Download Selezione ARIR - ARIR Associazione riabilitatori della insufficienza

• Numero 02
• Anno I
• Dicembre 2006
Selezione ARIR
INTERNATIONAL
AFFILIATE
Poste italiane s.p.a. - Spedizione in Abbonamento Postale - D.L. 353/2003 (conv. In L. 27/02/2004 n.46) art.1, comma 2, DCB Milano.
da
e
AARC Times
Anatomy and Physiology of Tracheostomy
Scott K Epstein MD
Tracheostomy Tubes and Related Appliances
Dean R Hess PhD RRT FAARC
Facilitating Speech
in the Patient with a Tracheostomy
Dean R Hess PhD RRT FAARC
EDIZIONI
DIRETTORE RESPONSABILE
EDITOR IN CHIEF
GIOVANNI OLIVA
[email protected]
REDAZIONE
EDITORIAL STAFF
ANTONELLA SANNITI,
ANDREA TETTAMANTI
RESPONSABILI SCIENTIFICI
SCIENTIFIC ACCOUNTEES
ENRICO CLINI,
ELENA REPOSSINI
BOARD EDITORIALE
EDITORIAL BOARD
ANNA BRIVIO,
PAOLA CAPONE,
MARTA CORNACCHIA,
PAMELA FRIGERIO,
MARTA LAZZERI,
GIANCARLO PIAGGI,
MAURIZIO SOMMARIVA,
SERGIO ZUFFO
ARIR:
www.arirassociazione.org
AARC:
www.aarc.org
EDITORE
EDITOR
ARIR EDIZIONI
ASSOCIAZIONE RIABILITATORI
DELL’INSUFFICIENZA RESPIRATORIA
UNITÀ SPINALE
A.O. OSPEDALE NIGUARDA
CA’ GRANDA MILANO
PIAZZA OSPEDALE MAGGIORE 3
20162 MILANO
IMPAGINAZIONE E PRESTAMPA
INK GRAPHICS COMMUNICATIONS S.R.L.
VIA IV NOVEMBRE, 52/A
20019 SEGURO DI SETTIMO M.SE (MI)
STAMPA OFFICINA GRAFICA S.R.L.
VIA DELLA MECCANICA, 6
VIGANO DI GAGGIANO 20083 (MI)
REG. TRIBUNALE DI MILANO N.967
06-07-06
DEL
Il periodico “Selezione ARIR da Respiratory
Care e AARC Times” costituisce il secondo
impegno editoriale dell’Associazione
Riabilitatori dell’Insufficienza Respiratoria
(ARIR).
Le motivazioni di questa realizzazione
si delineano nell’ambito dell’attività
di didattica e aggiornamento che
l’associazione svolge ormai da 20 anni.
È proprio realizzando corsi per Fisioterapisti
in molti ospedali italiani che l’Associazione
ha conosciuto direttamente quali sono
i principali problemi ed ostacoli che
il Fisioterapista incontra nel processo
continuo di aggiornamento in materia
di Fisioterapia e Riabilitazione Respiratoria.
Uno degli aspetti cruciali per mantenersi
“al passo con i tempi” ,oltre a partecipare
a corsi specifici, è rappresentato dalla
possibilità di entrare in contatto con
esperienze e realtà più evolute ma
al tempo stesso applicabili alla realtà
italiana.
I criteri di valutazione e monitoraggio,
le tecniche operative, gli approcci
e le metodiche sono ciò che il Fisioterapista
deve acquisire per incrementare l’efficacia
del suo intervento.
La realtà della Fisioterapia e Riabilitazione
Respiratoria è molto diversa da paese
a paese ed in particolare rispetto alla realtà
americana e questo rende l’aggiornamento
un’operazione complessa e difficoltosa
oltre che onerosa.
L’ARIR dagli inizi della sua costituzione
si è posta tra i vari obiettivi anche quello
di ridurre le difficoltà e facilitare
l’aggiornamento dei Fisioterapisti Italiani
organizzando corsi e convegni a cui ha
invitato e invita numerosi colleghi stranieri,
esperti nei diversi ambiti della Fisioterapia
e Riabilitazione Respiratoria, promuovendo
così lo scambio culturale e professionale
tra le diverse realtà europee e anche
extra-europee.
Con la realizzazione di “Selezione ARIR
da Respiratory Care e AARC Times”
l’ARIR intende rispondere ulteriormente
e in modo concreto ad una esigenza
centrale della formazione: l’accesso
alle pubblicazioni scientifiche.
Questo periodico offre a chi si occupa
di Fisioterapia e Riabilitazione Respiratoria
la possibilità di accedere ad alcune delle
pubblicazioni scientifiche della American
Association for Respiratory Care (AARC),
selezionando quelle più vicine alla realtà
italiana.
“Selezione ARIR da Respiratory Care
e AARC Times” è un periodico semestrale
che nasce dalla volontà congiunta di ARIR
e AARC frutto dell’affiliazione delle due
Associazioni e sarà distribuito gratuitamente
ai soci ARIR e verrà pubblicato nel website
dell’Associazione www.arirassociazione.org
nello spazio riservato ai soci.
A nome del Direttivo ARIR
Il Presidente ARIR
Ft Marta Lazzeri
The review "ARIR selection from Respiratory
Care and AARC Time" is the second editorial
engagement of the Italian Associazione
Riabilitatori della Insufficienza Respiratoria
(ARIR)
The reasons of this workmust be found
in the educational and updating activity
that the association has been developing
from more than 20 years.
The association has directlyknown,
during its courses which are the principal
problems and obstacles in many italian
hospitals. Above all, the necessity of a
continuous updating in physiotherapy
and respiratory care.
In addition to attend specific courses,
one of the meaning aspect to bring up
to date, is to meet more developed
experiences and reality suitable to
the italian ones.
The evaluation criteria and the operative
techniques are the elements that
any physiotherapist must study to
ameliorate the efficacy of his/her job.
The reality of physiotherapy and
respiratory care is very different from
country to country, particularly from
the US one, thus making the updating
a very difficult and expensive operation.
From the beginning, one of ARIR objective
has been that of making easy the updating
of the italian physiotherapists, thus
organizing events on specific topics
(courses and congress). So far, many
foreign people, experts in physiotherapy
and respiratory care, has been invited
from ARIR with the goal of promoting
the cultural and professional exchange
from european and extra European
experiences.
With the realization of "ARIR selection
from Respiratory Care and AARC Time",
ARIR wants to answer in a concrete way
to a principal exigence of the professional
education: the access to the scientific
articles.
This review offers to people who are
encharged in physiotherapy and respiratory
care the access to scientific articles of the
American Association for Respiratory Care
(AARC), selecting the ones closer to the
italian reality.
"ARIR selection from Respiratory Care
and AARC Time" is a six month review
born from the ARIR and AARC agreement,
and it will be distributed for free to the
ARIR members and published in the
ARIR website (www.ariassociazione.org)
in the page reserved to its members.
From the Board of Directors
The President of Arir
Marta Lazzeri
PRESIDENTE
PRESIDENT
AND FOUNDING MEMBER
DALLO STATUTO DELLA ASSOCIAZIONE
FROM THE STATUTE OF THE ASSOCIATION:
Art. 1: è costituita l’Associazione Riabilitatori
dell’Insufficienza Respiratoria (A.R.I.R.).
Art.1: The Associazione Riabilitatori
dell’Insufficienza Respiratoria (A.R.I.R.) was
established in Milan on October 25, 1989.
MARTA LAZZERI
[email protected]
VICE PRESIDENTE
VICE PRESIDENT
AND FOUNDING MEMBER
GIOVANNI OLIVA
[email protected]
SEGRETERIA
SECRETARY
ANNA BRIVIO
[email protected]
TESORIERE
TREASORER
ALESSIA COLOMBO
CONSIGLIERI
BOARD
PAMELA FRIGERIO
GIANCARLO PIAGGI
ELENA REPOSSINI
ANTONELLA SANNITI
MAURIZIO SOMMARIVA
SERGIO ZUFFO
CONSIGLIERI ONORARI
HONORARY BOARD
ROBERTO ADONE
MONICA BASSI
ANDREA BELLONE
ITALO BRAMBILLA
Art. 3: l’Associazione non ha finalità di lucro e
intende promuovere la prevenzione e la
riabilitazione delle patologie respiratorie.
Per il conseguimento dei suoi scopi
l’Associazione concorre a:
• Diffondere in campo clinico terapeutico
e home care, la pratica della fisioterapia
e riabilitazione respiratoria.
• Organizzare la formazione, l’aggiornamento,
il coordinamento, la promozione dello sviluppo
professionale dei fisioterapisti con specifiche
competenze in ambito respiratorio.
• Sostenere in campo scientifico e sociale
l’educazione e l’igiene respiratoria.
• Promuovere la ricerca scientifica nel campo
della fisioterapia e della riabilitazione
respiratoria.
Art. 4: sono soci le persone e gli enti che
verranno ammessi dal Consiglio e che
verseranno la quota di Associazione.
Art. 5: i soci si dividono in quattro categorie:
1. soci fondatori
2. soci ordinari
3. soci sostenitori
4. soci onorari
Sono soci fondatori coloro che hanno sottoscritto
l’atto Costitutivo dell’Associazione e coloro i quali
pur non avendo sottoscritto l’atto costitutivo sia
attribuita dal Consiglio tale qualifica.
Sono soci ordinari i fisioterapisti accettati dal
Consiglio direttivo e che versano annualmente
la quota associativa stabilita
Sono soci sostenitori persone fisiche e
giuridiche che intendono sostenere gli scopi
che l’Associazione si prefigge.
Sono soci onorari le persone e gli enti ai quali il
Direttivo attribuisce tale qualifica, ritenendole in
grado, per qualità, titoli o attività, di dare
all’Associazione un contributo d’opera o
di prestigio.
Art. 6: l’Associazione trae mezzi per
conseguire i propri scopi dai contributi dei soci
e da ogni altro provento che le confluisca.
Art. 9: i soci hanno diritto:
di partecipare alle assemblee e di usufruire
del materiale tecnico e didattico
dell’Associazione, così come, in via
prioritaria, di beneficiare delle iniziative
promosse dall’Associazione,
Art.3: PURPOSE OF THE ASSOCIATION
ARIR is a no profit entity, promoting the
prevention and rehabilitation of respiratory
disease. In order to do this ARIR strives to:
• Promote the practice of respiratory therapy
and pulmonary rehabilitation within the
clinical and therapeutic fields;
• Organize the training, continuing education,
coordination, and the promotion and the
professional development of physiotherapist
having specific competencies in the respiratory
fields;
• Support respiratory care understanding the
hygiene within the scientific and social realms;
• Promote scientific research in the field of
physiotherapy and respiratory rehabilitation.
Art. 4: All persons and entities that are
accepted by the Board of Directors and who
pay the associational fee are considered
members.
Art. 5: There are four categories
of membership:
1. Founding members
2. Regular members
3. Sustaining members
4. Honorary members.
Those who have taken part in the signing
of the associational statute and those whom,
thought not having signed the statute, are
deemed valid candidates by the Board of
Directors are founding members.
Physiotherapists accepted by the Board
of Directors and who pay the established
yearly associational fee are considered
regular members.
Natural and juridical persons who wish to
support the pre-established purpose of the
association are considered sustaining
members.
Persons and entities to which the Board
of Directors deems such status appropriate,
for reasons of capabilities, qualities, titles
or activities able to give the Association
a contribution of work or prestige, are
considered honorary members.
Art. 6: The Association obtains the means of
carrying out its purpose from the contributions
of its members and from any other proceeds
going towards it.
Art. 9: MEMBER RIGHTS
The members have the right to: participate
at he assemblies, utilize the technical and
teaching materials of the Association, as well
as enjoy, as privileged members, the benefits
of the activities promoted by the Association.
New collaboration between ARIR and AARC
On behalf of the American Association for Respiratory Care (AARC) I want to welcome you to the result of a
new partnership between ARIR and AARC, the first issue of Selezione ARIR da Respiratory Care e AARC Times.
In this publication you will find manuscripts which have been published in AARC’s peer reviewed science journal, Respiratory Care. These manuscripts have been selected by ARIR for your benefit in an effort to offer more
education to those who provide respiratory care services in Italy and are members of ARIR.
Even though the American Association for Respiratory Care is comprised primarily of respiratory therapists,
we recognize and respect the many other health care professionals around the world such as physiotherapists, respiratory therapy physiologists, physicians and nurses who provide these services. Twenty countries
from all parts of the world collaborate through the AARC International Council. ARIR is one of its members, of
course. Through the Council we have engaged with the ARIR leadership and have now developed a partnership which will permit ARIR to select manuscripts published in Respiratory Care as well as articles published
in another monthly publication by AARC which is called AARC Times.
