Tracheostomy Tubes Modern tracheostomy tubes are made of polyvinylchloride, a soft substance that conforms to the shape of the trachea, but is rigid enough to avoid collapse Unlike their metal predecessors, they have little tissue reactivity, causing less tracheal wall irritation Several manufacturers package sterile tracheostomy tubes for onetime use Intensivists directing the long-term airway management of their patients may prefer one manufacturer to another, but the emergency physician does not need to know the minor differences among the products However, the emergency physician should know what types of tracheostomy tubes are stocked by the ED’s facility and how to convert from the patient’s brand and size to an available tube with suitable dimensions Three dimensions determine the size of a tracheostomy tube: the inner diameter, the outer diameter, and the length The inner diameter refers to the same measurement used in describing the size of an endotracheal tube, ranging from 2.5 to 10 mm This measurement is generally imprinted on the flanges of the tracheostomy tube and is standardized among manufacturers The outer diameter and length are often not identified on the tube and can vary considerably among manufacturers When a tracheostomy tube change is indicated and an identical replacement is not available, the clinician should choose a tube that has dimensions as close as possible to the patient’s original Select a replacement tube that has all three dimensions either equal to or slightly smaller than the patient’s usual tube Down sizing to a smaller tube may be indicated as a temporizing measure until a more suitable replacement tube can be located A tracheostomy tube may be cuffed or uncuffed An infant or young child may have a cuffed tracheostomy tube, especially if he or she has an airway anomaly or has developed tracheomegaly Checking for the presence of a cuff is important because the cuff must be deflated before removing the tube Some tracheostomy tubes are fenestrated The hole in the posterior aspect of the tube facilitates retrograde movement of air through the larynx, allowing vocalization In addition, some tracheostomy tubes have an inner cannula that is positioned within the lumen of the tracheostomy tube (i.e., the outer cannula) so that it can be removed for cleaning while the airway is maintained by the outer cannula Importantly, the proximal portion of the inner cannula is required to connect the tracheostomy to the manual resuscitator bag; therefore, the inner cannula must be in place when bag–valve ventilation is performed ( Fig 135.2 )