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Negus® silver tracheostomy tube

This is a silver tracheostomy tube with an introducer and a choice of inner tubes, with and without speaking valves (Figure 10.18b). The outer tube does not have a safety catch so the inner tube can at times be coughed out inadvertently.

Additional tracheostomy supplies

Speaking valves

These are plastic devices with two-way valves that fit onto the 15 mm hub of the fenestrated inner tube. Distinction should be made between open and closed position valves.

The open position speaking valve (e.g. Rusch® valve) (Figure 10.19) is open by default and closes with positive pressure (expiration) which diverts air through the upper airways past the vocal cords, thus allowing production of a voice.

The closed position speaking valve (e.g. Passy Muir® valve) (Figure 10.20) is closed by default and requires negative pressure (i.e. the patient’s inspiratory effort) to open. Once expiration starts, it closes, causing air to be diverted as described above. This type of valve can be used in ventilator circuits, always with cuff deflation, for patients who are mechanically ventilated.

Figure 10.19 Rusch speaking valve.

Figure 10.20 Passy Muir valve.

If a non-fenestrated cuffed tube is in place, the cuff should always be deflated before a speaking valve is fitted as the patient will not be able to exhale (Clotworthy 2006b). Ordinarily, practitioners will also consider changing a non-fenestrated tube for a fenestrated tube (double lumen, with fenestrated inner tube). This will allow air to be diverted through the fenestrations of the tube in addition to air already diverted around the tube to the upper airways. If a non-fenestrated tube is in place, depending on the size of the tracheostomy tube and the diameter of the patient’s trachea, sufficient air may not be diverted past the cuff. This will result in pressure building up because the patient will not be able to breathe out and the valve will not be tolerated. In this case it will be necessary for a complete outer tube change to a fenestrated tube.

However, anecdotal evidence from practice (often in critical care environments) would suggest that in some instances cuff deflation alone (without changing a non-fenestrated tube for a fenestrated tube) may be sufficient to allow air diversion past the cuff through the upper airways as described above. It is important that each individual case is considered carefully and that practitioners weigh up the potential discomfort and distress a complete tracheostomy tube change may cause against the potential risks of fitting a speaking valve on a non-fenestrated tube. It is therefore imperative that when a speaking valve is used for the first time, the patient is carefully monitored for any signs of respiratory distress. If the patient experiences difficulty in breathing, an inability to vocalize or they begin to sound wheezy or stridulous, the speaking valve should be removed immediately and the patient reassessed (ICS 2008).

Decannulation plug

This is a small plastic plug which fits into the outer fenestrated tube (Figure 10.21). It is used to encourage patients to divert air around the tube past and into the nose and mouth before removal of the tracheostomy tube as described previously. Alternatively, a small plastic plug (Kapitex®) or a blind hub (Shiley®) can be fitted into or over the inner fenestrated tube. This is particularly useful for patients who are still producing tenacious secretions as the plug or hub can be removed to enable the inner tube to be cleaned (Harkin 2004).

Figure 10.21 Decannulation plug.

Specific patient preparations

Care of the patient with a tracheostomy requires a multidisciplinary approach. Patients may have issues with pain and discomfort, swallowing, speech, mobility and general care. Speech and language therapists will play a pivotal role in the assessment and management of the patient’s impaired swallowing and speech. Specialized physiotherapists are skilled in mobilization rehabilitation (see Chapter