We hope that you will find the information contained in the first issue of Volume One to be useful in your practice. Moreover, we look forward to providing even more opportunities to learn about respiratory care by making more materials available to you from Respiratory Care Journal and AARC Times in the future.
While we all recognize that throughout the world we may be separated by distance, culture, and language, we
also recognize that respiratory patients deserve the best care possible. Toward that end, we are delighted to
collaborate with other organizations such as ARIR in order to provide increased access to information regarding the treatment of these patients.
If you wold like to subscribe to either of our publications please feel free to visit the AARC website at
www.aarc.org/resources/subscritions for more information. The AARC is grateful for the recognition that ARIR
has given it and we will endeavor to do our utmost to provide you with the latest information about all aspects
of respiratory care.
On behalf of the AARC we hope you find the new partnership with ARIR and the opportunity to access articles of interest to you in your practice of value.
Sam Giordano
executive director
AARC executive office
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
1
Affiliation of ARIR to AARC has also been carried out through
its adhesion to the International Council for Respiratory Care.
ARIR is representing Italy within ICRC through Sergio Zuffo, respiratory physiotherapist
member of ARIR's board of directors.
www.irccouncil.org
MISSION STATEMENT
The International Council for Respiratory Care (ICRC) is dedicated to advancing the safe, effective and ethical practice of respiratory care worldwide through the following initiatives:
•
Promoting the art, science, clinical practice and educational foundation required for the attainment of high
quality respiratory care outcomes in all nations;
•
Developing and disseminating evidence-based standards of care according to the special needs and
resources of individual nations;
•
Facilitating interaction among and between the allied health professions, nursing, the medical specialties, hospitals and clinics, service companies and industry;
•
Encouraging the creation and growth of related respiratory care organizations in individual nations, and
•
Providing educational resources for patients, caregivers and the general public in respiratory health promotion, disease prevention and rehabilitation as appropriate in individual nations.
STRATEGIC GOALS
1.
2.
3.
4.
5.
6.
7.
8.
2
Establish a global, real time, bi-directional communication system
Enhance and facilitate the acquisition of information relevant to the clinical practice of respiratory care
Promote respiratory education
Establish transparent operational policies and procedures
Identify and secure appropriate resources
Develop a marketing and public communications plan
Assist with the development and promulgation of safe and ethical practice standards and clinical protocols
for respiratory care
Develop and make available educational materials for the public on health promotion and disease prevention
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
Anatomy and Physiology of Tracheostomy
Scott K Epstein MD
Respir Care 2005;50(3):476—482. © 2005 Daedalus Enterprises
Introduction
Anatomy
Physiology
Humidification
Airflow Resistance
Respiratory Mechanics in Bench Studies
Tracheostomy Compared to the Native Upper Airway
Tracheostomy Compared to Translaryngeal Endotracheal Intubation
Summary
The trachea is easily accessible at the bedside. As such it provides ready access for emergency
airway cannulation (eg, in the setting of acute upper airway obstruction) and for chronic airway
access after laryngeal surgery. More commonly, tracheostomy tubes are placed to allow removal of
a translaryngeal endotracheal tube. Tracheostomy tubes have an important effect on respiratory
physiology. The most recent and methodological robust studies indicate that these tubes reduce
resistive and elastic work of breathing, when compared to endotracheal tubes. This is a result of
tracheostomy tubes lessening inspiratory and expiratory airways resistance and intrinsic positive
end-expiratory pressure. Whether these physiologic benefits are of clinical importance in enhancing
weaning success remains to be elucidated. Key words: tracheostomy, resistance, elastance, work of
breathing, mechanical ventilation, weaning, extubation. [Respir Care 2005;50(3):476 – 482. © 2005
Daedalus Enterprises]
Introduction
The trachea is easily accessible at the bedside. As such
it provides ready access for emergency airway cannulation
(eg, in the setting of acute upper-airway obstruction) and
for long-term airway access after laryngeal surgery. More
commonly, tracheostomy tubes are placed to allow re-
Scott K Epstein MD is affiliated with the Department of Medicine, Caritas-St Elizabeth’s Medical Center, Tufts University School of Medicine,
Boston, Massachusetts.
Scott K Epstein MD presented a version of this paper at the 20th Annual
New Horizons Symposium at the 50th International Respiratory Congress, held December 4–7, 2004, in New Orleans, Louisiana.
Correspondence: Scott K Epstein MD, Department of Medicine, Caritas-St Elizabeth’s Medical Center, 736 Cambridge Street, Boston MA
02135. E-mail: [email protected].
moval of a translaryngeal endotracheal tube (ETT). The
procedure can be done surgically or percutaneously, and
with either technique the procedure can be performed in
the operating room or at the bedside in the intensive care
unit (ICU).
Anatomy
The lower respiratory tract starts at the vocal cords.
Inferior to the vocal cords, the rigid cricoid cartilage
encases a 1.5–2.0-cm region known as the subglottic
space. Access to this space is possible via the cricothyroid ligament, a membrane that runs from the thyroid
cartilage inferiorly to the cricoid cartilage. Inferior to
cricoid is the trachea, a cylindrical tube that extends inferiorly and slightly posteriorly. The trachea is made up of
18 –22 C-shaped rings consisting of rigid cartilage anteri-
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
3
Fig. 1. Major landmarks in the neck. (From Reference 3, with permission.)
orly and laterally, and a membranous posterior portion. In
the average adult, the distance from cricoid to carina is
approximately 11 cm in length, with a range of 10 –13 cm.
On average, the trachea is 2.3 cm in width and 1.8 cm from
posterior membrane to the anterior cartilaginous aspect.
The trachea is wider in men than in women.1,2
In examining the landmarks of the neck, it is evident
that the trachea is protected by strap muscles (sternohyoid,
sternothyroid, sternocleidomastoid) and bony structures
(manubrium and sternum) (Fig. 1).3 Furthermore, the trachea is positioned posterior to a number of blood vessels
and the thyroid isthmus. Branches of the bronchial, inferior thyroid, innominate, and subclavian arteries provide
the blood supply to the trachea.1,2
Knowledge of neck and tracheal anatomy is essential
for understanding the various approaches to establishing a
tracheostomy (Fig. 2).4 As an example, surgical tracheostomy tubes are typically placed in the region of the 2nd to
4th tracheal rings and may entail removal of tracheal cartilage or the creation of a cartilaginous flap. Percutaneous
tracheostomy tubes are typically placed between the 1st
4
and 2nd or between the 2nd and 3rd tracheal cartilages.
The technique takes advantage of the Seldinger method,
followed by progressive dilation of the space between tracheal rings to provide access to the trachea. Another approach is to place a tube through the cricothyroid membrane (cricothyroidotomy).5 Though still used extensively
in some centers, in other centers it has been replaced by
percutaneous tracheostomy. Cricothyroidotomy can be
used to gain emergency access to the airway, but its association with numerous complications has led some to
advocate replacing this tube within 48 –72 hours with a
standard tracheostomy. The procedure is carried out by a
transverse incision through the skin and the membrane and
then spreading the incision vertically to allow placement
of the tube. Because the cricothyroid membrane is bounded
by 2 rigid structures (thyroid cartilage and cricoid cartilage) that are not easily dilated, the height of this membrane limits the size of the tube that can be placed. In
addition, the curve of a standard adult tracheostomy tube
and the close soft tissue distance between anterior skin and
trachea (at the level of the cricothyroid membrane) causes
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
Epiglottis
Hyoid
bone
Thyrohyoid
membrane
chronic inflammatory changes.6 Lack of adequate humidification also leads to desiccation of the tracheal mucosa
and reduced ciliary function. Indeed, by these actions and
by diminishing effective cough and increasing secretions,
tracheostomy tubes predispose to respiratory-tract infection. Furthermore, these tubes also hamper effective swallowing, thereby predisposing to aspiration.
Airflow Resistance
Thyroid
cartilage
In studying the physiologic effects of the tracheostomy
tube, one may examine pristine tubes in vitro using a lung
model. Alternatively, in vivo investigations have been conducted comparing the effects of tracheostomy to spontaneous breathing through the native upper airway, breathing before and after tracheostomy decannulation, or to
breathing through an ETT. Investigators have also examined the work of breathing (WOB) imposed by the tracheostomy.
Airflow resistance of the normal upper airway is substantial, constituting up to 80% of total airway resistance
during nose breathing and 50% during mouth breathing.
Theoretically, tracheostomy tubes should decrease airflow
resistance, but in fact this does not occur because of the
smaller radius (inner diameter 7– 8 mm) of the tubes. Tracheostomy tubes may reduce dead space by up to 100 mL,
when compared to spontaneous breathing.6 This occurs
because the tubes are small and bypass the glottic and
supraglottic spaces.
The resistance to flow of gas through a tube, represented
by the Poiseuille equation, is directly proportional to length,
while being inversely proportional to the radius of the tube
raised to the 4th power (when flow is laminar). When flow
becomes turbulent, airways resistance becomes inversely
proportional to the radius of the tube raised to the 5th
power. Indeed, at flows above 0.25 L/s, flow becomes
turbulent when the inner diameter of a tube is ⬍ 10 mm.7
Thus, small reductions in tube radius result in large increases in resistance. Turbulent flow occurs when flow
rates are high, when secretions adhere to the inside of the
tube and because of tube curvature. When compared to the
ETT, the tracheostomy tube has the potential to decrease
the resistive WOB. Tracheostomy tubes are shorter, more
rigid, less likely to be deformed in the upper airway (by
being placed below the vocal cords and the rigid structures
of the subglottic region), and are easier to keep clean (they
more effectively facilitate airway suctioning and removal
of secretions). By decreasing resistance, expiratory flow
can be enhanced, and the tendency to dynamic hyperinflation and the development of intrinsic positive end-expiratory pressure (PEEP) is reduced. Therefore, when compared to ETTs, tracheostomy tubes have the potential to
also reduce the elastic WOB.
Humidification
Respiratory Mechanics in Bench Studies
As with an ETT, many changes in airway physiology
occur with insertion of a tracheostomy tube. Bypassing the
nasal airway, these artificial airways disturb the normal
humidification and warming of inspired air. Therefore, air
must be humidified using heated humidifiers or heat-andmoisture exchangers. In the absence of adequate humidification, the trachea develops squamous metaplasia and
Davis et al examined WOB in a bench lung model study
comparing endotracheal and tracheostomy tubes with the
same inner diameter.8 “Question mark” shaped ETTs were
used to simulate the tortuous route that these tubes often
take in vivo. With either type of tube, WOB and pressure
drop across the tube increased as flow rate increased (leads
to turbulence) and as tube diameter decreased. At high
Cricothyroid
ligament
Cricothyroidotomy
Cricoid
cartilage
Subcricoid
space
Percutaneous
tracheostomy
1st
2nd
Standard
tracheostomy
Tracheal
rings
3rd
Fig. 2. Anterior oblique view of larynx and trachea. The preferred
anatomic locations for placing standard tracheostomy, percutaneous tracheostomy, and cricothyroidotomy are indicated. (From
Reference 4, with permission.)
the tip of the tube to impinge on the posterior membrane
of the trachea.
Physiology
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
5
Tracheostomy Compared to the Native Upper
Airway
How does flow across the tracheostomy tube compare
with that of the spontaneous airway? Older studies found
that airways resistance was greater with a tracheostomy
than when breathing across the normal airway.10 –12 More
recently, Haberthur et al studied 10 medical ICU patients
breathing spontaneously through tracheostomy tubes.13 To
determine the pressure drop across the tracheostomy tube
and the imposed WOB (ie, the additional WOB attributable to the tube), the investigators passed a thin, 1.6-mm
catheter through the lumen of the tube. A linear interpolation algorithm was applied to correct for the pressure
drop induced by this special catheter. While breathing on
a continuous positive airway pressure circuit, the pressure
drop across the tracheostomy tube was as high as 20 cm
H2O when inspiratory flow rates exceeded 10 L/min. This
represented a substantial increase in the expected pressure
drop across the native upper airway, of 1.2 cm H2O at a
flow of 0.3 L/s and 5.2 cm H2O at a flow of 2.0 L/s.
