Components of Tracheostomy Tubes:
Standard tracheostomy tubes have similar components including the outer cannula, inner cannula, flange, obturator, hub, cuff, pilot balloon and cap.
Outer Cannula: The outer cannula, or tube shaft of the tracheostomy tube, is the main outside component of the tube. It can be fenestrated (with holes) or non-fenestrated. The purpose of the fenestrations is to provide airflow to the pharynx. The outer cannula remains inside the patient until the patient is decannulated, or the tube requires changing. The outer diameter (O.D.) refers to the distance between the outside walls of the outer cannula, and is measure in millimeters.
Inner Cannula: The inner cannula fits inside the outer cannula, and can be disposable or non-disposable, and fenestrated or non-fenestrated. Inner cannulas are made to be removed and cleaned (nondisposable), or replaced (disposable) to keep the airway patent and prevent tube obstruction. It is important to pay close attention to the size of the outer cannula so the correctly sized inner cannula is used.
There are four ways the inner cannula is secured inside the outer cannula: prong clip, luer lock, ring clip, and telephone jack style. Single lumen airways (link to Bivona and pediatric tubes) do not use an inner cannula.
The inner diameter (I.D.) refers to the distance between the inside walls of the inner cannula, and is measured in millimeters. Using an inner cannula decreases the usable airway diameter, increases airway resistance, and may increase the work of breathing (Carter, A. et al, 2013; Cowan, T. et al, 2001). Pediatric tubes do not offer inner cannulas, because the tube itself is already very small.
Obturator: The obturator is used only during insertion of the tracheostomy tube, and removed immediately after insertion. It extends slightly beyond the distal tip of the tube, is rounded, and makes for less traumatic insertion of the blunt ended tracheostomy tube. The obturator should be kept in a bag at the patient’s bedside in the event emergent recannulation is necessary.
Flange: The flange, or neck plate, should lie against the skin on the neck, and is where information about the tracheostomy tube can be found. Tracheostomy tube brand, size with inner and outer diameter, and cuff type are located on the flange. For longer term tracheostomy patients, care should be taken when choosing the brand of tube, as the flanges very greatly. Some flanges are very stationary, rigid, uncomfortable, and can be responsible for skin breakdown due to constant friction. Others, like the Tracoe twist have a flange that moves around two axes: vertically and horizontally. This flexibility allows patients to turn their head and neck without the tube exerting pressure on the trachea. The flange also provides slots (tape eyelet) used to secure the tube around the patient’s neck with twill tape, or the more common velcro tracheostomy tube tie.
Tracheostomy Tube Tie: The trach tie is used to secure the tracheostomy tube in place and prevent accidental decannulation. Trach ties may not be suitable in some patients to avoid neck pressure from the ties. For example the tracheostomy tube may be sutured for a patient who recently underwent local or free flap surgery, to avoid neck pressure from the ties. A patient should not be discharged from the hospital with a tracheostomy tube sutured in place (Mitchell, 2013). See Tracheostomy Care and Management for information on tracheostomy tie changes.
There are a few different materials used for tracheostomy ties: twill, Velcro ties, and stainless steel metal chain. There is currently no consensus as to the superiority of one material over another. The most commonly utilized trach ties in institutional settings is the Velcro(R) type.
Hub: The hub is the part of the tracheostomy tube that protrudes from the neck. This provides a standard, universal 15mm diameter connection necessary for connecting ventilator tubing, resuscitation bags, anesthesia equipment, speaking valves, and caps.
NOTE: Some tracheostomy tubes offer a low profile inner cannula which does not have the 15mm hub. These low profile inner cannulas come packaged with several other types of inner cannulas. The box with all inner cannulas should be kept at the bedside, because if the patient uses a speaking valve, or requires emergency resuscitation or mechanical ventilation, the low profile inner cannula must be exchanged for the inner cannula with the 15mm hub.
