Before getting into types, it helps to know the parts:
Outer cannula — the main body of the tube that sits in the trachea
Inner cannula (some tubes only) — a removable inner tube that can be cleaned without removing the outer cannula
Neck plate (flange) — the flat piece that rests against the skin and holds the tube in position; tube ties or velcro collars attach here
Cuff (some tubes only) — an inflatable balloon around the tube near the tip that creates a seal in the trachea when inflated
Pilot balloon (cuffed tubes only) — the small external balloon connected to the cuff that indicates inflation status
15 mm connector — the standard fitting at the top of the tube that connects to ventilator tubing, bag-valve-mask, or speaking devices
Obturator — a smooth-tipped insert used during tube insertion; removed once the tube is in place
The single most important characteristic of a tracheostomy tube is whether or not it has a cuff.
Cuffed tubes have an inflatable balloon near the tip of the outer cannula. When inflated, the cuff seals the airway against the tracheal wall, ensuring all air delivered by a ventilator goes into the lungs (rather than escaping up around the tube into the upper airway).
Uncuffed tubes have no balloon. Air can move freely around the tube as well as through it — meaning air can pass through the upper airway, vocal cords, mouth, and nose. Patients with uncuffed tubes can typically speak, can breathe partly through the upper airway, and have less risk of tracheal wall injury from cuff pressure over time.
When cuffed tubes are used: Mechanical ventilation (the cuff seal is needed for effective ventilation), aspiration protection (the cuff helps prevent secretions or stomach contents from entering the lower airway), some surgical scenarios
When uncuffed tubes are used: Stable long-term tracheostomy patients not on a ventilator, pediatric patients (most pediatric trach tubes are uncuffed by default), decannulation preparation (uncuffed tubes are typically used for capping trials per published recommendations from clinical consensus guidelines)
Not all cuffs are the same. The main cuff variations:
High-volume, low-pressure (HVLP) cuff — the standard cuff design on most modern tubes. The cuff is large in diameter when inflated, applying low pressure across a wide area of tracheal wall. Reduces tracheal injury compared to older high-pressure cuffs. Pressure typically maintained at around 25 cm H₂O measured with a manometer.
Tight-to-shaft (TTS) cuff (Bivona) — a silicone cuff that, when deflated, sits flat against the tube shaft so the tube acts essentially like an uncuffed tube. When inflated, it creates a seal. Used for patients who need a cuff sometimes (e.g., overnight on a ventilator) but want to be cuffless for daytime speech and comfort. Bivona TTS cuffs are filled with sterile water, not air, because air diffuses out through silicone.
Foam-filled cuff (Bivona Fome-Cuf) — a self-inflating cuff with foam inside. The foam expands when the pilot balloon is open to room air, creating a continuous seal. The clinician does not actively inflate it. Used for persistent cuff leaks where standard cuffs can't maintain a seal. Important: speaking valves and capping are contraindicated with Fome-Cuf tubes because the cuff is always partially inflated.
Single-Lumen tubes (also called single-cannula) are exactly what they sound like — one tube, no removable inner piece. Bivona silicone tubes are typically single-lumen. To clear secretions, the tube is suctioned. Cleaning the inside of the tube requires either replacement or specific protocols.
Double-Lumen tubes (also called double-cannula) have a removable inner cannula that fits inside the outer cannula. Most Shiley and Portex tubes are double-lumen. The inner cannula can be removed, cleaned (or replaced if disposable), and reinserted without removing the outer cannula. This is a major workflow advantage for managing secretions and tube hygiene — particularly for adult trach patients with high secretion loads.
The double-lumen system is what many clinical teams refer to as the most important practical difference between Bivona-style (single-lumen, soft silicone, reuse-capable) and Shiley-style (double-lumen, firmer PVC, typically disposable) tubes.
A fenestrated tube has one or more openings (fenestrations) on the curved upper surface of the outer cannula, above the cuff (if cuffed). Fenestrations allow air to move through the tube into the upper airway — through the vocal cords, mouth, and nose.
