Tracheostomy Tube

  • Tracheotomy = procedure
  • Tracheostomy = stoma (opening)

2. Components 

Outer Cannula

  • Main tube that stays in trachea
  • Provides structural airway

 Inner Cannula

  • Removable
  • Prevents blockage from secretions
  • Can be disposable or reusable

 Exam pearl: Inner cannula obstruction = most common cause of sudden deterioration

 Fenestration (optional)

  • Opening in tube
  • Allows airflow to vocal cords → speech


3. Types of Tracheostomy Tubes

Based on Cuff

1. Cuffed Tube

2. Uncuffed Tube


Based on Fenestration

1. Fenestrated Tube

  • Has opening → allows speech
  • Used in weaning / rehabilitation

Not used during ventilation (air leak)


2. Non-Fenestrated Tube

  • Standard ICU tube
  • Safer during ventilation

Based on Cannula

1. Single Cannula

  • No inner cannula
  • Higher obstruction risk

2. Double Cannula

  • Preferred in ICU
  • Easy cleaning


 Based on Material

  • PVC (most common, disposable)
  • Silicone (flexible, long-term)
  • Metal (rare now; e.g., Jackson tube)

 Special Tubes

Type

Feature

Use

Extra-long

Longer shaft

Obesity, thick neck

Adjustable flange

Depth adjustable

Anatomical variation

Speaking valve compatible

One-way valve

Speech (e.g., Passy-Muir)


 4. Sizing 

 Size Parameters

  1. Inner Diameter (ID) → airflow resistance
  2. Outer Diameter (OD) → tracheal fit
  3. Length

 Adult Selection (General Rule)

Patient

Typical Size

Adult female

6–7 mm ID

Adult male

7–9 mm ID

 Aim:

  • ID large enough for ventilation
  • OD < 2/3 tracheal diameter


 5. Cuff Pressure 

  • Target: 20–30 cm H₂O

Why important?

Low Pressure

High Pressure

Aspiration

Tracheal ischemia

Air leak

Tracheal stenosis

Inadequate ventilation

Tracheoesophageal fistula

Measure with manometer (NOT pilot balloon palpation)


 6. Indications 

 Prolonged ventilation

  • 7–10 days (guideline varies)

Airway protection

  • Low GCS
  • Stroke

Secretion management

  • Weak cough

Upper airway obstruction

  • Tumor, edema


7. Methods of Tracheostomy

 Surgical Tracheostomy


  • Done in OT
  • Better for:
    • Difficult anatomy
    • Emergency

Percutaneous Dilatational Tracheostomy (PDT)

  • ICU bedside
  • Uses Seldinger technique

 Preferred in ICU


 8. Complications 

 Immediate

  • Bleeding
  • Pneumothorax
  • False passage
  • Tube misplacement

 Early

  • Tube blockage(most common acute problem)
  • Infection
  • Subcutaneous emphysema

 Late

  • Tracheal stenosis
  • Tracheomalacia
  • Tracheoesophageal fistula
  • Tracheo-innominate fistula (= catastrophic bleed (sentinel bleed warning )

9. Tracheostomy Emergency Algorithm

 Scenario: Sudden desaturation

DOPE approach:

  • D → Displacement
  • O → Obstruction
  • P → Pneumothorax
  • E → Equipment failure

If cannot ventilate:

  • Remove tube
  • Attempt oxygen via stoma
  • Bag-mask via mouth if early stoma

 10. Care & Maintenance 

Routine Care

  • Humidification (VERY IMPORTANT-prevents plugging)
  • Suctioning
  • Inner cannula cleaning
  • Stoma care

Tube Change

  • First change(not compulsory): if done then only after track maturation
  • Surgical → 5–7 days
    • Percutaneous → 3–5 days

 Timeline of Tract Maturation

  • Begins: ~48–72 hours
  • More stable: 3–5 days
  • Fully matured: ~5–7 days (or longer in surgical)

From:

  • British Thoracic Society
  • Intensive Care Society
  • American Thoracic Society

First change = after tract maturation

Subsequent changes = only when clinically indicated