Winter 2003, Vol. 17, No. 4
Louie Boitano, MS, RRT, Northwest Assistive Breathing Center, Pulmonary Clinic, University of Washington, Seattle, Washington
Individuals who need long-term ventilatory support through a secure airway connection and/or cannot protect their airways because of swallowing (bulbar) problems often use tracheostomy positive pressure ventilation. People with motor neuron diseases such as ALS or muscular dystrophies often have bulbar muscle impairment and, when use of non-invasive mechanical ventilation becomes ineffective, need a tracheostomy. A tracheostomy is also the safest and most commonly used mode of airway management for infants and children with progressive muscle weakness, inability to handle secretions, central or obstructive sleep apnea, or whose airways have not developed.
There are two primary types of tracheostomy tubes: cuffless and cuffed. There are several manufacturers and a variety of brands from which to choose. The tubes can be disposable, usually made of PVC plastic or silicone, or nondisposable, made of metal, such as silver or stainless steel. Both cuffed and cuffless tracheostomy tubes are available with or without inner cannulas. Inner cannulas are available in reusable and disposable types, and are removed for periodic cleaning, or if need be, for immediate clearing of secretions blocking the airway while keeping the artificial airway in place.
Tracheotomy. The surgical procedure in which an incision is made into the trachea (windpipe or upper airway).
Tracheostomy. The surgical opening (stoma) through which a tracheostomy tube is placed to maintain a secure airway.
Outer cannula. The outer part of the tracheostomy tube. Some tracheostomy tubes have only a single tube, others have an outer tube plus an easily removable inner tube.
Inner cannula. The inner part that can be removed for cleaning or when it gets clogged with secretions. It is held in place by either a twist lock or pressure clip fitting at the base of the flange. However, not all tracheostomy tubes have this.
Flange. A lateral neckplate that helps hold the tracheostomy tube in place. It has slits through which to thread a tie to fasten around the neck.
The three largest U.S. manufacturers of these tubes are:
- Puritan Bennett Inc., Pleasanton, CA
- Portex, Inc., Keene, NH
(Portex, Bivona, Blue Line)
- Boston Medical Products, Inc., Westborough, MA
(Montgomery, Moore, TRACOE®)
Cuffless Tracheostomy Tubes. Cuffless tracheostomy tubes are desirable because they allow exhaled air to pass through the upper airway enabling the individual to speak. A Passy-Muir speaking valve can be attached to the outer end of a cuffless tube to enhance speech by directing all exhaled air through the upper airway.
Most product lines have a range of standard tube diameters and lengths. These tracheotomy tubes are available with and without inner cannulas, and will support most people in need of a cuffless tracheostomy tube. For individuals with either thick or thin necks who cannot easily use the standard trach tubes, the Shiley brand offers an XLT (extended length trach) tube and Blue Line Extra Length tubes are available from Portex. Extended length tracheostomy tubes can be very helpful for people with difficult airways that are narrow, dilated, or misshapen. Both the Shiley XLT and Bivona tubes are composed of a soft, flexible silicone compound that can provide greater comfort.
Cuffed Tracheostomy Tubes. These have a donut-shaped balloon surrounding the lower end of the tube that, when inflated, creates a seal between the tube and the trachea to protect the lungs from exposure to solids and liquids. These can be divided into three types: 1) high volume-low pressure, 2) low volume-high pressure and 3) foam cuffs. The Shiley and the Portex tubes use air to inflate the cuff.
High volume-low pressure cuffs are cylindrical-shaped and are used when a continuous seal between the trachea and the tube is needed to prevent aspiration of secretions or food. Examples of high volume-low pressure cuffed tracheostomy tubes are the Shiley LPC and the Portex Blue Line brands.
Low volume-high pressure cuffs are more circular-shaped and are generally used for intermittent sealing between the tube and trachea during sleep and while eating to prevent aspiration, such as the Bivona TTS™ (tight-to-shaft) model. When deflated, the cuff is flat to the exterior surface of the tube, allowing exhaled air to pass freely between the tube and tracheal wall.
The Bivona Fome-Cuf® is a type of high volume-low pressure cuff that uses the passive expansion of a foam rubber-filled cuff to maintain a seal with the tracheal wall. The foam cuff provides a continuous seal and can be used as an alternative to air-filled cuffs when persistent air leaks occur with mechanical ventilation.
These types of cuffed tracheostomy tubes come in standard diameters and lengths, as well as extended length tubes (Shiley XLT and Portex Extra Horizontal Length Tube models).
Passy-Muir speaking valves can be used with air-filled cuffed tracheostomy tubes, but with great caution. The cuff MUST ALWAYS be deflated when the Passy-Muir valve is in place in order to allow free exhalation through the upper airway. Use of a Passy-Muir valve without deflating the cuff may cause lung injury and possible asphyxiation.
Specialty Tracheostomy Tubes. Talking tracheostomy tubes are offered by Puritan Bennett (Phonate™), Portex (Trach Talk Blue Line®), and Boston Medical (Montgomery® VENTRACH) to enable speech with an inflated cuffed tube.
Portex Blue Line Extra Length Tubes have two independently inflated cuffs on the lower end of the extended length tube that allow flexibility in sealing the tube in alternate locations, or increasing the seal by inflating both cuffs at the same time.