Indeed, the imposed WOB was increased at higher flow
rates, reaching a level sometimes associated with failure to
wean from mechanical ventilation (Fig. 3).13 Similarly,
Davis et al found that WOB increased after extubation and
then was reduced again after placement of a tracheostomy
tube.14
In the studies discussed thus far, physiologic calculations were made as the patient breathed through the tracheostomy. What happens when the tracheostomy is in
place but the patient must breath around the tube? This
exact circumstance often occurs during trials to assess readiness for decannulation, when the tracheostomy tube is
capped. In a single case physiologic study, Criner et al
6
Imposed WOB (J/L)
flow rates of 1–1.5 L/s, WOB was less through the tracheostomy tube. Presumably the longer ETT magnified
the effects of turbulent flow on airways resistance. At
lower flow rates (0.5 L/s) the benefit of shorter tube length
for the tracheostomy was apparently counterbalanced by
the increased curvature of those tubes, leading to no difference in the WOB.
In studying ETTs, Wright et al found that in vivo resistance exceeded in vitro resistance.9 This resulted from
deformation of these thermolabile ETTs and the adherence
of secretions to the inner lumen of the tube (thereby increasing turbulence and narrowing the tube radius). Similarly, Yung and Snowdon demonstrated in vitro that the
pressure drop across a tracheostomy tube (and therefore
the resistance), at any given flow rate, was greater for a
crusted tube than a clean tube.7 These investigators also
compared 3 different types of tracheostomy tubes and found
greatest resistance with the tube that was longer, had a
shorter radius of curvature, and a rougher inner surface.
Low
High
Minute Ventilation
Fig. 3. Imposed work of breathing (WOB) during spontaneous
breathing through a tracheostomy tube at 2 different levels of
ventilation. (Adapted from Reference 13.)
examined the effect of mouth breathing while a capped,
fenestrated, tracheostomy tube was in place, with the balloon deflated.15 Airways resistance and the tension-time
index were higher with the tube in place, when compared
to breathing with a capped Montgomery tube or after decannulation (Fig. 4).
Other studies have compared respiratory mechanics of
breathing through the tracheostomy and mouth breathing
(without the tracheostomy in the airway). To determine the
effect of then removing the tracheostomy tube, Chadda et
al examined 9 neuromuscular patients who underwent decannulation.16 With removal of the tube (eg, mouth breathing), resistance and elastance were unchanged, but dead
space increased from 156 mL to 230 mL, tidal volume
(VT) and minute ventilation increased (PaCO2 was unchanged), and WOB increased by 30%. Moscovici da Cruz
et al studied 7 patients who underwent surgical tracheostomy for malignancy, 3 of whom had tumors of the larynx
and tonsils not felt to be causing upper-airway obstruction.17 When compared to spontaneous breathing, tracheostomy was associated with a trend toward lower resistive
WOB and reductions in elastic WOB, intrinsic PEEP, and
pressure-time product.
Tracheostomy Compared to Translaryngeal
Endotracheal Intubation
Tracheostomy, compared to translaryngeal endotracheal
intubation, has been purported to have many physiologic
benefits, including improved patient comfort, more efficient airway care (improved airway suctioning), better oral
care, and provision of a more secure airway, allowing for
safe patient transfer out of the acute-care ICU.18,19 One of
the most important benefits is the potential to improve
patient liberation from mechanical ventilation. Failure to
wean often results from an imbalance between reduced
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
Tension Time Index
Raw (cm H2O/L/S)
WOB (J/L)
PEEPi (cm H2O)
Fig. 4. Airways resistance (Raw) and tension-time index while breathing through a tracheostomy tube, a Montgomery tube, and after
decannulation. (Adapted from Reference 15.)
Fig. 5. Work of breathing (WOB) in joules per liter (J/L) before (with
endotracheal tube) and after tracheostomy (T) tube placement in 8
patients. (From Reference 25, with permission.)
Fig. 6. Intrinsic positive end-expiratory pressure (PEEPi) before
(with endotracheal tube) and after tracheostomy (T) tube placement in 8 patients. (From Reference 25, with permission.)
respiratory muscle capacity and increased WOB.20,21 Even
in patients without pre-existing lung disease, the WOB
imposed by artificial airways can lead to iatrogenic weaning failure.22 In those with substantial underlying disease,
slight reductions in imposed WOB resulting from placement of a tracheostomy may be important. Therefore, comparison of WOB through the ETT and the tracheostomy
tube is of critical importance.
In a study before and after tracheostomy in 20 mechanically ventilated patients with chronic obstructive pulmonary disease, Lin et al found that, when compared to ETTs,
tracheostomy tubes were associated with a lower peak
airway pressure (33 cm H2O vs 29 cm H2O), but there was
no difference in WOB, pressure-time product, or airways
resistance.23 Mohr et al studied 45 surgical ICU patients
before and after tracheostomy during mechanical ventilation with combined synchronized intermittent mandatory
ventilation and pressure support.24 No differences were
found in respiratory rate, VT, minute ventilation, peak airway pressure, dead space, or blood gases. Furthermore, no
differences were noted in these variables when patients
weaned within 72 hours of tracheostomy were compared
to those remaining on ventilation ⬎ 5 days postoperatively.
In contrast to these studies, 2 superbly performed investigations indicate that tracheostomy does offer physiologic improvements, when compared to translaryngeal
ETTs. Diehl et al examined 8 medical ICU patients (3 with
diaphragmatic weakness, 2 with chronic obstructive pulmonary disease, 1 with asthma, 3 with coma) who had
been ventilated for a mean of 31 days.25 Patients were
studied 24 hours prior to and 6 hours after surgical tracheostomy, at 3 different ventilator settings: baseline pressure support; 5 cm H2O above baseline pressure support;
and 5 cm H2O below baseline pressure support. The diameter of the inner cannula of the tracheostomy tube was
identical to the inner diameter of the removed ETT (8 mm
in 7 patients, 7 mm in 1 patient). Tracheostomy was associated with trends in reductions in VT, respiratory rate,
and minute ventilation. At all pressure-support levels, tra-
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
7
Table 1.
Table 2.
Respiratory Variables Before and After Tracheostomy in
20 Surgical Intensive-Care Patients
Inner Diameter, Length, and Dead Space of Endotracheal
and Tracheostomy Tubes
Variable
Before
Tracheostomy
After
Tracheostomy
p
Tube Type
VT (mL)
V̇E (L/min)
f (breaths/min)
PEEPi (cm H2O)
PTP (cm H2O 䡠 s/min)
WOB (J/L)
WOB (J/min)
Exp Raw (cm H2O/s)
329 ⫾ 104
9.2 ⫾ 3.0
28 ⫾ 5
2.9 ⫾ 1.7
236 ⫾ 122
0.97 ⫾ 0.32
8.9 ⫾ 2.9
9.4 ⫾ 4.1
312 ⫾ 119
8.1 ⫾ 3.1
26 ⫾ 6
1.6 ⫾ 1.0
155 ⫾ 101
0.81 ⫾ 0.46
6.6 ⫾ 1.4
6.3 ⫾ 4.5
0.47
0.26
0.51
0.02
0.09
0.09
0.04
0.07
Endotracheal
No. 6.0
No. 7.0
No. 8.0
No. 8.5
Tracheostomy*
Size 4
Size 6
Size 8
Size 10
VT ⫽ tidal volume
V̇E ⫽ minute volume
f ⫽ respiratory rate
PEEPi ⫽ intrinsic positive end-expiratory pressure
PTP ⫽ pressure-time product
WOB ⫽ work of breathing
Exp Raw ⫽ expiratory airway resistance (From Reference 14, with permission.)
cheostomy was associated with a decrease in the airwayocclusion pressure, a measure of respiratory drive. Moreover, reductions in both resistive WOB (Fig. 5) and elastic
WOB, as indicated by a reduction in intrinsic PEEP (Fig.
6), occurred with placement of the tracheostomy. The latter physiologic benefits may explain the improvement in
patient-ventilator synchrony seen in 3 patients who had frequent trigger asynchrony while breathing through an ETT.
Davis et al studied 20 surgical ICU patients (14 men, 6
women, mean age 58 years) with acute lung injury, ventilated for a mean of 16 days, who met extubation criteria
but had failed extubation twice before the decision was
made to proceed with tracheostomy.14 Eighty percent of
these patients had a #8 (8 mm inner diameter) ETT, while
the remainder had a #7 (7 mm inner diameter) tube. Physiologic measurements were made 6 – 8 hours before and
10 –12 hours after placement of a surgical tracheostomy.
Tracheostomy was associated with trends in reduction in
pressure-time product and expiratory airways resistance
(Table 1). Importantly, as in the study by Diehl et al,25
WOB (J/min) and intrinsic PEEP decreased after placement of the tracheostomy. Assuming equivalent inner diameter, reductions in resistive WOB most likely result
from the reduction in tube length in going from ETT to
tracheostomy tube (Table 2). Although dead space is also
lower with tracheostomy, the magnitude is quite limited.
Tracheostomies differ from ETTs because the former
may have a removable inner cannula. This inner cannula
allows for easy removal and cleaning and occludes the
fenestration to allow for effective mechanical ventilation.
Cowan et al used a lung model to compare the physiologic
effects of nonfenestrated tubes with and without the inner
cannula.26 Tubes of various sizes were studied during different ventilator settings (respiratory rate 12, 24, and 36
8
ID
(mm)
Length
(cm)
Dead Space
(mL)
6.0
7.0
8.0
8.5
31.5
34.5
35.5
36.5
11.0
15.0
18.0
24.0
5.0
7.0
8.5
9.0
10.0
12.0
12.0
12.0
3.0
5.0
6.0
8.0
*Tracheostomy tube size is not equal to inner diameter.
ID ⫽ inner diameter (From Reference 14, with permission.)
breaths/min, VT 300 and 500 mL). Not unexpectedly, WOB
decreased when the inner cannula was removed.
Summary
Tracheostomy tubes have an important effect on respiratory physiology. The most recent and methodological
robust studies indicate that these tubes reduce resistive and
elastic WOB when compared to ETTs. This is a result of
tracheostomy tubes lessening inspiratory and expiratory
airways resistance and intrinsic PEEP. Whether these physiologic benefits are of clinical importance in enhancing
weaning success remains to be elucidated.
REFERENCES
1. Rood S. Anatomy for tracheotomy. In: Myers E, Stool SE, Johnson
JT, editors. Tracheotomy. New York: Churchill Livingstone; 1985:
89–97.
2. Streitz JM Jr, Shapshay SM. Airway injury after tracheotomy and
endotracheal intubation. Surg Clin North Am 1991;71(6):1211–1230.
3. Heffner JE, Sahn SA. The technique of tracheostomy and cricothyroidotomy. J Crit Illness 1987;2(1):79–87.
4. Silvestri GA, Colice GL. Deciding timing and technique for tracheostomy. Contemp Intern Med 1993;5(3):20–31.
5. Johnson J. Alternatives to tracheotomy: cricothyroidotomy. In: Myers E, Stool SE, Johnson JT, ed. Tracheotomy. New York: Churchill
Livingstone; 1985:83–88.
6. Motoyama E. Physiologic alterations in tracheostomy. In: Myers E,
Stool SE, Johnson JT, editors. Tracheotomy. New York: Churchill
Livingstone; 1985:177–200.
7. Yung MW, Snowdon SL. Respiratory resistance of tracheostomy
tubes. Arch Otolaryngol 1984;110(9):591–595.
8. Davis KJ, Branson RD, Pormebka D. A comparison of the imposed
work of breathing with endotracheal and tracheostomy tubes in a
lung model. Respir Care 1994;39(6):611–616.
9. Wright PE, Marini JJ, Bernard GR. In vitro versus in vivo comparison of endotracheal tube airflow resistance. Am Rev Respir Dis
1989;140(1):10–16.
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10. Cavo J, Ogura JH, Sessions DG, Nelson JR. Flow resistance in
tracheotomy tubes. Ann Otol Rhinol Laryngol 1973;82(6):827–830.
11. Cullen JH. An evaluation of tracheostomy in pulmonary emphysema. Ann Intern Med 1963;58:953–960.
12. Kim BM FH. Tracheostomy and physiologic dead space in emphysema. Clin Res 1962;10:258.
13. Haberthur C, Fabry B, Stocker R, Ritz R, Guttmann J. Additional
inspiratory work of breathing imposed by tracheostomy tubes and
non-ideal ventilator properties in critically ill patients. Intensive Care
Med 1999;25(5):514–519.
14. Davis K Jr, Campbell RS, Johannigman JA, Valente JF, Branson
RD. Changes in respiratory mechanics after tracheostomy. Arch Surg
1999;134(1):59–62.
15. Criner G, Make B, Celli B. Respiratory muscle dysfunction secondary
to chronic tracheostomy tube placement. Chest 1987;91(1):139–141.
