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Category: Tracheostomy tubes

Tracheostomy Tube Sizes and Comparison Tool

Tracheostomy Sizes and Comparison Tool Compare different tracheostomy tube sizes for inner diameter, outer diameter, length and cuff NOTE: All Portex, Bivona, Uniperc, Tracoe, and…

Tracheostomy Education January 7, 2020

Cuffed versus Cuffless Tracheostomy Tubes

Cuffed versus cuffless tracheostomy. Explains the purpose of a cuffed tracheostomy and when to deflate the cuff or switch to a cuffless tracheostomy …

Tracheostomy Education November 2, 2019

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What is a cuffed tracheostomy tube?

A tracheostomy tube may be either "cuffed" or "cuffless (uncuffed)." A cuffed tracheostomy tubes has a balloon-like feature at the distal end of the tube. There are three main types of cuffs: low-pressure cuffs, low-volume cuffs and foam-filled cuffs. The cuff can be inflated or deflated with air or water depending on which type of cuff is present.

Patients with COVID-19 with tracheostomy are a high risk for aerosolizing A cuffed tracheostomy tube with the cuff inflated allows for a closed system and is the most likely to prevent cross-contamination of staff, equipment, other patients.

For more information on patients with COVID-19 and tracheostomy and mechanical ventilation please see our article, COVID-19 Tracheostomy and Mechanical Ventilation.

In Progress 14 Lessons
Adult Tracheostomy Care Webinar: Home Edition
katrina-cambigue 21% Complete Last activity on April 8, 2022 Coming soon Adult Tracheostomy Care: Home Edition Webinar! 20% off until April 15th! Adult Tracheostomy Care: Home Edition is a 1 hour recorded webinar which provides information about performing tracheostomy care for adult patients in the home environment. Learn about suctioning, inner cannulas (disposable vs non-disposable), tracheostomy tube cleaning (if indicated), stoma care, cuff management, humidification and communication with the interdisciplinary team. Videos are used to aide in learner comprehension of tracheostomy care. A sample interdisciplinary communication form will be provided as well as home care guideline samples. Webinar objectives
- Identify the indications for and complications of a tracheostomy
- Note the differences and limitations of tracheostomy care at home versus acute care
- Demonstrate how to perform trach care (inner cannula changes, site care, cuff management, suctioning)
- Identify the steps for tracheostomy tube changes
- Discuss patient/family education for humidification, oxygen, nebulizers, and mechanical ventilation with trachs.
Instructor: Katrina Cambigue BS, RCP, RRT-ACCS Katrina is a respiratory therapist at Kaiser Santa Rosa Pulmonary Rehab as well and a clinical instructor at Napa Valley Community College.
Start Course 0 Lessons
Decannulation Webinar: SLP Perspective
tracheducation 0% Complete 0/0 Steps Coming soon! Buy now at a 20% discount!! Decannulation Webinar: SLP perspective is an advanced course on determinants of decannulation and importance of the SLP's input for decannulation. This is a 2.5 hours of material in a recorded webinar. The course will provide information on FEES to view secretion management to help to determine safety of decannulation. There will be video cases to show secretion management and information on patient readiness. Information on cough strength and improving the cough and swallow will be provided to help in the decannulation process. Cuff deflation, speaking valves and capping will also be described. The course will also provide a multi-disciplinary decannulation sample protocol. This webinar is a guide to help decannulate patients quicker and safer. It is recommended to take Flexible Endoscopic Evaluation of Swallowing for Patients with Tracheostomy and Mechanical Ventilation prior to this course. Course presenter: Nicole DePalma, MS CCC-SLP Nicole is the owner of NDoscopy Dysphagia Specialists, a mobile FEES (flexible endoscopic evaluation of swallowing) company servicing New York and New Jersey. Her areas of expertise include dysphagia management and critically complex patients including tracheostomy and mechanical ventilation in a variety of settings including acute care, long term acute, subacute, and skilled nursing. She is also a Clinical Consultant for Passy-Muir, Inc. Course Format: Video Powerpoint with author narration and video samples Course Certificate is provided upon completion.
Complete 14 Lessons
Evidence-Based Swallowing Evaluation for Patients with Tracheostomy and Mechanical Ventilation Webinar
Nicole 100% Complete Last activity on November 15, 2021
Swallowing Evaluation for Patients with Tracheostomy and Mechanical Ventilation Course provides in-depth information about how to perform an initial swallow assessment for this patient population. The course includes effects of tracheostomy on swallowing, research of cuff deflation and how/when to perform cuff deflation, explanation of common mechanical ventilation settings and mechanical ventilation considerations with swallowing, timing of swallow evaluation, Blue Dye testing information, and speaking valves. Instrumental swallow assessment comparison of modified barium swallow studies (MBS) and flexible endoscopic evaluation of swallowing (FEES) and the advantages and disadvantages. Ventilator associated-pneumonia factors is also included. Covid-19 considerations for patients with tracheostomy and mechanical ventilation is also covered.

