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Welcome to Core IM, a virtual medical community! Core IM strives to empower its colleagues of all levels and backgrounds with clinically applicable information as well as inspire curiosity and critical thinking. Core IM promotes its mission through podcasts and other multimodal dialogues. 91������ has teamed up with Core IM to offer continuing medical education, available exclusively to 91������ members by completing the CME/MOC quiz.

Pearl One: Trach Basics

• What is a tracheostomy?
  • A tracheostomy is a surgical airway that bypasses the nasopharynx in order to deliver oxygen directly to the trachea
• What components make up a tracheostomy tube?
  • The outer cannula makes up the body of the trach.
  • The outer cannula connects to a flange or face plate which contains key details about the trach (e.g. size, brand etc) 
    • Tracheostomy tubes are each assigned a number that represents its size, which usually correlates with the inner diameter of the outer cannula
      • OD can refer to the outer diameter of the trach (outer cannula) or the outer diameter of the inner cannula, depending on manufacturer
      • ID can refer to the inner diameter of the trach (outer cannula) OR the inner diameter of the inner cannula, depending on manufacturer
      • Compare different trach sizes and details using this
  • The disposable inner cannula exists to be exchanged, preventing secretion buildup without requiring a full trach change.
• What are the variations of a tracheostomy tube?
  • There are different brand names of tracheostomy tubes, such as Portex and Shiley.
  • “XLT” stands for “extra long tube” and is an optional adjustment for tracheostomy tubes.
    • Proximal XLTs are longer proximally and useful in patients with more neck tissue.
    • Distal XLTs are longer distally and useful in patients with tracheal stenosis or other abnormalities in the trachea. Adjustable length trachs with locking mechanisms also exist for patients with complex anatomy.
  • Trach tubes may have cuffs, i.e. a balloon at the end
    • When inflated, the cuff
      • creates a seal for positive pressure ventilation
      • may protect from large aspiration events in the short-term
    • Downsides to cuff over-inflation [1] [2] include
      • Tracheal necrosis and
      • Impaired swallowing (which could increase aspiration risk long-term).
    • Finding the happy medium of cuff pressure is key.
  • To explore specific variations, check out this and this

Pearl Two: Bedside Triage & Complications

• Ask yourself the following questions:
  • What is the indication of a tracheostomy?
    • One indication is chronic ventilator dependence (e.g. neuromuscular weakness, difficulty weaning off ventilator).
      • Treat trach tube malfunctions as an airway emergency in patients who are ventilator dependent. 
    • Another indication is secretion management (e.g. vocal cord paralysis, stroke).  We have more time to problem-solve around trach tube malfunctions in these patients.
    • Patients not on ventilators are often transitioned to trach collar (or sometimes called trach masks), which is essentially a humidified nasal cannula through the trach.
  • When was the tracheostomy tube first placed?
    • Timing of initial trach tube placement guides management of common complications.
    • An early trach tube is the first trach placed. This will be sutured in, is typically in place for about 2 weeks , and is higher risk to manipulate because the tract has not fully epithelialized.
    • A trach is mature about 2 weeks (can be as early as 5-8 days) after placement, and is much safer to manipulate because the tract has epithelized. Sutures are generally removed around time of trach maturation.    
• The big 3 complications
  • Accidental Decannulation (Trach tube “fell out”)
    • Early Trach: reinserting a trach tube has a high risk of creating a false tract (ending up in the wrong place) potentially causing pneumomediastinum and other complications.
      • Instead, prepare to “ventilate from above” ie from the nasopharynx such as with non-rebreather or intubating if necessary.
    • Mature Trach: trach tube can be safely replaced because the tract has epithelized.
      • Replacement is done with the obturator, an insertable rigid plastic piece that stiffens the trach tube to facilitate insertion.
        • Know where to find the obturator in your patient’s room!
      • As a precaution, stock 2 spares in the room: 1 of the same size, and 1 a size smaller
  • Obstruction
    • Early Trach:
      • Suction inside the trach tube
      • Replacing the inner cannula (but not the whole trach)
      • If needed, ventilate from above
        • When ventilating from above in a patient with a cuffed trach tube, the cuff must be deflated for oxygen to make it down to the lungs
    • Mature Trach: same options as with an early trach, with the addition of full trach replacement if needed
  • Bleeding
    • Early Trach: bleeding from the trach tube is typically mucosal and can be treated with pressure or silver nitrate
    • Mature Trach: 
      • Feared (but rare) cause of bleeding is a tracheoinnominate fistula
        • Caused by erosion into the innominate artery
        • Brisk airway bleed and requires immediate surgical treatment.
        • Try to achieve tamponade by either over-inflating the trach cuff or using a finger occlusion technique ()
  • Bonus: Tension Pneumothorax
    • Rare complication but always one to consider in the immediate post-procedure period
• Caveat to Ventilating From Above
  • In patients who have had laryngectomy or who have fixed upper airway obstruction, the tracheostomy is their only airway (i.e. cannot be intubated).
    • Instead of ventilating from nasopharynx, provide oxygen through the tracheostomy stoma