16. Chadda K, Louis B, Benaissa L, Annane D, Gajdos P, Raphael JC,
Lofaso F. Physiological effects of decannulation in tracheostomized
patients. Intensive Care Med 2002;28(12):1761–1767.
17. Moscovici da Cruz V, Demarzo SE, Sobrinho JB, Amato MB, Kowalski LP, Deheinzelin D. Effects of tracheotomy on respiratory
mechanics in spontaneously breathing patients. Eur Respir J 2002;
20(1):112–117.
18. Astrachan DI, Kirchner JC, Goodwin WJ Jr. Prolonged intubation
vs. tracheotomy: complications, practical and psychological considerations. Laryngoscope 1988;98(11):1165–1169.
19. Heffner JE. Tracheotomy application and timing. Clin Chest Med
2003;24(3):389–398.
20. Vassilakopoulos T, Zakynthinos S, Roussos C. The tension-time
index and the frequency/tidal volume ratio are the major pathophysiologic determinants of weaning failure and success. Am J Respir
Crit Care Med 1998;158(2):378–385.
21. Jubran A, Tobin MJ. Pathophysiologic basis of acute respiratory
distress in patients who fail a trial of weaning from mechanical
ventilation. Am J Respir Crit Care Med 1997;155(3):906–915.
22. Kirton OC, DeHaven CB, Morgan JP, Windsor J, Civetta JM. Elevated imposed work of breathing masquerading as ventilator weaning intolerance. Chest 1995;108(4):1021–1025.
23. Lin MC, Huang CC, Yang CT, Tsai YH, Tsao TC. Pulmonary mechanics in patients with prolonged mechanical ventilation requiring
tracheostomy. Anaesth Intensive Care 1999;27(6):581–585.
24. Mohr AM, Rutherford EJ, Cairns BA, Boysen PG. The role of dead
space ventilation in predicting outcome of successful weaning from
mechanical ventilation. J Trauma 2001;51(5):843–848.
25. Diehl JL, El Atrous S, Touchard D, Lemaire F, Brochard L. Changes
in the work of breathing induced by tracheotomy in ventilator-dependent patients. Am J Respir Crit Care Med 1999;159(2):383–388.
26. Cowan T, Op’t Holt TB, Gegenheimer C, Izenberg S, Kulkarni P.
Effect of inner cannula removal on the work of breathing imposed by
tracheostomy tubes: a bench study. Respir Care 2001;46(5):460–
465.
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9
Tracheostomy Tubes and Related Appliances
Dean R Hess PhD RRT FAARC
Respir Care 2005;50(4):497—510. © 2005 Daedalus Enterprises
Introduction
Metal Versus Plastic Tracheostomy Tubes
Tracheostomy Tube Dimensions
Tracheostomy Tube Cuffs
Changing the Tracheostomy Tube
Fenestrated Tracheostomy Tubes
Dual-Cannula Tracheostomy Tubes
Percutaneous Tracheostomy Tubes
Subglottic Suction Port
Stoma Maintenance Devices
Mini-Tracheostomy Tubes
Summary
Tracheostomy tubes are used to administer positive-pressure ventilation, to provide a patent airway, to provide protection from aspiration, and to provide access to the lower respiratory tract for
airway clearance. They are available in a variety of sizes and styles, from several manufacturers.
The dimensions of tracheostomy tubes are given by their inner diameter, outer diameter, length,
and curvature. Differences in length between tubes of the same inner diameter, but from different
manufacturers, are not commonly appreciated but may have important clinical implications. Tracheostomy tubes can be angled or curved, a feature that can be used to improve the fit of the tube
in the trachea. Extra proximal length tubes facilitate placement in patients with large necks, and
extra distal length tubes facilitate placement in patients with tracheal anomalies. Several tube
designs have a spiral wire reinforced flexible design and have an adjustable flange design to allow
bedside adjustments to meet extra-length tracheostomy tube needs. Tracheostomy tubes can be
cuffed or uncuffed. Cuffs on tracheostomy tubes include high-volume low-pressure cuffs, tight-toshaft cuffs, and foam cuffs. The fenestrated tracheostomy tube has an opening in the posterior
portion of the tube, above the cuff, which allows the patient to breathe through the upper airway
when the inner cannula is removed. Tracheostomy tubes with an inner cannula are called dualcannula tracheostomy tubes. Several tracheostomy tubes are designed specifically for use with the
percutaneous tracheostomy procedure. Others are designed with a port above the cuff that allows
for subglottic aspiration of secretions. The tracheostomy button is used for stoma maintenance. It
is important for clinicians caring for patients with a tracheostomy tube to understand the nuances
of various tracheostomy tube designs and to select a tube that appropriately fits the patient. Key
words: airway management, fenestration, inner cannula, tracheostomy button, tracheostomy tube, cuff,
tracheostomy, suction, stoma. [Respir Care 2005;50(4):497–510. © 2005 Daedalus Enterprises]
Dean R Hess PhD RRT FAARC is affiliated with the Department of
Respiratory Care, Massachusetts General Hospital, and Harvard Medical
School, Boston, Massachusetts.
Dean R Hess PhD RRT FAARC presented a version of this paper at
the 20th Annual New Horizons Symposium at the 50th International
10
Respiratory Congress, held December 4–7, 2004, in New Orleans, Louisiana.
Correspondence: Dean R Hess PhD RRT FAARC, Respiratory Care,
Ellison 401, Massachusetts General Hospital, 55 Fruit Street, Boston MA
02114. E-mail: [email protected].
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
Fig. 1. Components of a standard tracheostomy tube. (Courtesy of
Smiths Medical, Keene, New Hampshire.)
Fig. 2. Tracheostomy tube with inner cannula and obturator.
Introduction
Tracheostomy tubes are used to administer positivepressure ventilation, to provide a patent airway in patients
prone to upper-airway obstruction, to protect against aspiration, and to provide access to the lower respiratory
tract for airway clearance. Tracheostomy tubes are available in a variety of sizes and styles from several manufacturers. The inner diameter (ID), outer diameter (OD),
and any other distinguishing characteristics (percutaneous,
extra length, fenestrated) are marked on the flange of the
tube as a guide to the clinician. Some features are relatively standard among typical tracheostomy tubes (Fig. 1).
However, there are many nuances among them. It is important for clinicians caring for patients with a tracheostomy tube to understand these differences and to use that
understanding to select a tube that appropriately fits the
patient. Surprisingly little has been published in the peerreviewed literature on the topic of tracheostomy tubes and
related appliances.1–3 This paper describes characteristics
of tracheostomy tubes used in adult patients.
Metal Versus Plastic Tracheostomy Tubes
Tracheostomy tubes can be metal or plastic (Fig. 2).
Metal tubes are constructed of silver or stainless steel.
Metal tubes are not used commonly because of their expense, their rigid construction, the lack of a cuff, and the
lack of a 15-mm connector to attach a ventilator. A smooth
rounded-tip obturator passed through the lumen of the tracheostomy tube facilitates insertion of the tube. The obturator is removed once the tube is in place. Plastic tubes
are most commonly used and can be made from polyvinyl
chloride or silicone. Polyvinyl chloride softens at body
temperature (thermolabile), conforming to patient anatomy and centering the distal tip in the trachea. Silicone is
naturally soft and unaffected by temperature. Some plastic
tracheostomy tubes are packaged with a tracheal wedge
(Fig. 3). The tracheal wedge facilitates removal of the
Fig. 3. The tracheal wedge is used to disconnect the ventilator
circuit while minimizing the risk of dislodgement of the tracheostomy tube. (Courtesy of Smiths Medical, Keene, New Hampshire.)
ventilator circuit while minimizing the risk of dislodgement of the tracheostomy tube.
Tracheostomy Tube Dimensions
The dimensions of tracheostomy tubes are given by their
ID, OD, length, and curvature. The sizes of some tubes are
given by Jackson size, which was developed for metal
tubes and refers to the length and taper of the OD. These
tubes have a gradual taper from the proximal to the distal
tip. The Jackson sizing system is still used for most Shiley
dual-cannula tracheostomy tubes (Table 1). Single-cannula tracheostomy tubes use the International Standards
Organization method of sizing, determined by the ID of
the outer cannula at its smallest dimension. Dual-cannula
tracheostomy tubes with one or more shaft sections that
are straight (eg, angled tubes) also use the International
Standards Organization method. The ID of the tube is the
functional ID. If an inner cannula is required for connection to the ventilator, the published ID is the ID of the
inner cannula. The OD is the largest diameter of the outer
cannula.
When selecting a tracheostomy tube, the ID and OD
must be considered. If the ID is too small, it will increase
the resistance through the tube, make airway clearance
more difficult, and increase the cuff pressure required to
create a seal in the trachea. Mullins et al4 estimated the
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11
Table 1.
Jackson Tracheostomy Tube Size
Table 2.
Jackson
Size
Inner Diameter
With IC (mm)
Inner Diameter
Without IC
(mm)*
Outer Diameter
(mm)
4
6
8
10
5.0
6.4
7.6
8.9
6.7
8.1
9.1
10.7
9.4
10.8
12.2
13.8
*The inner diameter of the outer cannula is for narrowest portion of the shaft.
IC ⫽ inner cannula (Adapted from Shiley Quick Reference Guide, courtesy of Tyco
Healthcare, Pleasanton, California.)
resistance through Shiley tracheostomy tubes at 11.47, 3.96,
1.75, and 0.69 cm H2O/L/s for size 4, 6, 8, and 10 adult
tubes, respectively. If the OD is too large, leak with the
cuff deflated will be decreased, and this will affect the
ability to use the upper airway with cuff deflation (eg,
speech). A tube with a larger OD will also be more difficult to pass through the stoma. A 10-mm OD tube is
usually appropriate for adult women, and an 11-mm OD
tube is usually appropriate for adult men as an initial tracheostomy tube size. Differences in tracheostomy tube
length between tubes of the same ID but from different
manufacturers are not commonly appreciated (Table 2),
and this can have important clinical implications (Fig. 4).
Tracheostomy tubes can be angled or curved (Fig. 5), a
feature that can be used to improve the fit of the tube in the
trachea. The shape of the tube should conform as closely
as possible to the anatomy of the airway. Because the
trachea is essentially straight, the curved tube may not
conform to the shape of the trachea, potentially allowing
for compression of the membranous part of the trachea,
while the tip may traumatize the anterior portion. If the
curved tube is too short, it can obstruct against the posterior tracheal wall (Fig. 6), which can be remedied by using
either a larger tube, an angled tube, a tube with a flexible
shaft, or a tube with extra length. Angled tracheostomy
tubes have a curved portion and a straight portion. They
enter the trachea at a less acute angle and may cause less
pressure at the stoma. Because the portion of the tube that
extends into the trachea is straight and conforms more
closely to the natural anatomy of the airway, the angled
tube may be better centered in the trachea and cause less
pressure along the tracheal wall.
Tracheostomy tubes are available in standard length or
extra length. Extra-length tubes are constructed with extra
proximal length (horizontal extra length) or with extra
distal length (vertical extra length) (Fig. 7). In the case of
one manufacturer, extra distal length is achieved by a double cuff design (Fig. 8 and Table 3). This design also
allows the cuffs to be alternatively inflated and deflated,
which may reduce the risk of tracheal-wall injury, although
this has never been subjected to appropriate clinical study.
12
Dimensions of Portex Flex DIC and Shiley SCT
Tracheostomy Tubes*
Portex Flex DIC
Shiley SCT
ID
(mm)
OD
(mm)
Length
(mm)
ID
(mm)
OD
(mm)
Length
(mm)
6.0
7.0
8.0
9.0
10.0
8.2
9.6
10.9
12.3
13.7
64
70
74
80
80
6.0
7.0
8.0
9.0
10.0
8.3
9.6
10.9
12.1
13.3
67
80
89
99
105
*Note that the principal difference between the tubes is in their length. The Portex tube can
be used with an inner cannula, which reduces the inner diameter (ID) by 1 mm.
DIC ⫽ disposable inner cannula
SCT ⫽ single cannula tube.
OD ⫽ outer diameter
Extra proximal length facilitates tracheostomy tube placement in patients with a large neck (eg, obese patients).
Extra distal length facilitates placement in patients with
tracheal malacia or tracheal anomalies. Care must be taken
to avoid inappropriate use of these tubes, which may induce distal obstruction of the tube. Rumbak et al5 reported
a series of 37 patients in whom substantial tracheal obstruction (tracheal malacia, tracheal stenosis, or granulation tissue formation) caused failure to wean from mechanical ventilation. In 34 of the 37 patients, the obstruction
was relieved by use of a longer tube, which effectively
bypassed the tracheal obstruction.