Free access to the Evidenced-Based Swallowing Evaluation Community is also included. Here, you can ask the instructor any questions in a private forum.

Course presenter: Nicole M. DePalma, MS CCC-SLP

Nicole is the owner of NDoscopy Dysphagia Specialists, a mobile FEES (flexible endoscopic evaluation of swallowing) company servicing New York and New Jersey. Her areas of expertise include dysphagia management and critically complex patients including tracheostomy and mechanical ventilation in a variety of settings including acute care, long term acute, subacute, and skilled nursing. She is also a Clinical Consultant for Passy-Muir, Inc.

Course Format: Video Powerpoint with author narration and video samples

Course Certificate is provided upon completion.

In Progress 14 Lessons
Adult Tracheostomy Care Webinar: Home Edition
katrina-cambigue 21% Complete Last activity on April 8, 2022 Coming soon Adult Tracheostomy Care: Home Edition Webinar! 20% off until April 15th! Adult Tracheostomy Care: Home Edition is a 1 hour recorded webinar which provides information about performing tracheostomy care for adult patients in the home environment. Learn about suctioning, inner cannulas (disposable vs non-disposable), tracheostomy tube cleaning (if indicated), stoma care, cuff management, humidification and communication with the interdisciplinary team. Videos are used to aide in learner comprehension of tracheostomy care. A sample interdisciplinary communication form will be provided as well as home care guideline samples. Webinar objectives
- Identify the indications for and complications of a tracheostomy
- Note the differences and limitations of tracheostomy care at home versus acute care
- Demonstrate how to perform trach care (inner cannula changes, site care, cuff management, suctioning)
- Identify the steps for tracheostomy tube changes
- Discuss patient/family education for humidification, oxygen, nebulizers, and mechanical ventilation with trachs.
Instructor: Katrina Cambigue BS, RCP, RRT-ACCS Katrina is a respiratory therapist at Kaiser Santa Rosa Pulmonary Rehab as well and a clinical instructor at Napa Valley Community College.
Start Course 0 Lessons
Decannulation Webinar: SLP Perspective
tracheducation 0% Complete 0/0 Steps Coming soon! Buy now at a 20% discount!! Decannulation Webinar: SLP perspective is an advanced course on determinants of decannulation and importance of the SLP's input for decannulation. This is a 2.5 hours of material in a recorded webinar. The course will provide information on FEES to view secretion management to help to determine safety of decannulation. There will be video cases to show secretion management and information on patient readiness. Information on cough strength and improving the cough and swallow will be provided to help in the decannulation process. Cuff deflation, speaking valves and capping will also be described. The course will also provide a multi-disciplinary decannulation sample protocol. This webinar is a guide to help decannulate patients quicker and safer. It is recommended to take Flexible Endoscopic Evaluation of Swallowing for Patients with Tracheostomy and Mechanical Ventilation prior to this course. Course presenter: Nicole DePalma, MS CCC-SLP Nicole is the owner of NDoscopy Dysphagia Specialists, a mobile FEES (flexible endoscopic evaluation of swallowing) company servicing New York and New Jersey. Her areas of expertise include dysphagia management and critically complex patients including tracheostomy and mechanical ventilation in a variety of settings including acute care, long term acute, subacute, and skilled nursing. She is also a Clinical Consultant for Passy-Muir, Inc. Course Format: Video Powerpoint with author narration and video samples Course Certificate is provided upon completion.
Complete 14 Lessons
Evidence-Based Swallowing Evaluation for Patients with Tracheostomy and Mechanical Ventilation Webinar
Nicole 100% Complete Last activity on November 15, 2021
Swallowing Evaluation for Patients with Tracheostomy and Mechanical Ventilation Course provides in-depth information about how to perform an initial swallow assessment for this patient population. The course includes effects of tracheostomy on swallowing, research of cuff deflation and how/when to perform cuff deflation, explanation of common mechanical ventilation settings and mechanical ventilation considerations with swallowing, timing of swallow evaluation, Blue Dye testing information, and speaking valves. Instrumental swallow assessment comparison of modified barium swallow studies (MBS) and flexible endoscopic evaluation of swallowing (FEES) and the advantages and disadvantages. Ventilator associated-pneumonia factors is also included. Covid-19 considerations for patients with tracheostomy and mechanical ventilation is also covered.

