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Tracheostomies
112
Tracheostomy-Related Supplies
There are a variety of tracheostomy-related supplies and equipment available
for the patient’s convenience that are primarily for home use.
Tracheostomy Bibs.
it helpful to wear a type of bib designed to protect their clothing. Bibs are also
available that can filter and warm the environmental air.
Scarves or Ascots.
tracheostomy may camouflage it by wearing decorative scarves or ascots. Some
of these are available in materials that resist staining and moisture.
Shower Protection Devices.
tracheostomy or laryngectomy tube while showering can use a shower protection device. Otherwise, patients should be taught to avoid facing the water flow.
Tube Spacer.
the patient is wearing protective clothing around the stoma.
Grid or Mesh Screens.
vent inhalation and aspiration of particulate matter or foreign bodies.
A tube spacer can be used to prevent blocking the aperture when
Patients who have a large amount of secretions may find
Patients who are concerned about the appearance of their
Patients who are concerned water may enter their
A mesh screen can be used to filter air in order to pre-
Summary
There are many choices of tracheostomy tubes. Each tube has its own characteristics with inherent strengths and precautions. The major categories of tracheostomy tubes include cuffed or cuffless and single- or dual-cannula. Many
special-use tracheostomy tubes are also available, such as extra-length or talking
tracheostomy tubes. One must have a clear understanding of the primary goals
in order to choose the best tube for a particular patient. Chapter 4 discusses the
details of the next step—fitting and changing the tracheostomy tube.
Key Points
Tracheostomy tubes can be classified into four categories: dual-cannula, ■
cuffed tubes; single-cannula, cuffed tubes; dual-cannula, cuffless tubes;
and single-cannula, cuffless tubes.
■
Tracheostomy tubes are constructed of a variety of materials, including
polyvinyl chloride, silicone, nylon, stainless steel, and silver.
■
Tracheostomy tubes with inner cannulas should be used in patients who
have large amounts of secretions.
■
Laryngectomy tubes are always cuffless and are usually shorter than a
standard tube.
■
Cuffless tracheostomy tubes can be used in patients who can protect
their airway.
Chapter 3 Types of Tracheostomy Tubes and Related Appliances
References
Bernhard, W. N., Yost, L., Joynes, D., Cothalis, S., & Turndorf, H. (1985). Cuff pressures in endotra-
cheal and tracheostomy tubes. Related cuff physical characteristics. Chest, 87, 720–725.
Dhand, R., & Johnson, J. C. (2006). Care of the chronic tracheostomy. Respiratory Care, 51(9),
984–1001.
Duguet, A., D’Amico, L., Biondi, G., Prodanovic, H., Gonzalez-Bermejo, J., & Similowski, T.
(2007). Control of tracheal cuff pressure: A pilot study using a pneumatic device. Intensive
Care Medicine, 33, 128–132.
Faris, C., Koury, E., Philpott, J., Sharma, S., Tolley, N., & Narula, A. (2007). Estimation of trache-
ostomy tube cuff pressure by pilot balloon palpation. Journal of Laryngology and Otology,
121(9), 869–871.
Guha, Q., Mostafa, S. M., & Kendall, J. B. (2001). The Montgomery T-tube: Anaesthetic problems
and solutions. British Journal of Anaesthesia, 87(5), 787–790.
Hall, A. M., & Watt, J. W. (2008). The use of tracheal stoma stents in high spinal cord injury: A
patient-friendly alternative to long-term tracheostomy tubes. Spinal Cord, 46(11), 753–755.
Huang, C. (2001). Use of the silicone T-tube to treat tracheal stenosis or tracheal injury. Annals
of Thoracic and Cardiovascular Surgery, 7(4), 192–196.
Quigley, R. L. (1988). Tracheostomy—an overview. Management and complications. British
Journal of Clinical Practice, 42(10), 430–434.
St. John, R. E., & Malen, J. F. (2004). Contemporary issues in adult tracheostomy management.
Critical Care Nursing Clinics of North America, 16(3), 413–430.
Wahidi, M. M., & Ernst, A. (2003). The Montgomery T-tube tracheal stent. Clinics in Chest Medi-
cine, 24, 437–443.
Wouters, K.M.A., Byreddy, R., Gleeson, J., & Morley, A. P. (2008). New approach to anaesthetiz-
ing a patient at risk of pulmonary aspiration with a Montgomery T-tube in situ. British
Journal of Anaesthesia, 101, 354–357.
Wright, C. D. (2003). Minitracheostomy. Clinics in Chest Medicine, 24(3), 431–435.
