Self-expanding foam-filled tracheostomy tube cuffs and the management of airway emergencies

Abstract

McGrath et al. have produced excellent multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies 1. The guidelines recommend the use of bed head signs to improve the management of patients with tracheostomy tubes but these do not include information regarding the type of cuff on the tracheostomy tube. A 53-year-old man with severe pneumonia resulting in empyema had a 9.0-mm tracheostomy tube with a self-expanding foam filled cuff (Bivona® Fome-Cuf®, Smiths Medical, UK) inserted surgically. As sedation was weaned the patient became agitated and pulled the pilot balloon from the deflation line of the tracheostomy. The tracheostomy was pulled out slightly and a small leak was audible but neither oxygenation nor ventilation was compromised. The self-expanding foam filled cuff of the Bivona Fome-Cuf tracheostomy must be deflated by manual aspiration of air via the deflation line and this is not possible if the deflation line is cut. The tracheostomy tube cuff therefore remained inflated. Gentle manipulation of the tracheostomy back into position resulted in complete resolution of the cuff leak. The patient was then taken to theatre to change the tracheostomy tube. Before the tracheostomy tube could be removed the foam cuff had to be deflated by aspiration of air. The deflation line therefore had to be repaired. Although commercial kits for repair of the pilot balloon can be used 2 these are not available at our institution. Instead, we inserted a 23-G venous cannula (after removal of the needle) into the loose end of the deflation line. This was connected to a 3-way tap and attached to a 20-ml syringe. The cuff was deflated, the tracheostomy tube was removed over a bougie and a new tracheostomy tube was railroaded over the bougie without complication. Similar techniques have been reported for repair of inflation lines of reusable laryngeal mask airways 3, 4. This situation is unusual because most tracheostomy tube cuffs are air-filled and deflate if the inflation line is cut. The resulting cuff leak is usually managed by replacement of the damaged tracheostomy tube, which can easily be removed. The management of a tracheostomy tube with a self-expanding foam filled cuff differs significantly. In this case the leak was caused by displacement of the tracheostomy tube and the cuff remained expanded. This is important to recognise because attempts to remove a tracheostomy tube without deflation of its cuff could result in significant trauma to the trachea and pre-tracheal tissues. If the pilot balloons are removed from the inflation/deflation lines, the Bivona Aire-Cuf® (Smiths Medical) and Fome-Cuf can only be distinguished by close inspection of the flange of the tracheostomy tube. McGrath et al. recommend the use of bed head signs to improve the management of patients in centres using tracheostomy tubes with the Bivona Aire-Cuf or similar devices. We support this but advocate modification of the sign to include details regarding the cuff of the tracheostomy tube as this can significantly affect the management of these patients.