Tracheostomy tubes are available in a variety of sizes and styles from several manufacturers. It is imperative that clinicians are able to identify the patient has a tracheotomy tube, the brand, type, size (ID and OD), composition material of the tube and cuff, whether or not the tube is fenestrated, or if it is a custom tube. The tracheostomy tube should be selected based on the individual patient’s anatomy and clinical needs, therefore an adequate range or tracheostomy tubes should be stocked. Tube selection/preference is also influenced by physicians and purchasing contracts.
Materials:
Tracheostomy tubes are made of a variety of medical grade materials: plastic, silicone, polyurethane, sterling silver, and stainless steel. Two types of plastics commonly used are (PVC) polyvinyl chloride (Shiley and Portex) and polyurethane (Tracoe). Plastic tubes are single patient use, and considered disposable. The Clinical Consensus Guidelines (2013) recommend a plastic tube be used for initial placement.
Silicone tubes are softer and less rigid than plastic or metal, and are commonly used in pediatric airways or for adapting to special needs airways. Because of the secretion resistance properties of silicone, they are manufactured without inner cannulas. Silicone tubes are single patient use, but may be sterilized and reused for the same patient.
Metal tubes, commonly referred to as Jackson tubes, are constructed of silver or stainless steel. They are heavier and more rigid than plastic, and typically cuffless. Many metal tracheostomy tubes do not have the 15mm hub as a standard part. For these reasons, they are rarely used in acute care facilities, but are sometimes utilized in the skilled nursing facility or the home care environment. Metal tubes are considered non-disposable and can be sterilized for multiple patient use.
This is a metal, Jackson tracheostomy tube with a Martin style inner cannula. Without a 15mm hub on this inner cannula, it is impractical to manage this airway in a clinical setting. Special adapters are required to accommodate resuscitation equipment, ventilator circuits, or speaking valves. A spare, plastic, cuffed tracheostomy tube with a 15mm hub should be placed at the bedside of patients with metal tubes in case of any airway or cardiac emergency.
This metal, Jackson tracheostomy tube offers an inner cannula with a 15mm hub allowing connection to ventilator tubing, resuscitation bags, anesthesia equipment, speaking valves, and caps.
This is the metal, Jackson tube with an improved inner cannula. It is very recognizable, as the outer circumference of the inner cannula has ridges like a dime. Without adapters, this tube will not accommodate resuscitation equipment, ventilator circuits, or speaking valves. A spare, plastic, cuffed tracheostomy tube with a 15mm hub should be placed at the bedside in case of any airway or cardiac emergency.
NOTE: When choosing a Passy-Muir(R) Valve for a patient with a metal tracheostomy tube, it is important to note the size of the tube, and type of inner cannula. If the metal tube is size 4, 5, or 6, and has the improved inner cannula, the Passy-Muir Valve of choice would be the PMV 2020.
NOTE: The PMA 2020-S adapter attaches to the improved inner cannula, turning it into a 15mm hub. Once the adapter is attached to the inner cannula, a speaking valve can be attached to the “0”ring. For patient comfort, attach the “0” ring and valve in sterile fashion, then insert the inner cannula. In the event of an emergency, resuscitation equipment will interface with this inner cannula and “0” ring adapter; however once the situation has stabilized, this airway would best be managed with a standard cuffed, plastic tube with a 15mm hub.
Tracheostomy tubes are made of a variety of medical grade materials: plastic, silicone, polyurethane, sterling silver, and stainless steel. Two types of plastics commonly used are (PVC) polyvinyl chloride (Shiley and Portex) and polyurethane (Tracoe). Plastic tubes are single patient use, and considered disposable. The Clinical Consensus Guidelines (2013) recommend a plastic tube be used for initial placement.
Silicone tubes are softer and less rigid than plastic or metal, and are commonly used in pediatric airways or for adapting to special needs airways. Because of the secretion resistance properties of silicone, they are manufactured without inner cannulas. Silicone tubes are single patient use, but may be sterilized and reused for the same patient.