Several tube designs have a spiral wire reinforced flexible design (Fig. 9 and Table 4). These also have an adjustable flange design to allow bedside adjustments to meet
extra-length tracheostomy tube needs. These tubes are not
compatible with lasers, electrosurgical devices, or magnetic resonance imaging. Because the locking mechanism
on the flange tends to deteriorate over time, use of these
tubes should be considered a temporary solution. For longterm use, the adjustable-flange tube should be replaced
with a tube that has a fixed flange. Custom-constructed
tubes are available from several manufacturers to meet this
need.
Low-profile tracheostomy tubes (Fig. 10) can be used in
patients with laryngectomy or sleep apnea. They have a
small discreet flange, and they can be cuffed or uncuffed.
One of 2 inner cannulae can be used. A low-profile inner
cannula is used for spontaneous breathing, and an inner
cannula with a 15-mm connector can be used to attach a
ventilator.
Tracheostomy Tube Cuffs
Tracheostomy tubes can be cuffed or uncuffed (Fig. 11).
Uncuffed tubes allow airway clearance but provide no
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
8 Portex DIC; 74 mm Long
8 Shiley SCT; 89 mm Long
Fig. 4. A patient with a Portex 8 tracheostomy tube in place. Note the poor fit on both the anterior-posterior film and the transverse section
by computed tomography (left). Note the improved fit when the tube was changed to a Shiley 8 single-cannula tube (SCT). The principal
difference between the tubes is their length. DIC ⫽ disposable inner cannula.
Angled
Curved
Fig. 5. Angled versus curved tracheostomy tubes. Note that the
angled tube has a straight portion and a curved portion, whereas
the curved tube has a uniform angle of curvature.
protection from aspiration. Cuffed tracheostomy tubes allow for airway clearance, offer some protection from aspiration, and positive-pressure ventilation can be more effectively applied when the cuff is inflated. Although cuffed
tubes are generally considered necessary to provide effective positive-pressure ventilation, a cuffless tube can be
used effectively in long-term mechanically ventilated patients with adequate pulmonary compliance and sufficient
oropharyngeal muscle strength for functional swallowing
and articulation.6 Specific types of cuffs used on tracheostomy tubes include high-volume low-pressure cuffs,
tight-to-shaft cuffs (low-volume high-pressure), and foam
cuffs (Fig. 12). High-volume low-pressure cuffs are most
commonly used.
Tracheal capillary perfusion pressure is normally 25–35
mm Hg. High tracheal-wall pressures exerted by the inflated cuff can produce tracheal mucosal injury (Fig. 13).7–15
Because the pressure transmitted from the cuff to tracheal
wall is usually less than the pressure in the cuff, it is
generally agreed that 25 mm Hg (34 cm H2O) is the maximum acceptable intra-cuff pressure. If the cuff pressure is
too low, silent aspiration is more likely.16,17 Therefore, it is
recommended that cuff pressure be maintained at 20 –25
mm Hg (25–35 cm H2O) 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 minimum occlusion pressure or the minimum leak technique are not recommended. In particular, the minimum leak technique is
not recommended because of the risk of silent aspiration
of pharyngeal secretions.
Intra-cuff 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. Cuff pressure is measured with a syringe, stopcock, and manometer (Fig. 14).
This method allows cuff pressure to be measured simultaneously with adjustment of cuff volume. Methods in
which the manometer is attached directly to the pilot bal-
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
13
Fig. 6. A curved tracheostomy tube in which the distal end abuts the posterior tracheal wall. There is a hint of this on the anterior-posterior
chest radiograph (left), and this was confirmed by bronchoscopy (right). Approaches to this problem include replacing the tube with one
that is larger, angled, or of extra length.
Standard
Vertical Extra Length
Portex
Horizontal Extra Length
Double Cuff
Shiley XLT
Extra Length
Poor Position
Proximal Extra Length
Distal Extra Length
Horizontal Extra Length
Fig. 8. Extra-length tracheostomy tubes. (Courtesy of Smiths Medical, Keene, New Hampshire and Tyco Healthcare, Pleasanton,
California.)
Fig. 7. Position of extra-length tracheostomy tubes in the trachea.
Note that inappropriate use of an extra-length tube can cause
distal tracheostomy-tube obstruction. (From Reference 5, with permission.)
loon are discouraged because they cause air to escape from
the cuff to pressurize the manometer. Commercially available systems can also be used to measure cuff pressure.
A common cause of high cuff pressure is that the tube
is too small in diameter, resulting in overfilling of the cuff
to achieve a seal in the trachea. If the volume of air in the
cuff needed to achieve a seal exceeds the nominal volume
of the cuff, this suggests that the tube diameter is too
small. The nominal cuff volume is the volume below which
14
the cuff pressure is ⬍ 25 mm Hg ex vivo. 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. A cuff management algorithm is shown in Figure 15.18
The tight-to-shaft cuff minimizes airflow obstruction
around the outside of the tube when the cuff is deflated. It
is a high-pressure low-volume cuff intended for patients
requiring intermittent cuff inflation. When the cuff is deflated, speech and use of the upper airway is facilitated.
The cuff is constructed of a silicone material. It should be
inflated with sterile water because the cuff will automatically deflate over time in-situ due to gas permeability.
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
Table 3.
Inner
Diameter
(mm)
Dimensions of Several Commercially Available Extra
Length Tracheostomy Tubes
Outer
Diameter
(mm)
Length (mm)
Portex Extra Horizontal Length Blue Line Tracheostomy Tubes
7.0
9.7
84 (horizontal length 18)
8.0
11.0
95 (horizontal length 22)
9.0
12.4
106 (horizontal length 28)
Portex Double Cuff Blue Line Tracheostomy Tubes (Extra Vertical
Length)
7.0
9.7
83 (vertical length 41)
8.0
11.0
93 (vertical length 45)
9.0
12.4
103 (vertical length 48)
10.0
13.8
113 (vertical length 52)
Shiley TracheoSoft XLT Proximal Extension Tracheostomy Tubes
5.0
9.6
90 (20 proximal, 37 radial, 33 distal)
6.0
11.0
95 (23 proximal, 38 radial, 34 distal)
7.0
12.3
100 (27 proximal, 39 radial, 34 distal)
8.0
13.3
105 (30 proximal, 40 radial, 35 distal)
Shiley TracheoSoft XLT Distal Extension Tracheostomy Tubes
5.0
9.6
90 (5 proximal, 37 radial, 48 distal)
6.0
11.0
95 (8 proximal, 38 radial, 49 distal)
7.0
12.3
100 (12 proximal, 39 radial, 49 distal)
8.0
13.3
105 (15 proximal, 40 radial, 50 distal)
Table 4.
Dimensions of Flexible Tracheostomy Tubes With an
Adjustable Flange
Inside
Diameter
(mm)
Outside
Diameter
(mm)
Rusch Ulr TracheoFlex With Adjustable Flange
7.0
10.8
8.0
11.7
9.0
12.7
10.0
13.7
11.0
14.2
Bivona Mid-Range Adjustable Neck Flange
6.0
8.7
7.0
10.0
8.0
11.0
9.0
12.3
Length
(mm)
82
107
137
137
137
110
120
130
140
Fig. 10. Low-profile tracheostomy tube. (Courtesy of Smiths Medical, Keene, New Hampshire.)
Fig. 9. Flexible tracheostomy tubes with adjustable flange. Hv ⫽
high-volume. LP ⫽ low-pressure.
Fig. 11. Uncuffed and cuffed tracheostomy tubes. (Courtesy of
Smiths Medical, Keene, New Hampshire and Tyco Healthcare,
Pleasanton, California.)
A foam cuff consists of a large-diameter high-residualvolume cuff composed of polyurethane foam covered by a
silicone sheath (Fig. 16).19,20 The concept of 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, air in the cuff is
evacuated by a syringe attached to the pilot port. Once the
tube is in place, the syringe is removed to allow the cuff to
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
15
Low Pressure
Tight to Shaft
Foam
Fig. 12. Examples of low-pressure, tight-to-shaft, and foam-filled tracheostomy tube cuffs.
Fig. 14. Diagram of the equipment used to measure cuff pressure.
Fig. 13. Anterior-posterior chest radiograph of a patient with substantial tracheal dilation at the site of the tracheostomy tube cuff.
re-expand against the tracheal wall. The pilot tube remains
open to the atmosphere, so the intra-cuff 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. The proper size is important to maintain a seal and the
benefit from the pressure-limiting advantages of the foamfilled cuff. If the tube is too small, the foam will inflate to
its unrestricted size, 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
16
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 long availability of this cuff type, it is not commonly
used. Its use is often reserved for patients who have already developed tracheal injury related to the cuff.
Changing the Tracheostomy Tube
Occasionally a tracheostomy tube must be changed (eg,
if the cuff is ruptured or if a different style of tube is
needed). The need for routine tracheostomy tube changes
is unclear. In an observational study, Yaremchuk21 reported fewer complications due to granulation tissue after
implementation of a policy in which tracheostomy tubes
were changed every 2 weeks.
Changing the tracheostomy tube is usually straightforward once the stoma is well formed, which may require
7–10 days after the tracheostomy is first placed. If the tube
must be changed before the stoma is well formed, it is
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
Fig. 15. Algorithm to address issues with an artificial airway cuff leak. (From Reference 18.)
advisable that the physician who performed the initial placement perform the tracheostomy tube change. In these cases
it is also important that an individual skilled in endotracheal intubation is available in the event that the tracheostomy tube cannot be replaced. Generally, it is easier to
replace the tube with one that has a smaller OD.
The new tracheostomy tube can usually be inserted using the obturator packaged with the tube. If difficulty is
anticipated during a tracheostomy tube change, a tube
changer can be used to facilitate this procedure. The tube
changer is passed through the tube into the trachea. The
tube is then withdrawn while keeping the tube changer in
place and the new tube is then passed over the tube changer
into the trachea.
Fenestrated Tracheostomy Tubes
The fenestrated tracheostomy tube is similar in construction to standard tracheostomy tubes, with the addition
of an opening in the posterior portion of the tube above the
cuff (Fig. 17). In addition to the tracheostomy tube with a
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
17
Fig. 16. Foam cuff design. (Courtesy of Smiths Medical, Keene, New Hampshire.)
Fig. 17. Fenestrated tracheostomy tubes. Note the 2 styles of
fenestration.
Fig. 18. With fenestrated tracheostomy tube and cuff deflation,
the patient can breathe through the upper airway. (Courtesy of
Smiths Medical, Keene, New Hampshire.)
fenestration, a removable inner cannula and a plastic plug
are supplied. With the inner cannula removed, the cuff
deflated, and the normal air passage occluded, the patient
can inhale and exhale through the fenestration and around
the tube (Fig. 18). This allows for assessment of the patient’s ability to breathe through the normal oral/nasal route
(preparing the patient for decannulation) and permits air to
18
Fig. 19. Examples of decannulation caps (below) and associated
inner cannulae (above). (Courtesy of Tyco Healthcare, Pleasanton,
California.)
Fig. 20. Measurement for fenestration. A: Hyperextend head for
good visualization. B: Bedside measurements with sterile pipe
cleaners, anterior and posterior wall-to-skin measurement. C. Measurements determine location of fenestration on tracheostomy
tube. (From Reference 1, with permission.)
pass by the vocal cords (allowing phonation). Supplemental oxygen administration to the upper airway (eg, nasal
cannula) may be necessary if the tube is capped. The cuff
must be completely deflated by evacuating all of the air
before the tube is capped. The decannulation cap (Fig. 19)
is then put in place to allow the patient to breathe through
the fenestrations and around the tube.
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
Fig. 21. Inspiratory pressures required to generate flows with fenestrated and nonfenestrated tracheostomy tubes. (From Reference 23, with
permission.)
Table 5.
Comparison in Tube Dimensions for Shiley Single-Cannula
Tube and Dual-Cannula Tube*
Shiley SCT
Inner
Diameter
(mm)
6.0
8.0
10.0
Fig. 22. Airway resistance during tracheostomy-tube occlusion.
CF, CI ⫽ cuffed fenestrated, cuff inflated. CF, CD ⫽ cuffed fenestrated, cuff deflated. NC, F ⫽ uncuffed fenestrated. (From Reference 24, with permission.)
Fig. 23. An example of an inner cannula in which the 15-mm ventilator attachment is connected to the inner cannula. If the inner
cannula is removed, it is not possible to attach the ventilator.
