Fenestrated Tracheostomy Tubes:A Systematic Review of Literature

Sarah Boisen MSN, RN, Vinciya Pandian PhD, MSN, RN, ACNP-BC, FAAN, Shifali Mathews BS

Pediatrics, The Johns Hopkins Hospital, Baltimore, MD

Results

Fenestrated tracheostomy tubes:• Are useful in facilitating phonation, weaning from

mechanical ventilation and serving as a bridge to decannulation.

• Can lead to partial obstruction, complete obstruction or granulation tissue formation if tube is mal-fitting

• Factory manufactured tubes have precut fenestrations—ensuring proper tube and fenestration fit is imperative to avoid improper fit.

• Do not have FDA guidelines available to support the manual customization of fenestrations in factory manufactured non-fenestrated tubes by clinicians.

• Are not recommended as the first tube of choice for initial insertion.

• Necessitate trained professional guidance to prepare patient for change in air passage.

Further research is necessary to:Ø Investigate the benefits and challenges of fenestrated

tracheostomy tubes.Ø Develop guidelines that support the safe customization

of fenestrations in non-fenestrated tracheostomy tubes.Ø Explore newer models of tracheostomy tubes available

to facilitate phonation, wean from mechanical ventilation and act as a bridge to decannulation.

To summarize evidence from multiple studies regarding the benefits and challenges associated with use of fenestrated tracheostomy tubes in various settings.

Adam SI, Srinet P, Aronberg RM, et al. Verbal communication with the Blom low profile and Passy-Muir one-way tracheotomy tubespeaking valves. J Commun Disord 2015;56:40-46.

Andersson G. The Swedish modification of the tracheostomy tube to permit speech. Paraplegia 1993;31(4):203-206.Beard B, Monaco FJ. Tracheostomy Discontinuation: Impact of Tube Selection on Resistance during Tube Occlusion. Respir Care

1993;38(3):267-270.Berlet T, Marchon M. Leakage Characteristics of Dual-Cannula Fenestrated Tracheostomy Tubes during Positive Pressure

Ventilation: A Bench Study. Anesthesiol Res Pract 2016;2016:9272865.Hussey JD, Bishop MJ. Pressures required to move gas through the native airway in the presence of a fenestrated vs a

nonfenestrated tracheostomy tube. Chest 1996;110(2):494-497.Kunduk M, Appel K, Tunc M, et al. Preliminary report of laryngeal phonation during mechanical ventilation via a new cuffed

tracheostomy tube. Respir Care 2010;55(12):1661-1670.Leder SB, Pauloski BR, Rademaker AW, et al. Verbal communication for the ventilator-dependent patient requiring an inflated

tracheotomy tube cuff: A prospective, multicenter study on the Blom tracheotomy tube with speech inner cannula.Head Neck 2013;35(4):505-510.Merritt RM, Bent JP, Smith RJ. Suprastomal granulation tissue and pediatric tracheotomy decannulation. Laryngoscope

1997;107(7):868-871.Powell HF, Hanna-Jumma S, Philpott JM, et al. National survey of fenestrated versus non-fenestrated tracheostomy tube use and

the incidence of surgical emphysema in UK adult intensive care units. The Intensive Care Society 2011;12(1):25-Snyder GM. Individualized Placement of Tracheostomy Tube Fenestration and In-Situ Examinations with Fiberoptic Layngoscope.

Respir Care 1983;28(10):1294-1298.

Objectives

ResultsOne of the main benefits of a tracheostomy is the ability to facilitate speech with the assistance of one-way speaking valves. In mechanically ventilated patients, cuff deflation to allow this is not always clinically feasible.

Fenestrated tracheostomy tubes do not necessitate cuff deflation as they have a fenestration, or opening in the outer curvature of the tube that allows air to pass.

As a result, they are often used to help patients wean from mechanical ventilation, act as a bridge to decannulation and aid in the early restoration of phonation, all of which can greatly improve quality of life.

Despite these benefits, variations in clinical practice exist due to a lack of scientific consensus. There exists a need to identify the benefits and challenges associated with proper utilization of a fenestrated tracheostomy tube.

1 Mixed (patient-based data + case study)

6 Case Studies

4 Non-patient-based research studies

6 Patient-based research studies

16 Total Studies Benefits:

Facilitation of phonation

Improvement in pulmonary

mechanics

Weaning from the ventilator

Bridge to decannulation

Decreased airway

resistance

Challenges:

Shortness of breath

Anxiety

Oxygen desaturation

Malposition

Air leakage

Granulation tissue

Subcutaneous emphysema

Phonation

Bridge to Decannulation

Weaning from ventilation

Author (Year) Type Setting Outcomes Measured

Adam (2015) Patient-based Hospital, inpatientHeart rate, Respiratory rate, Oxygen saturation,

duration and intensity of speech, functional verbal communication rating

Leder (2013) Patient-based Long-Term ventilator facilitiesMaximum phonation duration, speech

intelligibility, and oxygen saturation

Kunduk (2010) Patient-based ICUPhonation, suctioning frequency, peak pressures,

BP, & oxygen saturation

Merritt (1997) Patient-based Hospital, inpatient Fiberoptic laryngoscopy for airway alterations

Andersson (1993) Patient-based Home Phonation

Snyder (1983) Patient-based ICU Fiberoptic laryngoscopy for airway alterations

Berlet (2016) Non-patient based Laboratory/SimulationLeakage characteristics to simulate risk for

subcutaneous emphysema

Hussey (1996) Non-patient based Laboratory/SimulationInspiratory pressures to generate inspiratory flow

to simulate work of breathing

Beard (1993) Non-patient based Laboratory/Simulation Airway resistance to simulate work of breathing

Powell (2011) Non-patient-based ICUNational online and telephone survey of practices

regarding use of fenestrated tubes

Background

Methods

Considerations

Conclusions

References

Table 1: Patient-based and Non-patient-based Findings

Figure 1: Primary Benefits