Why fenestrations matter: Allow speech without removing the tube, reduce work of breathing during capping trials, useful in decannulation preparation, can be used with a cap once cuff is fully deflated (cuffed fenestrated tubes only)
How fenestrated tubes work: The fenestrated outer cannula has the holes. A non-fenestrated inner cannula (typically with a colored top to distinguish from the fenestrated inner cannula) is used during ventilation — it blocks the fenestrations to maintain a sealed system. A fenestrated inner cannula (different colored top) is inserted to enable speech and upper airway breathing. For ventilation, the cuff is inflated and non-fenestrated inner cannula is used. For weaning or speech, the cuff is deflated and fenestrated inner cannula is used.
Three brand families dominate the modern tracheostomy market:
Shiley (Medtronic / Mallinckrodt)
The most widely used brand in US hospitals
PVC plastic construction (firmer, more rigid than silicone)
Most models are double-lumen (with inner cannula)
Disposable single-patient use
Sizing: most Shiley dual-cannula tubes use the Chevalier Jackson sizing system; Shiley Flex tubes use the ISO sizing system
Common variants: Shiley Cuffed (most common for ICU/vent), Shiley Cuffless, Shiley Fenestrated, Shiley Flex (newer, ISO-sized), Shiley XLT (extra-length proximal or distal)
Portex (Smiths Medical / ICU Medical)
Original cuffless plastic tube manufacturer (the first "Ivory" endotracheal tubes were Portex)
Modern lineup includes Blue Line, BLUselect, BluPerc (percutaneous insertion kits)
Some Portex tubes have a suction port above the cuff (subglottic suctioning) — used to reduce ventilator-associated pneumonia by suctioning secretions that pool above the cuff
BLUselect uses ISO sizing
Bivona (originally a separate brand, now part of ICU Medical / Smiths-Portex family)
Soft silicone construction
Typically single-lumen (no inner cannula)
Many models can be sterilized and reused for the same patient (per manufacturer guidance) — a major cost difference for long-term home use
Soft, flexible — gentler on pediatric and atypical-anatomy airways
Common variants: Bivona Aire-Cuf (air-filled cuff), Bivona TTS (tight-to-shaft, water-filled), Bivona Uncuffed, Bivona Fome-Cuf (foam-filled), Bivona Adjustable (variable flange position)
Pediatric Bivona tubes are heavily used due to flexibility advantages in growing airways
Tracoe (and other smaller brands)
Polyurethane construction
Specific niches in long-term care
Less common in US but well-represented in European markets
Available in extra-long proximal length (longer between the flange and the tube curve — useful for patients with thick necks or significant subcutaneous tissue) or extra-long distal length (longer below the curve — useful when the standard length doesn't reach below tracheal pathology).
The flange position can be moved along the tube shaft to accommodate variable neck anatomy. Particularly useful for obese patients, post-surgical anatomy, or pediatric growth.
A separate small lumen that opens above the cuff. Subglottic suctioning use: continuous or intermittent suction (typically 100–120 mmHg) to remove secretions that pool above the cuff before they leak around it into the lower airway. This is a strategy for reducing ventilator-associated pneumonia.
Speech use: a small flow of air can be infused above the cuff (occluding the open port with a finger) to allow speech in long-term ventilator-dependent patients with the cuff inflated.
Made of silver or stainless steel. Heavier and more rigid than plastic. Typically uncuffed. Inherently antimicrobial. Removable and easy to clean — patients often report fewer secretion problems and less odor with metal tubes. Used long-term in stable trach patients, and historically standard before plastic tubes dominated.
Most pediatric tubes are uncuffed and increase size. Cuffed pediatric tubes are used only when needed for positive-pressure ventilation or aspiration prevention. The pediatric airway is small and the cricoid cartilage often provides natural sealing during ventilation.
Sizing differs. Pediatric sizing is based on age and airway diameter. Common pediatric sizes are 3.0, 3.5, 4.0, 4.5, 5.0 mm inner diameter (Bivona pediatric and Shiley neonatal/pediatric).