Cuff: The cuff is a balloon like structure that surrounds the shaft of the tracheostomy tube. (see/link to types of cuffs section) The main purpose of the cuff is to seal the airway when it is necessary to maintain critical control over mechanical ventilation. The cuff does not prevent aspiration, but may be recommended in some cases to help reduce gross aspiration. It is important to monitor the pressure/volume of air/water in the cuff in order to prevent tracheal damage and esophageal impingement. In a study using canine cadavers, cuffed tracheostomy tubes increased airway pressures compared to cuffless tracheostomy tubes. (see/link to section on long term complications of trach and section on how to manage cuff pressure correctly)
Pilot Line: The pilot line, or inflation line, leads from the cuff to the pilot balloon. It is a pathway for air into and out of the cuff. (show syringe attached to pilot balloon)
Pilot Balloon: The pilot balloon is sack-like, and contains a spring loaded valve (called a luer valve). This valve is where you attach the syringe to either inflate or deflate the cuff. This luer valve also prevents the air from leaking out the pilot balloon. The pilot balloon indicates the amount of air in the cuff. When the pilot balloon is inflated such as in the diagram below, the cuff is inflated.
NOTE: A speaking valve or cap should NOT be used when the cuff is inflated, as these devices will block airflow through the upper airway and the patient would be unable to exhale.
When the pilot balloon is deflated, such as in the diagram below, the cuff is deflated. When the cuff is deflated, some airflow is allowed to escape through the upper airway. A cap or speaking valve can be placed once the cuff is COMPLETELY deflated.
The Bivona Fome-Cuf(™) is a one-of-a-kind special foam filled cuff that does not require the clinician to inflate it with air - it is self filling. (link to types of cuff section) This type of cuff is contraindicated for any speaking valve applications, as you can never assure it will stay deflated.
Cap: The cap, plug, or cork, is a small plastic piece that is placed on the 15mm hub of the tracheostomy tube. The cap blocks all airflow through the tracheostomy tube and the patient must therefore inhale and exhale around the tracheostomy tube. It is frequently used as a tool during decannulation trials. Some sleep apnea patients use caps or speaking valves throughout the day, and remove them at night. Others may need to uncap for an occasional suction procedure. The inner cannula is sometimes removed prior to cap placement. Caps are often used with smaller diameter tubes, cuffless tubes, or fenestrated tubes, therefore they are not packaged in every tracheostomy tube. However, most manufacturers have some variation available for their product, even if it is sold separately.
Outer Cannula: The outer cannula, or tube shaft of the tracheostomy tube, is the main outside component of the tube. It can be fenestrated (with holes) or non-fenestrated. The purpose of the fenestrations is to provide airflow to the pharynx. The outer cannula remains inside the patient until the patient is decannulated, or the tube requires changing. The outer diameter (O.D.) refers to the distance between the outside walls of the outer cannula, and is measure in millimeters.
Inner Cannula: The inner cannula fits inside the outer cannula, and can be disposable or non-disposable, and fenestrated or non-fenestrated. Inner cannulas are made to be removed and cleaned (nondisposable), or replaced (disposable) to keep the airway patent and prevent tube obstruction. It is important to pay close attention to the size of the outer cannula so the correctly sized inner cannula is used.
There are four ways the inner cannula is secured inside the outer cannula: prong clip, luer lock, ring clip, and telephone jack style. Single lumen airways (link to Bivona and pediatric tubes) do not use an inner cannula.
The inner diameter (I.D.) refers to the distance between the inside walls of the inner cannula, and is measured in millimeters. Using an inner cannula decreases the usable airway diameter, increases airway resistance, and may increase the work of breathing (Carter, A. et al, 2013; Cowan, T. et al, 2001). Pediatric tubes do not offer inner cannulas, because the tube itself is already very small.
Obturator: The obturator is used only during insertion of the tracheostomy tube, and removed immediately after insertion. It extends slightly beyond the distal tip of the tube, is rounded, and makes for less traumatic insertion of the blunt ended tracheostomy tube. The obturator should be kept in a bag at the patient’s bedside in the event emergent recannulation is necessary.