Free access to the Evidenced-Based Swallowing Evaluation Community is also included. Here, you can ask the instructor any questions in a private forum.

Course presenter: Nicole M. DePalma, MS CCC-SLP

Nicole is the owner of NDoscopy Dysphagia Specialists, a mobile FEES (flexible endoscopic evaluation of swallowing) company servicing New York and New Jersey. Her areas of expertise include dysphagia management and critically complex patients including tracheostomy and mechanical ventilation in a variety of settings including acute care, long term acute, subacute, and skilled nursing. She is also a Clinical Consultant for Passy-Muir, Inc.

Course Format: Video Powerpoint with author narration and video samples

Course Certificate is provided upon completion.

Types of cuffed tracheostomy tubes

High Volume-low Pressure Cuffs

Cuffs with a high volume have low-pressure and are called "high volume low-pressure cuffs." As per manufacturer recommendation, Bivona Aire-Cuf (Smiths Medical North America, Dublin, Ohio) and Shiley cuffs (Covidien, Mansfield, Massachusetts) should be inflated with air only.

High volume-low pressure cuffs are generally dual cannula tracheostomy tubes. Dual cannula tubes have an inner cannula and an outer cannula. Because of the large volume, a larger surface area is in contact with the tracheal wall, which lowers the incidence of damaging the tracheal mucosa. However, these cuffs occupy a large amount of space when the cuffs are deflated during ventilator weaning. The resistance from the cuff may result in difficulty exhaling through the upper airway when the cuff is deflated or difficulty tolerating a speaking valve or cap.

cuff deflated tracheostomy — high volume low-pressure tracheostomy tube with the cuff deflated. Trach mannequin available for purchase in store

High volume-low pressure cuffs are the most frequently used tracheostomy tube in the US.

Low Volume High Pressure Cuffs

Cuffs with a low volume have a high pressure and are called "low volume high-pressure cuffs." These are single cannula tracheostomy tubes such as the Bivona Tight to Shaft (TTS). As per manufacturer recommendations Bivona TTS tracheostomy tubes should be filled with sterile water only. If filled with air, the cuff will deflate over time due to gas impermeability.

Low volume high-pressure cuffs are just as the name describes. There is a smaller surface area that is in contact with the tracheal wall, resulting in a high pressure seal. Although the seal may be more effective for positive pressure ventilation to be maintained, there may be a higher risk of tracheal injury. However, when the cuff is deflated, there is no resistance to airflow through the upper airway and essentially act as a cuffless tracheostomy tube.

