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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4597_Библиотеки_им_академика_М_И_Перельмана.pdf
Tracheostomies
102
tracheostomy tube to meet their needs. A specific length of tracheostomy tube
can be ordered, or a specific curvature of the tube can be ordered, often by sending CT scans to the manufacturer. Other options are a TTS cuff on an extra-long
shaft or specifying the placement of a fenestration. These custom tracheostomy
tubes often come at a premium price. In addition, depending on the manufacturer, custom-designed tubes often take up to 2 weeks, so some advance planning is necessary. Because of the time and expense required to manufacture
these custom tubes, it is important that exact measurements be taken and the
goals of treatment be clearly discussed between the managing service, the tracheostomy specialist, and the manufacturer.
New Tracheostomy Products
New types of tracheostomy tubes are being introduced with the purpose of
overcoming the complications of standard tubes and meeting the specific needs
of patients. One of these tubes is discussed here.
Blom Tracheostomy Tube System
Blom tracheostomy tube system. Reprinted by permission of Pulmodyne (Indianapolis,
Indiana).
Structure: Cuffed, dual-cannula, fenestrated
Material: Outer cannula—kostrate and barium; cuff—polyvinyl chloride; neck flange—
polycarbonate and polyvinyl chloride; standard cannula—polyurethane and polypropylene;
speech cannula—silicone and poly propylene
Chapter 3 Types of Tracheostomy Tubes and Related Appliances
Manufacturer: Pulmodyne
Unique Features: Speech cannula with two valves (flap valve and bubble valve), exhaled
volume reservoir, subglottic suctioning cannula; fenestration is 1 mm above the cuff so the
fenestration does not contact the tracheal mucosa when inflated
Use: For the ventilator-dependent patient who wishes to speak
The Blom tracheostomy tube system is new and was designed for the ventilator-dependent patient who desires to speak regardless of cuff inflation. It
has a fenestrated shaft; however, the fenestration is only 1 mm above the cuff.
When the cuff is fully inflated, the fenestration is reported to avoid contact with
the tracheal mucosa. It also has two valves that redirect air. During inspiration,
the flap valve opens, and the bubble valve expands into the fenestration and
seals it. This allows all the air to be delivered to the patient’s lungs and prevents air from escaping into the upper airway. On exhalation, the mechanism is
reversed—the flap valve closes and the bubble valve collapses to unblock the
fenestration and allow air up through the fenestration to the vocal cords. The
actual use and potential of this tracheostomy tube cannot be fully appreciated
until the results of clinical trials have been evaluated.
103
Tracheostomy Accessories and Appliances
There are many appliances and supplies available for the tracheostomy patient. These include speaking valves, tracheostomy buttons, disconnect wedges,
HMEs, decannulation plugs, shower protection devices, and more. Some of
these supplies and the conditions in which they may be helpful are discussed
in this section.
Speaking Valves
Speaking valves are one-way valves used to facilitate phonation. Air enters the
tracheostomy on inspiration but is diverted on expiration through the oropharynx. The variety of valves is discussed in detail in chapter 6.
Stoma Maintenance Devices
There are a variety of devices available that maintain stoma patency. Often
these devices are employed during the rehabilitation phase or for patients who
cannot otherwise be decannulated. Using these devices, patients can proceed
through the rigors of rehabilitation; however, the airway can be immediately
accessed if problems are encountered.
Tracheostomy Button and Stoma Stent.
temporary stent to maintain the patency of the stoma (Figure 3.4). The tracheostomy button must fit within the stoma tract and not into the airway. Spacers
are used to ensure a snug fit. In order to properly fit a tracheostomy button,
the stoma must be round rather than irregular. Fitting a tracheostomy button is
A tracheostomy button is used as a
Tracheostomies
104
3.4
Olympic
tracheostomy
button with spacers.
Image courtesy of
Natus Medical.
discussed in chapter 4. A tracheostomy button provides a low-profile appearance while allowing breathing through the upper airway; however, a ventilator
adapter is available when access to the airway is desired (Figure 3.5).
3.5
Ventilator adapter
for Olympic
tracheostomy
button. Image
courtesy of Natus
Medical.
