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Tracheostomy Tubes: Types, Indications, and Risks

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Taking care of tracheostomy tubes is one of the biggest components of in the field of Respiratory Care. When a patient can’t maintain their airway, manage secretions, or ventilate on their own, a surgeon will place an artificial airway in the trachea known as a tracheostomy tube.

Once inserted, the tube will need to be properly cleaned, secured, changed, and suctioned by the Respiratory Therapist. When the patient is ready to go home, it is also the responsibility of the RT to educate the patient and their caretakers on how to perform these tasks.

Because a tracheostomy tube require such detailed care, learning about the proper management techniques can be intimidating. Hopefully, this guide can help make that process a bit easier for you. So if you’re ready, let’s get into it.

Tracheostomy Tubes

What is a Tracheostomy Tube?

A tracheostomy tube is an artificial airway that bypasses the patient’s upper airway and is inserted directly into the trachea via a stoma. The tube is most often made from silicone or polyvinyl material.

When a patient no longer needs the airway, steps can be taken to wean them off the tracheostomy tube before it is eventually removed and the stoma itself can be closed.

Indications for a Tracheostomy

Below are the primary indications for a tracheostomy:

  • A patient is unable to protect their airway
  • The patient will require mechanical ventilation for more than one or two weeks
  • The patient can’t manage their own secretions and require frequent tracheal suctioning
  • The patient has a difficult airway or sudden trauma/swelling in their upper airway and attempts to intubate via the endotracheal or nasotracheal have failed

As a Respiratory Therapist, by knowing the indications for a tracheostomy, you can feel confident recommending this procedure at the appropriate time.

How is a Tracheostomy Tube Inserted?

Tracheotomies (the procedure that creates the opening or stoma in the patient’s neck where a tracheostomy tube will be placed through) are performed by surgeons or doctors.

In a traditional surgical procedure, they will sedate the patient and use a local anesthetic such as lidocaine to numb the area where the tracheostomy will be created. A 3 to 4 cm incision is made in the patient’s neck and tools such as a bronchoscope, introducer needle, and a dilator are used to insert the tracheostomy tube.

Tracheostomy Tube Placement

Tracheostomy tubes are placed level with the second or third tracheal rings. It should be big enough to occupy 65 to 75% of the diameter of the patient’s trachea.

Risks and Complications of a Tracheostomy

The most common risks and complications of a tracheostomy include:

  • Infection
  • Pneumomediastinum if the tracheostomy is false tracked
  • Damage to the larynx or trachea, such as tracheal or laryngeal lesions, the formation of granulomas, etc
  • Obstruction to the tracheostomy tube from secretions or blood clots that prevent ventilation
  • Accidental decannulation of the tracheostomy tube
  • Tracheomalacia
  • Tracheoesophageal fistulas

As a Respiratory Therapist, it’s important to know each of the risks and complications in order to provide the best care possible for the patient.

Types of Tracheostomy Tubes

There are several different kinds of tracheostomy tubes that are designed to accommodate patients with different anatomies and preferences. Below is a list of some of the different styles of tracheostomy tubes:

  • Cuffed tracheostomy tubes
  • Uncuffed tracheostomy
  • Tracheostomy tubes with disposable inner cannulas
  • Tracheostomy tubes with reusable inner cannulas
  • Fenestrated tracheostomy tubes (tubes with a hole above the cuff to help the patient with weaning or speaking)
  • Tracheostomy tubes with a proximal extended length (usually used to allow for prone positioning in neonatal or pediatric patients)
  • Tracheostomy tubes with distally extended lengths (used to accommodate patients with conditions that call for a tracheostomy tube with extra lengths, such as tracheomalcia or stenosis)
  • Custom tracheostomy tubes that are designed to accommodate patients with airways and conditions requiring unique tracheostomy tubes

Now that you know about all the different types of tracheostomy tubes, now let’s take a look at exactly how they work.

How Does a Tracheostomy Tube Work?

A tracheostomy tube works by allowing the patient to breathe through the tracheostomy tube that has been inserted into their stoma, bypassing their upper airway completely.

Because patients with tracheostomy tubes are not breathing through their nose and receiving natural humidification, either a heat-moisture-exchanger (HME) or another device delivering humidification to the airway is required.

What are the Parts of a Tracheostomy Tube?

Below are the parts of a tracheostomy tube:

  • The outer cannula, which is outer structure of the tracheostomy tube
  • The flange or the piece of the tracheostomy that rests against the patient’s neck and prevents the tracheostomy tube from going completely into the patient’s trachea. The flange also has slots in it for tracheostomy ties to secure to
  • An inner cannula
  • A cuff
  • A pilot balloon connected to an inflation tube that is used to inflate the cuff
  • An obturator that is used to prevent damage to the trachea during insertion of the tracheostomy tube and removed immediately after insertion

Knowing the parts of a tracheostomy tube is important in order to truly understand how the unit operates.

What is a Fenestrated Tracheostomy Tube?