Bivona Adjustable Hyperflex Tubes from Portex are soft flexible tubes with a thin spiral wire molded in the tube wall that prevents constriction with tube flex. An adjustable flange collar allows the tube length to be adjusted to a desired length. Hyperflex tubes are available with TTS or low pressure cuffs.
A new Blue Line tracheostomy tube from Portex will allow suctioning of the airway above the cuff. This feature will allow the user to remove excessive upper airway secretions that could accumulate above the cuff and flow through the stoma.
The decision to use a specific tracheostomy tube is best made with input from both the physician and the individual. Custom tracheostomy tubes can also be made, however the variety of tracheostomy tube types and lengths along with the development of more comfortable, soft tracheostomy tubes provides readily available alternatives to support a wide range of needs.
Dikeman, K.J., Kazandjian, M.S. Communication and swallowing management of tracheostomized and ventilator-dependent adults. San Diego, Singular Publishing Group, 1995.
Driver, L.E., Nelson, V.S., Warschausky, S.A. The ventilator-assisted child: a practical resource guide. San Antonio, Communication Skill Builders, 1997.
Jerry Daniel, Vancouver, Washington
Sometimes an innovative product comes along that truly makes a difference in living at home with a ventilator. As a polio survivor, it has been my choice for more than 40 years to use a trach tube to interface with my home care ventilators. When my wife became my full-time caregiver in 2000, we both became aware of nuisance chores associated with my trach.
Suctioning does not completely remove secretions from inner cannulas. Unless you can afford disposable ones, cleaning inner cannulas has always been routine drudgery — soaking and cleaning with pipe cleaners — that hasn't changed over the years. Now I use Bivona's silicone adult single cannula uncuffed tracheostomy tubes, and cleaning inner cannulas is history.
The Bivona soft silicone trach tube has no inner cannula, and secretions do not stick to the silicone surface so it is easy to clean in a mild soapy solution. It also works well with the Portex swivel connector. The Bivona trach tube is approximately half as expensive as the metal one I used to use; we change it about once a month. Besides being less expensive, it is less work for my caregiver. That's a winning combination.
E.A. Oppenheimer, MD, Pulmonary Medicine (retired), Los Angeles, California
If you can currently talk, you can continue to talk with a tracheostomy. Many people believe that a tracheostomy impairs speech, but this is only true when the medical personnel involved do not know how to help a person with a tracheostomy achieve speech properly. There are a number of ways to achieve speech:
- fitting a cuffless tracheostomy tube to allow some air to leak upwards around the trach tube during the inspiratory breath, thus allowing speech as well as clearing secretions;
- using a cuffed tracheostomy tube that is not fully inflated — the so-called "minimal leak technique" that allows some air to leak upwards around the trach tube during the inspiratory breath — thus allowing speech as well as clearing secretions. (This was also particularly useful to avoid tracheal mucosal pressure injury many years ago before the low-pressure higher-volume trach cuffs were developed.)
- using a Passy-Muir tracheostomy speaking valve (www.passy-muir.com) with an uncuffed tracheostomy tube to allow smooth speech both during inspiration and expiration, and also to improve swallowing.
March 31, 2004
Dear Ms. Fischer,
We noted with interest the sidebar on page 9 of your last issue, entitled "Talking with Tracheostomy Ventilation." We heartily endorse Dr. Oppenheimer's reassurance that people will be able to speak with cuff deflation (or use of a cuffless tube) when tracheostomized. And, we would like to add that there are simple adjustments to ventilator settings that offer attractive alternatives to a one-way valve (such as a Passy-Muir valve). These include lengthening inspiratory time and applying 5 to 10 cm H2O of positive end-expiratory pressure when using volume-controlled ventilation (Hoit et al., 1994, 2003; Hoit & Banzett, 1997). The advantages of such adjustments are that they can produce speech that is just as good as the one-way valve, but with greater safety and a lower cost (Hoit & Banzett, 2003). Another way to improve speech with invasive ventilation is to use of bilevel (pressure-controlled) positive pressure ventilation (Prigent et al., 2003); however, this form of ventilation is only approved for in-hospital use in the United States.
Jeannette Hoit PhD, CCC-SLP
Robert Banzett, PhD
Hoit, J., & Banzett, R. (1997). Simple adjustments can improve ventilator-supported speech. American Journal of Speech-Language Pathology, 6, 87-96.
Hoit, J., & Banzett, R. (2003). Je peux parler! American Journal of Respiratory and Critical Care Medicine, 167, 101-102.
Hoit, J., Banzett, R., Lohmeier, H., Hixon, T., & Brown, R. (2003). Clinical ventilator adjustments that improve speech. Chest, 124, 1512-1521.
Hoit, J., Shea, S., and Banzett, R. (1994). Speech production during mechanical ventilation in tracheostomized individuals. Journal of Speech and Hearing Research, 37, 53-63.
Prigent, H., Samuel, C., Louis, B., Ablnum, M-F., Zerah-Lancner, F., Lejaille, M., Raphael, J-C. & Lofaso, F. (2003). Comparative effects of two ventilatory modes on speech in tracheostomized patients with neuromuscular disease. American Journal of Respiratory and Critical Care Medicine, 167, 114-119.