Optimizing patient outcomes with the Tracoe Twist Plus tracheostomy tube
Appropriate tracheostomy tube selection is critical for minimizing complications such as hemorrhage, pressure-induced tissue necrosis, and tracheal stenosis; and for supporting optimal patient outcomes. Since no single tube suits every patient, an individualized approach is necessary. Healthcare providers must consider several factors including the patient’s height, weight, airway anatomy, indication for tracheostomy, respiratory function, secretion management, communication needs, and overall safety and comfort. Therefore, tube characteristics—like material, type, inner and outer diameter, length, neck flange mobility, and special features for communication and suctioning—must be carefully considered to ensure each patient receives the most suitable tracheostomy tube at every stage of care. Tracoe Twist Plus tracheostomy tubes (Figure 1) offer a wide range of features designed to meet patients’ needs throughout their journey, from insertion to decannulation.
Figure 1. Tracoe Twist Plus with a high-volume, low-pressure cuff and two inner cannulas
Features and benefits of Tracoe Twist Plus
Tracoe Twist Plus tracheostomy tubes offer numerous benefits designed to enhance patient comfort, care, and outcomes. These tubes feature dual cannulas, with a locking ring to secure the inner cannula in place for enhanced stability and safety. The tube's sizing corresponds to the inner diameter of the inner cannula, which serves as the patient’s actual airway. Distinct labeling on the neck flange and intuitive sizing provides clarity for both patients and healthcare providers. These tracheostomy tubes are available with a high volume, low-pressure cuff or in a cuffless option, as well as fenestrated or non-fenestrated options to suit various clinical needs. Additionally, the pivoting neck flange swivels both vertically and horizontally, accommodating natural head and neck movements. The tube’s thin, stable walls optimize the inner to outer diameter ratio, improving airflow, and enhancing patient comfort.
The importance of optimizing the inner to outer diameter ratio
The Intensive Care Society recommends tracheostomy tubes with a large functional inner diameter to reduce airway resistance and a small outer diameter to allow airflow around the tube when the cuff is deflated, as well as to minimize tracheal trauma.1
Small changes in tracheostomy dimensions significantly impact respiratory workload.2 For example, if the inner diameter of the tracheostomy tube is reduced from 8mm to 7mm, airflow is decreased by 41% (based on Hagen-Poiseuille equation for laminar flow). Therefore, every millimeter counts. Selecting a tracheostomy tube with an optimal inner diameter is critical for minimizing work of breathing and ensuring adequate ventilation.
In addition to an optimized inner diameter (I.D.) for increased airflow, a tracheostomy tube with a small outer diameter (O.D.) is crucial for facilitating airflow around the tracheostomy tube and into the upper airway once the cuff is deflated. This may enable the use of a speaking valve and support upper airway functions such as phonation, swallowing, and coughing. Furthermore, because adequate airway patency is a prerequisite for decannulation, many patients require tracheostomy downsizing to ensure sufficient exhalation around the tube and to tolerate capping. Most decannulation pathways include tracheostomy downsizing or capping trials3 – both of which depend on an outer diameter that does not take up excessive space in the airway. Therefore, careful consideration of outer diameter is essential in tracheostomy management.
To address these needs, Tracoe Twist Plus was designed to optimize the inner-to-outer diameter ratio by maximizing the inner diameter for airflow while minimizing the outer diameter to preserve airway space (Figure 2).
Figure 2. Tracoe Twist Plus Tracheostomy Tube Sizing Chart. This chart shows the corresponding inner diameter and outer diameter measurements for sizes 07 to 10. I.D. = inner diameter of the inner cannula; O.D. = outer diameter of the outer cannula.
One center investigated whether switching from their previous brand of tracheostomy tube to Tracoe Twist Plus with its optimized inner to outer diameter ratio impacted outcomes. Their quality improvement study reported the following results4:
- Reduced number of tracheostomy tube changes
- Reduced critical care length of stay
- Decreased time to decannulation
Tracoe Twist Extract tracheostomy tube
Tracoe Twist Plus is also available with a subglottic suction channel. This version, Tracoe Twist Plus Extract (Figure 3), offers all the features and benefits described above, with the addition of an innovative flat subglottic suction channel that can be connected to a syringe or suction tubing to effectively remove secretions pooling above the cuff. Subglottic suctioning reduces the volume of secretions and consequently increases the risk of bacterially contaminated secretions entering the lower respiratory tract. For this reason, subglottic suctioning is recommended as a preventative measure against ventilator-associated pneumonia.5,6
Figure 3. Tracoe Twist Plus Extract Tracheostomy Tube. This version of the Tracoe Twist Plus includes a flat subglottic suction channel designed for effective secretion management and use in above cuff vocalization (ACV).
