Tracheostomy Tubes: Types, Indications, and Risks (2023)

Tracheostomy tubes are an essential component in the management of various respiratory conditions and surgical procedures, allowing direct airway access below the level of the larynx.

Their utilization spans a broad spectrum of clinical situations, from providing a secure airway in long-term ventilated patients to bypassing upper airway obstructions.

Understanding the diverse types of tracheostomy tubes, their indications, and potential risks is crucial for medical professionals, caregivers, and even patients themselves.

This article provides a comprehensive overview of tracheostomy tubes and the importance of their role in the field of respiratory care.

What is a Tracheostomy Tube?

A tracheostomy tube is a medical device inserted into a surgically created opening in the trachea, known as a tracheostomy, to facilitate breathing. It provides direct access to the lower airway, bypassing the nose and mouth. Tracheostomy tubes are used for various reasons, including prolonged ventilation, upper airway obstructions, or secretion management.

Indications

The placement of a tracheostomy tube is a significant medical intervention with specific indications. Here are the primary reasons why a tracheostomy might be considered:

• Prolonged Mechanical Ventilation: Patients who require long-term assistance from a ventilator to breathe may benefit from a tracheostomy, as it can offer a more stable and comfortable airway than an endotracheal tube.
• Upper Airway Obstruction: Obstructions can be due to tumors, trauma, infections, or congenital anomalies. A tracheostomy bypasses these obstructions, ensuring an open airway.
• Airway Protection: In cases where patients are at risk of aspiration (inhaling food, fluids, or secretions into the lungs), a tracheostomy can provide a safer way to protect the lower airways.
• Secretion Management: Patients with conditions that produce excessive respiratory secretions, such as cystic fibrosis or certain neuromuscular diseases, might benefit from a tracheostomy. It facilitates easier suctioning and clearance of these secretions.
• Neuromuscular Disorders: Conditions like amyotrophic lateral sclerosis (ALS), myasthenia gravis, or Guillain-Barré syndrome may weaken respiratory muscles, necessitating a tracheostomy for improved respiratory support.
• Severe Trauma or Surgeries: Injuries to the face, neck, or upper airway, or surgeries involving these areas, might require a tracheostomy as a temporary or permanent measure to secure the airway.
• Altered Conscious Level: Patients with decreased levels of consciousness may be unable to protect their airway, making tracheostomy an option.
• Burns or Inhalation Injuries: Burns or injuries that result from inhaling hot gases or toxic substances can compromise the airway. A tracheostomy can bypass the injured area, ensuring proper ventilation.
• Anatomic Abnormalities: Conditions or surgeries that alter the structure of the upper airway might necessitate a tracheostomy.

Note: While these are common indications, the decision to perform a tracheostomy is a complex one and must be individualized to each patient’s clinical scenario, balancing the benefits against potential risks.

Types

Tracheostomy tubes come in various types, each designed to address specific clinical needs. Here are some of the main types:

• Cuffed Tracheostomy Tubes: These tubes have an inflatable cuff that seals the airway, ensuring that all air passes through the tube. This type is often used for patients on mechanical ventilation.
• Uncuffed Tracheostomy Tubes: These tubes lack an inflatable cuff and are typically used for pediatric patients or adults who do not require a sealed airway.
• Fenestrated Tracheostomy Tubes: These have small holes or fenestrations on the outer cannula. When the inner cannula is removed, the patient can breathe through both the tube and fenestrations, allowing them to speak and participate in weaning trials.
• Shiley Tracheostomy Tubes: A brand-specific type known for its standardized design and sizes.
• Metal (Silver) Tracheostomy Tubes: These are rigid tubes made of metal, often used for patients who have had a tracheostomy for a long time.
• Double Cannula Tracheostomy Tubes: These tubes have an outer cannula that stays in place and an inner cannula that can be removed and cleaned.
• Single Cannula Tracheostomy Tubes: These lack a removable inner cannula.
• Adjustable Flange Tracheostomy Tubes: The flanges on these tubes can be adjusted to alter the tube’s length inside the trachea, accommodating patients with unusual neck anatomy or tracheal depth.
• Pediatric and Neonatal Tracheostomy Tubes: Specifically designed for children and newborns, these tubes are smaller and more flexible.
• Tracheostomy Tubes with Speaking Valves: These are designed to allow patients to speak by directing airflow through the vocal cords.