Metal tubes, commonly referred to as Jackson tubes, are constructed of silver or stainless steel. They are heavier and more rigid than plastic, and typically cuffless. Many metal tracheostomy tubes do not have the 15mm hub as a standard part. For these reasons, they are rarely used in acute care facilities, but are sometimes utilized in the skilled nursing facility or the home care environment. Metal tubes are considered non-disposable and can be sterilized for multiple patient use.
This is a metal, Jackson tracheostomy tube with a Martin style inner cannula. Without a 15mm hub on this inner cannula, it is impractical to manage this airway in a clinical setting. Special adapters are required to accommodate resuscitation equipment, ventilator circuits, or speaking valves. A spare, plastic, cuffed tracheostomy tube with a 15mm hub should be placed at the bedside of patients with metal tubes in case of any airway or cardiac emergency.
This metal, Jackson tracheostomy tube offers an inner cannula with a 15mm hub allowing connection to ventilator tubing, resuscitation bags, anesthesia equipment, speaking valves, and caps.
This is the metal, Jackson tube with an improved inner cannula. It is very recognizable, as the outer circumference of the inner cannula has ridges like a dime. Without adapters, this tube will not accommodate resuscitation equipment, ventilator circuits, or speaking valves. A spare, plastic, cuffed tracheostomy tube with a 15mm hub should be placed at the bedside in case of any airway or cardiac emergency.
NOTE: When choosing a Passy-Muir(R) Valve for a patient with a metal tracheostomy tube, it is important to note the size of the tube, and type of inner cannula. If the metal tube is size 4, 5, or 6, and has the improved inner cannula, the Passy-Muir Valve of choice would be the PMV 2020.
NOTE: The PMA 2020-S adapter attaches to the improved inner cannula, turning it into a 15mm hub. Once the adapter is attached to the inner cannula, a speaking valve can be attached to the “0”ring. For patient comfort, attach the “0” ring and valve in sterile fashion, then insert the inner cannula. In the event of an emergency, resuscitation equipment will interface with this inner cannula and “0” ring adapter; however once the situation has stabilized, this airway would best be managed with a standard cuffed, plastic tube with a 15mm hub.
Tracheostomy Tube Dimensions
The dimensions of tracheostomy tubes are given by their ID, OD, length, and curvature. These variables should be considered when selecting the appropriate tracheostomy tube. The tracheostomy tube size, shape and diameter should be chosen based on the tube fit with the airway without pressure on the tracheal wall, and also taking speech and airway clearance into consideration (Mitchell, 2013).
Sizing:
Choosing the appropriate inner and outer diameter sizes of the tracheostomy tube are important when recommending a the initial tracheostomy tube and any tracheostomy tube changes. When determining the appropriate diameter of the tracheostomy tube, there are a few aspects to consider: lung mechanics, upper airway resistance and airway clearance, ventilation and communication/speech needs, and indications for the procedure (Mitchell, 2013).
It is also important to understand that different manufacturers follow different sizing guidelines. Some tracheostomy tubes utilize the Jackson sizing system, while other tubes use the International Standards Organization (ISO) method. Most Shiley dual cannula tracheostomy tubes use the Jackson system and single cannula Bivona tracheostomy tubes use ISO. If an inner cannula is needed to connect to the ventilator, then the published ID is the ID of the inner cannula. The OD is the largest diameter of the outer cannula (Hess, 2005).
Sizing is important when recommending tracheostomy tube changes. Measurements of inner diameter, outer diameter and length with different manufacturers even though the same number is assigned to the tracheostomy tube. For example, a clinician recommending downsizing needs to be aware that one size 6 tracheostomy tube is not necessarily the same outer diameter or length as a different brand of size 6 tracheostomy tube. The clinician should assess the inner and outer diameter measurements and length to compare the tracheostomy tubes and ensure the appropriate selection. Since sizings vary, it is recommended that the exact duplicate of the tracheostomy tube in use be kept at bedside for replacement if needed.