Unfortunately fenestrated tracheostomy tubes often fit
poorly. The standard commercially available tubes can
substantially increase flow resistance through the upper
airway if the fenestrations are not properly positioned. The
Shiley DCT
Outer
Diameter
(mm)
Size
8.3
10.9
13.3
6
8
10
Inner Diameter (mm)
Outer
Diameter
(mm)
6.4 (8.1 without IC)
7.6 (9.1 without IC)
8.9 (10.7 without IC)
10.8
12.2
13.8
*Note: Inner diameter of outer cannula is for narrowest portion of the shaft.
SCT ⫽ single-cannula tube
DCT ⫽ dual-cannula tube
IC ⫽ inner cannula
risk of this complication may be decreased if a tube with
several fenestrations rather than a single fenestration is
used. Techniques have been described to assure proper
placement of the fenestrations within the airway (Fig. 20).
Moreover, custom-fenestrated tubes can be ordered from
several manufacturers. Even with these measures, the fenestrations may become obstructed by the formation of granulation tissue, resulting in airway compromise.22 Proper
position of the fenestrations in the airway should be inspected regularly.
Hussey and Bishop23 reported that the effort required
for gas flow across the native airway in the absence of a
fenestration can be substantial (Fig. 21). Beard and Monaco24 reported that the presence of a cuff, either inflated
or deflated, can increase the amount of ventilatory work
required of the patient (Fig. 22). They recommended that
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
19
Fig. 24. Imposed work of breathing (WOB) for Shiley size 6, 8, and
10 tracheostomy tubes, with tidal volumes of 500 and 300 mL and
respiratory rates of 12, 24, and 32 breaths/min. Black bars denote
WOB with the cannula in place. Open bars denote WOB with the
cannula removed. (From Reference 26, with permission.)
Portex Per-fit
Fig. 26. Standard (top left) and modified (top right) Portex Per-fit
percutaneous tracheostomy tubes. Bronchoscopic views of the
distal tracheostomy tube opening from the standard (bottom left)
and modified (bottom right) tracheostomy tubes. (From Reference
27, with permission.)
Shiley Perc
Fig. 25. Portex and Shiley percutaneous tracheostomy tubes.
(Courtesy of Smiths Medical, Keene, New Hampshire and Tyco
Healthcare, Pleasanton, California.)
Table 6.
Dimensions of Tracheostomy Tubes Designed Specifically
to Be Inserted Using Percutaneous Technique
Tube
Inner Diameter
(mm)
Outer Diameter
(mm)
Length
(mm)
Portex Per-fit 7
Portex Per-fit 8
Portex Per-fit 9
Shiley 6 PERC
Shiley 8 PERC
7.0 (6.0 with IC)
8.0 (7.0 with IC)
9.0 (8.0 with IC)
6.4
7.6
9.6
10.9
12.3
10.8
12.2
82.0
86.0
93.0
74
79
IC ⫽ inner cannula
uncuffed tubes should be used to decrease patient work of
breathing when the tube is capped, to improve patient
comfort during the process of decannulation. If the cuff is
deflated or an uncuffed tube is used, the patient must be
observed carefully for potential aspiration of upper-airway
secretions or oral fluids. Upper-airway reflexes should be
carefully assessed before attempts at cuff deflation and
decannulation.
Dual-Cannula Tracheostomy Tubes
Some tracheostomy tubes are designed to be used
with an inner cannula, and these are called dual-cannula
20
tracheostomy tubes. In some cases, the 15-mm attachment is on the inner cannula, and a ventilator cannot be
attached unless the inner cannula is in place (Fig. 23).
The inner cannula can be disposable or reusable. The
use of an inner cannula allows it to be cleaned or replaced at regular intervals. It has been hypothesized that
this may reduce biofilm formation and the incidence of
ventilator-associated pneumonia. However, data are
lacking to support this hypothesis, and the results of one
study suggested that changing the inner cannula on a
regular basis in the critical care unit is unnecessary.25
The inner cannula can be removed to restore a patent
airway if the tube occludes, which may be an advantage
for long-term use outside an acute care facility. If a
fenestrated tracheostomy tube is used, the inner cannula
occludes the fenestrations unless there are also fenestrations on the inner cannula.
One potential issue with the use of an inner cannula is
that it reduces the ID of the tracheostomy tube (Table 5)
and thus the imposed work of breathing for a spontaneously breathing patient is increased. This was investigated
by Cowan et al26 in an in vitro study, in which they reported a significant decrease in imposed work of breathing
when the inner cannula was removed (Fig. 24). They concluded that increasing the ID of the tracheostomy tube by
removing the inner cannula may be beneficial in spontaneously breathing patients.
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
Fig. 27. Portex Blue Line Ultra Suctionaid tracheostomy tube. The arrow indicates the position of the suction port above the cuff. (Courtesy
of Smiths Medical, Keene, New Hampshire.)
Table 7.
Dimensions of Portex Blue Line Ultra Suctionaide
Tracheostomy Tube Designed for Subglottic Suction
Inner Diameter
(mm)
6.0
7.0
7.5
8.0
8.5
9.0
Outer Diameter
(mm)
Length
(mm)
9.2
10.5
11.3
11.9
12.6
13.3
64.5
70.0
73.0
75.5
78.0
81.0
Fig. 28. Olympic tracheostomy button (Olympic Medical, Seattle,
Washington) positioned against the anterior tracheal wall. The tube
is occluded with a solid plug (A) and fitted exactly to length with
spacing washers (B). On the right is shown the distal flower-petal
flanges (C) that expand to fit the tube into the trachea without
sutures or ties. A positive-pressure adapter (D) can be attached to
allow assisted ventilation. (From Reference 3, with permission.)
a low-profile cuff designed to reduce insertion force and
more readily conform to the patient’s anatomy. Although
the design of the cuff makes insertion of the tube easier,
the cuff characteristics resemble those of a low-volume
high-pressure cuff rather than a low-pressure high-volume cuff. The Shiley PERC tracheostomy tube has a
tapered distal tip and inverted cuff shoulder for easier
insertion. It is designed specifically to be used with the
Cook Percutaneous Tracheostomy Introducer Set. This
cuff provides a low-pressure seal.
Trottier et al27 reported that 57% of patients with a
Portex Per-Fit tracheostomy tube placed percutaneously
had a ⱖ 25% obstruction of the tracheostomy tube,
and ⱖ 40% obstruction was visualized in 41% of the
patients (Fig. 26). The cause of the partial tracheostomy-tube obstruction was the membranous posterior tracheal wall encroaching on the tracheostomy tube lumen.
Several patients displayed a dynamic component to the
obstruction, such that when the patient’s intrathoracic
pressure increased, the degree of obstruction also increased. One patient displayed clinical signs and symptoms of tracheostomy-tube obstruction. This patient was
obese and had a large neck, such that the tracheostomy
tube was too short for the patient. These findings
prompted the investigators to recommend modifications
to the tube to lessen the degree of partial tracheostomytube obstruction. The standard tracheostomy tube was
modified to include a shortened posterior bevel (the
longest portion of the tracheostomy tube posteriorly)
and a decreased length and angle of the tracheostomy
tube. Following this modification, ⱖ 25% tube obstruction was observed in only 1 of 17 patients.
Subglottic Suction Port
Percutaneous Tracheostomy Tubes
Several tracheostomy tubes are designed specifically
for insertion as part of the percutaneous dilatational
tracheostomy procedure (Fig. 25 and Table 6). The Portex Per-fit flexible tube features a tapered distal tip and
Endotracheal tubes have been available for some time
with a port above the cuff to facilitate aspiration of subglottic secretions, minimize their aspiration past the cuff,
and thus decrease the risk of ventilator-associated pneumonia. Subglottic secretion drainage is associated with
decreased incidence of ventilator-associated pneumonia,
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
21
Fig. 29. Montgomery T-tube (left) and Montgomery silicone tracheal cannula (right). (From Reference 1, with permission.)
especially early-onset pneumonia.28 –33 Based on this evidence, it has been recommended that clinicians consider
the use of subglottic secretion drainage.34 A tracheostomy
tube capable of subglottic suction has recently become
available (Fig. 27). To date, there has been no report of the
effectiveness of this tube. One consideration in its use is
that a larger OD of the tube is necessary to facilitate the
suction port (Table 7).
Stoma Maintenance Devices
Several approaches can be used for stomal maintenance
in patients who cannot be decannulated. One of the easiest
approaches is to use a small cuffless tracheostomy tube
(eg, 4 cuffless). Another approach is to use a tracheostomy
button (Fig. 28).32 These appliances are generally made of
Teflon and consist of a hollow outer cannula and an inner
solid cannula. This device fits from the skin to just inside
the anterior wall of the trachea. With the solid inner cannula in place, the patient breathes through the upper airway. When the inner cannula is removed, the patient can
breathe through the button, and a suction catheter can be
passed through the button to aid airway clearance. Since a
tracheostomy button does not have a cuff, its use is limited
when there is a risk of aspiration or during positive-pressure ventilation. Other devices used for stomal maintenance include the Montgomery T-tube and the Montgomery silicone tracheal cannula (Fig. 29).
Mini-Tracheostomy Tubes
The mini-tracheostomy tube is a small bore cannula (4.0
mm ID) inserted into the trachea through the cricothyroid
membrane or the tracheal stoma after decannulation. It can
be used for oxygen administration. However, it is used
primarily for patients with airway clearance issues35 because it allows bronchial lavage and suctioning with a 10
French suction. It is uncuffed and generally unsuitable for
provision of positive pressure ventilation.
Summary
Tracheostomy tubes are available in a variety of sizes
and styles. It is important for respiratory therapists and
22
physicians caring for patients with tracheostomy tubes to
understand these differences and select a tube that appropriately fits the patient.
ACKNOWLEDGMENT
I wish to thank the staff of the Respiratory Acute Care Unit (RACU) who
have taught me that selection of the correct tracheostomy tube makes a
difference.
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13. Dunn CR, Dunn DL, Moser KM. Determinants of tracheal injury by
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15. Honeybourne D, Costello JC, Barham C. Tracheal damage after
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17. Bernhard WN, Cottrell JE, Sivakumaran C, Patel K, Yost L, Turndorf H. Adjustment of intracuff pressure to prevent aspiration. Anesthesiology 1979;50(4):363–366.
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19. Kamen JM, Wilkinson CJ. A new low-pressure cuff for endotracheal
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20. King K, Mandava B, Kamen JM. Tracheal tube cuffs and tracheal
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21. Yaremchuk K. Regular tracheostomy tube changes to prevent formation of granulation tissue. Laryngoscope 2003;113(1):1–10.
22. Siddharth P, Mazzarella L. Granuloma associated with fenestrated
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23. Hussey JD, Bishop MJ. Pressures required to move gas through the
native airway in the presence of a fenestrated vs a nonfenestrated
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25. Burns SM, Spilman S, Wilmoth D, Carpender R, Turrentine B, Wiley
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32. Smulders K, van der Hoeven H, Weers-Pothoff I, VandenbrouckeGrauls C. A randomized clinical trial of intermittent subglottic secretion drainage in patients receiving mechanical ventilation. Chest
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34. Long J, West G. Evaluation of the Olympic trach button as a precursor to tracheostomy tube removal (abstract). Respir Care 1980;
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35. Bonde P, Papachristos I, McCraith A, Kelly B, Wilson C, McGuigan
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23
Facilitating Speech in the Patient With a Tracheostomy
Dean R Hess PhD RRT FAARC
Respir Care 2005;50(4):519—525. © 2005 Daedalus Enterprises
Introduction
Facilitation of Speech in the Ventilator-Dependent Patient
With a Tracheostomy
Talking Tracheostomy Tube
Cuff Down With Speaking Valve
Cuff Down Without Speaking Valve
Patients Not Mechanically Ventilated
Talking Tracheostomy Tube
Cuff-Down Finger Occlusion
Cuff Down With Speaking Valve
Summary
A tracheostomy tube decreases the ability of the patient to communicate effectively. The ability to
speak provides an important improvement in the quality of life for a patient with a tracheostomy.
In mechanically ventilated patients, speech can be provided by the use of a talking tracheostomy
tube, using a cuff-down technique with a speaking valve, and using a cuff-down technique without
a speaking valve. Speech can be facilitated in patients with a tracheostomy tube who are breathing
spontaneously by use of a talking tracheostomy tube, by using a cuff-down technique with finger
occlusion of the proximal tracheostomy tube, and with the use of a cuff-down technique with a
speaking valve. Teamwork between the patient and the patient care team (respiratory therapist,
speech-language pathologist, nurse, and physician) can result in effective restoration of speech in
many patients with a long-term tracheostomy. Key words: speaking valve, speech, talking tracheostomy tube, tracheostomy, mechanical ventilation, complications. [Respir Care 2005;50(4):519 –525.
