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.
Cuffs with a high volume have low-pressure and are called “high volume low-pressure cuffs.” They are generally dual cannula tracheostomy tubes and are filled with air. 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 tolerating a speaking valve or cap.
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). 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.
Foam filled cuffs are made out of foam material to prevent injury to the tracheal mucosa for patients with tracheal abnormalities. Because a foam filled cuff cannot be completely deflated it is an absolute contraindication to speaking valve and capping use.
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.
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.
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.
How to deflate the cuff
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 again and suction 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 with a deflated cuff.
How to maintain the cuff pressure?
Cuffed 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.
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?
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.
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. 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. 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.
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 cuff less.
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.