Subglottic Suction:
Subglottic suction refers to the technique in which the tracheostomy tube is modified to allow removal of secretions pooling above the cuff, which prevents further aspiration of these secretions into the larger airways. Clinical studies have shown frequent or continuous suctioning of subglottic secretions decreases the risk of ventilator-associated pneumonia (VAP). An important consideration for tracheostomized patients is to understand that a slightly larger OD of the tube is needed to facilitate the suction port and tubing.
These devices are not infallible, and were not intended to replace good airway care. In one study that looked at endotracheal tube (ETT) subglottic suction failures, suction lumen failure occurred in 50% of the airways. In 43% of the cases, prolonged suction drew tracheal mucosa into the subglottic port occluding it entirely. One study conducted by Clinimark Labs found that periodic saline rinses of the suction port and lumen loosened secretions and cleared the lumen more effectively than an air bolus. Saline was more effective at preventing and clearing clogs, and more efficient for suctioning secretions.
Cuffs: Cuffs differ greatly from brand to brand in regards to the material they are made of, their shape, what medium is used to fill them, and the fit of the cuff against the tube when it is deflated.
High volume, low pressure, air filled cuffs are soft plastic (with the exception of the Silicone tube) that conform to the tracheal wall. They are the most commonly used cuffs. Even though they are designed to be low pressure cuffs, care must be taken to monitor and manage cuff pressures. (see/link to section on cuff mgt) When most plastic cuffs are deflated, they do not fold flush against the shaft of the tube, creating higher airway resistance and potential secretion retention around that deflated cuff. Patients with larger deflated cuffs had higher expiratory pressures when a speaking valve was placed (Johnson, 2009). This remaining bulk could delay successful speaking valve or capping trials, thereby increasing the length of stay.
Foam cuffs are covered with a thin sheath and filled with a sponge like material. This cuff self-inflates when air pressure and cuff pressures equalize. In its resting position, the cuff is inflated, but by design limits the pressure inside the cuff to no more than approximately 25cmH2O of pressure. This pressure limiting factor helps reduce further damage to the tracheal wall. The foam cuff is especially useful in cases of tracheomalacia, as it conforms to the tracheal wall preventing airway collapse. It is very difficult to deflate this cuff, and because of its self-inflating property it is contraindicated for any and all speaking valve or capping applications. When using this type of cuff during mechanical ventilation, a special nipple adapter can be placed between the patient and the hub of the tube. The pilot line of the foam cuff is then attached to the nipple port, where air from the ventilator travels to the cuff during inspiration causing it to over-inflate, (sometimes required to seal the airway during mechanical ventilation) but during exhalation the cuff relaxes, once again limiting pressure/damage to the tracheal wall.
Water filled cuffs are available with the Bivona (Smiths Medical) line of silicone tubes, and are referred to as TTS, or Tight To Shaft™. This high pressure, low volume cuff should be filled with sterile water. Do NOT use normal saline, as over time the salt solution will deteriorate the pilot balloon mechanism (Mitchell, 2013). The unique feature of this cuff is when you deflate it, the material hugs the shaft of the tube, eliminating the bulk of plastic remaining in the airway. This feature streamlines airflow around the shaft of the tube whenever the cuff is deflated, and may facilitate earlier trials of speaking valves without the need to downsize to a smaller diameter tube.
NOTE: As you see, all tracheostomy tubes and cuffs are not created equal. When weaning from mechanical ventilation and preparing for decannulation, the tube and cuff you choose may have a significant impact on your patient’s success.
Double Cuffed Extra Long Tube: This Portex (Smith’s Medical) extra long tube offers 2 cuffs. The double cuff design allows the clinician to alternate inflating cuffs. This reduces the risk of tracheal damage, and helps correct tracheal problems such as T-E fistula, stenosis, and malacia.
Cuffless Tubes: Uncuffed or cuffless tubes do not have a cuff at the distal end of the tube. Cuffless tubes are easily recognized because they do not have a pilot balloon. A cuffless tube allows air to flow upward around the perimeter of the tube for leak speech. Compared to cuffed tracheostomy tubes, cuffless tubes reduce airway resistance during use of a speaking valve or cap (Johnson, 2013). Unless a patient requires critical control over mechanical ventilation, or suffers from profound dysphagia, a cuff is not necessary. A cuffless tracheostomy tube should be considered once a patient can tolerate cuff deflation, or does not require critical control of mechanical ventilation.
Custom Tracheostomy Tubes: Most companies offer variations to the standard tracheostomy tube, and can customize the tube to meet specialty airway needs. Examples of customizations are: custom fenestrations, cuff placements, lengths, and angles. They can even design customized seals to manage excessive air leaks around oversized stomas.
