tracheostomy tubes - jivd · tracheostomy tubes dean r. hess phd rrt assistant director of...

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

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0;55

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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