Note: Each type of tracheostomy tube serves specific patient needs and clinical scenarios. It’s crucial to select the appropriate type based on the patient’s clinical condition, anatomy, and intended use.

Risks and Complications

As with any surgical procedure, tracheostomy placement carries potential risks and complications. These can be categorized into early and late complications:

Early Complications

• Bleeding: Some bleeding is expected, but excessive bleeding can be a significant complication.
• Pneumothorax: This is the presence of air between the lung and the chest wall, leading to lung collapse.
• Injury to Surrounding Structures: Damage can occur to the esophagus, surrounding blood vessels, or nerves.
• Tube Misplacement: The tube can be accidentally placed into the tissue between the tracheal rings or into the esophagus.
• Subcutaneous Emphysema: Air can accumulate under the skin around the tracheostomy site, causing swelling and discomfort.
• Air Embolism: Rarely, air can enter the bloodstream, which can be life-threatening.
• Infection: Infections can develop at the tracheostomy site.

Late Complications

• Tracheal Stenosis: Scarring can cause narrowing of the trachea at or near the tracheostomy site.
• Tracheomalacia: Softening of the tracheal walls can occur due to prolonged pressure from the tube.
• Granulation Tissue: Over time, granulation (scar) tissue can form around the tracheostomy site, potentially obstructing the airway.
• Tracheo-esophageal Fistula: An abnormal connection can form between the trachea and the esophagus.
• Tube Blockage: The tube can become blocked by mucus, blood, or tissue.
• Tube Displacement: The tube can become dislodged, either partially or completely.
• Tracheocutaneous Fistula: An abnormal connection can form between the trachea and the skin.
• Chronic Infection: Persistent infections can occur at the tracheostomy site or within the lungs.
• Difficulty Swallowing: Some patients may experience difficulty swallowing (dysphagia) related to the tracheostomy.
• Cosmetic Concerns: After the tracheostomy tube is removed, there may be a scar or indentation at the site.

Note: It’s important for healthcare providers to be aware of these potential complications and to educate patients and caregivers about signs to watch for. Regular follow-up and proper tracheostomy care can minimize many of these risks.

Parts of a Tracheostomy Tube

A tracheostomy tube is a complex device with multiple components, each designed for specific functions.

Here are the primary parts of a tracheostomy tube:

• Outer Cannula: The main body of the tube that sits within the trachea. It is the largest part and provides the main pathway for airflow.
• Inner Cannula: Located inside the outer cannula, this is a removable tube that can be cleaned or replaced. Its presence helps maintain the patency of the airway and allows for easier cleaning without needing to replace the entire tracheostomy tube.
• Cuff: This is an inflatable balloon-like structure located around the outer cannula. When inflated, the cuff seals against the tracheal wall, ensuring that air from mechanical ventilation goes into the lungs and preventing aspiration of secretions.
• Pilot Balloon: A small external balloon connected to the cuff via a thin tube. It indicates whether the cuff is inflated or deflated.
• Cuff Inflation Line: A small tube that connects the pilot balloon to the cuff, allowing air to be inserted or removed from the cuff.
• Obturator: A temporary, solid guide used to insert the tracheostomy tube smoothly. It has a rounded tip to prevent trauma during insertion. After placement, the obturator is removed.
• Flange (or Neck Plate): A flat piece attached to the outer cannula, which lies against the patient’s neck. It has holes through which ties or Velcro bands are threaded to secure the tube in place.
• Fenestrations: Some tracheostomy tubes have one or more holes on the outer cannula above the cuff (if present). These allow the patient to breathe through both the tube and the fenestrations when the inner cannula is removed, facilitating speech and weaning from the tube.

Understanding the parts of a tracheostomy tube is crucial for healthcare providers, caregivers, and patients to ensure proper use, maintenance, and troubleshooting of the device.