These may be a good option for patients who are off mechanical ventilation during the day, and on nocturnal ventilation and requiring a cuffed tube. These patients should have limited secretions if using a TTS tracheostomy tube since there is no inner cannula. The inner cannula can be removed if there is a blockage from mucous, whereas if the tube does not have an inner cannula and it becomes blocked the entire tube may need to be removed.

Foam Filled Cuffs

Foam filled cuffs are made out of foam material to prevent injury to the tracheal mucosa for patients with tracheal abnormalities. When the foam filled tracheostomy tube is in place, the pilot tube remains open to the atmosphere, so the intracuff pressure is at ambient levels. The open pilot port also permits compression and expansion of the cuff during the ventilatory cycle. The degree of expansion of the foam is a determining factor of the degree of tracheal wall pressure. As the foam further expands, lateral tracheal wall pressure increases. When used properly, this pressure does not exceed 20 mm Hg (27 cm H2O) (Hess, 2014).

Because a foam filled cuff cannot be completely deflated it is an absolute contraindication to speaking valve and capping use. There is also risk for spontaneous reinflation with a foam filled cuff.

Foam filled cuffs are not used frequently. They are typically used in patients with known tracheal damage due to the cuff.

What is the purpose of the cuff of the tracheostomy tube?

Regardless of the type of cuffed tracheostomy tube, the purpose of the cuff is to maintain the air delivered from the mechanical ventilator to the lungs. It may be necessary to keep the cuff of the tracheostomy tube inflated so all the air delivered from the ventilator goes to the lungs and then back to the ventilator on exhalation to be measured and monitored. This is often the case during the acute disease process. Once the patient is stabilized, the cuff may be deflated or the tube may be changed to a cuffless tracheostomy tube. Even patients on mechanical ventilation may be candidates for deflating the cuff or cuffless tracheostomy tubes.

Does the cuff prevent aspiration?

It is a common misconception that the cuff of the tracheostomy tube prevents aspiration. The definition of aspiration is any material that passes below the level of the vocal folds. The cuff is located below the level of the vocal folds. So any material that reaches the cuff has already been aspirated. The cuff does not form an impenetrable seal and therefore aspirated material that reaches the cuff, passes around the cuff and into the lower airways. There are some patients who have excessive secretions and poor airway protection in which the cuff can help to reduce the amount of secretions that enter the lungs.

Some research has shown that an inflated cuff may cause impaired swallow physiology. The cuff may reduce the ability for the larynx to elevate, which is important for protecting the airway from aspiration. The cuff may also reduce sensation through the oropharynx, impair subglottic pressures for swallowing, and impair the natural cough reflex. Increased cuff pressures may actually make it more difficult to elicit a swallowing reflex (Ametheiu, 2012).

On rare occasions, a patient may have a severe swallowing impairment with inability to clear the airway for airway protection. These patients are unable to tolerate cuff deflation noted by a significant change in vital signs or respiratory distress during cuff deflation. An inflated cuff can provide a means of bypassing the secretions that are unable to be cleared during cuff deflation through the upper airway.

Please see swallowing management for patients with tracheostomy for more information.

How to deflate the cuff

A physician order is needed prior to cuff deflation. Always educate the patient on any procedure to reduce anxiety and improve cooperation. Staff should wear appropriate PPE during cuff deflation.

Cuff deflation is a aerosol generating procedure and is particularly high risk for spreading SARS-CoV-2 (the virus that causes COVID-19) when patients are on mechanical ventilation. For patients with COVID-19, caution should be used prior to cuff deflation. The patient should be in an isolated room or cohorted with other patients with COVID-19 prior to cuff deflation.

Check the vital signs prior and during cuff deflation.
Suction the patient through the tracheostomy tube prior to deflating the cuff. Suction the oral cavity as needed.
Slowly deflate the cuff by placing a syringe into the pilot balloon and fully removing all of the air or water.
Continue to monitor for any signs of distress.
Suction through the tracheostomy tube and the oral cavity as needed.

The first time the cuff is deflated may be uncomfortable for the patient and may take time for the patient to get used to the sensation of airflow through the upper airway. Therefore, multiple attempts may be required before the patient is able to manage a fully deflated cuff.

