Misconception: “We can’t deflate the cuff because the patient will aspirate”
Clinicians often have a misconception that the tracheostomy cuff prevents aspiration. However, evidence indicates that:
Aspiration occurs at the level of the vocal folds. Therefore, any material that reaches the tracheostomy cuff has already been aspirated.
The cuff may create a reservoir for aspirated and pooled secretions to colonize.
Cuffs do not form a complete seal against the tracheal wall, therefore material may leak around the cuff and into the lower airway.
Up to 87% of mechanically ventilated patients aspirate with inflated cuffs and 77% of those aspirations are silent.1
Clinical Research that Supports Cuff Deflation and Application of the Passy Muir Valve
There are more cases of aspiration in patients with the cuff inflated than with the cuff deflated. Aspiration rate has been shown to be 2.7 times greater for cuff inflation versus cuff deflation conditions within the same patient.2 Silent aspiration rates have been shown to be 22.6% for cuff inflated versus 7.2% for deflated conditions.3
There are higher rates of respiratory infections with cuff inflation. In a randomized controlled study of critically ill patients, the cuff inflated group had significantly more respiratory infections including ventilator-associated pneumonia with rates of 36% versus 20% with cuffs deflated.4
Swallow physiology is impaired with an inflated cuff. There is reduced laryngeal elevation with cuff inflated versus cuff deflated.3 The swallow reflex is progressively more difficult to elicit and swallow latency is increased with higher cuff pressures.5
Use of a Passy Muir® Valve improves swallowing and reduces aspiration more often and more significantly than cuff deflation alone.1,6-8Subglottic pressures are consistently zero when the tube is open to atmospheric pressure.9,10 With the Valve, there is a restoration of subglottic pressure at an average of 8-10cm H2O. The Valve also facilitates expiratory volume through the upper airway after swallow, which helps to expel liquid or food particles that may be misdirected through the trachea during swallowing.11
- Elpern, E., et al. (1994). Pulmonary Aspiration in Mechanically Ventilated Patients with Tracheostomies. Chest, 105:583-586.
- Davis, et al. (2002) Swallowing with a Tracheotomy Tube in Place: Does Cuff Inflation Matter? Journal of Intensive Care Medicine.17(3): 132-135.
- Ding, R. & Logeman, J. (2005). Swallow Physiology in Patients with Trach Cuff Inflated or Deflated: A Retrospective Study. Head & Neck. Sep;27(9):809-13
- Hernandez, G. et al. (2013). The effects of increasing effective airway diameter on weaning from mechanical ventilation tracheostomized patients: a randomized controlled trial. Intensive Care Medicine. Jun;39(6):1063-70
- Amathieu, R. et al. (2012). Influence of the cuff pressure on the swallowing reflex in tracheostomized intensive care unit patients. British Journal of Anaesthesia. Oct;109(4):578-83.
- Suiter, D. et. al. (2003). Effects of Cuff Deflation and One Way Speaking Valve Placement on Swallow Physiology. Dysphagia, 18: 284-292.
- Stachler, R. et al. (1996). Scintigraphic Quantification of Aspiration Reduction with the Passy Muir® Valve. The Laryngoscope. 106(2): 231-234.
- Dettelbach, M., et al. (1995). Effect of the Passy Muir® Valve on Aspiration in Patients with Tracheostomy. Head & Neck, 297-300.
- Gross, R., et al. (2003). Direct measurement of subglottic air pressure while swallowing. The Laryngoscope, 116: 753-760.
- Eibling, D. & Gross, R. (1996). Subglottic air pressure: a key component of swallowing efficiency. Annals of Otology, Rhinology & Laryngology, 105 (4):253-258.
- Prigent, H., et al. (2011). Effect of a tracheostomy speaking valve on breathing–swallowing interaction. Intensive Care Medicine. Published online: 24 November 2011.