Tracheostomy Tube Selection
Consensus
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Use metal tubes only in special
circumstances
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PVC tubes fit most children
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Silicone tubes may provide better fit for some
patients
Children require a tracheostomy for many different
reasons. The size, shape, and composition of the tracheostomy tube
will be determined by the patient's individual problems. The
selection of the first tracheostomy tube is usually made by the
surgeon at the time the tracheotomy is created. However, other
members of the team should subsequently offer important input
regarding whether the initial tube is the optimal one for a given
child or whether a different tube would be preferable. There are no
research data available documenting optimal choices in tracheostomy
tube selection. Therefore, selection of the optimal tube for any
patient will depend upon the collective expertise of the
tracheostomy team. These five characteristics of tracheostomy tubes
should be considered when selecting a tracheostomy tube for a
specific patient.
Tracheostomy tubes must fit the airway and the
functional needs of the patient. Selection of the optimal size and
curvature of the tracheostomy tube is critical in children to avoid
1) damage to the airway, 2) problems with ventilation and speech
development, and 3) ill-fitting tubes that are uncomfortable.
In most cases the tracheostomy tube should extend at least two
centimeters beyond the stoma and no closer than 1-2 cm to the
carina. Shorter is better than longer for most patients.
The diameter of the tracheostomy tube should be selected to avoid
damage to the tracheal wall, to minimize work of breathing, and
promote translaryngeal airflow when possible.
The radius of curvature of the shaft of the tracheostomy tube
should leave the axis of the distal portion of the tube in a
colinear position with the axis of the child's trachea. Appropriate
positioning of the tracheostomy tube within the trachea can be
determined either radiographically or by direct visualization with
flexible bronchoscopy.
All tracheostomy tubes should be fitted with a 15-mm universal
adapter to allow for bag ventilation in an emergency. Metal tubes
are often made without this adapter.
Composition of tube
Metal (Jackson) -- Very rigid
Polyvinyl chloride (Shiley) -- some flexibility
Silicone (Bivona) -- most flexible
The use of metal tracheostomy tubes in children is usually
limited to special circumstances such as after tracheal
reconstruction or in the event that a tube with an inner cannula is
needed.
The polyvinylchloride tubes fit most children.
The silicone tubes have more flexibility than the PVC tubes and may
provide a better fit for some children whose individual anatomy
presents problems in finding a good fit.
Consensus
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- Uncuffed tubes are preferred over cuffed tubes
- Limited indication for cuffed tubes
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- Translaryngeal airflow is desirable
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- Physician modified tubes used only in urgent cases
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Uncuffed tubes are preferred in children under most
circumstances. Exceptions occur in children requiring ventilation
with high pressures, requiring ventilation only at night, or with
chronic translaryngeal aspiration.
If a cuffed tube is used, it is preferable to use one with a
low-pressure, high volume cuff. The lowest pressure that meets the
medical needs of the patient should be used to avoid unnecessary
injury to the tracheal mucosa. Cuff pressure should be monitored on
a regular basis.
Clinical experience indicates that fenestrated tracheostomy tubes
facilitate speech by allowing better translaryngeal air flow. Some
clinicians believe that fenestrated tubes also aid in the clearance
of secretions. Other clinicians feel that these tubes promote the
development of granulation tissue along the tracheal wall at the
level of the fenestrations. There is little scientific data to
support either of the latter two opinions.
Translaryngeal air flow either around the barrel of the tube or
through fenestrations is desirable.
Off-the-shelf tracheostomy tubes fit the majority of patients. The
patients who require a custom tracheostomy tube for an optimal fit
can usually tolerate a standard off-the-shelf size until a custom
built tube can be specially ordered from the manufacturer.
Tracheostomy tubes modified by physicians or other caregivers
should be used only in urgent situations until a specially ordered
custom tracheostomy tube is available.
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