113
Web Resources
Arcadia Medical Corporation, manufacturer of Arcadia tracheostomy tubes, http://www.arca
diamedical.com
Boston Medical, manufacturer of TRACOE, Montgomery, and Singer tracheostomies and re-
lated devices, http://www.trachs.com
Covidien, manufacturer of Shiley tracheostomy tubes, http://www.nellcor.com
Premier Medical Products, manufacturer of Jackson original, Jackson Improved, and Air-Lon
tracheostomy tubes, http://www.premusa.com
Pulmodyne, manufacturer of the Blom tracheostomy tube, http://www.pulmodyne.com
Smiths Medical, manufacturer of Bivona and Portex tracheostomies and related devices, http://
www.smiths-medical.com
Teleflex Medical, Pilling, manufacturer of Jackson, Mayo Clinic, Holister, and Tucker tracheos-
tomy products, http://www.teleflexmedical.com
TM
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Fitting and
Changing a
Tracheostomy
Tube
Linda L. Morris
4
Fitting tracheostomy tubes is both a science and an art. One might believe it is a
routine and straightforward procedure, but this is hardly the case. There are numerous factors to consider when determining the optimal size and type of tracheostomy tube, particularly the patient’s ability to protect his or her airway, the
amount and thickness of secretions, if positive-pressure ventilation is required,
anatomical considerations, if the patient wishes to speak, airway pressures, the
size of the tracheostomy tube versus the size of the airway, and lung mechanics.
Each of these factors must be taken into consideration in order to provide for
the individual needs of each patient.
Considerations When Fitting a Tracheostomy Tube
Before Fitting a Tracheostomy Tube
There are numerous factors to consider when fitting a patient with a tracheostomy tube. Short-term and long-term goals should be identified and reviewed
on a regular basis. Questions include the following:
115
Tracheostomies
116
Will the patient require mechanical ventilation for the next week, next ■
month, or some other time frame?
■
Does the patient desire to speak?
Is the patient able to manage airway secretions? ■
Is the patient ready to be weaned from mechanical ventilation? ■
Can the patient be managed with nocturnal positive-pressure ventilation ■
and a tracheostomy collar during the day?
■
Is the patient on a path to rehabilitation, or will the patient require longterm care?
■
Does the family have the capability to safely manage the patient at
home?
There are questions to ask at each point in the patient’s hospitalization,
discharge planning, rehabilitation, and outpatient settings because the goals
often change as the patient progresses through each phase of treatment and
recovery.
When fitting a tracheostomy tube, it is necessary to examine the inner diameter, outer diameter, and length of the tracheostomy tube in place; consider
individual patient issues; and then determine the primary and secondary goals.
If wishing to speak is a secondary goal, enough air must pass around the outside of the tube to easily reach the vocal cords. If a primary goal is to deliver
positive-pressure ventilation, then an adequate seal would be the priority. The
challenge comes when there are multiple or conflicting goals—for example,
a patient who requires positive-pressure ventilation but who also desires to
speak. Another challenging example is a patient who requires a longer tracheostomy tube but who also has copious thick secretions. One must constantly
balance goals with priorities.
Assessing the Resistance of the Tracheostomy Tube
When fitting the optimal tracheostomy tube, one must first consider size. Poiseuille’s Law states that flow is dependent on the radius and length of the tube.
P = V˙8Ln/πr4
In this equation, P is the pressure gradient across the tube, V˙ represents gas
flow, L represents tube length, n represents gas viscosity, r represents the tube
radius, and 8 and π represent constants. In other words, when flow is laminar,
resistance is directly proportional to the radius of the tube raised to the fourth
power. However, when flow is turbulent, resistance becomes inversely proportional to the radius raised to the fifth power. Because of this, a small decrease
in radius will dramatically increase resistance (Beachey, 2007; Epstein, 2005).
Compared to endotracheal tubes, a tracheostomy tube makes the elastic and
resistive work of breathing easier. The shorter length of the tracheostomy tube,
as well as its more rigid structure and placement in the subglottic region, makes
it easier to facilitate effective bronchial hygiene (Epstein). By lessening the resistance that secretions create, intrinsic PEEP is reduced, decreasing the elastic
work of breathing.
Chapter 4 Fitting and Changing a Tracheostomy Tube
Pierson (2005) clearly outlined the general principles of airflow with regard
to artificial airways:
■
The larger the inner diameter, the lower the resistance.
The shorter the tube, the lower the resistance. ■
Irregular walls of the tube (such as those produced by secretions) in- ■
crease resistance.
