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Tracheostomies
92
Singer Laryngectomy
Singer laryngectomy tube. Photo courtesy of Boston Medical Products. All
rights reserved.
Structure: Uncuffed, single-cannula, short, narrow curvature
Material: Silicone
Manufacturer: Boston Medical Products
Unique Features: Clear and very flexible material
Use: To maintain patency of the stoma following laryngectomy
The Singer laryngectomy tube is clear, flexible, and made of silicone. It has
a low-profile appearance and comes in 28 sizes. The flange is designed to cover
a wide surface area to keep tracheostomy ties away from the healing stoma. The
Singer tube should be rinsed under running water to clean. If crusts or mucus
plugs are seen, it should be soaked in hot, soapy water for at least 10 minutes
and cleaned with a nonabrasive brush. The manufacturer recommends it be
soaked overnight in a 3% hydrogen peroxide solution and then rinsed and air
dried.
Chapter 3 Types of Tracheostomy Tubes and Related Appliances
Provox LaryTube
Structure: Uncuffed, single-cannula, short, narrow curvature
Material: Silicone
Manufacturer: Natus Medical
Unique Features: Fenestrated model is for use with voice prosthesis; can be used with its own
heat moisture exchanger (HME) system
Use: For the laryngectomy patient in whom secretions are not a concern
The Provox LaryTube is made of flexible silicone and has a conical gradation from the short neck flange to the shaft. It comes in a standard model, a
fenestrated model (for use with a voice prosthesis), and a model with a ring that
attaches to an adhesive base plate for wear without ties around the neck. This
tube can also be used with its own HME system.
Bivona Laryngectomy
93
Structure: Uncuffed, single-cannula, short, narrow curvature
Material: Silicone
Manufacturer: Smiths Medical
Unique Features: Wider neck flange; short and long lengths for three
different sizes
Use: For the laryngectomy patient in whom secretions are not a concern
Bivona
laryngectomy
tube. Photo
courtesy of
Smiths Medical.
The Bivona laryngectomy tube comes in three different sizes (9.5, 11, and
13) in three different lengths (55, 85, and 105 mm).
Fenestrated Tracheostomy Tubes
Fenestrated tracheostomy tubes can be cuffed or uncuffed. The term comes from
the French word la fenêtre, meaning window. The shaft of the fenestrated tube
has an opening on the dorsal aspect that allows for an added boost of air to the
vocal cords. The standard placement of the fenestration is at a point on the shaft
one-third of its length as measured from the neck flange. Many clinicians do not
realize that this fenestration must be measured to fit so that it aligns centrally
within the airway. A failure to precisely fit this tracheostomy tube can result in
the abutment of the fenestration with the anterior or posterior wall of the trachea,
resulting in the growth of granulation tissue within the fenestration. The removal
Tracheostomies
94
of a tracheostomy tube with a growth of this granulation tissue can be a surgical
challenge. Manipulation of a fenestrated tracheostomy tube should be preceded
by a thorough assessment of its placement within the airway. Initially, this can
be done by shining a light within the opening of the tracheostomy and looking
through the tube, with the patient’s head in different positions. If a pale pink color
is seen, it may be granulation tissue within the fenestration, and a consultation
with an otolaryngologist should be done immediately. One can also attempt to
gently move the tracheostomy within the stoma to assess for the mobility of the
tube itself. The forceful removal of a fenestrated tracheostomy tube with an unrecognized growth of granulation tissue can result in hemorrhage and an airway
catastrophe. For these reasons, many centers do not routinely place fenestrated
tracheostomies. If a fenestrated tracheostomy remains the best option for the patient, the procedure to fit the tracheostomy tube is discussed in chapter 4.
Shiley Fenestrated FEN, CFN, DFEN, DCFN
Structure: Cuffed (FEN, DFEN) or uncuffed (CFN,
DCFN), dual-cannula
Material: Rigid polyvinyl chloride
Manufacturer: Covidien
Unique Features: FEN and DFEN tubes have one large
oval fenestration; CFN and DCFN tubes have narrower
fenestrated slits
Use: For the patient who desires to speak
Shiley DCFN tracheostomy tube (Covidien).
Shiley manufactures four types of fenestrated tracheostomy tubes—the
FEN, CFN, DFEN, and DCFN—which are all made of rigid polyvinyl chloride.
The Shiley FEN and DFEN are cuffed tubes; the CFN and the DCFN are cuffless tubes. Both the FEN and the CFN have a standard, nondisposable inner
cannula and a fenestrated, nondisposable inner cannula. The DFEN and the
DCFN have only a standard (nonfenestrated) disposable inner cannula. The
fenestration of the FEN and the CFN is a large oval aperture on the dorsal
Chapter 3 Types of Tracheostomy Tubes and Related Appliances
aspect of the shaft. The fenestration of the DFEN and the DCFN is a set of
linear slits along the dorsal aspect of the tube. Because the DFEN and DCFN
have only a standard (nonfenestrated) inner cannula, they can only be used as
a fenestrated tube without the inner cannula in place.
