Are there criteria for selecting bedside tracheostomy tubes?

Criteria for Selecting Bedside Tracheostomy Tubes

The selection of tracheostomy tubes should be based on specific anatomical and clinical criteria, with the tube extending at least 2 cm beyond the stoma but remaining 1-2 cm from the carina to minimize complications and optimize patient outcomes. 1

Size and Length Considerations

• Tube Length: Must extend at least 2 cm beyond the stoma, but stay 1-2 cm away from the carina 1

• Diameter Selection: Should be chosen to:

  • Avoid tracheal wall damage
  • Minimize work of breathing
  • Promote translaryngeal airflow when possible 1
  • Consider that smaller tubes may be beneficial in some patients, while others require tubes with a closer fit to tracheal diameter 1

• Curvature: The distal portion must be concentric and colinear with the trachea to prevent complications 1

  • Requires assessment via radiographs or flexible bronchoscopy 1
  • Improper alignment may cause esophageal obstruction, tracheal wall erosion, or fistula formation 1

Tube Composition and Features

• Material Options:

  • Silicone tubes: Highly flexible, can conform to airway shape 1
  • Polyvinyl chloride tubes: Variable flexibility 1
  • Metal tubes: Rigid, used in special circumstances (e.g., after laryngeal reconstruction) 1

• Inner Cannula Considerations:

  • Beneficial for patients with thick secretions 1
  • Allows cleaning without changing the entire tube 1
  • Note: Increases airflow resistance by an average factor of 2.2 2
  • Can significantly increase work of breathing 2

• Universal Adapter: All tubes should have a 15-mm "universal" adapter for emergency ventilation 1

Cuffed vs. Uncuffed Tubes

• Cuffed Tubes: Consider for:

  • Patients requiring mechanical ventilation with high pressures
  • Nocturnal ventilation needs (cuff inflated at night, deflated during day)
  • Prevention of chronic aspiration 1

• Cuff Pressure Management:

  • Low-pressure/high-volume cuffs: Keep pressures below 20 cm H₂O 1
  • Monitor cuff pressure regularly to prevent airway epithelium damage 1
  • Excessive pressure can lead to tracheal wall erosion and acquired tracheomegaly 1

Fenestrated vs. Non-fenestrated Tubes

• Fenestrated Tubes: Consider for patients who:
  • Need enhanced speech capability
  • Require a tube with closer fit to tracheal diameter
  • Would benefit from translaryngeal airflow 1

Special Considerations

• Patient-Specific Factors:

  • Tracheal size and shape
  • Indication for tracheostomy
  • Lung mechanics
  • Upper airway resistance
  • Speech, ventilation, and airway clearance needs 1

• High-Risk Situations:

  • Improper tube selection can lead to serious complications:
    • Tracheal wall erosion
    • Tracheo-innominate artery fistula
    • Tracheoesophageal fistula
    • Stomal breakdown 1
    • Increased work of breathing 2

Monitoring and Assessment

• Confirm proper tube placement and fit using:
  • Neck/chest radiographs
  • Flexible bronchoscopy 1
  • Regular reassessment as patient's condition changes

By following these evidence-based criteria for tracheostomy tube selection, clinicians can minimize complications and optimize patient outcomes while ensuring proper airway management.