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Tracheostomy Tube Cuffs Tracheostomy tubes can be cuffed or uncuffed. Uncuffed tubes allow airway clearance but provide no protection from aspiration. Cuffed tracheostomy tubes allow secretion clearance and offer some protection from aspiration, and positive-pressure ventilation can be more effectively applied when the cuff is inflated.
Specific types of cuffs used on tracheostomy tubes include high-volume low-pressure cuffs, tight-to-shaft cuffs low-volume high-pressureand foam cuffs. High-volume low-pressure cuffs are most commonly used.
Tracheal capillary perfusion pressure is normally 25—35 mm Hg.
Because the pressure transmitted from the cuff to the tracheal wall is usually less than the pressure in the cuff, it is generally agreed that 30 cm H2O 22 mm Hg is the maximal acceptable intracuff pressure. If the cuff pressure is too low, silent aspiration is more likely. Therefore, it is recommended that cuff pressure be maintained at 20—30 cm H2O 15—22 mm Hg to minimize the risks for both tracheal wall injury and aspiration.
A leak around the cuff is assessed by auscultation over the suprasternal notch or the lateral neck. Techniques such as the minimal occlusion pressure or minimal leak technique are not recommended.
In particular, the minimal leak technique is Respiratory therapist research paper recommended as it may increase the risk of silent aspiration. Intracuff pressure should be monitored and recorded regularly eg, once per shift and more often if the tube is changed, if its position changes, if the volume of air in the cuff is changed, or if a leak occurs.
In addition to the increased potential for airway injury with higher cuff pressures, the swallowing reflex is more difficult to elicit with increasing cuff pressure, and when activated, the resulting motor swallowing activity and efficiency in elevating the larynx are depressed.
Another common cause of high cuff pressure is malposition of the tube eg, cuff inflated in the stoma. Other causes of high cuff pressure include overfilling of the cuff, tracheal dilation, and use of a low-volume high-pressure cuff.
The tight-to-shaft cuff minimizes air-flow obstruction around the outside of the tube when the cuff is deflated.
It is a low-volume high-pressure cuff intended for patients requiring intermittent cuff inflation. When the cuff is deflated, speech and upper airway use are facilitated. The cuff is constructed of silicone. It should be inflated with sterile water because otherwise the cuff will automatically deflate over time due to gas permeability.
A single-lumen tube with a tight-to-shaft cuff might be useful to minimize resistance when breathing through the tube and when breathing around the tube with the cuff deflated.
The foam cuff was designed to address the issues of high lateral tracheal wall pressures that lead to complications such as tracheal necrosis and stenosis. Before insertion, a syringe attached to the pilot port evacuates air in the cuff. Once the tube is in place, the syringe is removed to allow the cuff to re-expand against the tracheal wall.
The pilot tube remains open to the atmosphere, so the intracuff pressure is at ambient levels. The open pilot port also permits compression and expansion of the cuff during the ventilatory cycle.
The degree of expansion of the foam is a determining factor of the degree of tracheal wall pressure. As the foam further expands, lateral tracheal wall pressure increases. When used properly, this pressure does not exceed 20 mm Hg 27 cm H2O.
The proper size is important to maintain a seal and the benefit from the pressure-limiting advantages of the foam-filled cuff. If the tube is too small, the foam will inflate to its unrestricted size and not touch the tracheal wall, causing loss of ventilation and loss of protection against aspiration.
If a leak occurs during positive-pressure ventilation with the foam cuff, it can be attached to the ventilator circuit so that cuff pressure approximates airway pressure.
If the tube is too large, the foam is unable to expand properly to provide the desired cushion, with increased pressure against the tracheal wall. The manufacturer recommends periodic cuff deflation to determine the integrity of the cuff and to prevent the silicone cuff from adhering to the tracheal mucosa.
Despite the availability of this cuff type for many years, it is not commonly used. Its use is often reserved for patients who have already developed tracheal injury related to the cuff.Topics could encourage teamwork, highlight a new workplace innovation or method, offer educational tips, or draw attention to a co-worker who is working on a research paper, for example.
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