Tracheostomy cuff deflation

Prior to cuff deflation it is preferable to switch to a home volume ventilator set for patient s comfort and adequate minute ventilation, with note taken of the peak airway pressure (Paw) Suctioning through the mouth and through the tracheostomy is necessary. With the cuff deflated, brief suctioning or use of the MIE may also be necessary. The Paw falls as the cuff is deflated, so the delivered volume should be increased to reach the previously observed Paw- Respiratory rate may need to be increased temporarily to improve patient comfort. Glottic function may require a few days to recover. Sa02 should be maintained at >90%. 

Once cuff deflation is tolerated comfortably, a Passy-Muir valve (PMV) should be added in-line, directly onto or close to the tracheostomy. Progressive hyperinflation from... 

Careful patient selection prevents unsafe levels of alveolar hypoventilation with subsequent hypoxemia and hypercapnea, especially if the tidal volume leakage is >20%. Any compensatory increase in respiratory rate and shortened expiratory time, attributable to the air leakage, may aggravate dynamic hyperinflation, especially among patients with airflow obstruction (15). Ventilator-supported speech has been reported in patients with neuromuscular diseases (NMD) and intact bulbar function (16-19). The physiologic characteristics that enable this population to tolerate ventilator-supported speech include little or no decrease in chest wall or lung compliance and the absence of airflow obstmction. Therefore, patients with NMD may be ventilated with a deflated or cuffless tracheostomy tube accepting the modest compromise in alveolar ventilation (16,20-22). Patient populations, such as those with chronic obstructive pulmonary disease may be able to tolerate cuff deflation for short periods provided there is adequate supervision. 

The third condition is the creation of an effective and adjustable air leak channel during tracheostomy cuff deflation. An effective channel has a lower impedance compared to the tracheostomy tube and exhalation HMB, in order to allow airflow to reach the vocal cords. If the impedance is too high, exhaled volume is diverted to the tracheostomy tube... 

Suction subglottic secretions before deflating tracheostomy cuff... 

Qregoretti C, Squadrone V, Fogliati C, et al. Trans-tracheal open ventilation in acute respiratory failure secondary to severe COPD exacerbation. Am J Respir Crit Care Med 2006 173 877-881. Bach JR, Alba AS. Tracheostomy ventilation. A study of efficacy with deflated cuffs and cuffless tubes. Chest 1990 97 679-683. 

Bach JR, Alba AS. Tracheostomy ventilation study of efficacy of deflated cuffs and cuffless tubes. Chest 1990 97 679-683. 

The channel s impedance is mainly affected by the tracheal diameter in relation to the outer diameter of the tracheostomy tube and the added resistance of the volume of the deflated floppy cuff (Fig. 5). 

Deflate cuff, remove inner tube, cork tracheostomy with size 4.0, attach mask to ventilator tubing, and apply by hand or secure with straps. Encourage slow deep breathing while observing for signs of distress, reconnect after 5 min and reinflate cuff. 

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