Bivona pediatric tubes dominate. Soft silicone is more forgiving in growing pediatric airways than rigid PVC. Bivona pediatric tubes typically have a monthly replacement schedule per manufacturer.
Single-lumen design is standard pediatric. Removing an inner cannula in a small pediatric airway is impractical and would compromise the tube's already-small inner diameter.
Neonatal flanges are sized specifically for newborn anatomy.
Pediatric airway anatomy — infant airways are 25% smaller in diameter than adult airways, with more pliable cartilage and greater vulnerability to mucosal trauma. This is why pediatric trach care protocols (suctioning depth, catheter sizing, suction pressure) differ from adult protocols.
For a deeper look at pediatric tracheostomy considerations, see our guide on pediatric trach normalcy and the pediatric hospital discharge guide.
Tracheostomy tube sizing is genuinely confusing because two different systems are in use:
Jackson sizing (older system) — uses a number that doesn't directly correspond to a specific millimeter measurement; rather, the number reflects a historical sizing convention. Most legacy Shiley dual-cannula tubes still use Jackson sizing.
ISO sizing (International Organization for Standardization, modern system) — sizes the tube according to the inner diameter of the narrowest part of the tube (which includes the inner cannula if one is required for ventilator connection). All Portex, Bivona, Uniperc, Tracoe, and Shiley Flexible Tracheostomy Tubes use ISO sizing.
The implication: a "size 6 Shiley" (Jackson) and a "6.0 ISO" tube are not necessarily the same dimensions. Always check the dimensions printed on the flange when sizing a replacement.
For adult initial placement, common starting sizes are:
Adult women: tubes with an outer diameter around 10 mm
Adult men: tubes with an outer diameter around 11 mm
Sizing decisions account for upper airway resistance, ventilation needs, communication needs, and indication for the tracheostomy.
Most tube comparison content lists features. It rarely addresses what actually changes for the patient and family with different tube choices.
Speech. A patient with a cuffed tube and inflated cuff cannot speak. Switch to a fenestrated tube with cuff deflated and a fenestrated inner cannula — speech becomes possible. Switch to an uncuffed tube — speech becomes more natural still. For long-term tracheostomy patients, the conversation about speech often drives the conversation about tube choice.
Sleep. Cuff pressure on the tracheal wall, particularly with overinflated standard cuffs over time, can cause discomfort during sleep and contribute to tracheal wall thinning and scarring. Tight-to-shaft (TTS) cuffs deflated overnight, or transition to uncuffed tubes, reduce this.
Bathing and water exposure. All tracheostomy patients must keep water out of the tube. The Heat-Moisture Exchanger (HME) cover that fits over the tube during bathing helps. Specific waterproof devices designed for trach patients exist for shallow swimming with pulmonologist clearance.
Hospital readmission risk. Standardization of pediatric trach care — including tube selection appropriate to the patient's stage and needs — has been associated with reduced hospital readmission rates in published research. The wrong tube for the wrong patient creates secretion management problems, work-of-breathing problems, and infection risk that lead back to the hospital.
Decannulation trajectory. Patients moving toward decannulation typically transition tube types: from cuffed to uncuffed, sometimes through a fenestrated phase, sometimes through a downsized tube before capping trials. The published literature on decannulation protocols emphasizes that tube selection through the weaning process directly affects success rates. See our companion guide on tracheostomy decannulation for the full process.
Caregiver workload. Single-lumen Bivona tubes require active suctioning to clear secretions. Double-lumen Shiley/Portex tubes allow inner cannula removal and cleaning between full tube changes. The workload difference matters for families managing care at home.
These daily-life considerations — alongside the medical specifics — are why tube selection is reviewed periodically rather than set once. The right tube for week 1 may not be the right tube for month 6.
Tube selection is the responsibility of the prescribing physician — typically a pulmonologist, otolaryngologist (ENT), or in pediatric cases the pediatric pulmonologist or pediatric ENT — based on:
Indication for tracheostomy
Ventilator needs
Patient anatomy (neck size, airway diameter, anatomic variants)
Communication needs
Aspiration risk
Secretion volume
Anticipated duration of tracheostomy
Surgical placement technique
Patient and family preferences (where appropriate)
Tube selection is reviewed at scheduled tube changes and may evolve as the patient's clinical status changes.