Subglottic suction refers to the technique in which the tracheostomy tube is modified to allow removal of secretions pooling above the cuff, which prevents further aspiration of these secretions into the larger airways. Clinical studies have shown frequent or continuous suctioning of subglottic secretions decreases the risk of ventilator-associated pneumonia (VAP). An important consideration for tracheostomized patients is to understand that a slightly larger OD of the tube is needed to facilitate the suction port and tubing.
These devices are not infallible, and were not intended to replace good airway care. In one study that looked at endotracheal tube (ETT) subglottic suction failures, suction lumen failure occurred in 50% of the airways. In 43% of the cases, prolonged suction drew tracheal mucosa into the subglottic port occluding it entirely. One study conducted by Clinimark Labs found that periodic saline rinses of the suction port and lumen loosened secretions and cleared the lumen more effectively than an air bolus. Saline was more effective at preventing and clearing clogs, and more efficient for suctioning secretions.
Cuffs: Cuffs differ greatly from brand to brand in regards to the material they are made of, their shape, what medium is used to fill them, and the fit of the cuff against the tube when it is deflated.
High volume, low pressure, air filled cuffs are soft plastic (with the exception of the Silicone tube) that conform to the tracheal wall. They are the most commonly used cuffs. Even though they are designed to be low pressure cuffs, care must be taken to monitor and manage cuff pressures. (see/link to section on cuff mgt) When most plastic cuffs are deflated, they do not fold flush against the shaft of the tube, creating higher airway resistance and potential secretion retention around that deflated cuff. Patients with larger deflated cuffs had higher expiratory pressures when a speaking valve was placed (Johnson, 2009). This remaining bulk could delay successful speaking valve or capping trials, thereby increasing the length of stay.
Foam cuffs are covered with a thin sheath and filled with a sponge like material. This cuff self-inflates when air pressure and cuff pressures equalize. In its resting position, the cuff is inflated, but by design limits the pressure inside the cuff to no more than approximately 25cmH2O of pressure. This pressure limiting factor helps reduce further damage to the tracheal wall. The foam cuff is especially useful in cases of tracheomalacia, as it conforms to the tracheal wall preventing airway collapse. It is very difficult to deflate this cuff, and because of its self-inflating property it is contraindicated for any and all speaking valve or capping applications. When using this type of cuff during mechanical ventilation, a special nipple adapter can be placed between the patient and the hub of the tube. The pilot line of the foam cuff is then attached to the nipple port, where air from the ventilator travels to the cuff during inspiration causing it to over-inflate, (sometimes required to seal the airway during mechanical ventilation) but during exhalation the cuff relaxes, once again limiting pressure/damage to the tracheal wall.
Water filled cuffs are available with the Bivona (Smiths Medical) line of silicone tubes, and are referred to as TTS, or Tight To Shaft™. This high pressure, low volume cuff should be filled with sterile water. Do NOT use normal saline, as over time the salt solution will deteriorate the pilot balloon mechanism (Mitchell, 2013). The unique feature of this cuff is when you deflate it, the material hugs the shaft of the tube, eliminating the bulk of plastic remaining in the airway. This feature streamlines airflow around the shaft of the tube whenever the cuff is deflated, and may facilitate earlier trials of speaking valves without the need to downsize to a smaller diameter tube.
NOTE: As you see, all tracheostomy tubes and cuffs are not created equal. When weaning from mechanical ventilation and preparing for decannulation, the tube and cuff you choose may have a significant impact on your patient’s success.
Double Cuffed Extra Long Tube: This Portex (Smith’s Medical) extra long tube offers 2 cuffs. The double cuff design allows the clinician to alternate inflating cuffs. This reduces the risk of tracheal damage, and helps correct tracheal problems such as T-E fistula, stenosis, and malacia.
Cuffless Tubes: Uncuffed or cuffless tubes do not have a cuff at the distal end of the tube. Cuffless tubes are easily recognized because they do not have a pilot balloon. A cuffless tube allows air to flow upward around the perimeter of the tube for leak speech. Compared to cuffed tracheostomy tubes, cuffless tubes reduce airway resistance during use of a speaking valve or cap (Johnson, 2013). Unless a patient requires critical control over mechanical ventilation, or suffers from profound dysphagia, a cuff is not necessary. A cuffless tracheostomy tube should be considered once a patient can tolerate cuff deflation, or does not require critical control of mechanical ventilation.
Custom Tracheostomy Tubes: Most companies offer variations to the standard tracheostomy tube, and can customize the tube to meet specialty airway needs. Examples of customizations are: custom fenestrations, cuff placements, lengths, and angles. They can even design customized seals to manage excessive air leaks around oversized stomas.