A fenestrated tracheostomy tube is a tracheostomy tube that has a hole above the tube’s cuff. This hole, combined with removal of the patient’s inner cannula, can allow airflow through the patient’s upper airway. Capping a fenestrated tube with the inner cannula removed and the cuff deflated can allow you to gauge the function of the patient’s upper airway.

When a patient has a fenestrated tube, they are at risk of developing granular tissue at the site of the fenestration. If your patient has started growing granular tissue, you will likely notice some bleeding from their airway or signs of airway obstruction. If this happens, notify the patient’s physician.

Tracheostomy Tube Sizes

While the size and length of tracheostomy tubes can vary from brand-to-brand, the most common sizes used across the neonatal, pediatric and adult populations are sizes 2.5 to 9.0. The size tracheostomy tube you will use on a patient is often selected based on the patient’s age or weight.

Because each patient has a unique airway, you may have to go up or down in sizes or order tracheostomies with custom lengths to best accommodate the anatomy of your patient’s airway.

Below are the general guidelines for selecting the proper tracheostomy tube size:

  • Preemie under 2 kg: 2.5mm internal diameter (ID)
  • Infant: 3.0 to 3.5.mm ID cuffless neonatal size
  • 6 to 18-month-old: 3..5 to 4.0 ID neonatal or pediatric size
  • 18-month-old to 5-year-old: 4.0 to 4.5 ID pediatric size
  • 4-year-old to 10-year-old: 4.5 to 6.0 ID pediatric size
  • 10-year-old to 14-year-old: 5.0 to 6.5 ID pediatric or adult size
  • 14-year-old and up: 6.0 to 9.0 ID adult size

Again, please check with each tube manufacturer to confirm the proper tube size for each individual patient.

How to Perform Tracheostomy Tube Suctioning?

Suctioning a tracheostomy for the first time can be a daunting task for students. I remember how nervous I was suctioning a trach for the first time. But the more you study the steps and the more you perform the task, the better you’ll get at suctioning tracheostomies and it’ll eventually feel like second nature to you.

Below are the steps for properly suctioning a tracheostomy tube:

Step 1:
Wash your hands, don your personal protective equipment (be sure to put on eye protection to protect yourself against any airborne secretions) and gather your equipment. To suction a tracheostomy, you will need a suction canister, a vacuum mounted to the wall, suction tubing, a sterile suction kit, sterile gloves, water-soluble lubricant, sterile saline, and sterile water.

Step 2:
Introduce yourself to the patient, confirm their identity and explain the procedure to the patient.

Step 3:
Make sure your patient is in a semi-fowler’s position and place a towel on their chest to absorb any secretions that may get on their chest.

Step 4:
Hyperoxygenate the patient with 100% FiO2 using either the setting on your ventilator that allows you to hyperoxygenate your patient if they are mechanically ventilated or by using a bag-valve mask and giving four to six breaths with it if your patient is not mechanically ventilated.

Step 5:
Ensure your vacuum pressure is set to the correct vacuum pressure by setting up your suction, occluding the tubing, and seeing what pressure the vacuum reads.

Step 6:
Make sure all of your supplies are open and within reach before donning your sterile gloves. After putting on your sterile gloves, designate a “clean” and a “dirty” hand. Your clean hand is the one you will use to suction and the dirty one is the hand you will use to control the vacuum.

Step 7:
Wrap your sterile suction catheter around your clean hand and dip the tip of the catheter into your sterile lubricant. When you’re ready to suction, unwrap the catheter from your clean hand, insert the catheter into your patient’s tracheostomy. Once you hit resistance, draw the catheter back slightly before using your thumb to occlude the vacuum port. Continue suctioning as you draw the catheter out of the patient’s tracheostomy, spending no more than 12 to 15 seconds suctioning per pass.

Step 8:
Once your catheter has been drawn completely out of your patient’s trach, let them recover for a few seconds. If your catheter has become occluded by thick secretions, suction up some sterile water or sterile saline to cleanse it. Judge whether your patient needs another pass of suctioning.

Step 9:
When you’re done suctioning, give your patient another boost of 100% oxygen for one minute. Assess your patient for any change in the presentation of your patient and document the procedure.

Now that you know all the proper steps, you can feel confident while suctioning a tracheostomy tube during clinical practice.

How to Perform Tracheostomy Care?

Properly cleaning and caring for a tracheostomy is an essential step in preventing the tracheostomy from becoming infected or accidentally decannulated. Below are the steps to tracheostomy care:

1. Gather and Check All Required Equipment

To perform trach care you will need to gather the following:

  • Personal protective equipment, including eye protection. Because the patient’s secretions may become airborne if they cough during this procedure, you will want to wear either a face shield or goggles to protect yourself
  • Suction supplies, including a vacuum mounted to the wall, a canister, suction tubing and a sterile suction catheter kit
  • Sterile gloves
  • Hydrogen peroxide and sterile water for cleaning of the stoma and trach tube.
  • Gauze and cotton swabs
  • Split gauze or trach sponges
  • Trach ties
  • A new inner cannula if the patient has a disposable inner cannula or a brush to clean a reusable inner cannula

Keep in mind that other materials may be needed, depending on the condition of the patient. These are just some of the most common examples.