A patient stabilized off the ventilator may transition from a cuffed Shiley to an uncuffed Bivona. A pediatric patient's sizing changes with growth. A patient developing decannulation readiness may move through fenestrated and downsized tubes during weaning.
Manufacturer recommendations (generally — always defer to specific product instructions and physician orders):
Shiley PVC tubes — replace every 29 days per Shiley manufacturer guidance
Portex Blue Line tubes — up to 30 days per package insert
Portex Bivona tubes — up to 29 days per package insert; certain models can be sterilized and reused for the same patient (up to 10 times for selected silicone tubes)
Tubes with inner cannulas — generally not recommended for use beyond 30 days
Pediatric Bivona — monthly replacement schedule
For specific replacement protocols and home replacement guidance, see our guide on tracheostomy emergency response and the tracheostomy decannulation process.
Q: What's the difference between a cuffed and uncuffed tracheostomy tube?
A: Cuffed tubes have an inflatable balloon near the tip that seals against the tracheal wall when inflated — needed for ventilator support and aspiration prevention. Uncuffed tubes have no balloon; air can move freely around the tube, allowing speech and breathing through the upper airway. Most pediatric tubes and most stable long-term adult tubes are uncuffed.
Q: What's the difference between Shiley and Bivona tubes?
A: Shiley tubes are firm PVC plastic, typically double-lumen (with inner cannula), single-patient disposable. Bivona tubes are soft silicone, typically single-lumen (no inner cannula), and many models can be sterilized and reused for the same patient. Bivona is more flexible — common in pediatric and atypical anatomy. Shiley is more rigid and dominant in adult ICU/hospital use.
Q: What is a fenestrated tracheostomy tube?
A: A fenestrated tube has one or more openings on the curve of the outer cannula above the cuff. These openings allow air to flow up through the vocal cords for speech and reduce work of breathing during capping. Used with a fenestrated inner cannula for speech, or non-fenestrated inner cannula for sealed ventilation.
Q: What does TTS mean on a Bivona tube?
A: TTS stands for Tight-To-Shaft. The cuff inflates for a seal when needed and, when deflated, sits flat against the tube shaft so the tube functions essentially like an uncuffed tube. Used for patients who need cuff sometimes (overnight ventilation) but cuffless function during the day. TTS cuffs are filled with sterile water, not air.
Q: What is a Fome-Cuf tube?
A: The Bivona Fome-Cuf is a self-inflating tube with a foam-filled cuff. The foam expands when the pilot balloon is opened to room air. Used when standard cuffs cannot maintain a seal due to anatomic challenges. Speaking valves and capping are contraindicated with Fome-Cuf tubes.
Q: How is pediatric tracheostomy different?
A: Pediatric tubes are smaller, mostly uncuffed, mostly single-lumen Bivona-style. Pediatric airways are 25% smaller than adult and require pediatric-specific suctioning and care protocols per AARC and ATS guidelines. Pediatric trach is its own specialty with different care than adult.
Q: How often does a tracheostomy tube need to be replaced?
A: Manufacturer guidance: Shiley PVC every 29 days; Portex Blue Line up to 30 days; Bivona up to 29 days (some pediatric Bivonas monthly with reuse capability for selected silicone tubes). Frequency depends on physician orders and clinical scenario.
Q: What sizing system does my loved one's tube use — Jackson or ISO?
A: Check the flange — the size is printed there. Most legacy Shiley dual-cannula tubes use Jackson sizing. All Portex, Bivona, Tracoe, and Shiley Flexible tubes use ISO sizing. Numbers are not directly interchangeable — always verify inner and outer diameter.
Q: Can a tracheostomy tube be removed permanently?
A: Yes, through a process called decannulation. When the underlying reason for the tracheostomy improves and readiness criteria are met, the tube is removed and the stoma typically closes on its own. See our tracheostomy decannulation guide for the full process.
