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The tube and the cuff
Tube choice is about airway protection, secretion clearance, and speech — usually in that order early and reversed later.
- Components: outer cannula, inner cannula (removable and cleaned), obturator (used only for insertion), flange, and cuff pilot balloon.
- Fenestrated tubes allow speech with the inner cannula removed and the cuff deflated; never suction through a fenestration or use one with a cuff inflated and the fenestration open.
- Cuff pressure 20–25 mm Hg (about 25–30 cm H2O). Above 30 mm Hg exceeds tracheal capillary perfusion pressure and produces ischemia, stenosis, and eventually tracheomalacia or a tracheoesophageal fistula.
- Use minimal leak or minimal occluding volume technique and document the pressure each shift.
- Long-term complications: granulation tissue, stomal infection, tube obstruction, and tracheoinnominate fistula — sentinel bleeding around a trach is an emergency.
At the bedside
Always keep an identical tube and one size smaller, an obturator, and a manual resuscitator at the bedside.