Tracheostomy Tube Selection and Management

Tube Composition and Design

The American Thoracic Society recommends tracheostomy tubes made from silicone, polyvinyl chloride, or metal, each with its own set of advantages and disadvantages, including flexibility and airway resistance 1, 3
Metal tubes are used in special circumstances, such as with Aboulker stents after laryngeal reconstruction, but may increase airway resistance in small children due to their inner cannulas 1, 4
Tubes with inner cannulas are beneficial for patients with thick secretions, allowing for cleaning without changing the entire tube, and are recommended by the American College of Chest Physicians 3, 5

The American College of Chest Physicians prefers uncuffed tubes in most circumstances, especially in pediatric patients, due to the lower risk of tracheal injury 2, 6
Cuffed tubes have specific indications, including patients requiring ventilation with high pressures, nocturnal ventilation, or those with chronic translaryngeal aspiration, as recommended by the American Thoracic Society 6, 8
High-volume/low-pressure cuffs are the preferred option, maintaining pressures below 20 cm H₂O to preserve airway epithelium perfusion, according to the American College of Chest Physicians 2, 7

Fenestrated tubes have openings in the posterior portion to enhance translaryngeal airflow, aiding speech and secretion clearance, and are recommended by the American Speech-Language-Hearing Association for patients with speaking valves 6, 9
Non-fenestrated tubes are more commonly used, especially in pediatrics, but may not be suitable for patients requiring speech facilitation, as noted by the American Academy of Otolaryngology 6, 9

The American College of Chest Physicians recommends selecting a tube length that extends at least 2 cm beyond the stoma and remains 1-2 cm above the carina, and a diameter that avoids tracheal wall damage and minimizes breathing work 1, 4
The curvature of the distal portion should be concentric and colinear with the trachea to prevent complications, as recommended by the American Thoracic Society 1, 4

Adjustable flange tubes allow customization of insertion length and are recommended by the American College of Chest Physicians for patients with unusual airways 6, 9
Specially manufactured tubes are required for a small minority of patients with unusual airways, and physician-modified tubes should only be used temporarily in urgent situations, as noted by the American Thoracic Society 6, 9

Improper tube selection can cause complications, including esophageal obstruction, tracheal wall erosion, and fistula formation, and the American College of Chest Physicians recommends careful consideration of tube size and fit 1, 10
Cuff management is critical to prevent tracheal injury, and the American Thoracic Society recommends maintaining appropriate cuff pressures, below 20 cm H₂O for high-volume/low-pressure cuffs 2, 7
Inner cannula considerations, including the potential for increased airway resistance, should be taken into account when selecting a tube, as recommended by the American College of Chest Physicians 3, 5