■
The sharper the curve of the tube, the greater the resistance.
All these factors contribute to work of breathing and must be considered
when fitting a tracheostomy tube. Major indications for placing a tracheostomy
tube include prolonged mechanical ventilation with endotracheal intubation,
upper airway obstruction, airway protection, and the facilitation of bronchial
hygiene (Shapiro, Harrison, Kacmarek, & Cane, 1985)—the acronym VOPS (ventilation, obstruction, protection, secretions).
In hospitals, it is advisable to fit the tracheostomy patient with a tube with a
standard 15-mm connector to enable the use of a mechanical resuscitation bag
or ventilator in the event of an emergency. Some low-profile tubes eliminate the
15-mm connector for a more cosmetic appearance. However, many hospitalbased practitioners are not familiar with the low-profile tracheostomy tube, nor
that some can be converted to a standard inner cannula with a 15-mm connector, which could result in confusion during an emergency.
117
Choosing a Cuffed Versus Uncuffed Tube
The earliest tracheostomy tubes were cuffless. In the 1960s, tracheostomy tubes
were constructed with small-volume cuffs. These cuffs were smaller than the
airway, and pressures of 160 to 300 mm Hg were required to fill the cuffs (Rumbak et al., 1997). Larger volume cuffs that required lower inflation pressure
were developed in the 1970s.
The first decision when choosing the type of tracheotomy tube is whether or
not the patient requires a cuffed tube. Patients who require positive-pressure ventilation almost always require a cuffed tube. If the patient is ventilator dependent,
a tube with a low-pressure cuff would minimize pressure against the tracheal
wall. However, the patient who is only partially dependent on positive-pressure
ventilation—e.g., using nocturnal ventilation at night and a high- humidity tracheostomy collar during the day—could use a different tube. In that case, a Bivona
TTS or Arcadia CTS tracheostomy tube could provide the added advantage of
capping during the day. Any concerns about their high-pressure cuffs would be
offset by intermittent inflation. Because the cuff lies completely against the shaft
when deflated, creating no airflow obstruction, the Bivona TTS and the Arcadia
CTS tubes are the only cuffed tracheostomy tubes that can be capped safely when
the cuff is deflated. A properly fitted, fenestrated tube may also be capped; however, this tube has a standard high-volume, low-pressure cuff.
Positive-Pressure Ventilation and Choice of Tube.
ventilation is required, a cuffed tracheostomy tube is necessary to ensure the set
tidal volume is delivered. If a cuffless tube is used with a ventilator-dependent
Whenever positive-pressure
Tracheostomies
118
patient, there will be a large leak of air around the tube because of the significant difference in delivered to returned tidal volume. This difference can be
problematic—not only in ventilator alarms sounding, but also in terms of respiratory distress, hypoxemia, and hemodynamic instability. Occasionally, however,
some ventilator-dependent patients with cuffless tracheostomy tubes use what
is called “leak speech” in order to phonate. (See chapter 6 for a detailed discussion about leak speech.) However, if these patients become unstable or critically
ill, a cuffed tube is always advisable. In this circumstance, patients will need the
benefit of receiving the entire tidal volume. Until a cuffed tracheostomy tube
can be placed, ventilator settings should be adjusted by increasing flow and/or
minute ventilation to compensate for the large deficit in returned volumes.
The success of managing a ventilator-dependent patient with a tracheostomy revolves around several factors: volume delivered versus volume returned,
adequate seal of the cuff within the airway, and resistance to gas delivered.
When the volume returned is much less than the tidal volume delivered, ventilator alarms will sound with an alert indicator for a system leak. This leak
could be in one of three main locations: the ventilator circuit, the seal of the cuff
against the airway, or within the cuff itself. See chapter 5 for a comprehensive
discussion about leaks.
If it has been determined that there is sufficient air in the cuff and a leak
remains, tracheomalacia is the presumed cause. Tracheomalacia is commonly
caused by chronic overinflation of the cuff. This added pressure against the
elastic tracheal tissue causes it to weaken and balloon out in the area of the cuff.
Like overstretched elastic, the tracheal tissue appears to stretch in the area of
increased pressure. This stretch is limited, however, and can result in tracheal
erosion if the pressures are too great over a prolonged period of time. Tracheoscopy can be used to visualize the extent of the defect.
The method to resolve a leak due to tracheomalacia is to place the cuff in a
different location within the trachea. This is usually done by placing a tracheostomy tube with a slightly longer length so as to place the cuff inferior to the area
of tracheomalacia (see Figure 4.1).
