What type of tracheostomy tube is recommended for a patient with unknown age, weight, and medical condition?

Tracheostomy Tube Selection

For most patients, start with an uncuffed polyvinyl chloride or silicone tracheostomy tube with appropriate sizing (extending at least 2 cm beyond the stoma and remaining 1-2 cm above the carina), reserving cuffed tubes specifically for mechanical ventilation, nocturnal ventilation needs, or chronic aspiration. 1

Tube Composition Selection

Polyvinyl chloride (PVC) tubes are the standard first-line choice for most patients due to their availability, cost-effectiveness, and adequate flexibility. 1, 2

Silicone tubes should be selected when standard PVC tubes do not provide optimal fit, as they conform better to individual airway anatomy. 1, 2 These are particularly useful in patients with unusual airway geometry.

Metal tubes are reserved for special circumstances only, such as after laryngeal reconstruction with Aboulker stents. 1 A critical pitfall: metal tubes significantly increase airway resistance in small children due to their inner cannulas and typically lack the 15-mm universal adapter needed for emergency bag ventilation. 1

Cuffed vs. Uncuffed Decision Algorithm

Uncuffed tubes are preferred in the majority of circumstances, particularly in pediatric patients, to minimize risk of tracheal injury. 1, 2

Use cuffed tubes only when:

• Patient requires positive-pressure mechanical ventilation with high pressures 1, 3
• Patient needs only nocturnal ventilation (cuff inflated at night, deflated during day for speech) 1, 3
• Patient has chronic translaryngeal aspiration from bulbar dysfunction 1, 4

When selecting cuffed tubes, always choose high-volume/low-pressure cuffs over low-volume/high-pressure designs to preserve airway epithelium perfusion. 1, 2, 3 Maintain cuff pressure between 20-30 cm H₂O—pressures above 20 cm H₂O decrease epithelial perfusion and risk tracheal injury. 1, 3

Critical caveat: Cuffed tubes do NOT prevent aspiration; they are indicated for ventilation management in patients who also have aspiration, not as an aspiration prevention strategy. 4

Inner Cannula Considerations

Dual-cannula tubes (with inner cannula) are specifically indicated for patients with thick, copious secretions that rapidly accumulate on tube walls. 1, 2 The inner cannula can be cleaned without requiring frequent complete tracheostomy changes. 1

Avoid inner cannulas in small children when using metal tubes, as this significantly increases airway resistance. 1

Fenestrated vs. Non-Fenestrated

Non-fenestrated tubes are the standard choice for most patients, especially in pediatrics. 1, 2

Fenestrated tubes should be considered only when:

• Patient requires enhanced translaryngeal airflow for speech 1, 2
• Tracheostomy tube is large relative to airway diameter and patient uses speaking valves 1
• Patient needs improved secretion clearance while using speaking valve 1

Major pitfall: Fenestrated tubes carry significant risk of granulation tissue formation at the fenestration site (60% complication rate in one study), plus risks of tracheomalacia and tracheal stenosis. 5 Use only when translaryngeal airflow cannot be achieved by downsizing to a smaller tube. 1

Sizing Specifications

Length: Tube must extend at least 2 cm beyond the stoma and remain 1-2 cm above the carina. 1, 2

Diameter: Select to avoid tracheal wall damage while minimizing work of breathing. 1 Some patients breathe well with tubes small relative to tracheal diameter (breathing around and through the tube), while others require closer fit and breathe only through the tube. 1

Curvature: The distal portion must be concentric and colinear with the trachea—verify with chest radiograph or flexible bronchoscopy. 1 Improper alignment causes complications including esophageal obstruction, tube occlusion by tracheal wall, tracheal erosion, and fistula formation. 1

Universal Safety Feature

All tracheostomy tubes must have a 15-mm universal adapter to allow emergency bag ventilation—this is non-negotiable. 1 Metal tubes commonly lack this feature and should be avoided for this reason alone in most circumstances. 1

Special Circumstances

Adjustable flange tubes with flexible silicone design allow bedside length adjustments for patients with unusual airways or large necks. 1, 6 Off-the-shelf tubes fit the majority of patients; specially manufactured tubes are needed only for a small minority. 1

Physician-modified tubes (cut and smoothed) should only be used temporarily in urgent situations until a properly manufactured tube is available, as modifications void warranties and cannot achieve optimal edge smoothing. 1