© 2005 Daedalus Enterprises]
Introduction
Placement of a tracheostomy facilitates long-term mechanical ventilation, minimizes large-volume aspiration,
and bypasses upper-airway obstruction. However, it also
decreases the ability of the patient to communicate effectively. It is possible to restore voice in many patients with
Dean R Hess PhD RRT FAARC is affiliated with the Department of
Respiratory Care, Massachusetts General Hospital, and Harvard Medical
School, Boston, Massachusetts.
Dean R Hess PhD RRT FAARC presented a version of this paper at the
20th Annual New Horizons Symposium at the 50th International Respiratory Congress, held December 4–7, 2004, in New Orleans, Louisiana.
24
tracheostomy who are cognitively intact and free of laryngeal or pharyngeal dysfunction. The ability to speak provides an improvement in the quality of life for a patient
with a tracheostomy. In order to achieve adequate voice, a
subglottic (tracheal) pressure of a least 2 cm H2O is required.1–3 In normal persons the tracheal pressure is 5–10
cm H2O during speech. Flow through the upper airway
during normal speech is 50 –300 mL/s (3–18 L/min).4,5
There are a variety of techniques to achieve this in tracheostomized patients who are either ventilator-dependent or
Correspondence: Dean R Hess PhD RRT FAARC, Respiratory Care,
Ellison 401, Massachusetts General Hospital, 55 Fruit Street, Boston MA
02114. E-mail: [email protected].
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
Fig. 1. Talking tracheostomy tube. Note that gas flow exits above
the cuff and provides flow through the upper airway to facilitate
speech. The arrow indicates the point of gas flow into the trachea
above the cuff. (Adapted from illustrations provided courtesy of
Smiths Medical, Keene, New Hampshire.)
breathing spontaneously. The purpose of this paper is to
describe these methods.
Facilitation of Speech in the Ventilator-Dependent
Patient With a Tracheostomy
Talking Tracheostomy Tube
The talking tracheostomy tube (Fig. 1) was designed to
assist the patient to speak in a low, whispered voice.6 –13
With the cuff inflated, a gas line with a thumb port is
connected to a gas source. The flow is adjusted to 4 – 6
L/min and the thumb port is occluded by the patient or
caregiver. Gas passes through the larynx, allowing the
patient to speak in a soft whisper. Note that the talking
tracheostomy tube allows the use of voice with the cuff
inflated. Thus, this technique decouples speech and breathing. There is no loss of ventilation during speech with this
device, and the inflated cuff reduces the risk of aspiration.
There are several limitations to the use of the talking
tracheostomy tube, and for these reasons this tube is not
commonly used. Unless this tube is inserted at the time of
the tracheostomy procedure, the use of this tube requires a
tube change. In many cases, the voice quality is not good—a
whisper at best. Voice quality may improve with higher
flows,10,11 but this can be associated with a potentially
greater risk of airway injury. If the resistance to airflow
retrograde through the stoma is less than that through the
upper airway, much of the added flow may leak from the
stomal site and not be available for speech.12 One study
reported stoma complications associated with a talking
tracheostomy tube, but the tube used in that study is no
longer commercially available (Communi-Trach I).13 Upper-airway secretions can interfere with the quality of voice,
and secretions above the cuff can lead to a clogged gas
flow line.11,12 An important limitation is the need for an
assistant to control gas flow in many patients.12 It has also
been observed that several days of use may be necessary
before the patient is able to develop voice with this de-
Fig. 2. The voice tracheostomy tube. The cuff expands with positive pressure from the ventilator, which results in inflation of the
lungs without a leak through the upper airway. On exhalation, the
cuff deflates and some of the exhaled gas exits through the vocal
cords, allowing the patient to speak. (From Reference 14, with
permission.)
vice.10,11 Practice and training may be necessary to master
the use of this device, and even with such, some patients
cannot develop adequate voice.11
A voice tracheostomy tube, not yet commercially available, has been described.14 It is specially configured so
that the cuff inflates with positive pressure and deflates
during the expiratory phase (Fig. 2). This tube was used in
16 patients, and all but one were able to speak with this
tube. There were no changes in PaO2 or PaCO2 with the use
of this tube.
Cuff Down With Speaking Valve
When using a speaking valve with the cuff deflated or
with a cuffless tube, gas flows from the ventilator into the
tracheostomy tube during inhalation but exits through the
upper airway during exhalation (Fig. 3). In other words,
the speaking valve is a one-way valve designed to attach to
the proximal opening of the tracheostomy tube. Before
placing the speaking valve, the cuff must be completely
deflated. It may be necessary to increase the tidal-volume
delivery from the ventilator to compensate for volume loss
through the upper airway during the inspiratory phase.
Some patients are able to control oropharyngeal muscle
tone sufficiently to minimize the leak through the upper
airway during the inspiratory phase.
The alarms on most critical-care ventilators are intolerant of a speaking valve. This can be addressed by using a
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
25
Fig. 4. Airflow during ventilator-supported speech. The black circles represent occlusions and the gray circle represents higherthan-usual impedance. During inhalation (left), air flows both toward the lungs and through the larynx. During usual exhalation
(center), most of the air flows toward the ventilator. This is because the impedance of the ventilator circuit is much lower than
that of the laryngeal pathway during speech production. With positive end-expiratory pressure (PEEP) (right), the impedance of the
ventilator circuit is higher than usual, so that more air flows through
the larynx. (From Reference 18, with permission.)
Fig. 3. Placement of a speaking valve between the ventilator and
the tracheostomy tube results in the exhaled gas passing through
the upper airway (rather than into the ventilator circuit). (Adapted
from illustrations courtesy of Passy-Muir, Irvine, California.)
26
Fig. 5. Left: Changes in speaking rate (syllables per minute) for
lengthened inspiratory time (TI), positive end-expiratory pressure
(PEEP), and lengthened TI plus PEEP. Right: Changes in speaking
rate with 5, 8, and 12 cm H2O PEEP. (From Reference 18, with
permission.)
Tracheal Pressure (cm H2O)
ventilator with a speaking valve mode (eg, Puritan Bennett
760) or a portable home-care ventilator. Heated humidifiers can be used with a speaking valve. However, a heatand-moisture exchanger should not be used, because no
exhaled gas passes through it if a speaking valve is in
place. If an in-line closed suctioning system is used, the
speaking valve should be connected to the side port to
allow the catheter to easily pass into the tracheostomy
tube. The volume of dead space in the ventilator circuit is
unimportant when a speaking valve is used, because there
is no potential for rebreathing in the circuit.
Adequate cuff deflation, tracheostomy tube size, tracheostomy tube position, and upper-airway obstruction should
be assessed if the patient is unable to exhale adequately
through the upper airway. Some patients complain of discomfort due to airflow through the upper airway when the
speaking valve is in place. This can result from drying of
the pharyngeal membranes, inability to ventilate adequately, and increased noise levels. This may be the result
of decreased pharyngeal or laryngeal tone due to weakness
or atrophy from lack of flow through the upper airway
during prolonged mechanical ventilation. This can be addressed by using a slow cuff deflation over several minutes. Initial placement of the speaking valve may stimulate
coughing, which may be the result of secretions pooled
above the cuff. This can be minimized by clearance of
pharyngeal and tracheal secretions before the cuff is deflated. Some patients can communicate during both the
inspiratory and expiratory phase of the ventilator. This is
only problematic if it results in inadequate ventilation dur-
Fig. 6. Tracheal pressure waveforms generated during speech production with a one-way valve and with a positive end-expiratory
pressure (PEEP) valve set to 15 cm H2O. (From Reference 18, with
permission.)
ing speech. A speech-language pathologist can help patients who have difficulty adjusting to the speaking valve.
Passy et al15 reported their experience in a series of 15
ventilator-dependent patients in whom a speaking valve
was used. In all 15 patients there was an improvement in
speech intelligibility, speech flow, elimination of speech
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
Fig. 7. Left: Recording from a patient during a vowel-holding trial with continuous mandatory ventilation (CMV) and pressure-support
ventilation (PSV). Note the increase in inspiratory time during speech and the improvement in speech duration during both inhalation and
exhalation with PSV, compared with CMV. PT ⫽ tracheal pressure. Right: Distribution of maximum speech duration over the phases of the
respiratory cycle during a reading test with CMV and PSV. (From Reference 21, with permission.)
hesitancy, and speech time. In a series of 10 chronically
ventilator-dependent patients, Manzano et al16 reported that
a speaking valve was effective in improving communication in 8 of the 10 patients. In one patient, use of the
speaking valve was not possible because adequate ventilation was not possible with the cuff deflated. In a second
patient, the speaking valve was not effective because of
laryngopharyngeal dysfunction.
Cuff Down Without Speaking Valve
Hoit et al17–20 have published several papers related to
cuff-down techniques to facilitate speech without the use
of a speaking valve. They have shown that simple manipulations on the ventilator allow the patient to speak during
both the inspiratory phase and expiratory phase. Moreover, the lack of a speaking valve may increase safety
should the upper airway become obstructed.
If the cuff is deflated, gas can escape through the upper
airway during the inspiratory phase (Fig. 4). During speech,
this has been shown to be about 15% of the delivered tidal
volume, which may cause a small increase in PCO2 (⬍ 5
mm Hg).17 This leak results in the ability to speak during
the inspiratory phase. It has been shown that increasing the
inspiratory time setting on the ventilator increases breathing rate (syllables per minute) (Fig. 5).18,19 If the positive
end-expiratory pressure (PEEP) setting on the ventilator is
zero, most of the exhaled gas exits through the ventilator
circuit rather than the upper airway. In this situation, there
is little ability to speak during the expiratory phase. If
PEEP is set on the ventilator, then expiratory flow is more
likely to occur through the upper airway, which increases
speaking rate. The use of a longer inspiratory time and
higher PEEP are additive in their ability to improve speaking rate (see Fig. 5).18 Tracheal pressure (important for
speech) is similar with the use of PEEP and the use of a
speaking valve (Fig. 6). By prolonging the inspiratory time
and using PEEP, mechanically ventilated patients with a
tracheostomy may be able to use 60 – 80% of the breathing
cycle for speaking.17–20 Anecdotally, I have observed such
patients who are able to speak throughout the entire ventilatory cycle without any pauses for breathing. This is
unlike normal subjects without tracheostomy tubes, who
speak only during the expiratory phase.
The ventilator is normally flow-cycled during pressuresupport ventilation. In the presence of a leak through the
upper airway, the ventilator may fail to cycle appropriately, and thus result in a prolonged inspiratory phase.
Although this would usually be considered undesirable, it
might facilitate speech. Prigent et al21 reported that pressure support with PEEP and the cuff deflated resulted in an
increase in inspiratory time during speech, and this improved speech duration during both the inspiratory and
expiratory phase (Fig. 7). This occurred with minimal effect on gas-exchange variables.
Patients Not Mechanically Ventilated
Talking Tracheostomy Tube
Although not common practice, a talking tracheostomy
tube can be used in a patient with a tracheostomy who is
not mechanically ventilated. For example, this may be
considered in a patient who is cognitively able to speak but
is at risk for aspiration if the cuff is deflated.
Cuff-Down Finger Occlusion
With the cuff down (or with a cuffless tube), the patient
(or caregiver) can place a finger over the proximal opening
of the tracheostomy tube to direct air through the upper
airway and thus produce speech (Fig. 8).22 Some patients
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
27
Table 1.
Speaking Valve Contraindications
Unconscious or comatose patient
Inflated tracheostomy tube cuff
Foam-cuffed tracheostomy tube
Thick and copious secretions
Severe upper-airway obstruction
Abnormal lung mechanics that prevent sufficient exhalation (high
resistance, high compliance)
Speaking valves are not intended for use with endotracheal tubes
Fig. 8. Finger occlusion technique to direct exhaled gas through
the upper airway rather than through the tracheostomy tube. (From
Reference 22, with permission.)
Fig. 10. Equipment used to measure tracheal pressure when a
speaking valve is applied.
Fig. 9. Speaking valves for use with a tracheostomy tube. Arrows
indicate gas flow during inhalation and exhalation. (Adapted from
illustrations courtesy of Passy-Muir, Irvine, California and Tyco
Healthcare, Pleasanton, California.)
are quite facile with this technique, but many do not have
the coordination to master this method.
