastic tube with an introducer, cuff and two inner tubes (one permanent, this has a white top; one fenestrated inner tube, this has a green top)
  • a spare non-fenestrated inner tube (which has a red top) must also be available and is used to replace the white top inner tube when this is cleaned
  • used with  the inner tube (white top) in situ and the cuff inflated when the patient requires full ventilatory suppor
  • used with the inner tube (white top) removed and the cuff deflated as the final stage in the process of weaning the patient from using the tracheostomy. By covering the external end of the tube with a one-way valve or decannulation plug, the patient will be able to breathe through their nose and mouth in the normal way. It is more difficult to breath through this system than it is to breath normally as the tube causes some obstruction, and this must be considered beforehand.

Talking tracheostomy tubes

  • e.g. Puritan Bennett (PhonateTM), Portex (Trach Talk Blue Line®), and Boston Medical (Montgomery® VENTRACH)
  • enable speech with an inflated cuffed tube

Portex Blue Line Extra Length Tubes

  • have two independently inflated cuffs on the lower end of the extended length tube that allow flexibility in sealing the tube in alternate locations (may reduce mucosal injury), or increasing the seal by inflating both cuffs at the same time.

Bivona Adjustable Hyperflex Tubes from Portex

  • soft flexible tubes with a thin spiral wire molded in the tube wall that prevents constriction with tube flex
  • adjustable flange collar allows the tube length to be adjusted as desired

Bivona Fome-Cuf®

  •  high volume-low pressure cuff that uses the passive expansion of a foam rubber-filled cuff to maintain a seal with the tracheal wall
  • foam cuff provides a continuous seal and can be used as an alternative to air-filled cuffs when persistent air leaks occur with mechanical ventilation

OTHER INFORMATION

Emergency equipment should be present at the patient’s bedside in a visible location:

  • Spare tracheostomy tubes – same size/type and size 7 or 7.5
  • Hooks and dilators
  • Laerdel resuscitation bad with straight attachment (to connect tracheostomy tube to bagging circuit)
  • 10 mL syringe

Sizes of tracheostomy tubes

  • sizes of tracheotomy tubes vary between different types and different manufacturers
  • if change a tracheostomy tube for a different type, check that not ‘the size’ matches, but that internal diameter, outer diameter, length and curvature are appropriate (check manufacturer documentation for these)

References and Links

LITFL

Journal articles

  • Hess DR. Tracheostomy tubes and related appliances. Respir Care. 2005 Apr;50(4):497-510. PMID: 15807912.
CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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