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Use of Tracheostomy Tube Cuff

see also: Tracheotomy - Tracheostomy; Montgomery Canula Tracheotomy
Montgomery Canula insertion in clinic; Four-flap Epithelial Lined Tracheotomy

  1. PURPOSE
    1. To form a seal between the tracheostomy tube and tracheal wall to prevent aspiration and/or facilitate effective ventilation with a ventilation bag/mechanical ventilator.
  2. EQUIPMENT
    1. Mercury manometer
    2. 10 cc syringe
    3. Three-way stopcock
    4. Digital P-V gauge
  3. PROCEDURE
    Icon

    NOTE:
    This procedure is written specifically for the Shiley® disposable cannula low pressure cuffed tracheostomy tube
    (see Precautions, Considerations, and Observations below).

    1. Wash hands thoroughly.
    2. Explain procedure to the patient.
    3. To inflate the cuff, inject air into adaptor at the end of the pilot balloon. Inject the least amount of air needed to adequately create a seal around the tube. The amount of air necessary will vary depending on the diameter of the tracheostomy tube and the patient's trachea. Inject 0.5 cc of air at a time until air cannot be felt or heard escaping from the nose or mouth (usually 5 to 8 cc).
    4. If the patient is able to talk, the cuff is not inflated adequately (air is vibrating the vocal cords).
    5. Small pilot balloon on outside of the tube will inflate, indicating that the cuff is inflated.
    6. Cuff pressure measurement using a mercury manometer:
      1. Measure cuff pressure using a three-way stopcock and mercury manometer.
      2. Attach the pilot balloon adaptor and the mercury manometer to the stopcock.
      3. Attach a syringe to the stopcock to adjust the pressure by removing or adding air as indicated.
      4. Fifteen mm of mercury air pressure is usually adequate to obtain minimum occluding volume. The pressure should always be less than 25 mm Hg.
    7. Cuff pressure measurement using digital P-V gauge:
      1. Slide gauge open to "5 cc" marking.
      2. Depress red "zero set" button. "888" followed by "000" will appear on the display.
      3. Press gray button to turn the gauge on and connect the pilot balloon to the end of the gauge.
      4. Read the cuff pressure measurement on the display.
      5. Air pressure should not exceed 34 cm H20. The pressure may be reduced or increased by slowly moving the thumb wheel slide piston.
    8. To deflate, place syringe into adaptor at end of pilot balloon and pull back on plunger until pilot balloon is completely deflated and resistance is met.
    9. Suction before deflating the cuff and immediately after deflating because secretions often pool above the tracheostomy tube cuff.
    10. Wash hands thoroughly.
  4. PRECAUTIONS, CONSIDERATIONS, AND OBSERVATIONS
    1. The following are indications for cuff inflation:
      1. Inflate cuff 24 hours following initial tracheostomy tube placement (prevents accumulation of subcutaneous air and aspiration of secretions)
      2. Manual assisted ventilation/mechanical ventilation
      3. Meals or nasogastric tube feedings for 30 minutes after if problems with aspiration are anticipated
      4. As ordered by physician
    2. Overinflation of the cuff may damage the cuff or increase pressure against the tracheal wall causing ischemia, softening of tracheal cartilage, or mucosal erosion.
    3. The tracheostomy cuff should be deflated as ordered by physician. The Shiley disposable cannula low pressure cuff does not require hourly deflation to minimize tracheal injury if the minimum occluding volume for cuff inflation is utilized. Periodic cuff deflation is recommended to minimize potential for infection from pooled secretions above the cuff. The amount of time that the cuff remains deflated depends on the patient's condition.
    4. It is not necessary to deflate the cuff to perform suctioning.
    5. After determining amount of air needed to obtain minimum occluding volume, note amount on patient care plan.
    6. The pressure in the tracheostomy tube cuff should be monitored at least every 8 hours if the cuff is inflated continuously.
    7. To inflate the cuff with the digital P-V gauge, set slide gauge at "0 cc" mark and then proceed as described in "cuff pressure measuring using digital P-V gauge" (7 above).
    8. Refer to package instructions concerning cuff management for brands of tracheostomy tubes other than the Shiley disposable cannula low pressure cuffed tracheostomy tube.
    9. Always test the tracheostomy tube cuff for leakage before inserting the tube. Inflate the cuff with the volume of air indicated in the following table. Observe for deflation over several minutes or immerse the tube in sterile saline and observe for leakage.
  5. TABLE V.B.3.1 - LEAK TEST INFLATION VOLUMES FOR THE SHILEY DISPOSABLE CANNULA LOW PRESSURE CUFFED TRACHEOSTOMY TUBE

Tube Size Number

Maximum Inflation Volume

4

11 cc

5

14 cc

8

17 cc

10

20 cc

 

  1. SUGGESTED READINGS
    1. Digital P-V Gauge Instructions: Endotracheal, Tracheostomy, Inflation, Deflation, Cuff Pressure Monitoring, and Maintenance. St. Louis, Mo: Mallinckrodt Medical, Inc.