If a tracheostomy tube with a cuff is required, one should understand the differences between different types of cuffs that are available. We must be concerned with the pressure that is exerted on the tracheal wall and be vigilant that blood flow is not occluded.
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Uncuffed Tracheostomy Tubes
The application for a cuffless tube are as follows: long term airway management, post laryngectomy, or situations where airway secretion clearance is more important than the need for mechanical ventilation.
Chronically mechanical ventilated patients may also use an uncuffed tube but will have an airway leak. Experience and skill with breathing with this leak can be adapted to by the patient.
The uncuffed tracheostomy tube will not allow for a seal. Because of this the airway is not protected from vomitus, or aspirated secretions.
A Jackson Tube is another example of a cuffless tracheostomy tube. It is used for long term needs such as upper airway obstruction. A Jackson tube is typically made of stainless steel and is cleaned and replaced by the patient.
“Barrel” Shaped, Low Pressure Cuff
Low Pressure Cuff
A low pressure cuff has the shape of a barrel or cylinder. It can be also called a “Low Pressure, High Volume” cuff. The shape of the cuff provides a large surface area where the cuff touches the tracheal wall this is due to the cylindrical shape.
Low pressure cuff style tracheostomy tubes are generally the first type of tracheostomy tube placed however the selection and use of various tracheostomy styles is patient dependent.
The material of the deflated cuff occupies space in the trachea when it is deflated. This situation may create a greater work of breathing due to the reduced space in the trachea for air flow. For some patients this may have a greater effect for others a lesser effect. However, this must be taken into consideration if weaning is planned for a patient who may have developed respiratory muscle weakness over the course of their illness.
Deflated Low Pressure
Tight-to-Shaft (TTS)
A tight-to-shaft (TTS) style cuff is one that can also be termed “High Pressure, Low Volume” compared to a Low Pressure style of tracheostomy tube discussed in the previous section. The cuff of the tight-to-shaft (high pressure, low volume) tracheostomy tube is filled with sterile water verses air. The cuff deflate over time due to the permeability of gas.
Bivona TTS (tight-to-shaft), High Pressure Cuff deflated
“Bubble” shape – High Pressure Cuff inflated
The tight-to-shaft (TTS) style tracheostomy tube gets its name because the cuff has a smaller surface area which comes in contact with the tracheal wall. The cuff of a tight to shaft tracheostomy takes on the shape of a bubble (compare this with the barrel shape of the “Low Pressure Cuff”). The pressure exerted on the trachea is more focused due to the smaller surface area
When deflated, the tight-to-shaft cuff does not cause extra resistance or occlusion inside the trachea.
A tight-to-shaft cuff benefits the patient that requires short term cuff inflation. Such as during nocturnal ventilation or intermittent mechanical ventilation.