4.1
Tracheomalacia and repositioning the tracheostomy tube. On the left, tracheomalacia has
developed around the inflated cuff. On the right, a longer tracheostomy tube has been
placed, allowing the cuff to be positioned below the level of tracheomalacia.
Chapter 4 Fitting and Changing a Tracheostomy Tube
119
Airway Protection.
of tracheostomy tube is airway protection. If the patient is able to protect his or
her airway, then a cuffless tube usually offers the most benefits. However, without adequate intrinsic reflex airway protection, a cuffed tube must be chosen.
Following this decision, other features can then be considered, such as phonation and single- versus dual-cannula tubes.
Airway protection is primarily influenced by intact swallow and adequate
cough. The epiglottis closes over the trachea during swallowing in order prevent
food and fluid from entering the trachea. A study on normal adults by Mendell
and Logemann (2007) showed that the sequence of events in the pharyngeal
swallow varied depending on the age of the patient and the volume and consistency of the bolus. The dominant sequence was hyoid and laryngeal elevation,
followed by posterior tongue retraction and then laryngeal vestibular closure.
On a larger bolus, laryngeal vestibule closure occurred before the tongue base
movement—and it was thought this would add to airway protection. The sequence of events during the swallow was dependent on other factors such as
age and comorbidities. Normal participants in their 60s and 70s had longer time
differences between hyoid elevation and upper esophageal sphincter opening
than younger subjects (Mendell & Logemann; Robbins, Hamilton, Lof, & Kempster, 1992). Neurological injury or disease may greatly influence a patient’s ability to swallow, so it is advisable to obtain a swallow evaluation from a speech
pathologist whenever the patient’s swallow is in question. A detailed discussion
on the physiology of swallow is provided in chapter 1.
Strength of Cough.
side; however, a more objective measure is called vital capacity. Normal vital
capacity is 50–70 ml/kg of body weight (Douce, 2003). However, after days or
weeks of oral intubation, the ability to cough can be compromised because the
glottic mechanism is bypassed. The lowest acceptable vital capacity that determines adequacy of cough is 15 ml/kg of body weight—or approximately 1 liter
for most adults (Shapiro et al., 1985). Another measure of cough strength is the
peak cough flow, which should be at least 360 liters per minute (Bach, 1993).
Lower than this indicates poor cough strength. The primary danger of poor
cough strength is the inability to clear secretions, which can result in the retention of secretions, respiratory distress, and hypoxemia.
Usually the best way to improve cough strength is vigorous exercise. In an
unpublished case series by this author, a program of deep breathing and arm
exercises was prescribed to tracheostomy patients who were able to independently move at least one of their upper extremities. Exercises were demonstrated to the patient, the primary nurse, and the family when available, and the
patient was encouraged to do 10 (or more) repetitions per hour. All the patients
who complied, even partially, demonstrated improvement in vital capacity after
only 2 days—often by at least 100%, and in one case by 700%. These results are
the foundation of a more robust, randomized, and controlled trial to compare
this simple exercise program with standard care for tracheostomy patients and
evaluate other outcomes.
Incentive spirometry is ideal for tracheostomy patients who have the manual dexterity to use it. However, it can only be used for patients who are capped
and breathing through their native airway, as it requires use of a mouthpiece.
Another important factor in determining the proper type
Strength of cough can be subjectively observed at the bed-
Tracheostomies
120
Deep breathing and arm exercises result in the enhanced early mobilization of
secretions.
Swallowing.
swallowing mechanism is disrupted by the prolonged presence of an endotracheal tube, and tracheotomy patients, particularly those with an inflated cuff,
sometimes report discomfort with swallowing. Furthermore, the frequency of
silent aspiration and reduced laryngeal elevation is increased with cuff inflation (Ding & Logemann, 2005).
Mental Status.
often require a cuffed tracheostomy tube. However, unresponsive patients are
sometimes able to protect their airway to a certain degree. Mental status alone
is not a determining factor in fitting or downsizing a tracheostomy tube. If an
unresponsive patient has an effective spontaneous cough and swallow, the patient can be considered for downsizing. The primary factors to be considered
are swallow, cough, and secretions.
An intact swallow is essential for ensuring airway protection. The
Unresponsive patients usually present more of a challenge and
Choosing a Dual- Versus Single-Cannula Tracheostomy Tube
Another consideration is the choice between a dual- or single-cannula tube.
