The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [373]
A fenestrated tube is the most suitable for phonation and weaning. A cap (known as a decannulation plug – see Figure 10.21) is placed onto the tube, occluding the artificial airway. This enables air flow through as well as around the tracheostomy tube, allowing the patient to breathe via the oral and nasal passages again. The cap can be left in situ for certain periods of time until the patient can tolerate the tube occluded continuously for an uninterrupted period of time. The Intensive Care Society (ICS 2008) states that this period of time should be a minimum of 4 hours uninterrupted, though common practice is 24 hours in ward environments. Once this has occurred, removal of the entire tube, known as decannulation, can be considered (Harkin 2004, Serra 2000). The decannulation procedure should ideally take place in the morning, during normal working hours, to ensure that a specialist assessment can be sought if the patient requires tracheostomy tube reinsertion (Harkin 2004).
Shiley® fenestrated cuffed tube
This tube is very similar to the cuffless fenestrated tube although it has an outer cuff to facilitate ventilation and protect against aspiration, and only two inner tubes (Figure 10.15d). Both inner tubes have the universal 15 mm extension at the upper aspect to facilitate connection to other apparatus, and one of these (with a green coloured hub) also has a fenestration midway down the tube. The outer tube also has a fenestration in the middle of the cannula, again to encourage a return to normal function. The fenestrated tube can also be occluded with a cap, to assess the patient’s oral and nasal airway, first ensuring that the cuff has been completely deflated and that the fenestrated inner tube is in situ. This tube is particularly useful for weaning patients who require both periods of cuff inflation (to protect the airway) and cuff deflation (to enable a speaking valve to be used) (Russell 2004).
Specialist function tubes
Kapitex Tracheotwist® fenestrated tube
This is a plastic tube with an introducer and two inner tubes (Figure 10.16). One of these inner tubes has an extension at its upper end to facilitate connection to other apparatus. The other inner tube has a fenestration midway down the tube, while the outer tube also has a fenestration consisting of a series of small holes. This helps to reduce the risk of granulation tissue growing through the fenestration. The neck plate or flange moves in a vertical and horizontal direction, enabling the plate to move as the patient moves. An inner tube with integrated speaking valve can be ordered separately.
Figure 10.16 Kapitex Tracheotwist cuffed fenestrated tube.
Portex® Blue Line Ultra® ‘Suctionaid’ and Tracheotwist® 306 tracheostomy tubes
These are specialist tracheostomy tubes that have a facility for aspiration of subglottic secretions (Figure 10.17). They are mostly used for the prevention of ventilator-associated pneumonia (VAP) in critically ill patients, although they are now also indicated for use in patients with conditions such as bulbar palsy who are unable to effectively clear secretions accumulating above the tracheostomy tube. Suction should not be applied continuously due to the risk of laryngeal injury (ICS 2008).
Figure 10.17 Portex Blue-Line ‘Suctionaid’ tracheostomy tube.
Metal tubes
Jackson® silver tracheostomy tube
This is a silver tube with an introducer and inner tube (Figure 10.18a). The inner tube is locked in position by a small catch on the outer tube and may be removed and cleaned as necessary without disturbing the outer tube.
Figure