Tracheostomy Tube Suctioning

Tracheostomy tube suctioning is a critical procedure to clear secretions from the trachea and maintain airway patency. This helps to prevent respiratory distress, infections, and potential complications related to secretion buildup.

Suctioning ensures the airway remains open and helps in efficient ventilation and oxygenation.

Procedure

• Hand Hygiene and Precautions: Always start by washing your hands thoroughly. If you’re a healthcare provider or caregiver, wear gloves and possibly a mask and eye protection.
• Equipment Preparation: Gather all necessary equipment, including a suction catheter, suction machine or manual suction device, sterile saline (if required for moistening), and a clean container or basin.
• Oxygenate the Patient: Before suctioning, provide supplemental oxygen to the patient for several minutes if available, especially in hospitalized settings. This ensures adequate oxygenation during the procedure.
• Turn On and Adjust the Suction Machine: The suction should be set to the appropriate level, typically between 80-120 mmHg for adults.
• Inserting the Suction Catheter: Without applying suction, gently insert the catheter into the tracheostomy tube. Advance it until you feel resistance or the patient coughs, then pull back slightly.
• Apply Suction: While withdrawing the catheter, apply intermittent suction by covering and releasing the suction control opening. Rotate the catheter between your fingers while pulling it out to ensure all sides of the trachea are suctioned. The entire suctioning process should not take more than 10-15 seconds.
• Oxygenate Post-Suctioning: Offer supplemental oxygen again to the patient after suctioning.
• Repeat if Necessary: If there are still secretions present, you may need to repeat the suctioning. Allow the patient to rest for a minute or two between suctioning attempts.
• Dispose of Materials: Safely dispose of the suction catheter and any other materials. Clean and disinfect reusable equipment according to protocol.
• Monitor the Patient: Always observe the patient after suctioning. Check for improved breathing, oxygen saturation, and any signs of distress.

Considerations

• Frequency: Only perform suctioning as needed (i.e., PRN). Over-suctioning can cause irritation, while insufficient suctioning can lead to blockage and respiratory distress.
• Sterile Technique: Especially in hospital settings, it’s crucial to use a sterile technique to minimize the risk of introducing infections.
• Complications: Potential complications include hypoxia, trauma to the tracheal lining, bleeding, infection, and cardiac arrhythmias due to stimulation of the vagus nerve.

Note: It’s essential for anyone performing tracheostomy tube suctioning to be adequately trained and familiar with the equipment and technique to ensure patient safety.

What is Tracheostomy Care?

Tracheostomy care refers to the routine maintenance and cleaning of a tracheostomy site and the tracheostomy tube itself to ensure patient safety, comfort, and prevent complications.

Proper tracheostomy care is essential to prevent infections, maintain skin integrity, ensure the patency of the airway, and prolong the life of the tracheostomy equipment.

Steps to Performing Tracheostomy Care

• Cleaning the Stoma Site: Clean around the tracheostomy opening (stoma) with sterile saline or prescribed cleaning solution using sterile cotton swabs or gauze. Check the skin for signs of infection, irritation, or breakdown. Ensure the area is thoroughly dried to prevent skin maceration.
• Changing the Dressing: Use a split gauze or tracheostomy-specific dressing around the stoma to absorb any moisture or secretions. Change the dressing as needed, or at least once a day, and whenever it becomes wet or soiled.
• Suctioning: As previously detailed, suctioning is performed to remove secretions from the tracheostomy tube and trachea, ensuring a clear airway.
• Inner Cannula Care: If the tracheostomy tube has a removable inner cannula, remove and clean it with a prescribed solution. Some inner cannulas are disposable and can be replaced with a new one.
• Cuff Care: If the tracheostomy tube has a cuff, check its pressure regularly. Inflate and deflate the cuff as needed based on medical advice and the patient’s condition.
• Changing Tracheostomy Ties: Ties or Velcro bands keep the tracheostomy tube in place. Ensure they are snug but not too tight. You should be able to fit one or two fingers between the ties and the patient’s neck. Change ties when they become soiled or frayed.
• Tube Changes: Routine tube changes are performed to ensure the tube’s patency and integrity. The frequency is based on the patient’s age, tube type, and clinical situation. Always have a same-size and one-size-smaller tube available during changes in case of emergencies.
• Monitoring and Education: Monitor the patient’s breathing, comfort, and signs of complications. Educate patients and caregivers about signs of infection, obstruction, and other potential issues.
• Humidification: As the tracheostomy bypasses the upper airway’s natural humidifying mechanism, provide humidity (often through a humidifier or mist collar) to prevent the drying and thickening of secretions.

