What are the different types of tracheostomy (tracheal ostomy) tubes?

Types of Tracheostomy Tubes

Tracheostomy tubes come in various types including cuffed, uncuffed, fenestrated, non-fenestrated, tubes with inner cannulas, and specially manufactured tubes, each designed for specific patient needs and clinical scenarios. 1

Tube Composition and Design

• Material options: Tracheostomy tubes are available in silicone (highly flexible), polyvinyl chloride (flexible or rigid), and metal (rigid) 1
• Metal tubes are used in special circumstances such as with Aboulker stents after laryngeal reconstruction, but most have inner cannulas that reduce internal diameter and can lead to high airway resistance in small children 1
• Tubes with inner cannulas (dual-cannula tubes) are beneficial for patients with thick secretions as they allow cleaning without changing the entire tube 1, 2
• Silicone tubes are recommended when standard polyvinyl chloride tubes don't provide optimal fit, as they conform better to airway shape 1, 3

Cuffed vs. Uncuffed Tubes

• Uncuffed tubes are preferred in most circumstances, especially in pediatric patients 1
• Cuffed tubes have specific indications:
  • Patients requiring ventilation with high pressures 1, 4
  • Patients needing only nocturnal ventilation (cuff inflated at night, deflated during day) 1, 4
  • Patients with chronic translaryngeal aspiration 1
• Types of cuffs:
  • High-volume/low-pressure cuffs: Preferred option, should maintain pressures below 20 cm H₂O to preserve airway epithelium perfusion 1, 4
  • Low-volume/high-pressure cuffs: Must be carefully managed as they can place dangerous pressure on airway epithelium 1

Fenestrated vs. Non-fenestrated Tubes

• Fenestrated tubes have openings in the posterior portion that enhance translaryngeal airflow to aid speech and secretion clearance 1, 3
• Non-fenestrated tubes are more commonly used, especially in pediatrics 1
• Potential concern: Some experts believe fenestrated tubes may promote granulation tissue development at the fenestration site 1
• Indications for fenestrated tubes: Particularly useful with speaking valves when the tracheostomy tube is large relative to the airway 1

Size and Fit Considerations

• Length: Should extend at least 2 cm beyond the stoma and remain 1-2 cm above the carina 1
• Diameter: Selected to avoid tracheal wall damage, minimize breathing work, and when possible, promote translaryngeal airflow 1
• Curvature: The distal portion should be concentric and colinear with the trachea to prevent complications like tracheal wall erosion, fistula formation, or stomal breakdown 1
• Universal adapter: All tubes should have a 15-mm "universal" adapter for emergency bag ventilation (except some metal tubes) 1

Specialized Tubes

• Adjustable flange tubes: Silicone tubes with adjustable flanges allow customization of insertion length 1
• Specially manufactured tubes: Required for a small minority of patients with unusual airways 1
• Physician-modified tubes: Should only be used temporarily in urgent situations until manufacturer-made custom tubes are available 1

Common Pitfalls and Considerations

• Improper tube selection: A tube whose distal position isn't colinear with the trachea can cause complications including esophageal obstruction, tracheal wall erosion, and fistula formation 1
• Cuff management: Maintaining appropriate cuff pressures (below 20 cm H₂O for high-volume/low-pressure cuffs) is critical to prevent tracheal injury 1, 4
• Inner cannula considerations: While beneficial for secretion management, inner cannulas reduce the internal diameter of the tube, potentially increasing airway resistance 1, 2
• Tube changes: No consensus exists on optimal frequency, though weekly changes are common practice 1
• Speaking considerations: For patients who need speech facilitation, options include speaking valves with uncuffed or deflated-cuff tubes, fenestrated tubes, or specialized talking tracheostomy tubes 1, 5