Cuffless tubes are used for most pediatric patients with tracheostomies (Fig. 56.3), with an air leak around the tracheal tube used to preserve vocalization on exhalation. Patients with less compliant lungs often require a cuff to attain adequate inflation pressures for the lungs. Cuffs can be inflated with air or sterile water, depending on the manufacturer’s recommendation. Saline should not be used to inflate cuffs because they can form crystals that clog the inflation/deflation valve. Self-expanding foam cuffs are not commonly used.

Speaking valves are devices which fit on the end of the tracheotomy and contain a soft plastic flap that allows air to flow in through the tracheotomy during inspiration but prevents air from flowing out through the tracheotomy during expiration. This forces the air to egress though the vocal folds, thereby supporting phonation, effective cough, and Valsalva maneuvers. Speaking valves have been used for patients as young as 13 days of age (Engleman and Turnage-Carrier 1997) and for patients who require mechanical ventilation (Hull et al. 2005). A speaking valve is contraindicated in patients with severe subglottic stenosis or other lesions that might cause air-trapping. Some patients spontaneously learn to accomplish this same objective of forcing expiration through the vocal folds, either by occluding the end of the tracheotomy tube manually or by using their chins.

Mechanical issues may also be important. The external connector to a bag-mask device or mechanical ventilator tubing is universally sized but often is rather large relative to the neck of an infant and may interfere with normal head positioning or cause pressure at the stoma. Some tracheotomy tubes incorporate an extension which increases the distance between the universal adaptor and the tracheotomy flange, allowing more normal head positioning. The connections between the tracheotomy adaptor and the ventilator tubing can loosen, leak, or disconnect, particularly while turning or repositioning a patient. Extra caution to prevent disconnection or even decannulation is indicated if the patient requires extreme head positioning or if head turning is required for access to the lateral neck (e.g., for internal jugular central venous catheter placement). Some surgeons suture the tracheotomy flange to the skin of the neck for new tracheotomies; in this case scissors or a scalpel should be immediately available in case there is an emergency, such as a tracheotomy plug or tracheotomy displacement, requiring tracheostomy tube removal and replacement.