Flange: The flange, or neck plate, should lie against the skin on the neck, and is where information about the tracheostomy tube can be found. Tracheostomy tube brand, size with inner and outer diameter, and cuff type are located on the flange. For longer term tracheostomy patients, care should be taken when choosing the brand of tube, as the flanges very greatly. Some flanges are very stationary, rigid, uncomfortable, and can be responsible for skin breakdown due to constant friction. Others, like the Tracoe twist have a flange that moves around two axes: vertically and horizontally. This flexibility allows patients to turn their head and neck without the tube exerting pressure on the trachea. The flange also provides slots (tape eyelet) used to secure the tube around the patient’s neck with twill tape, or the more common velcro tracheostomy tube tie.
Tracheostomy Tube Tie: The trach tie is used to secure the tracheostomy tube in place and prevent accidental decannulation. Trach ties may not be suitable in some patients to avoid neck pressure from the ties. For example the tracheostomy tube may be sutured for a patient who recently underwent local or free flap surgery, to avoid neck pressure from the ties. A patient should not be discharged from the hospital with a tracheostomy tube sutured in place (Mitchell, 2013). See Tracheostomy Care and Management for information on tracheostomy tie changes.
There are a few different materials used for tracheostomy ties: twill, Velcro ties, and stainless steel metal chain. There is currently no consensus as to the superiority of one material over another. The most commonly utilized trach ties in institutional settings is the Velcro(R) type.
Hub: The hub is the part of the tracheostomy tube that protrudes from the neck. This provides a standard, universal 15mm diameter connection necessary for connecting ventilator tubing, resuscitation bags, anesthesia equipment, speaking valves, and caps.
NOTE: Some tracheostomy tubes offer a low profile inner cannula which does not have the 15mm hub. These low profile inner cannulas come packaged with several other types of inner cannulas. The box with all inner cannulas should be kept at the bedside, because if the patient uses a speaking valve, or requires emergency resuscitation or mechanical ventilation, the low profile inner cannula must be exchanged for the inner cannula with the 15mm hub.
Cuff: The cuff is a balloon like structure that surrounds the shaft of the tracheostomy tube. (see/link to types of cuffs section) The main purpose of the cuff is to seal the airway when it is necessary to maintain critical control over mechanical ventilation. The cuff does not prevent aspiration, but may be recommended in some cases to help reduce gross aspiration. It is important to monitor the pressure/volume of air/water in the cuff in order to prevent tracheal damage and esophageal impingement. In a study using canine cadavers, cuffed tracheostomy tubes increased airway pressures compared to cuffless tracheostomy tubes. (see/link to section on long term complications of trach and section on how to manage cuff pressure correctly)
Pilot Line: The pilot line, or inflation line, leads from the cuff to the pilot balloon. It is a pathway for air into and out of the cuff. (show syringe attached to pilot balloon)
Pilot Balloon: The pilot balloon is sack-like, and contains a spring loaded valve (called a luer valve). This valve is where you attach the syringe to either inflate or deflate the cuff. This luer valve also prevents the air from leaking out the pilot balloon. The pilot balloon indicates the amount of air in the cuff. When the pilot balloon is inflated such as in the diagram below, the cuff is inflated.
NOTE: A speaking valve or cap should NOT be used when the cuff is inflated, as these devices will block airflow through the upper airway and the patient would be unable to exhale.
When the pilot balloon is deflated, such as in the diagram below, the cuff is deflated. When the cuff is deflated, some airflow is allowed to escape through the upper airway. A cap or speaking valve can be placed once the cuff is COMPLETELY deflated.
The Bivona Fome-Cuf(™) is a one-of-a-kind special foam filled cuff that does not require the clinician to inflate it with air - it is self filling. (link to types of cuff section) This type of cuff is contraindicated for any speaking valve applications, as you can never assure it will stay deflated.
Cap: The cap, plug, or cork, is a small plastic piece that is placed on the 15mm hub of the tracheostomy tube. The cap blocks all airflow through the tracheostomy tube and the patient must therefore inhale and exhale around the tracheostomy tube. It is frequently used as a tool during decannulation trials. Some sleep apnea patients use caps or speaking valves throughout the day, and remove them at night. Others may need to uncap for an occasional suction procedure. The inner cannula is sometimes removed prior to cap placement. Caps are often used with smaller diameter tubes, cuffless tubes, or fenestrated tubes, therefore they are not packaged in every tracheostomy tube. However, most manufacturers have some variation available for their product, even if it is sold separately.