Rethinking tracheostomy care: cuffless tubes for patients with aspiration

Introduction Guidelines do not recommend cuffless tracheostomy tubes in patients at risk of aspiration, although there is no evidence supporting the protective effect of cuffed tubes against aspiration or pneumonia. The Zihlschlacht Neurological Rehabilitation Clinic has routinely implemented early transition to cuffless tubes to support rehabilitation, facilitate communication and improve quality of life. This study evaluates the impact of this approach on tracheostomy management and pneumonia rates. Methods Retrospective analysis included 124 non-ventilated, tracheostomized neurological patients admitted between January 2019 and December 2022. Outcomes were pneumonia, aspiration, secretion burden, and tolerance of speaking valves or decannulation caps. Results Of the 124 patients, 119 were admitted with cuffed tubes. Pneumonia was documented in 112 patients and aspiration in 77. All patients were switched to cuffless tubes within seven days, including those with severe aspiration. After conversion to cuffless tubes, suspected aspiration decreased from 29 to 13 and confirmed aspiration from 48 to 42 cases, totaling 55, while pneumonia fell to 14. Most patients tolerated speaking valves or decannulation caps immediately, required less suctioning, and showed a marked reduction in secretions. Discussion Early conversion to cuffless tubes did not increase aspiration pneumonia and was associated with improved secretion management and easier airway care. These findings challenge the presumed protective role of cuffed tubes and support the feasibility of early cuffless use in neurological rehabilitation. Aspiration risk alone should not preclude early cuffless management. Prospective studies are needed.