Tracheostomy Tubes at Coventry’s Ventilator Unit: Options and Choices

Adam J. Ross, CRT

At Coventry Skilled Nursing & Rehabilitation’s ventilator unit we utilize a plethora of tracheostomy tubes with our patients. There are many different styles, models, designs, and sizes to consider. Careful and comprehensive assessments must be made prior to providing a new or different tube for a patient. The objective is to provide for our patients an apparatus that will help facilitate the attainment of their individual long-term goals while minimizing complications.

Subacute ventilator units will see a wide variety of patients. There are long-term patients who will spend the rest of their lives under our care. There are occasionally short-term patients who may be able to be weaned from their breathing machine within weeks to months. Some of our patients will be guided to a full recovery; leaving our building without any tubes at all. Some others may only be able to partially recover and end up going home with a tracheostomy.

With such a diverse population of pathologies and prognoses it is important for the clinical care team to have an adequate array of devices to utilize. Every make and model has slight nuances that can make or break a patient’s progress or continued stability1, 3. Different sizes, materials, shapes, and other design features need to be carefully considered prior to insertion; depending on the individual’s diagnoses, prognoses, and reason for needing a tracheostomy their ideal device can vary wildly1,3,4.

The most common patient ventilator status we see, by a wide margin, is a chronic and non-weanable individual. These patients have diagnoses ranging from progressive neuromuscular disorders (ALS, e.g.) to decades old strokes that have kept them in an unresponsive persistent vegetative state since the original incident took place. Some of our chronic ventilator patients simply have poor airway maintenance and only utilize the breathing machine at night, but require the tube so that care providers can suction their trachea out routinely. Some can swallow, some can speak, and some can do neither. As we can see, even among the same subset of patients there are needs that differ greatly from one another.

The most common tube we see upon admission is a Shiley DCT. This thick-walled, rigid tube is a great choice for long-term ventilator or tracheostomy patients, especially if the only concern is to provide a table and patent airway. However, the Shiley tube’s dimensions can make it difficult for a patient to undergo speech and swallow trials5. Its Inside Diameter (ID) to Outside Diameter (OD) ratio produces a tube that takes up a lot of space within the patient’s airway thus restricting flow and often preventing progression or phonation5. Despite its drawback the tube continues to be a popular choice for stable, long-term tracheostomy patients due to its rugged construction and ease of care.

Another popular routine tracheostomy tube we utilize and admit patients with is the Portex DIC. Similar in shape to the aforementioned Shiley tube, the Portex has a significantly smaller OD to a given ID. These tubes can be used to provide an airway for a patient who has been identified as potentially progressive and some quality of life goals have been initiated. While slightly more flexible and lighter than Shileys, Portex tubes are still considered a standard and routine appliance.

The third and final tube we have been utilizing regularly within the facility is the Bivona TTS. This silicone tube is soft, comfortable, utilizes water instead of an air cuff, and has multiple benefits for many of our patients over the standard tubes. The “Tight to Shaft” cuff allows us to provide atraumatic tube changes as needed while permitting increased flow around the tube and out of the mouth during periods of cuff deflation4,5. Studies have shown that usage of the Bivona TTS has produced improved outcomes in terms of how quickly a weanable patient can begin speaking 5. Use of this tube has also decreased incidents of tube malposition, hemorrhage, and can even help heal ongoing stoma infections and complications seen with typical Polyvinyl Carbonate (PVC) tube construction in some patients5,6,7.

We have had many different types of tubes used as well. Some of our patients have required special order tubes that require our care team to design everything from the type of material to the length of the shaft and placement of the cuff. While we strive to standardize as much as we can, people can have amazingly different anatomical anomalies, material sensitivities, and tolerances. Very often a long-term patient’s needs change; having a tracheostomy tube for long periods of time changes your anatomy slowly among other known risks and complications.

While our top three most used tubes have proven to be adequate for most of our patient population, there will still be individuals whose needs surpass what can be taken from routine supplies. One thing that has made Coventry’s Ventilator Unit so successful has been early recognition of an apparatus’ insufficient or improper usage and a team effort to devise and implement a strategy to quickly replace it with something more suitable.

Sometimes the better strategy can be as simple as doing routine tube changes less frequently to prevent irritation or trauma. Regardless of a tube’s construction, studies show that a tracheostomy tube can last up to 90 days before requiring replacement2. This means that, for some patients, we are exposing them to less chance of injury or undue discomfort by changing a perfectly fine apparatus excessively. This is also a cost-saving idea as some of the less common tubes are much more expensive than our standard devices; 12 tubes a year versus 4 tubes a year is a big difference for patients with strained coverage or facility’s with a limited budget.

In conclusion it is paramount that ventilator and tracheostomy units be able to provide for their patients the devices needed to survive, progress, and maintain their statuses. Different patients have different needs and to try and limit tracheostomy tube availability to a few routine models is ill-advised and will negatively impact outcomes. People come in all shapes and sizes; there is a reason tracheostomy tubes do to.

References

[1] Dean L. Cuffed vs. Uncuffed Trachs: Ask the Experts http://www.ventusers.org/edu/valnews/val_25-3jun11p4-5.pdf

[2] Backman S. et. al. Material wear of polumeric trachestomy tubes: a six-month study. http://www.ncbi.nlm.nih.gov/pubmed/19205021

[3] Hess D. Tracheostomy Tubes and Related Appliances. April 2005, Respiratory Care Vol. 50 No. 4

[4] Kacmerack B. Tubes and Trachs A to Z: MGH Powerpoint http://foocus.com/power-point/Trachs-A-to-Z-FOCUS.pdf

[5] McCracken J. & Leasa D. Trach tubes designed to maximize safety may increase risk to ventilated pateintshttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC3220018/

[6] Dean L. Changing Tracheostomy Tube Material and Utilizing Silicone Dressings Healed This Stoma – A Case Reporthttp://www.mcarthurmedical.com/upload/product_file906.flex%20tc%20pad%20rt-apr%20may%202013

[7] Iodice F. et. al. Tracheobronchial haemorrhage in patients with neuromuscular disordershttp://www.sciencedirect.com/science/article/pii/S0954611105002465