Considerations

• Frequency: Daily tracheostomy care is necessary, but some components, like suctioning, might be performed more often based on the patient’s needs.
• Infection Prevention: Always maintain a clean and sterile technique, especially in hospital settings.
• Patient Comfort: Ensure the patient is comfortable and informed throughout the care process. Address any concerns or discomfort promptly.

Note: Regular and appropriate tracheostomy care reduces the risk of complications, ensures the longevity of the tracheostomy tube, and improves the overall quality of life for the patient.

FAQs About Tracheostomy Tubes

What is a Cuffed Tracheostomy Tube?

A cuffed tracheostomy tube has an inflatable balloon-like structure around its lower end, called a cuff. When inflated, this cuff seals against the walls of the trachea.

This seal ensures that all air passing through the trachea goes in and out of the tube, which is especially useful when the patient is on a mechanical ventilator. The cuff also prevents aspiration of secretions into the lungs.

What is an Uncuffed Tracheostomy Tube?

An uncuffed tracheostomy tube lacks the inflatable cuff. It is often used in situations where there is no need to seal off the airway completely, such as in pediatric patients or in adults who do not require mechanical ventilation.

Without a cuff, there’s less risk of tracheal wall damage due to prolonged pressure.

What is a Fenestrated Tracheostomy Tube?

A fenestrated tracheostomy tube contains one or more small holes (fenestrations) on its outer cannula above where a cuff would be located.

These fenestrations allow the patient to breathe through both the tube and their upper airway when the inner cannula is removed. This design can also enable the patient to speak and makes weaning from the tracheostomy tube easier.

What is a Capped Tracheostomy Tube?

A capped tracheostomy tube is a tracheostomy tube that has its external opening sealed with a cap.

The cap encourages the patient to breathe through the nose and mouth, which can be helpful during the process of weaning a patient off the tracheostomy tube or to allow for speech.

It’s crucial to monitor the patient closely when the tube is capped, ensuring they can breathe comfortably and adequately.

Can You Talk with a Tracheostomy Tube in Place?

Yes, some patients can talk with a tracheostomy tube in place, especially if they have a fenestrated tube.

For patients with a cuffed tube, deflating the cuff can allow some airflow to pass over the vocal cords, enabling speech.

Additionally, special speaking valves can be attached to the tracheostomy tube, directing exhaled air over the vocal cords to facilitate speech while maintaining a patent airway.

What is a Tracheostomy Collar?

A tracheostomy collar, often referred to as a “trach collar” or “mist collar,” is a device used to deliver supplemental oxygen or humidified air to a person with a tracheostomy tube.

It fits around the neck and connects to the tracheostomy tube, providing humidity and oxygen directly to the trachea.

This is especially beneficial since a tracheostomy bypasses the natural humidifying and warming function of the upper airway.

What is Percutaneous Tracheostomy?

Percutaneous tracheostomy is a minimally invasive procedure used to create a tracheostomy, which is an opening in the trachea (windpipe) to facilitate breathing.

Unlike the traditional surgical tracheostomy, which requires a more extensive incision and dissection in the neck, the percutaneous method is done at the bedside, typically in an intensive care unit, and uses a series of dilators to create the opening.

Final Thoughts

Tracheostomy tubes, though commonplace in critical care settings, are sophisticated devices with nuanced differences and uses.

The precise selection and management of these tubes can significantly influence a patient’s clinical outcome.

By familiarizing oneself with the variety of tracheostomy tube types, indications, and potential risks, healthcare providers can optimize patient care and mitigate complications.

As medicine continues to advance, it remains imperative for professionals to stay updated on the best practices and innovations associated with tracheostomy care.