Portex DIC Fenestrated
Structure: Cuffed or uncuffed, dual-cannula,
fenestrated
Material: Rigid polyvinyl chloride
Manufacturer: Smiths Medical
Unique Features: Color-coded disposable inner cannula
Use: For the patient who wishes to speak but for whom
secretions may be a concern
95
Portex DIC fenestrated uncuffed tracheostomy
tube. Photo courtesy of Smiths Medical.
The Portex DIC fenestrated tube has all the features of the other DIC tubes,
including a color-coded inner cannula based on size (see Table 3.1). The fenestration is composed of two slits along the shaft of the tube to allow air up to the
vocal cords.
Portex Flex DIC Fenestrated
Structure: Cuffed or uncuffed, dual-cannula, fenestrated
Material: Flexible polyvinyl chloride with silicone coating
Manufacturer: Smiths Medical
Unique Features: Color-coded disposable inner cannula
Use: For the patient who wishes to speak but for whom secretions may
be a concern
Portex Flex DIC
fenestrated cuffed
tracheostomy tube.
Photo courtesy of
Smiths Medical.
Tracheostomies
96
The Portex Flex DIC fenestrated tube has all of the features of the other
Flex DIC tubes, including a color-coded inner cannula based on size.
Portex Lo-Profile Fenestrated
Structure: Cuffed or uncuffed, dual-cannula, fenestrated
Material: Rigid polyvinyl chloride
Manufacturer: Smiths Medical
Unique Features: Low-profile inner cannula (without 15-mm adapter) and standard inner
cannula (with 15-mm adapter)
Use: For the patient who wishes to speak but for whom secretions may be a concern
Portex Blue Line Fenestrated and Portex Blue Line Ultra Fenestrated
Portex Blue Line Ultra fenestrated
tracheostomy tube. Photo courtesy of
Smiths Medical.
The Portex Blue Line Ultra tracheostomy tubes also come in fenestrated
versions. These fenestrated tubes come in cuffed and cuffless models. The fenestration of the Portex fenestrated tube is a series of linear slits along the dorsal
aspect of the tube. The pictures the Portex Blue Line Ultra fenestrated tracheostomy tube.
Structure: Cuffed or uncuffed, dual-cannula, fenestrated
Material: Siliconized polyvinyl chloride
Manufacturer: Smiths Medical
Unique Features: Blue neck flange, inflation line, and pilot
balloon
Use: For the patient who wishes to speak
Chapter 3 Types of Tracheostomy Tubes and Related Appliances
TRACOE Twist Fenestrated
Structure: Cuffed or cuffless, dual-cannula
Material: Flexible thermoelastic polyurethane
Manufacturer: Boston Medical Products
Unique Features: Fenestrations consist of several small
circular holes on dorsal aspect of shaft
Use: For the patient who wishes to speak but for whom
secretions may be a concern
TRACOE Twist fenestrated tracheostomy tube.
Photo courtesy of Boston Medical Products. All
rights reserved.
97
The TRACOE Twist tracheostomy tubes also come in fenestrated versions.
These fenestrated tubes come in cuffed and cuffless models. They have all the
features of the standard TRACOE Twist tubes, with the addition of an ovalshaped fenestration. Unlike other fenestrated models, the fenestrations on
this tube are a series of small circular holes on the dorsal aspect of the outer
cannula and a large oval aperture on the inner cannula. Model numbers for
the fenestrated versions of the TRACOE Twist tubes are 302 and 304. They are
packaged with a standard inner cannula with a 15-mm connector, a fenestrated
inner cannula, and an obturator.
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98
TRACOE Comfort Fenestrated
TRACOE Comfort fenestrated
tracheostomy tube. Photo courtesy of
Boston Medical Products. All rights
reserved.
Structure: Uncuffed, dual-cannula
Material: Flexible polyvinyl chloride
Manufacturer: Boston Medical Products
Unique Features: Clear, low profile; fenestrations are a series
of round holes; one model comes with a silver speaking valve
Use: For the patient who desires to speak
The TRACOE Comfort line of tracheostomy tubes also includes four models
that are fenestrated: 103, 103A, 104, and 104A. This type of fenestration is unique
to TRACOE tubes; the inner cannula has one large oval aperture while the outer
cannula has a series of round holes on the dorsal aspect of the shaft. Two of the
models (103 and 103A) also include a detachable silver speaking valve. Model
104 comes with a swivel speaking valve attached to the inner cannula.
Jackson Fenestrated
Structure: Uncuffed, dual-cannula
Material: Stainless steel or sterling silver
Manufacturer: Pilling (Teleflex Medical), Premier Medical Products
Unique Features: Large oval fenestration on dorsal aspect of shaft
Use: For the patient who prefers a metal tracheostomy tube and who
desires to speak
Jackson fenestrated
tracheostomy tube. Premier
Medical Products.