How to maintain the cuff pressure?

The cuffs should be checked routinely, adjusted to the appropriate pressure, and the tube replaced if the cuff is not holding air (Mitchel et al, 2012). Cuff pressure should be checked regularly with a cuff manometer. High cuff pressure can lead to mucosal ischemia and eventual injury with complications such as tracheal stenosis, necrosis, bleeding, ulcers, and fistulas. It is recommended that cuff pressures be maintained at 20-30cmH20 (15–22 mm Hg).

Due to the complications that can occur with a cuffed tracheostomy, cuff deflation or a cuffless tracheostomy tube should be considered if the patient is weaned from mechanical ventilation and is able to tolerate a deflated cuff without respiratory distress. More information about cuff management can be found here.

How do you determine if the patient has a cuffed tracheostomy tube?

Pilot balloon of a tracheostomy tube deflated

If the tracheostomy tube has a pilot line and pilot balloon, this is an indicator that the patient has a cuffed tracheostomy tube. The flange of the tracheostomy tube also indicates if the tracheostomy tube has a cuff in place. For example the original Legacy Shiley tracheostomy tubes indicate CFS on the flange for cuffless and may also say "No Cuff." DCT indicates disposible cuffed tracheostomy. The newer Shiley flexible tracheostomy tubes "cuffed" written on the flange.

When the pilot balloon is inflated, this indicates that the cuff is inflated. When the pilot balloon is deflated, this indicates that the cuff is deflated. Prior to placing a speaking valve or cap, always use a syringe to remove all air from the pilot balloon to make sure that the cuff is fully deflated even if the pilot balloon appears to be deflated. This is because sometimes there is a small amount of air in the pilot balloon that may not be visually observed. If the cuff is not completely deflated, the patient may have difficulty breathing with a valve in place. A speaking valve or cap is contraindicated with foam filled cuffs.

What is a cuffless tracheostomy tube?

A cuffless tracheostomy tube does not have a cuff (balloon like feature) at the end of the tube. If the patient does not require that the air from the ventilator is monitored and measured and is able to tolerate cuff deflation without respiratory distress, then a cuffless tracheostomy tube may be placed. Sometimes a adult patients on mechanical ventilation are managed with cuffless tracheostomy tubes, but it is not common. Typically patients are weaned from mechanical ventilation prior to placement of a cuffless tracheostomy tube. Pediatric and neonatal patients typically have cuffless tracheostomy tubes to prevent mucosal injury.

When a cuffless tracheostomy tube is placed, the flow of air is different then with a tracheostomy tube with an inflated cuff. With a cuffless tracheostomy tube air will flow in and out of the tracheostomy tube, however, air may also leak around the tracheostomy tube and through the upper airway. Some speech is possible with a cuffless tracheostomy tube depending on how much space is around the tracheostomy tube for airflow through the upper airway.

A cuffless tracheostomy tube does not have a pilot line or pilot balloon. The flange of the tracheostomy tube will indicate that the tracheostomy tube is cuffless.

Patients sometimes breathe easier when a tracheostomy tube is changed to a cuffless tracheostomy tube during speaking valve trials. As mentioned above, particularly with the high volume, low pressure cuffs, the bulk of the cuff occupies space even when deflated.

Summary

It is important to understand the difference between a cuffed and cuffless tracheostomy tube and when it is appropriate to deflate the cuff or change to a cuffless tracheostomy tube. Once the patient no longer requires mechanical ventilation and is able to tolerate cuff deflation without distress, a cuffless tracheostomy tube may be placed. Since cuff deflation can increase aerosol generation, care must be taken prior to this procedure. Staff must ensure appropriate PPE and it should be performed in isolation or with cohorted COVID-19 patients.

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Category: Tracheostomy tubes

Tracheostomy Tube Sizes and Comparison Tool

Cuffed versus Cuffless Tracheostomy Tubes

Tracheostomy Education Membership

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