Cuff Down With Speaking Valve
In the spontaneously breathing patient, a speaking valve
directs the exhaled gas through the upper airway, which
may allow the patient to speak (Fig. 9). This is probably
the most common method used to facilitate speech in spontaneously breathing patients with tracheostomy tubes. Al-
28
though many patients can use this method effectively, there
are several contraindications to the use of a speaking valve
(Table 1). The speaking valve should be used only for a
patient who is awake, responsive, and attempting to communicate. The patient must be able to exhale around the
tracheostomy tube and through the upper airway. The patient should be medically stable and must be able to tolerate cuff deflation. Although the speaking valve may facilitate oral expectoration of secretions, airway clearance
issues may occur if the patient has abundant secretions.
The patient’s risk for aspiration should be evaluated before
the speaking valve is placed. The speaking valve is generally considered inappropriate in a patient at risk of gross
aspiration. However, silent aspiration may occur even with
the cuff inflated.23 The input of a speech-language pathologist and use of techniques such as fiberoptic endoscopic
evaluation of swallowing can be valuable to assess the risk
of aspiration with cuff deflation.
The patient must be able to exhale effectively around
the tracheostomy tube when the speaking valve is placed.
This can be assessed by measuring tracheal pressure with
the speaking valve in place (Fig. 10). If the tracheal pressure is ⬎ 5 cm H2O during passive exhalation (without
speech) with the speaking valve in place, this may indicate
excessive expiratory resistance.24 The upper airway should
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
Fig. 11. Pressure and flow through a tracheostomy tube with 3 brands of speaking valve. Note that the bias-open design (Olympic) allows
flow through the valve during exhalation, whereas the bias-closed design does not. The bias-closed design thus directs more gas flow
through the upper airway to facilitate speech. (From Reference 26, with permission.)
be assessed for the presence of obstruction (eg, tumor,
stenosis, granulation tissue, secretions). The size of the
tracheostomy tube should be evaluated and consideration
given to downsizing the tube. The cuff on a tracheostomy
tube can also create an obstruction, even when deflated.
Consideration should be given to the use of an uncuffed
tube or a tight-to-shaft cuff. The use of a fenestrated tracheostomy tube can also be considered.
Before placing the speaking valve, the cuff must be
completely deflated. Before cuff deflation the upper airway should be cleared of secretions. A slow cuff deflation
often facilitates a smoother transition for the patient to
airflow in the upper airway. The lower respiratory tract
may need to be suctioned after cuff deflation because of
aspiration of secretions from above the cuff. The ability of
the patient to tolerate the speaking valve can be briefly
assessed by finger occlusion of the tracheostomy tube after
cuff deflation. Once the speaking valve is placed, carefully
assess the patient’s ability to breathe. Many patients initially tolerate short periods of speaking-valve-placement
until they become acclimated. If the patient experiences
difficulty with airway clearance when the speaking valve
is in place, the valve should be removed to allow the
patient to be suctioned. If the patient exhibits signs of
respiratory distress, remove the speaking valve immediately and reassess upper-airway patency.
Oxygen can be administered while the speaking valve is
in place, using a tracheostomy collar or an oxygen adapter
on the speaking valve. The patient may inhale through the
upper airway when the speaking valve is in place. This is
most likely with a small tracheostomy tube, in which inspiratory resistance through the tube may be greater than
the resistance through the upper airway. When this occurs,
oxygen administration to the upper airway may be required (eg, nasal cannula). Humidity can be applied using
a tracheostomy collar, but a heat-and-moisture exchanger
filter should not be used, because the patient will not ex-
hale through the heat-and-moisture exchanger. If inhaled
aerosol medications are given, the speaking valve should
be removed during this therapy.
There have been several evaluations of the aerodynamic
characteristics of speaking valves.25–27 The inspiratory resistance through speaking valves has been reported at about
2.5 cm H2O/L/s at a flow of 0.5 L/s, and is similar among
valves from several manufacturers.26 Speaking valves can
be either bias open or bias closed. The bias-open design
may result in incomplete closure during exhalation, resulting in expiratory flow through the valve (Fig. 11), which
limits flow through the upper airway and the ability to
speak.26,27
In addition to allowing speech, the use of a speaking
valve may have other benefits. Some studies have suggested that the speaking valve may improve swallow and
decrease the risk of aspiration,28 –33 although this has been
debated by others.34 Because the patients inhales through
the tracheostomy tube and exhales through the upper airway, rebreathing (dead space) may be reduced, but this has
not been studied. The use of a speaking valve may also
allow the patient to control exhalation (eg, pursed lips in
the patient with chronic obstructive pulmonary disease),
but this also has not been adequately studied. Improvements in olfaction have also been reported with the use of
a speaking valve.35
Summary
The ability to speak is an important aspect of the quality
of life for patients with a tracheostomy. A variety of techniques to achieve this are available for either mechanically
ventilated or spontaneously breathing patients. Teamwork
between the patient and the patient care team (respiratory
therapist, speech-language pathologist, nurse, physician)
can result in restoration of speech in many patients with
long-term tracheostomies.
Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
29
ACKNOWLEDGMENT
I wish to thank the patients and staff in the Respiratory Acute Care Unit
(RACU) of the Massachusetts General Hospital, who have taught me
most of what I share in this paper.
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9. Levine SP, Koester DJ, Kett RL. Independently activated talking
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RA. A prospective evaluation of speaking tracheostomy tubes for
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17. Shea SA, Hoit JD, Banzett RB. Competition between gas exchange
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18. Hoit JD, Banzett RB, Lohmeier HL, Hixon TJ, Brown R. Clinical
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Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02
DIRETTORE RESPONSABILE
EDITOR IN CHIEF
GIOVANNI OLIVA
[email protected]
REDAZIONE
EDITORIAL STAFF
ANTONELLA SANNITI,
ANDREA TETTAMANTI
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SCIENTIFIC ACCOUNTEES
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BOARD EDITORIALE
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MARTA CORNACCHIA,
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GIANCARLO PIAGGI,
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ARIR:
www.arirassociazione.org
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EDITORE
EDITOR
ARIR EDIZIONI
ASSOCIAZIONE RIABILITATORI
DELL’INSUFFICIENZA RESPIRATORIA
UNITÀ SPINALE
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06-07-06
DEL
Il periodico “Selezione ARIR da Respiratory
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impegno editoriale dell’Associazione
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The review "ARIR selection from Respiratory
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engagement of the Italian Associazione
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The reasons of this workmust be found
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From the beginning, one of ARIR objective
has been that of making easy the updating
of the italian physiotherapists, thus
organizing events on specific topics
(courses and congress). So far, many
foreign people, experts in physiotherapy
and respiratory care, has been invited
from ARIR with the goal of promoting
the cultural and professional exchange
from european and extra European
experiences.
With the realization of "ARIR selection
from Respiratory Care and AARC Time",
ARIR wants to answer in a concrete way
to a principal exigence of the professional
education: the access to the scientific
articles.
This review offers to people who are
encharged in physiotherapy and respiratory
care the access to scientific articles of the
American Association for Respiratory Care
(AARC), selecting the ones closer to the
italian reality.
"ARIR selection from Respiratory Care
and AARC Time" is a six month review
born from the ARIR and AARC agreement,
and it will be distributed for free to the
ARIR members and published in the
ARIR website (www.ariassociazione.org)
in the page reserved to its members.
From the Board of Directors
The President of Arir
Marta Lazzeri
PRESIDENTE
PRESIDENT
AND FOUNDING MEMBER
DALLO STATUTO DELLA ASSOCIAZIONE
FROM THE STATUTE OF THE ASSOCIATION:
Art. 1: è costituita l’Associazione Riabilitatori
dell’Insufficienza Respiratoria (A.R.I.R.).
Art.1: The Associazione Riabilitatori
dell’Insufficienza Respiratoria (A.R.I.R.) was
established in Milan on October 25, 1989.
MARTA LAZZERI
[email protected]
VICE PRESIDENTE
VICE PRESIDENT
AND FOUNDING MEMBER
GIOVANNI OLIVA
[email protected]
SEGRETERIA
SECRETARY
ANNA BRIVIO
[email protected]
TESORIERE
TREASORER
ALESSIA COLOMBO
CONSIGLIERI
BOARD
PAMELA FRIGERIO
GIANCARLO PIAGGI
ELENA REPOSSINI
ANTONELLA SANNITI
MAURIZIO SOMMARIVA
SERGIO ZUFFO
CONSIGLIERI ONORARI
HONORARY BOARD
ROBERTO ADONE
MONICA BASSI
ANDREA BELLONE
ITALO BRAMBILLA
Art. 3: l’Associazione non ha finalità di lucro e
intende promuovere la prevenzione e la
riabilitazione delle patologie respiratorie.
Per il conseguimento dei suoi scopi
l’Associazione concorre a:
• Diffondere in campo clinico terapeutico
e home care, la pratica della fisioterapia
e riabilitazione respiratoria.
• Organizzare la formazione, l’aggiornamento,
il coordinamento, la promozione dello sviluppo
professionale dei fisioterapisti con specifiche
competenze in ambito respiratorio.
• Sostenere in campo scientifico e sociale
l’educazione e l’igiene respiratoria.
• Promuovere la ricerca scientifica nel campo
della fisioterapia e della riabilitazione
respiratoria.
Art. 4: sono soci le persone e gli enti che
verranno ammessi dal Consiglio e che
verseranno la quota di Associazione.
Art. 5: i soci si dividono in quattro categorie:
1. soci fondatori
2. soci ordinari
3. soci sostenitori
4. soci onorari
Sono soci fondatori coloro che hanno sottoscritto
l’atto Costitutivo dell’Associazione e coloro i quali
pur non avendo sottoscritto l’atto costitutivo sia
attribuita dal Consiglio tale qualifica.
Sono soci ordinari i fisioterapisti accettati dal
Consiglio direttivo e che versano annualmente
la quota associativa stabilita
Sono soci sostenitori persone fisiche e
giuridiche che intendono sostenere gli scopi
che l’Associazione si prefigge.
Sono soci onorari le persone e gli enti ai quali il
Direttivo attribuisce tale qualifica, ritenendole in
grado, per qualità, titoli o attività, di dare
all’Associazione un contributo d’opera o
di prestigio.
Art. 6: l’Associazione trae mezzi per
conseguire i propri scopi dai contributi dei soci
e da ogni altro provento che le confluisca.
Art. 9: i soci hanno diritto:
di partecipare alle assemblee e di usufruire
del materiale tecnico e didattico
dell’Associazione, così come, in via
prioritaria, di beneficiare delle iniziative
promosse dall’Associazione,
Art.3: PURPOSE OF THE ASSOCIATION
ARIR is a no profit entity, promoting the
prevention and rehabilitation of respiratory
disease. In order to do this ARIR strives to:
• Promote the practice of respiratory therapy
and pulmonary rehabilitation within the
clinical and therapeutic fields;
• Organize the training, continuing education,
coordination, and the promotion and the
professional development of physiotherapist
having specific competencies in the respiratory
fields;
• Support respiratory care understanding the
hygiene within the scientific and social realms;
• Promote scientific research in the field of
physiotherapy and respiratory rehabilitation.
Art. 4: All persons and entities that are
accepted by the Board of Directors and who
pay the associational fee are considered
members.
Art. 5: There are four categories
of membership:
1. Founding members
2. Regular members
3. Sustaining members
4. Honorary members.
Those who have taken part in the signing
of the associational statute and those whom,
thought not having signed the statute, are
deemed valid candidates by the Board of
Directors are founding members.
Physiotherapists accepted by the Board
of Directors and who pay the established
yearly associational fee are considered
regular members.
Natural and juridical persons who wish to
support the pre-established purpose of the
association are considered sustaining
members.
Persons and entities to which the Board
of Directors deems such status appropriate,
for reasons of capabilities, qualities, titles
or activities able to give the Association
a contribution of work or prestige, are
considered honorary members.
Art. 6: The Association obtains the means of
carrying out its purpose from the contributions
of its members and from any other proceeds
going towards it.
Art. 9: MEMBER RIGHTS
The members have the right to: participate
at he assemblies, utilize the technical and
teaching materials of the Association, as well
as enjoy, as privileged members, the benefits
of the activities promoted by the Association.
• Numero 02
• Anno I
• Dicembre 2006
Selezione ARIR
INTERNATIONAL
AFFILIATE
Poste italiane s.p.a. - Spedizione in Abbonamento Postale - D.L. 353/2003 (conv. In L. 27/02/2004 n.46) art.1, comma 2, DCB Milano.
da
e
AARC Times
Anatomy and Physiology of Tracheostomy
Scott K Epstein MD
Tracheostomy Tubes and Related Appliances
Dean R Hess PhD RRT FAARC
Facilitating Speech
in the Patient with a Tracheostomy
Dean R Hess PhD RRT FAARC
EDIZIONI