Length:
Tracheostomy tubes are available in standard lengths or extra lengths. Extra length tracheostomy tubes can be constructed with extra proximal length or distal length. Extra proximal length tubes are for patients with large necks (obese patients). Extra distal length tubes are used to bypass tracheal anomalies such as stenosis or malacia. A study by Rumbek (1999) of 37 patients with substantial tracheal obstruction caused failure to wean. Insertion of a longer tracheotomy tube relieved the obstruction and allowed 35 out of 37 patients to be weaned from the ventilator within 1 week.
There are also manufacturer variations in lengths between tubes of the same inner diameter. These variations are not commonly appreciated but may have important clinical implications.
There are also adjustable tracheostomy tubes which have a movable flange so that the length of the tracheostomy tube from skin surface to trachea can be adjusted at the bedside. A locking mechanism on the flange maintains the chosen tube length. These tubes are used for patients with atypical anatomy and are for short term use.
Curvature:
Tracheostomy tubes can be curved or angled. These features can help to improve the fit of the tracheostomy tube into the airway. Patients with a fenestrated tracheostomy tube may need a particular angled tracheostomy tube so that the fenestration fits in an appropriate place in the trachea, and not against the anterior or posterior tracheal wall.
Single Lumen:
Single lumen tubes consist of the outer cannula only. These tubes offer the least amount of airway resistance. Some brands are made of secretion resistant silicone, and do not require an inner cannula. Most pediatric tracheostomy tubes are single lumen tubes, because their diameters are too small to accommodate an inner cannula.
Double Lumen:
Tracheostomy tubes with an inner cannula are called dual-cannula or double lumen tubes. Double lumen tubes are the most commonly used tracheostomy tube. Use of an inner cannula increases airway resistance (Cowan et al, 2001), but lends a safety factor in that it can be quickly changed in the event of a mucus plug, leaving the outer cannula in tact. Sometimes the inner cannula contains the 15mm hub, and a ventilator, speaking valve or cap cannot be placed unless the inner cannula is in place.
Fenestrated:
Fenestrated tubes have various shaped openings along the shaft of the inner and outer cannulas that were designed to allow airflow, with less resistance, through the larynx for better voicing. Some tubes offer both fenestrated and non fenestrated inner cannulas so the clinician needs to understand for speech production, use of the fenestrated inner cannula is indicated.
NOTE: It is not a requirement for the patient to have a fenestrated tracheostomy tube during speaking valve use.
A common drawback to using fenestrated tubes is the possibility for proliferation of granulation tissue (scar tissue) to grow into, and occlude the fenestrations. Due to the location of the fenestrations on a standard tube, they may rub and irritate the tracheal wall, causing granulomas to form. This scar tissue diminishes the effectiveness of the fenestrations, makes it difficult to pass a suction catheter, and complicates removal of the inner cannula or changing of the tube itself. For these reasons, unless you have a tube custom made with fenestrations in the optimal position along the shaft, standard fenestrated tracheostomy tubes are rarely used during prolonged tracheostomy.
NOTE: When using the tube with a single, large fenestration, it is important to remember to use the non fenestrated inner cannula when suctioning the patient. If the fenestrated inner cannula is left in during a suction procedure, there is potential for the suction catheter to cause damage to the tracheal wall.
Sizing:
Choosing the appropriate inner and outer diameter sizes of the tracheostomy tube are important when recommending a the initial tracheostomy tube and any tracheostomy tube changes. When determining the appropriate diameter of the tracheostomy tube, there are a few aspects to consider: lung mechanics, upper airway resistance and airway clearance, ventilation and communication/speech needs, and indications for the procedure (Mitchell, 2013).
It is also important to understand that different manufacturers follow different sizing guidelines. Some tracheostomy tubes utilize the Jackson sizing system, while other tubes use the International Standards Organization (ISO) method. Most Shiley dual cannula tracheostomy tubes use the Jackson system and single cannula Bivona tracheostomy tubes use ISO. If an inner cannula is needed to connect to the ventilator, then the published ID is the ID of the inner cannula. The OD is the largest diameter of the outer cannula (Hess, 2005).