A stoma stent (Figure 3.6) is similar to a tracheostomy button; however, the
cap may be directly attached to the stent itself. Stoma stents have been used in
patients with high spinal cord injury to access the airway for mechanical ventilation or bronchial hygiene (Hall & Watt, 2008).
Tracheal Cannula.
that it stents open the stoma and does not interfere with airflow. However, the
tracheal cannula is meant to allow direct access to the airway. The Montgomery cannula (Figure 3.7) is a corrugated tube that is an open system; however,
a tracheostomy button closes off access to the airway. It is easy to suction a
patient with a tracheal cannula, but the tracheostomy button does not provide
regular access to the airway for suctioning. The Montgomery cannula is made
of silicone and is very flexible. A ring washer holds it in place, and it comes with
its own detachable plug/ring set to allow phonation. The Montgomery speaking
valve was designed for use with the Montgomery cannula and comes in compatible sizes.
A tracheal cannula is similar to a tracheostomy button in
3.6
Hood stoma
stent. Hood Labs
(Pembroke,
Massachusetts).
3.7
Montgomery cannulas. Photo courtesy of Boston Medical Products. All rights reserved.
Tracheostomies
106
Disconnect Wedges
A disconnect wedge (Figure 3.8) is used when airway equipment (e.g., ventilator
tubing or a manual resuscitation bag) is difficult to remove from the 15-mm connector of the tracheostomy tube. Forceful removal should be avoided because
the tube can be damaged. The wedge is used as a lever on the 15-mm connecter
to disconnect the airway equipment from the tracheostomy tube. Disconnect
wedges are packaged with the Bivona and Arcadia lines of tracheostomy tubes.
3.8
Bivona TTS
tracheostomy tube
and disconnect
wedge (also
pictured are cotton
twill ties and red
cap). Photo courtesy
of Smiths Medical.
Caps and Decannulation Plugs
A tracheostomy cap or plug (Figures 3.9 and 3.10) is used to prevent air from
entering the tracheostomy tube, which forces the patient to breathe through his
or her mouth and nose, simulating normal breathing. The decannulation plug is
differentiated from the cap because it typically is applied by removing the inner
3.9
Shiley CAP (Covidien).
Chapter 3 Types of Tracheostomy Tubes and Related Appliances
cannula. The advantage of the cap or plug is that it allows the patient to phonate
easily without the use of digital occlusion.
Caps.
There are three primary types of caps: those applied to the tracheostomy
tube, those that replace the inner cannula, and graded plugs. A standard cap is applied externally to the tracheostomy tube to “plug the hole.” Th e Shiley CFS is the
only tracheostomy tube with its own capped inner cannula (Figure 3.11). One must
first remove the standard inner cannula and replace it with the capped inner cannula. Caps should never be used with standard cuffed tracheostomy tubes, even if
the cuff is completely deflated. The proper use of caps is discussed in chapter 6.
3.10
Bivona red cap.
Photo courtesy of
Smiths Medical.
107
3.11
Shiley CFS capped
inner cannula
(Covidien).
Tracheostomies
108
Decannulation Plugs: Shiley DCP, DDCP.
tube, a decannulation plug (Figure 3.12) can be used as a low-profile cap. The
use of a decannulation plug often requires the removal of the inner cannula
and the attachment of the decannulation plug to the outer cannula. However,
TRACOE provides red decannulation plugs for the outer cannulas of the
TRACOE Twist tubes (Models 505–04, 505–10) or blue decannulation plugs for
the inner cannulas (Models 504–04, 504–10).
Rather than capping a tracheostomy
3.12
Blom decannulation
plug. Reprinted
by permission
of Pulmodyne
(Indianapolis,
Indiana).
Decannulation Corks or Stoppers.
decannulation plug; however, it fits within (rather than around) the inner or
outer cannula of a tracheostomy tube. Typically, these corks are used for metal
tracheostomy tubes and can be ordered to fit based on tube size. They can be
ordered in gradations of occlusion in order to facilitate a gradual transition to
full upper-airway breathing (Figure 3.13). For example, they can be ordered
for one-fourth partial obstruction, one-half partial obstruction, three-fourths
partial obstruction, or full obstruction.
A cork or stopper is similar to a cap or
3.13
Graduated corks. Corks are graduated to provide partial to full obstruction. From left: 25%,
50%, 75%, and 100% obstruction.