Tracoe Twist Plus Extract for above cuff vocalization (ACV)
Above cuff vocalization (Figure 4) is a voicing technique typically used with patients who are alert, cooperative, and require an inflated cuff during mechanical ventilation. Since cuff inflation prevents the use of a speaking valve, ACV enables phonation for patients who would otherwise be voiceless. To facilitate ACV, the suction channel is used to introduce compressed air into the subglottic lumen. This airflow travels into the upper airway, passing through the vocal folds restoring audible voice.7,8 Use of ACV has been shown to be safe, restore earlier communication, and improve quality of life.7-10 Additionally, improvements in swallow frequency and aspiration ratings with use of ACV have been reported.10
Figure 4. Illustration showing airflow during ACV. The blue arrows indicate the flow of air introduced through the subglottic suction channel, above the cuff and into the upper airway to enable phonation.
Key takeaways
Selecting the right tracheostomy tube is critical to reducing complications and improving patient outcomes through an individualized approach that considers patient anatomy, respiratory needs, and comfort. The Tracoe Twist Plus tracheostomy tubes offer a range of features and benefits including an optimized inner to outer diameter ratio. Additionally, the Tracoe Twist Plus Extract includes a subglottic suction channel for effective secretion management and supports above cuff vocalization (ACV), promoting earlier communication and improved quality of life. These design advancements help clinicians deliver more personalized, efficient, and patient-centered tracheostomy care and may lead to faster decannulation.
References
1. Bodenham A, Bell D, Bonner S, Branch F, Dawson D, McGrath B, Mackenzie S. Standards for the care of adult patients with a temporary tracheostomy: Standards and Guidelines. Intensive Care Society Standards. 2014:29–32.
2. Carter A, Fletcher SJ, Tuffin R. The effect of inner tube placement on resistance and work of breathing through tracheostomy tubes: a bench test. Anaesthesia. 2013;68(3):276–82.
3. Singh RK, Saran S, Baronia AK. The practice of tracheostomy decannulation—a systematic review. J Intensive Care. 2017 Jun 20;5:38. doi:10.1186/s40560-017-0234-z. PMID: 28649385; PMCID: PMC5477679.
4. Partridge K. Does Tracheostomy Tube Design Impact Tracheostomy Weaning Outcomes – A Quality Improvement Project. Presented at the 8th International Tracheostomy Symposium; 2024.
5. Terragni P, Urbino R, Mulas F, et al. Occurrence of ventilator-associated pneumonia using a tracheostomy tube with subglottic secretion drainage. Minerva Anestesiol. 2020;86(8):844–52.
6. Souza CR, Santana VT. Impact of supra-cuff suction on ventilator-associated pneumonia prevention. Rev Bras Ter Intensiva. 2012;24(4):401–6.
7. Petosic A, Viravong MF, Martin AM, Nilsen CB, Olafsen K, Berntzen H. Above cuff vocalisation (ACV): A scoping review. Acta Anaesthesiol Scand. 2021;65(1):15–25.
8. Gajic S, Jacobs L, Gellentien C, Dubin RM, Ma K. Implementation of above-cuff vocalization after tracheostomy is feasible and associated with earlier speech. Am J Speech Lang Pathol. 2024;33(1):51–6.
9. Pandian V, Cole T, Kilonsky D, Holden K, Feller-Kopman DJ, Brower R, et al. Voice-related quality of life increases with a talking tracheostomy tube: a randomized controlled trial. Laryngoscope. 2020;130(5):1249–55.
10. McGrath BA, Wallace S, Wilson M, et al. Safety and feasibility of above cuff vocalisation for ventilator-dependent patients with tracheostomies. J Intensive Care Soc. 2019;20(1):59–65.