2. Suction the Tracheostomy

If there is one lesson you want to learn from us and not from a first hand experience, it is that you always want to suction a tracheostomy prior to performing tracheostomy care.

Because we have to remove anything that is covering a trach prior to cleaning it (such as an HME), any secretions the patient expectorates during trach care is liable to become airborne.

3. Cleanse or Replace the Inner Cannula

If your patient has a disposable inner cannula, then this step is easy for you. You will simply replace their inner cannula and insert a new one. If your patient has a reusable inner cannula, you will need to remove it, clean it and reinsert it. You clean an inner cannula by first soaking it in a mixture of half hydrogen peroxide and half sterile water.

You will then use a brush to scrub the inside and outside of the tube before rinsing the cannula in sterile water. After rinsing the cannula, let it dry before re-inserting it into your patient. Some tracheostomy tubes will not have an inner cannula at all. If this is the case, you can simply skip this step.

4. Inspect and Clean the Stoma

Once the inner cannula is re-inserted, you can shift your focus to the patient’s stoma site. You will want to check the site for any signs of infection and irritation, such as swelling or redness around the site. Any abnormalities in the patient’s stoma site should be brought up with the patient’s nurse and physician.

You will then use cotton swab applicators and/or sterile gauze that has been dipped in a mixture of half hydrogen peroxide and half sterile water to clean the stoma. When wiping the area, you want to ensure you wipe in a motion away from the stoma to prevent pushing any dirt or bacteria on the patient’s skin towards their stoma.

You will then place a dressing such as split gauze under your patient’s trach to absorb any drainage that comes out of their trach.

5. Replace the Patient’s Trach Ties

Remove the patient’s old trach ties and replace them with new ones, ensuring they are secure and you can only fit one finger under each side of the ties after placing the new ones on your patient.

Trach ties that are left too loose put the patient at risk of accidental decannulation, while ties that are placed too tightly may cause skin breakdown.

6. Perform a Patient Assessment

After performing tracheostomy care, you should then perform an assessment on your patient to ensure their saturations, color, breath sounds and overall presentation are still in good standing.

What is a Cuffed Tracheostomy Tube?

Cuffs on a tracheostomy tube serve the purpose of either allowing for delivery of positive pressure ventilation or reducing the risk of aspiration. Cuffs are essentially small balloons towards the end of a tracheostomy tube that can either be filled with air, fluid or made out of foam that will expand and fill with air until the cuff reaches the tracheal wall.

Maintaining appropriate cuff pressure of either 20 to 30 mmHg or cmH2O, depending on the type of cuff is vital when caring for a cuffed tracheostomy tube.

Pressures that are too high can cut off mucosal blood flow, cause tracheostenosis or other damage to the patient’s airway. Pressures that are too low may reduce the effective delivery of positive pressure ventilation or not fully protect against aspiration of secretions.

What is an Uncuffed Tracheostomy Tube?

An uncuffed tracheostomy tube is simply a tracheostomy tube that doesn’t have the balloon at the end of the tube. These tubes are most often used in the neonatal population or for patients who don’t need mechanical ventilation and can manage their secretions effectively.

What is a Capped Tracheostomy Tube?

A capped tracheostomy tube is simply a tube that has been covered or occluded with a cap. The cap prevents air from moving through the tracheostomy and forces the patient to breathe through their upper airway.

Caps are used to test if a patient will be able to breathe without their artificial airway and potentially have their tracheostomy removed. They can also be used to let tracheostomy patients speak, but may not be tolerated for longer periods of times by patients who haven’t regained full functionality of their upper airway yet.

What is a Tracheostomy Collar (Mask)?

A tracheostomy collar/mask is similar to an aerosol mask used on patients who don’t have tracheostomies, only a tracheostomy mask will sit on top of the patient’s tracheostomy and be secured around their neck. The tracheostomy mask is used to provide oxygen and/or humidity to the patient.

Can You Talk With a Tracheostomy Tube in Place?

Because tracheostomy tubes cause air to bypass the vocal cords, there are some steps patients with tracheostomy tubes must take in order to speak. Capping or covering a tracheostomy tube will force air to go out the patient’s upper airways and allow them to use their vocal cords.

But because occluding the tracheostomy tube causes an increase in airway resistance, some patients may not be able to tolerate this. Alternatively, a speaking valve can be placed on the outer portion of the tracheostomy tube.

These valves allow air to pass through the tracheostomy and valve on inhalation but do not allow air to pass through the valve on exhalation, forcing the air through the patient’s upper airway and enabling them to speak without occluding the tracheostomy tube.

Final Thoughts

So there you have it. Hopefully, this study guide on tracheostomy tubes can help you learn more about this important type of artificial airway and become comfortable with the idea of caring for them as a clinical practitioner.

Just to recap, you have now reviewed the insertion of the tracheostomy tubes, the parts, the steps of suctioning the tubes, and the procedure for cleaning the tube.

We also have a detailed guide on the topic of Endotracheal Intubation that I think you will enjoy. Thank you so much for reading and as always, breathe easy my friend

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