Chapter 3 Types of Tracheostomy Tubes and Related Appliances
Disposable and Spare Inner Cannulas
There are several types of inner cannulas meant for temporary use.
109
The Shiley SIC.
place in order to provide positive-pressure ventilation. Because of this, one must
have an extra inner cannula when cleaning the inner cannula of a Shiley tube.
The Shiley SIC, or spare inner cannula (Figure 3.14), is identified by its red 15-mm
connector and is a temporary inner cannula for use with the Shiley LPC, CFS,
FEN, or CFN. It is not intended for long-term use and should be replaced with the
permanent inner cannula as soon as tracheostomy care has been completed.
The inner cannula of a Shiley tracheostomy tube must be in
3.14
Clockwise from top left:
Shiley disposable inner
cannula (DIC), spare
inner cannula (SIC),
disposable fenestrated
inner cannula (DFIC),
disposable decannulation
plug, decannulation plug,
cap (Covidien).
Shiley DIC.
lar replacement, rather than cleaning. The disposable inner cannula for these
tubes is called the DIC.
Portex Per-Fit Inner Cannula.
eled distal tip for ease of insertion using the Seldinger technique over a dilator. The Per-fit inner cannula has a beveled tip to match the outer cannula.
Figure 3.15 shows the angled distal tip, which allows easier placement over a
dilator during insertion.
Disposable Inner Cannulas for Portex DIC.
have disposable inner cannulas that are color coded based on size (Figure 3.16).
The Shiley DCT tracheostomy tube inner cannulas require regu-
The Portex Per-fit tracheostomy tube has a bev-
Portex DIC tracheostomy tubes also
3.15
Portex Per-fit inner
cannulas. Photo courtesy
of Smiths Medical.
Tracheostomies
110
These inner cannulas must be replaced, rather than cleaned, on a regular basis.
These inner cannulas are for use with all versions of Portex DIC and Flex DIC
tracheostomy tubes.
3.16
Portex DIC
disposable inner
cannulas. Photo
courtesy of Smiths
Medical.
Antidisconnect Device (“Stronghold,” Covidien)
An antidisconnect device helps eliminate accidental disconnection of equipment
from the tracheostomy tube (Figure 3.17). It is available in adult and pediatric
sizes and is used to secure the tracheostomy tube to the ventilator tubing circuit.
3.17
Shiley Stronghold
(Covidien).
Chapter 3 Types of Tracheostomy Tubes and Related Appliances
Heat Moisture Exchanger
An HME is used to trap the moisture of exhaled gas, allowing the inspiration of
added humidity. These devices are especially helpful when patients experience
discomfort from dry mucus membranes. These devices can be used in-line with
the ventilator circuit or attached separately onto the 15-mm connector of the
tracheostomy tube.
Patients who prefer not to use an HME, but who have uncomfortably dry
mucous membranes, can use a thin layer of damp gauze draped over the tracheostomy. Saline nasal mist can also be sprayed within the tracheostomy at
intervals to moisten mucus membranes.
Ventilator Adapters
A ventilator adapter is available for use with the Bivona Fome-Cuf tracheostomy
tube (Figure 3.18). The ventilator adapter provides an additional inflation of air
into the cuff with inhalation and a slight deflation of the cuff with exhalation. It
is designed to be attached distally from an HME attached directly to the tracheostomy tube. The HME normally collects exhaled moisture from the circuit and
delivers it during inhalation. However, this ventilator adapter delivers moisturized air from the ventilator directly to the cuff. For this reason, an auto-control
device is connected to the dry side of the ventilator, and the port from the device
is connected to the pilot balloon. This will inflate the cuff with dry gas.
111
3.18
Bivona auto control
device for Fome-Cuf.
Photo courtesy of Smiths
Medical.
Tracheostomy-Securing Devices
Tracheostomy tubes can be secured to the neck in a variety of ways, including
cotton twill tape or softer collars with Velcro closures. Some patients prefer to
secure their tracheostomy to their neck with a chain. There is no one recommended device; however, the priority is tube security, especially in the early
postoperative period. It is recommended that no more than one finger fit under
the securing device. If the securing device is too loose, the patient can easily
cough out or otherwise dislodge the tracheostomy tube. If the device is too tight,
it can erode into the skin of the neck.