Friday, April 19, 2019
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Brief overview of Tubes and Buttons

From the trach tubes I have seen (worn, or touched) the Tracoe Twist tube seems to be the best tube made today. It is the only tube with a great neckplate swivel. This is important for turning your head, lying down, driving, etc. They can customize them to a degree. Get your doctor to order the tube way before surgery and do NOT accept a we will change it after. Also have your doctor order you 2-3 extra inner cannulas per trach tube. Trust me it will make your life easier especially when you are out of the house away from all your cleaning supplies. I am not connected with the company so I gain nothing for passing you this information.

The Vario by Tracoe is the only tube they make that I have not had in my hands to review but it sounds really interesting. It claims soft flexible tube that has a neck plate flanges that can be rotated either together of independently helping those with anatomical issues. It has 4 versions, one version that sounded interesting was a plastic one with x-ray contrast lines and one with a spring inside for bending the angle to make a prefect fit.

About trach tubes: The inner diameter of trach tubes need to be larger than most doctors realize. Remember then haven't had to wear one. (remind them of this too!)
The choice of cannula diameter can be made on practical considerations like ease of breathing through the tube. A 10mm cannula has 277% more of an area to breath through that a 6mm does. (Pause and think about this a minute, this means it only takes about 1/3 the energy to take air in through a 10mm as opposed to a 6mm cannula.) (The difference in these numbers is even greater when you get 1 or 2 mm of sludge/mucus in the trach tube.)
If you add a speaking valve to your trach tube then you need at least a 9mm-10mm ID (inner diameter) but bigger is better so no back pressure to make breathing hard.

Do NOT let the doctor convince you to "breath around the tube." If you doctor makes such a statement RUN do not walk to another doctor that has a clue. Note-You can find some trach doctors in the web links section, they are offered for information only and not a recommendation of any kind.
Not only is breathing around the tube more work for you and most times a struggle, it can also ruin your vocal cords for not having proper air flow (see below). Let alone the stress to your heart and other body parts due to struggling to get enough air.

Here are a few examples of different tubes and differences of their size 8:
(OD=outer diameter ID=inner diameter)

Shiley Disposable Cannula Cuffless Fenestrated 8DCFN- Size 8 OD 12.2mm ID 7.6 Length 79mm
Portex uncuffed Flec D.I.C.- Size 8mm OD 10.9mm ID 8.0mm Length 74mm
Portex uncuffed lo-profile- Size 8mm OD 11.3mm ID 8.0mm Length 75mm
Tracoe Twist- Size 8 OD 11.4 ID 8.0 length 76
Blom-Singer Laryngectomy Tube- Size 8 OD 12.0mm ID 9.5mm (This is what my hubby John and I modified for my trach tube)
***Since I had been using a Shiley 8 I went to a Blom-Singer 6103 Size 10 OD 13.5 ID 10.5mm Length 55mm It was a easy fit and having a silicone tube made it pretty easy going in and out.
So a larger size tube by a different company might fit in your current trach hole and you gain increased ID. You can do sizing up for larger trach tube but you should discuss this with your doctor.

If you are going to have a trach for a long time it is best to have a reusable tube rather than a disposable one.

The most common trach tube has 3 parts:
Outer cannula with faceplate and tube (this is what you take out about once a week for cleaning)
Inner cannula (this is what you take out and clean multiple times a day)
Obturator (this is what you use to insert outer cannula into stoma opening)

You should have your doctor write a prescription for Xylocaine 2% Jelly, you place a thin coat over the lower half of the outer cannula. This will not only make it easier to slide the tube in but will numb the area inside a bit and is okay to have in your stoma (as opposed to some of the things I hear folks using).

Ingrediants in Xylocaine 2% Jelly---Each ml of a clear to almost clear, slightly colored jelly contains: Lidocaine HCl 20 mg. Nonmedicinal ingredients: hydroxypropyl methylcellulose, methyl- and propylparabens (30 ml tube only), sodium hydroxide and/or hydrochloric acid to adjust pH 6.0 to 7.0 and water for injection. It's water-miscible base, characterized by high viscosity and low surface tension, allows close and prolonged contact with mucous membrane.

A fenestrated tube is needed for talking to allow the air to pass over the vocal cords without damaging them. It also helps with a productive cough. It also allows more normal/natural breathing.

Correctly placed fenestration allows air through the hole in the neck and to a degree through the mouth/nose. Also air passes correctly over the vocal cords for speaking.

Incorrectly placed fenestration or no fenestration, only allows air through the hole in the neck which can cause difficulty breathing. Also air does not pass correctly over the vocal cords for speaking.

There are a few different kinds of fenestration holes (depends on the manufacture)

Here is fenestration with 4 holes

Here is fenestration with multiple holes

Here is fenestration with one hole (most common)

There are also different colored tips and caps, mainly to facilitate staff awareness in hospitals and nursing facilities. Example with Shiley trach tubes: Red tip is a decannulation cannula. A fenestrated inner cannula with a green 15mm connector and white 15mm cap is used for upper airway breathing. Designed for use to bypass upper airway obstructions, provide long term ventilation, support and/or manage tracheal/bronchial secretions.


What my surgeon explained to me about air and vocal cords: The larynx extends from the trachea/windpipe. The vocal cords lies in the larynx/voice box. When you talk the trachea directs the air over the vocal folds/cords, the cords are stretch across the larynx the air goes over/between the cord causing them to vibrate to produce your voice. Without the correct amount of air flow you will in time damage your vocal cords. You can get vocal nodes which are callus like which will leave you with a raspy voice. You can get polyps, blisters, hemorrhages or vocal cord paralysis just to name a few.

If you did end up with damage vocal cords I suggest you check with Massachusetts Eye and Ear as they are doing amazing things surgically with restoring paralyzed vocal cords. Others working in the vocal cord area are Massachusetts General Hospital, Harvard Medical School and MIT (Massachusetts Institute of Technology)

Difference between cuffed and uncuffed tubes:

Cuffed are usually used with ventilators. When inflated the air goes into the tube and not around the tube. Also helps to prevent aspiration of oral or gastric secretions.
Cuffless are usually used for those with a permanent trach. You must have an effective cough and gag reflexes to protect yourself from aspiration. Cuffless tubes are rarely used in acute care.

Here is a variety of cuff trach tubes

If your doctor knows about the Hood Stoma Stent and KNOWS how to do the surgery so it fits right....this would be the best for OSA (plugged during the day open for sleeping at night). If you want the Hood, go see Dr. Isaac Eliachar (he invented the Hood) at the Cleveland Clinic Foundation in Ohio, he would be able to tell you if you are a candidate for Hood Stoma Stent, or his new procedure (see link in our news section) or the standard trach tube.
NOTE--Dr. Robert Lorenz has taken over Dr. Eliachar's patients since Dr. Eliachar has retired.
Your doctor will need to help decide if the goal is a button or a tube. I am sure Dr. Lorenz will talk with your doctor and provide help for him/her over the phone.
Problem with most buttons is getting a correct fit (long enough to not allow sides of stoma wall to close in and push button out) and one that will stay in place and not come out when you cough/sneeze or while sleeping (then your hole will start to close up) one that doesn't stick into the windpipe and stays just in stoma opening. Buttons in general seem not to be made for people with a very long stoma. Unless when they put your trach in they make the hole for a button (straight as opposed to curved for a tube) you will have problems getting one to fit correctly.

Check out Discussion Forums for more stuff on tubes and buttons.



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