Blom Tracheostomy Tube
Blom Tracheostomy Tube
The Blom Tracheostomy Tube is a revolutionary tracheostomy tube that allows adult ventilator dependent patients the ability to speak, regardless of cuff status. Patients are able to speak with a clear voice, with the cuff inflated. This is different from the Passy-Muir Speaking Valve (PMV). The PMV requires full cuff deflation and is not to be used with an inflated cuff. The patient would not be able to breath if the PMV was used with an inflated cuff. The Blom Tracheostomy would be most beneficial for patients who are not able to tolerate cuff deflation due to aspiration risk, medical status, etc.
How does the Blom Tracheostomy Tube work?
The Blom Tracheostomy Tube is a fenestrated tracheostomy tube. This means that there is an opening in the tube that permits airflow through the upper airway. The fenestration is located 1mm above the cuff, to help prevent the fenestration from touching the tracheal mucosa. The placement of the fenestration is supposed to reduce granulation tissue from forming.
The Valve Speech Cannula (VSC) is placed inside the fenestrated tracheostomy tube, after removal of the inner cannula. The VSC redirects the airflow to allow for speech with a cuffed tracheostomy. During inhalation, the airflow is directed through the speech cannula flap and down into the lungs, to ventilate the patient. No airflow escapes past the cuff during inhalation. During exhalation, the flap valve closes and the bubble collapses so that the air is redirected past the speech cannula and up through the fenestrated tracheostomy tube. The air continues through the vocal folds to allow for speech. It is possible to deflate the cuff for more oral airflow.
The Low Profile Valve is a seperate device that is used with non-fenestrated uncuffed or fenestrated cuffed tracheostomy tubes for spontaneously breathing patients. This device should not be used with mechanical ventilation (use the valve speech cannula).
The Exhaled Volume Reservoir is a serperate component that assists in preventing false low-expiratory minute volume alartms that would occur because the exhaled air is directed through the upper airway instead of back to the ventilator.
The Blom Tracheostomy Tube can be used with a subglottic suctioning cannula, which can suction secretions that are above the tracheostomy from the fenestration. This may help to prevent ventilator associated pneumonia.
Patient Candidacy for Blom Tracheostomy Tube:
- The patient must be ventilator dependent on a standard or portable ventilator
- The patient must have a Fenestrated Cuffed Blom Tracheostomy Tube
- The patient must be arousable and have the potential to communicate
- The patient may be in volume or pressure ventilation in any ventilatory mode
- The patient does not need to be breathing spontaneously
- The patient does not need to be able to tolerate cuff deflation
- The patient should not have copious, thick secretions requiring suctioning more than five times per hour
- The patient should have a patent, unobstructed upper airway
- FiO₂should not exceed 60%
- PEEP should not exceed 10
Warning: Patients who require PEEP should be placed on ventilators with Flow Trigger or supplemental bled in oxygen.
What ventilator setting changes should be made to facilitate tolerance of the Speech Cannula or alarm management?
Changes may include:
- Increasing the high pressure threshold during volume ventilation to compensate for the negligible restriction to gas flow when air is delivered during inspiration through the flap valve.
- Reducing inspiratory time or increasing peak flow to extend the expiratory phase and decrease the likelihood of air trapping when large tidal volumes, high breath rates, or high pressure control levels are used.
- Patients who require PEEP should be placed on ventilators with flow triggering or supplemental bleed in oxygen.
The Blom is not a specialty or custom tracheostomy tube and can be used as the initial tracheostomy tube. However, at this time the patient is most likely to be admitted to a hospital with a different tracheostomy tube such as a Shiley, Portex or Bivona. These are more common tracheostomy tubes at this time. Therefore, the entire tracheostomy tube must be changed to the Blom Tracheostomy Tube, to use the Blom Valve Speech Cannula or the Low Profile Valve. This is may be more difficult to do, and more costly than the Passy-Muir Speaking Valve. The PMV can fit onto the hub of all Shiley, Portex, Jackson metal, and Bivona (unable to use with foam filled Bivona). It seems that the PMV should be trialed first if the patient was admitted with a tracheostomy tube other than the Blom, if the cuff is able to be deflated.
However, the Blom Tracheostomy Tube system is another device that can be utilized in acute or long term care to help improve our patient’s communication. Patients on mechanical ventilation who are unable to tolerate cuff deflation are ideal candidates for the Blom Tracheostomy Tube to allow for speech. This may include patients with ALS, cervical spine injury, and progressive neurological disorders. The Blom Tracheostomy Tube system has shown to be safe and effective and well tolerated in individuals with mechanical ventilation (Kunduk, M. et. al, 2010).
Kunduk, M., Appel, K. Tunc, M., Alanoglu, Z., Alkis, N.Dursun, G., & Ozgursoy, O.B. Preliminary report of laryngeal phonation during mechanical ventilation via a new cuffed tracheostomy tube. Respiratory Care. 55(12) 1661-90.
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