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Tracheostomy Tubes Dean R. Hess PhD RRT
Assistant Director of Respiratory Care Massachusetts General Hospital
Associate Professor of Anesthesia Harvard Medical School
Editor in Chief RESPIRATORY CARE
Tracheostomy tubes
n Timing of tracheostomy: much opinion and emotion, little evidence; particularly for progressive respiratory failure (neuromuscular disease)
n Surgical procedure: usually percutaneous
Tracheostomy tubes
n Anatomy of a tracheostomy tube
n Tracheostomy tube changes
n Decannulation
Tracheostomy Tube Shapes
Angled Curved
Tracheostomy Tube Dimensions
ID (mm)
OD (mm)
Length (mm)
6.0 8.2 64
7.0 9.6 70
8.0 10.9 73
9.0 12.3 79
10.0 13.7 79
Portex Flex DIC Bivona Trach Tube Shiley SCT Tube Mid-Range Aire-Cuff
ID (mm)
OD (mm)
Length (mm)
6.0 8.3 67
7.0 9.6 80
8.0 10.9 89
9.0 12.1 99
10.0 13.3 105
Use of inner cannula decreases ID by 1 mm
ID (mm)
OD (mm)
Length (mm)
6.0 8.8 67
7.0 10.0 80
8.0 11.0 89
9.0 12.3 99
9.5 13.3 105
Poorly Fit Tracheostomy Tube
Tracheal Collapse
Exhalation Inhalation
Granulation Due to Poor Fit
Of 403 patients admitted to a respiratory care unit in 42 consecutive months, there were 40 cases of tracheostomy tube malposition (10%; 95% CI 7 to 13%).
Chest 2008;134:288
Chest 2008;134:288
Schmidt, Chest 2008;134:288
Extra Length Tracheostomy Tubes Shiley XLT Proximal Extra Length Distal Extra Length
Bivona Fixed-Flange Hyperflex
Portex Dual Cuff
Adjustable Flange Rusch Bivona
Portex
Cuffed versus Uncuffed Uncuffed n Allows for secretion
clearance n No protection from
aspiration n Positive pressure
ventilation less effective
Cuffed n Allows for secretion
clearance n Some protection from
aspiration n Positive pressure
ventilation more effective
Tracheostomy Tube Cuffs
Low Pressure Tight to Shaft Foam
air-inflated water-inflated self-inflated
Tracheostomy Tube Cuff Pressure n Tracheal capillary pressure 25 - 35 mm Hg
Seegobin, Br Med J 1984;288:965 n Aspiration risk with cuff pressure < 20 cm H2O
Bernhard, Anesthesiology 1979;50:363 Rello, AJRCCM 1996;154:111
n Set cuff pressure 20 - 30 cm H2O; minimal leak and minimal occlusion techniques discouraged.
n Continuous monitoring and inflation possible, but benefit unproven and not used in chronic care.
Dual Cannula Tubes n Ventilator attachment on inner cannula
n Allows cleaning/replacement of inner cannula – reduced biofilm formation?
n Inner cannula can be removed to restore a patent airway if tube occludes
n Inner cannula occludes fenestrations
n Inner cannula reduces inner diameter and increases imposed work of breathing
Effect of Inner Cannula on Size
ID (mm) OD (mm) 6.0 8.3 8.0 10.9
10.0 13.3
Size ID (mm) OD (mm) 6 6.4 (8.1 without IC) 10.8 8 7.6 (9.1 without IC) 12.2
10 8.9 (10.7 without IC) 13.8
Shiley SCT Tube Shiley DCT Tube
ID of outer cannula is for narrowest portion of the shaft
Fenestrated Trach Tubes n Permits use of upper airway when inner
cannula is removed, cuff is deflated, and speaking valve or decannulation cap applied
n Fenestrations should not touch the tracheal wall to minimize formation of granulation tissue
Portex Suctionaide
Blom Fenestrated Cuffed Tube
Subglottic suction
Speaking on ventilator; cuff inflated
Speaking valve; off ventilator
Kun
duk,
Res
pir C
are
2010
;55:
1661
Stomal Maintenance Devices
Olympic button Montgomery Cannula
Tracheostomy Tube Change n Reasons for change: change type,
downsize, broken (cuff), routine? n In a survey, 15% reported being aware of
a death associated with trach change (Tabaee, Laryngoscope 2007;117:573) n First tube change ranged from 3 to 7 days
n Tracheostomy tube change before day 7 is associated with earlier use of speaking valve and earlier oral intake (Fisher, Respir Care 2013;58:257)
Silicone Polyvinyl chloride Polyurethane All tubes, exposed in the trachea for 3 - 6 months, revealed major degradation and changes in the surface of the material. Polymeric tracheostomy tubes should be changed before the end of 3 months of clinical use.
Laryngoscope 2009;119:657
Tracheostomy Team n Systematic review and meta-analysis (Speed
and Harding, J Crit Care 2013;28,216.e1) n Low-quality evidence that multidisciplinary
tracheostomy care contributes to a reduction in tracheostomy time and increase speaking valve use.
n Insufficient evidence to determine that multidisciplinary tracheostomy teams reduce hospital or intensive care unit LOS.
n MGH trach team: RT, SLP, MD, RN
n Evaluated a low-risk tracheotomy clinical pathway, which provides a stepwise approach to decannulation.
n Baseline time to decannulation was 15.5 ± 12.1 days. n In pilot, time to decannulation decreased to 5.74
± 2.79 d n In follow-up, time to decannulation 8.13 ± 7.0 d n No effect on adverse events by use of the
pathway. Smith, JAMA Otolaryngol Head Neck Surg 2014;140:630
Cuff Deflation
Speaking Valve
Capping
Decannulation
Critical Care 2008,12:R26
O’C
onno
r 201
0;55
:107
6
Crit Care Med 2011;39:2240
Respir Care 2009;54:1644
Intensive Care Med 2008;34:1878
Schmidt, Hess, Bittner Crit Care Med 2011;39;2360
O’Connor 2010;55:1076
Facilitation of Speech with Tracheostomy
n Patients not mechanically ventilated n Talking trach tube n Cuff down finger occlusion/capping n Cuff down with speaking valve
n Mechanically ventilated patients n Talking trach tube n Cuff down n Cuff down with speaking valve
Speech in Ventilated Patients With Cuff Inflated
Blom Fenestrated Cuffed Tube
Subglottic suction
Speaking on ventilator; cuff inflated
Speaking valve; off ventilator
Kun
duk,
Res
pir C
are
2010
;55:
1661
Summary
n Tracheostomy tubes are available in a variety of sizes, shapes, and styles
n Clinicians should be knowledgeable of the variety of tube configurations available to meet their patients’ needs
n Facilitation of speech in patients with tracheostomy can improve quality of life
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