The amount and thickness of secretions determines whether or not a dualcannula tube is desirable. The primary advantage of a dual-cannula tube is that
the inner cannula can be removed, inspected, and cleaned or replaced if necessary. Single-cannula tubes do not have this feature. Secretions accumulate
and collect within the inner lumen of the tracheostomy tube, which results in
a narrowing of the inner diameter of the tube and can contribute to increased
resistance, work of breathing, or, worse, tube obstruction.
If other factors (such as the desire to speak, ventilator dependency, or
altered anatomy) are considered, a single-cannula tracheostomy tube may
be the better choice. Precautionary measures should be taken for patients
who have large amounts of thick secretions, including offering optimal fluids
to thin secretions and vigorous physical therapy to facilitate the mobility of
secretions.
Secretions and Tube Obstruction.
factors in the choice of tracheostomy tube. When the consistency of secretions
is thin, it is easier for them to be coughed or suctioned out. Not all patients
who have a large amount of secretions will require a cuffed tracheostomy tube.
However, patients who cannot manage their secretions will require a cuffed
tube. Thick secretions in a patient with a poor cough are the most worrisome
because mucus plugs can readily develop. Unresponsive patients who do not
cough may be retaining secretions. Patients with a poor cough reflex or who are
unresponsive should be regularly stimulated. Frequent turning and increasing the patient’s range of motion will help mobilize secretions. Other bronchial
hygiene maneuvers—such as percussion and vibration, postural drainage, and
bronchodilators—may be necessary to mobilize secretions, but they are applied
on an individual basis. All efforts to mobilize secretions should be followed by
tracheal suctioning to remove secretions from the airway.
The amount and thickness of secretions are
Chapter 4 Fitting and Changing a Tracheostomy Tube
121
Suctioning.
but it is vital to prevent mucus plugging and ensure patency of the airway (St.
John & Malen, 2004). Patients with a weak or absent cough will require the most
suctioning, regardless of the consistency of their secretions, as suctioning is one
effective way to stimulate secretions. Passing a suction catheter will ensure patency of the tube, but there is no evidence to determine the optimal frequency of
this maneuver. Patients with a strong cough will usually require less suctioning
unless their secretions are very thick and they are unable to fully expectorate
them.
The technique of suctioning has been described in several studies. Some
authors suggest the suction catheter should not go past the tip of the tracheostomy tube to avoid causing unnecessary stimulation and possible damage to
the tracheal wall. This shallow suctioning may be adequate in patients with
a strong cough. However, the potential danger is to patients without a strong
cough reflex. These patients are unable to effectively produce secretions and
will require stimulation, often in the form of deep tracheal suctioning. The failure to provide effective stimulation and secretion mobilization in patients who
are unresponsive can result in the inspissation of secretions, mucus plug formation, and obstruction of the tube—all of which have potentially serious consequences. See chapter 7 for further discussion of mobilization of secretions.
Suctioning a patient on a regular schedule is not recommended,
Choosing Optimal Tube Size
The choice of tracheostomy tube size goes hand in hand with determining the
need for cuffed versus uncuffed and single- versus dual-cannula tubes. The
appropriate size and type of tube for each patient are determined by the goal
of the care plan, which takes the following factors into consideration: need for
positive-pressure ventilation, phonation, amount and viscosity of secretions,
hemodynamic stability, airway anatomy, and coexisting medical disorders. The
initial step is to identify the inner diameter, outer diameter, and length of the
current tube and compare with the available choices. Tables 4.1, 4.2, and 4.3 list
the inner and outer diameters and lengths of tracheostomy tubes. This information will facilitate the optimal choice of tube for each patient.
If the patient is breathing exclusively through the tube, the largest inner
diameter is recommended; however, if the patient is breathing at least partially
around the tube, he or she could likely tolerate a tube with a much smaller
outer diameter. The process of downsizing should enable the patient to breathe
easier around the tube. Figure 4.2 shows the difference in airflow through a
larger versus a smaller tube. Refer to chapter 11 for a discussion about downsizing tracheostomy tubes.
Proper sizing will also ensure a low-pressure seal to the cuff. A tube that
is too small will not adequately seal the airway and, thus, will create numerous
problems (Figure 4.3A), including loss of airway pressures and overinflation of
the cuff. This can lead to the development of ventilator-associated pneumonia
(Guyton, Banner, & Kirby, 1991; Rumbak et al., 1997). A tube that is too large
can damage the tracheal mucosa, leading to granulation tissue or stenosis of
the trachea (Figure 4.3B). In this case, inflating the cuff will produce high cuff
pressures. Thus, the ratio of size of cuff to size of trachea is an important factor
for properly fitting a tracheostomy tube (Rumbak et al.).