Sizing is important when recommending tracheostomy tube changes. Measurements of inner diameter, outer diameter and length with different manufacturers even though the same number is assigned to the tracheostomy tube. For example, a clinician recommending downsizing needs to be aware that one size 6 tracheostomy tube is not necessarily the same outer diameter or length as a different brand of size 6 tracheostomy tube. The clinician should assess the inner and outer diameter measurements and length to compare the tracheostomy tubes and ensure the appropriate selection. Since sizings vary, it is recommended that the exact duplicate of the tracheostomy tube in use be kept at bedside for replacement if needed.
Length:
Tracheostomy tubes are available in standard lengths or extra lengths. Extra length tracheostomy tubes can be constructed with extra proximal length or distal length. Extra proximal length tubes are for patients with large necks (obese patients). Extra distal length tubes are used to bypass tracheal anomalies such as stenosis or malacia. A study by Rumbek (1999) of 37 patients with substantial tracheal obstruction caused failure to wean. Insertion of a longer tracheotomy tube relieved the obstruction and allowed 35 out of 37 patients to be weaned from the ventilator within 1 week.
There are also manufacturer variations in lengths between tubes of the same inner diameter. These variations are not commonly appreciated but may have important clinical implications.
There are also adjustable tracheostomy tubes which have a movable flange so that the length of the tracheostomy tube from skin surface to trachea can be adjusted at the bedside. A locking mechanism on the flange maintains the chosen tube length. These tubes are used for patients with atypical anatomy and are for short term use.
Curvature:
Tracheostomy tubes can be curved or angled. These features can help to improve the fit of the tracheostomy tube into the airway. Patients with a fenestrated tracheostomy tube may need a particular angled tracheostomy tube so that the fenestration fits in an appropriate place in the trachea, and not against the anterior or posterior tracheal wall.
Single Lumen:
Single lumen tubes consist of the outer cannula only. These tubes offer the least amount of airway resistance. Some brands are made of secretion resistant silicone, and do not require an inner cannula. Most pediatric tracheostomy tubes are single lumen tubes, because their diameters are too small to accommodate an inner cannula.
Double Lumen:
Tracheostomy tubes with an inner cannula are called dual-cannula or double lumen tubes. Double lumen tubes are the most commonly used tracheostomy tube. Use of an inner cannula increases airway resistance (Cowan et al, 2001), but lends a safety factor in that it can be quickly changed in the event of a mucus plug, leaving the outer cannula in tact. Sometimes the inner cannula contains the 15mm hub, and a ventilator, speaking valve or cap cannot be placed unless the inner cannula is in place.
Fenestrated:
Fenestrated tubes have various shaped openings along the shaft of the inner and outer cannulas that were designed to allow airflow, with less resistance, through the larynx for better voicing. Some tubes offer both fenestrated and non fenestrated inner cannulas so the clinician needs to understand for speech production, use of the fenestrated inner cannula is indicated.
NOTE: It is not a requirement for the patient to have a fenestrated tracheostomy tube during speaking valve use.
A common drawback to using fenestrated tubes is the possibility for proliferation of granulation tissue (scar tissue) to grow into, and occlude the fenestrations. Due to the location of the fenestrations on a standard tube, they may rub and irritate the tracheal wall, causing granulomas to form. This scar tissue diminishes the effectiveness of the fenestrations, makes it difficult to pass a suction catheter, and complicates removal of the inner cannula or changing of the tube itself. For these reasons, unless you have a tube custom made with fenestrations in the optimal position along the shaft, standard fenestrated tracheostomy tubes are rarely used during prolonged tracheostomy.
NOTE: When using the tube with a single, large fenestration, it is important to remember to use the non fenestrated inner cannula when suctioning the patient. If the fenestrated inner cannula is left in during a suction procedure, there is potential for the suction catheter to cause damage to the tracheal wall.