Pearl Three: Airway Clearance

• Hydration and Airway humidification
  • Rationale: Tracheostomies bypass the nasopharynx which typically humidifies air. As a result, secretions may become thicker and drier.
  • What helps with airway clearance in a patient with trach?
    • Adequate hydration
    • Humidification keep secretions from drying out
      • Trach collar (essentially humidified nasal cannula) provides humidified oxygen through the trachea
      • Heat moisture exchanger, which is a thin piece of paper that traps and recycles moisture.
• Suctioning
  • Use a flexible red rubber catheter for suctioning, which is less likely to cause airway irritation and bleeding than a rigid suction
  • Preventive suctioning can remove secretions before they dry out
• Pharmacologics
  • Albuterol is standard.[3] 
  • Avoid medications that can further dry secretions, such as ipratropium and glycopyrrolate
    • However, this is not a hard and fast rule in managing secretions. Sometimes, patients who have trouble with drooling or have copious secretions (e.g. hospice, parkinson's, other neurologic disease), you may want to use agents that thicken secretions.
  • Hypertonic saline can thin existing secretions by drawing water into mucus
• “Ask the patient”
  • Patients may have already found a regimen that works for them. Ask!

Pearl Four: Passy Muir Valves (Speaking valves)

• Determining readiness for phonation
  • Patients progress from larger trach tubes to smaller trach tubes to uncuffed trach tubes and finally to a speaking valve
  • Ideal candidates are awake, alert, off positive pressure and have controlled secretion burden
    • Technically, we can actually get they are fully weaned from ventilation (especially since the inability to speak can be so troubling for patients) but requires considerations of other factors
• Mechanics of speaking valves
  • Speaking valves are one-way valves that open on inhalation and close on exhalation.
    • Since the speaking valve closes on exhalation, outgoing airflow must go through the vocal cords and nasopharynx (and that air movement through the vocal cords generates sound and allows for phonation!)
• Trach cuff must be down
  • An inflated trach tube cuff with a speaking valve leads to air trapping. Incoming airflow cannot exit.
  • For this reason, speaking valves are generally avoided in a trach tube with a cuff (with a few expectations of cuffdown)
• Additional Support
  • When in doubt, consult your neighborhood respiratory therapist and speech and language pathologist

Pearl Five: Decannulation

• Determining readiness for decannulation
  • This is similar to determining readiness for phonation. Patients progress from larger to smaller trach tubes to uncuffed trach tubes and eventually to a capping trial
  • In a capping trial, a cap is placed over the trach tube for up to 48 hours.
  • The capping trial blocks all airflow through the trach tube and forces all airflow to go through nasopharynx
  • A capping trial is a test run before decannulation:
    • Use it to assess work of breathing and secretion tolerance
• Decannulation Process
  • Straightforward process wherein the trach tube is removed and the stoma covered with gauze.
  • The stoma typically heals over weeks to months.

Contributors

Shreya Trivedi, MD, 91������ Member – Author
Matt Tsai, MD – Author, host
Tim Rowe, MD – Author, host
Nick Mark, MD – Guest expert
Linda Morris, MD – Guest expert

Reviewers

Michael Brenner, MD
David Roberson, MD

Those named above, unless otherwise indicated, have no relevant financial relationships to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. All relevant relationships have been mitigated.

Release Date: March 8, 2023

Expiration Date: March 8, 2026

CME Credit

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American College of Physicians and Core IM. The American College of Physicians is accredited by the ACCME to provide continuing medical education for physicians.

The American College of Physicians designates this enduring material (podcast) for .75 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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