What Kind of Tube is This?! Linda M. Folk, RRT, LRT University of Michigan Health Centers Critical Care Support Services

Objectives 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.

1890’s Tracheostomy Tubes Outer cannula Outer cannula Inner Cannula

Cannula from the 1930’s

Sterling silver tube from late 1800’s to early 1900’s

Ivory case set by Maw, Son and Thompson from late 1800’s

Luers trachea cannula and obturator from 1890

Standard Shiley Tracheostomy Tube – Cuffed with Disposable Inner Cannula

Metal Tracheostomy Tube - Uncuffed Outer cannula Inner 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.

Proximal Extended Tracheostomy Tube Extension is from curve to flange cuff Inner cannula obturator This tube is extended from the curve to the flange (proximal) to accommodate patients with thick necks. The inner cannula is disposable.

Proximal and Distal Extended Tracheostomy Tubes Proximal extended trach tube Distal extended trach tube Distal extension Proximal 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

Cuffed Fenestrated Tracheostomy Tube Pilot balloon cuff fenestration plug Inner cannula obturator 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.

Using a Fenestrated Tracheostomy Tube

Using a Fenestrated Tracheostomy Tube

Bivona Fome-Cuff Tracheostomy Tube Foam cuff Pilot balloon obturator 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.

Bivona TTS tube (tight-to-shaft) 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.

Bivona TTS (Tight-to-Shaft) Tracheostomy Tube with Adjustable Flange cuff Close up of adjustable flange Flange-adjustable Pilot balloon 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.

Bivona adjustable tube with air cuff

Portex double cuff tube 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.

Passy Muir Valve 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.

Correct Use of the Passy Muir Valve INCORRECT CORRECT Cuff inflated Cuff deflated 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.

Portex Trach-Talk Tracheostomy Tube 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 T-tubes are used to stent the airway and provide a patent airway during healing or permanently.

Placement of a T-tube

Conclusion 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.