Linda M. Folk, RRT, LRTUniversity of Michigan Health Centers

Critical Care Support Services

Be able to identify the various tubes on the market and how to use them.

Be able pick a trach tube or accessory that would allow your ventilated patient to speak.

Be able to explain the use of a T-tube.

Outer cannula

Outer cannula

Inner Cannula

Outer cannulaInner cannula

Obturator

Metal tracheostomy tubes are for patients that need to maintain a patent airway and don’t need a cuffed tube. The tube is non-disposable. Patients are usually given two, so they can clean one and use one. They have a low profile on the neck and the patient can occlude the opening with their finger and talk. Special adapters are needed to connect a manual resuscitation bag to these tracheostomy tubes.

obturatorInner cannula

Extension is from curve to flange

cuff

This tube is extended from the curve to the flange (proximal) to accommodate patients with thick necks. The inner cannula is disposable.

Proximal extended trach tube

Distal extended trach tube

Proximal extension

Distal extension

Proximal extended tube – intended for patients with thick necks

Distal extended tube – intended for patients that need a longer tube to extend past damaged area of trachea or obstruction

fenestration

plug

Inner cannula obturator

cuff

Pilot balloon

Fenestrated tracheostomy tubes allow the patient to talk while still maintaining a patent airway. The cuff must be deflated completely. The inner cannula is removed and replaced with a plug. The patient breathes through the nose and mouth. Air moves through the fenestration and around the tube. Upon exhalation, the air moves back up through the fenestration and around the tube, through the vocal cords and the patient can speak. This picture shows a cuffed tube for the patient that is still requiring mechanical ventilation for periods of time. The plug is removed, the inner cannula replaced and the cuff inflated when returning the patient to the ventilator.

Foam cuff

obturatorPilot balloon

This Bivona tracheostomy tube utilizes a foam cuff. The pilot balloon is open to atmosphere and the cuff will fill automatically. Minimal pressure is then exerted on the tracheal wall. When used with patients on mechanical ventilation, the pilot balloon may be connected to a port, inline with the ventilator that will inflate the cuff more during inspiration and then release the pressure during exhalation. This helps the cuff seal during inspiration, but still maintain minimal pressure during exhalation. If not used in this manner, the red pilot balloon should not be capped.

When the cuff is deflated, it lies flat against the tube. This facilitates speaking and swallowing. The cuff is made of material that must be filled with sterile water. Air will diffuse out. Most beneficial for patients that only require nocturnal ventilation with minimal settings.

Flange-adjustable

Pilot balloon

cuff Close up of adjustable flange

This tracheostomy tube allows more length than a standard tracheostomy tube, if needed for thick necks or to bypass an area in the trachea that is obstructing, or tracheal mylasia. It has an adjustable flange that allows for adjustment in length if needed. It is very flexible and conforms to the trachea. Close monitoring of the flange should be done, by monitoring the number the flange is locked on. Also, there is no inner cannula. Close monitoring of the patency of the tube, by passing a suction catheter at least twice a shift, is necessary. The patient should always have humidified air or oxygen as well to minimize the chance of plugging of the tube. This tube is not meant to be permanent and should be replaced with a custom tube if needed.

This tube is used for patients that may have tracheal stenosis, malasia or to minimize risk of injury by inflating cuffs on a rotating basis.

One-way valve

This valve is placed on a patient’s tracheostomy tube, with cuff deflated, and allows the patient to speak. The patient is able to breath air through the one-way valve (and some from nose and mouth) and then when they exhale, the valve closes and all of the air moves through their vocal cords. This is easier for the patient than plugging the tube. A couple of safety notes: 1) the cuff must be deflated before placing the valve on the patient’s tube; 2) if the patient is having a lot of difficulty breathing (particularly exhaling) and coughing, the tracheostomy tube may be too large and need to be downsized (i.e, from a #8 to a #6); 3) the patient should not be left alone when first trying this valve until the patient shows they are able to tolerate it well and the patient knows how to remove it if having difficulty breathing. If on oxygen, have a trach mask and nasal cannula available as patient may do better with one or the other.

INCORRECT CORRECT

NO! NO! NO!

Never place the Passy Muir Valve on with the cuff inflated.

YES! YES! YES!

Cuff is always deflated when the Passy Muir Valve is on.

Cuff inflated Cuff deflated

The Portex Trach-Talk Tracheostomy tube is designed to allow patients that need the cuff inflated (usually patients on mechanical ventilation) to speak. The blue air line has an opening just above the cuff. The line is connected to an air flowmeter, set at 6-8 lpm. When the finger port is occluded, air exits the port above the cuff and flows up through the vocal cords so the patient can talk. The port must be cleared of secretions frequently so it doesn’t become occluded.

Tracheal Button

Tracoe tracheostomy button

The tube on the left has a mesh covering to protect from inhaling dirt. The one on the right comes with a cover that snaps on to allow speech.

Bivona talk trach

Similar to the Portex except with the benefit of having a foam cuff (right) or traditional air cuff (left)

T-tubes are used to stent the airway and provide a patent airway during healing or permanently.

Respiratory Care Practitioners should play a big role in the monitoring of patients with tracheostomies in the general care setting.

Become familiar with the various tracheostomy tubes on the market.