The objectives of this study are to - 1) explore the use and function of a fenestrated tracheostomy tube along with the advantages and disadvantages associated with its application in establishing phonation, 2) evaluate the different types of fenestrated tracheostomy tubes currently available in the market, their indications, contraindications, short-term complications, and long-term complications, and 3) compare fenestrated to non-fenestrated tracheostomy tubes to determine the effectiveness of their application.
Methods:
A systematic review of literature was conducted by retrieving 160 articles from Grey literature, 5 major databases (PubMed, CINAHL, Scopus, Cochrane, and Web of Science) and the bibliographies of included studies using keywords such as tracheostomy, fenestrated, speech, decannulation, and quality of life. The full texts were reviewed and a Population, Intervention, Comparison, Outcomes (PICO) analysis was conducted for sixteen articles that met inclusion criteria based on abstract and title review. Inclusion criteria were journals only, English language and presence of keywords, and exclusion criteria were poster abstracts, dissertations, conference proceedings, literature reviews, editorials or author replies, and studies involving transcutaneous fenestration or Blom-Singer tracheostoma valves. Quality appraisal and risk for bias were assessed with the Cochrane Handbook criteria which is based on a level system and in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) checklist. Two independent researchers abstracted data regarding study variables with a standardized extraction table, after which a third researcher cross-checked this information for accuracy. A total of 15 articles that were identified for final synthesis. Of them, there were 7 studies that presented case reports of 13 patients, 6 studies that were patient-based studies (104 patients); 3 bench studies conducted using various trachea models and simulations, and one that comprised of a national survey of clinicians. Data from case studies and non-case studies were synthesized separately.
Results:
The patients that had fenestrated tracheostomy tubes were either in the process of weaning from mechanical ventilation or from tracheostomy, or they had previously experienced difficulties in establishing audible phonation, voice intelligibility, and swallowing. In both patient based and non-patient based studies, the types of tubes that were analyzed were Shiley™ fenestrated tracheostomy tube (n = 4), Blom® tracheostomy tube with fenestrated speech inner cannula (n = 3), Portex® Blue Line Ultra® fenestrated tracheostomy tube (n = 1), Tracoe® Twist tracheostomy tube (n = 1), and Rusch® Tracheofix® tracheostomy tube (n=1).
Studies reviewed were conducted within wards, laboratory/ simulation, outpatient, ICU and nursing home/ rehab settings. Eleven studies reported a combination of both short (60%) and long-term (67%) complications associated with the use of fenestrated tracheostomy tubes. The most common short-term complications were anxiety/ shortness of breath (20%), subcutaneous emphysema (14%), tracheomalacia (14%), bleeding, tube displacement and pneumothorax while the long-term complications generally included tube displacement/ occlusion (27%), granulation tissue formation (20%), infection (20%) and stenosis (0.7%).
Although there are complications with fenestrated tracheostomy tubes, clinicians report that there is a need for them in order to improve phonation (47%), to decrease the work of breathing (27%), and to improve the overall quality of life. Fenestrated tubes were also used as a bridge for decannulation. Customizing the site of fenestration, using the right size tubes, using non-fenestrated inner cannulas when suctioning, or using fenestrated tracheostomy tubes only for short term are measures that can be taken to prevent these complications. The usage of the correct size for the fenestrated tubes also prevents transfenestration gas leakage.
Conclusion:
Fenestrated tracheostomy tubes have potential short-term and long-term complications, but these tubes may be beneficial in certain circumstances if other measures to facilitate phonation fail with other types of tracheostomy tubes. The establishment of selection criteria and safety measures is crucial to prevent these short-term and long-term complications. Additional prospective research is necessary to validate the advantages of fenestrated tracheostomy tubes and to outline a protocol that will educate clinicians on their safe use in decannulation and establishing phonation.