Chapter 3 Types of Tracheostomy Tubes and Related Appliances
The Jackson metal tracheostomy tube also comes in a fenestrated version.
Unless otherwise ordered, the fenestration is placed one-third of the distance
between the neck flange and the distal tip of the tube.
Double-Cuffed Tracheostomy Tubes
Structure: Double-cuffed, singlecannula
Material: Siliconized polyvinyl chloride
Manufacturer: Smiths Medical
Unique Features: Extra vertical length
with two separate cuffs
Use: For the patient with unusual
tracheal anatomy, fistulas, stenosis, or
tracheomalacia
99
Portex Blue Line tracheostomy tube with extra
vertical length with double cuff. Photo courtesy of
Smiths Medical.
In rare circumstances, a double-cuffed tube may be beneficial. The presence of two cuffs can be useful in special circumstances, such as cases of tracheomalacia, fistulas, or stenosis. One cuff can be inflated, allowing delivery of
positive-pressure ventilation. When a leak becomes apparent, that cuff can be
deflated and the other cuff inflated. This alternate deflation and inflation allows
for the reperfusion of the affected area. However, Quigley (1988) reported that
this advantage is somewhat controversial and suggested that mucosal injury may
extend over a greater surface area. Portex is the only company that currently
manufacturers a double-cuffed tube, but this model is reportedly scheduled to be
discontinued (personal communication, Mark Larue, Portex sales representative,
November 2008). If a double-cuffed tube is desired, it can be custom ordered.
T-Tubes
T-tubes are tracheal stents designed to maintain an open airway for patients
with tracheal stenosis or an airway reconstruction. First used in the mid-1960s,
T-tubes were used for the repair of tracheal injuries and tracheomalacia (Huang,
2001; Wouters, Byreddy, Gleeson, & Morley, 2008). The long limb is positioned
within the trachea, and the short limb projects through the stoma. T-tubes are
thought to be superior to silicone stents because they seldom migrate, can be
Tracheostomies
100
suctioned, and are easily removable. They are well tolerated and have been reported to remain in place for up to 20 years (Wahidi & Ernst, 2003).
Montgomery Safe-T-Tube
Structure: T-shaped airway stent
Material: Silicone
Manufacturer: Boston Medical
Products
Unique Features: Clear or radiopaque; includes plug/ring set;
Hebeler model has internal balloon
system to facilitate positive-pressure
ventilation
Use: To maintain adequate airway
or stent stenotic trachea during
reconstruction
Montgomery Safe-T-Tube. Photo courtesy of Boston Medical
Products. All rights reserved.
The Montgomery Safe-T-Tube comes in adult sizes 4.5–16 mm in external
diameter and pediatric sizes 4.5 to 8 mm in external diameter and has tapered
ends to minimize trauma to the tracheal tissue (Guha, Mostafa, & Kendall, 2001;
Wouters et al., 2008). It is made of silicone and is available in both clear and
Chapter 3 Types of Tracheostomy Tubes and Related Appliances
radiopaque models in five sizes: pediatric, standard, thoracic, extra long, and
tapered. In addition, a Hebeler model has an internal balloon to adjust airflow
through the upper end of the tube. It can be inflated for intermittent closure
of the upper limb in order to create a closed system between the tracheostomy
tube and the lungs. When positive-pressure ventilation is no longer required,
the balloon can be deflated, opening the upper limb for access to the upper
respiratory tract.
Mini-Tracheostomy Tubes
Patients who have weak secretion clearance may benefit from a mini-tracheostomy.
Indications for use of the mini-tracheostomy include patients after major thoracic or abdominal surgery at particular risk for pulmonary complications due to
advanced age, chronic lung disease, or poor functional status. In this case, the minitracheostomy is a percutaneous procedure in the operating room. It can be considered a useful adjunct in the care of patients with sputum retention.
Wright (2003) reported the success rate for the mini-tracheostomy at 96%–100%.
The average duration of use is about 1 week, although cannulas are sometimes in
place for several months. When the patient has regained an adequate cough and
no longer requires suctioning, the mini-tracheostomy can be removed. Swallowing
is reported to be normal while the cannula is in place and complications are rare.
Contraindications to the procedure include morbid obesity, neck mass, calcified
cricothyroid membrane, coagulopathy, and impending respiratory failure.
The Portex Mini-Trach II is a small-bore cannula of 4 mm internal diameter. The kit also includes a scalpel, suction catheter, 15-mm connector, and cotton twill tape.
101
Portex Mini-Trach II Kit. Photo courtesy of Smiths
Medical.
Custom-Designed Tracheostomy Tubes
Occasionally, patients have special needs that cannot be met by the standard
tracheostomy tubes available. For these patients, it is possible to custom order a