G.J. asks, "When patients with a tracheostomy are discharged home, what do they need to know to take care of themselves?"
Answer: Patients and families who are being discharged with a new tracheostomy need a great deal of teaching in order to become comfortable with their care. Ideally, this teaching takes place over a period of time, during several sessions and should begin as soon as possible before discharge. Teaching should include guidelines for infection control such as handwashing and proper handling of the tracheostomy and equipment. Patients should be given a list of supplies and instructed to ensure that all supplies have been received in the home before they leave the hospital.
Patients and family members should be taught about airway anatomy and parts of the tracheostomy tube, how they fit together. The most difficult thing for patients and family members to master is suctioning. They realize that suctioning creates discomfort and they are reluctant to cause discomfort for their loved one. However, effective suctioning is an essential skill.
They must also be taught how to clean the stoma and the inner cannula, and how to change the trach ties. When the tube is cuffed, they must also learn how to maintain effective cuff pressure. The tracheostomy tube must be changed at regular intervals (usually every 1-2 months), so they must learn how to change the entire tube. In addition, patients and family members must learn the early signs of infection so that they can report symptoms to their health-care provider.
Emergency management must begin in the home, so patient and family members should know what to do in the event of an obstructed tube and a dislodged tube, which are the most common emergencies.
Upon discharge, family members should place a call to the local fire department to provide information for emergency personnel so that they can be better prepared if dispatched to the home.
Patients and family members should know where emergency equipment is located, including the obturator, extra tracheostomy tubes, and manual resuscitation bag.
It is also important that patients are followed closely by a medical professional to regularly review their plan of care and ensure that needs are met.
More detailed information about tracheostomy care is presented in Chapter 7: Care of the Tracheostomy Patient and Chapter 12: Rehabilitation and Recovery. Emergency management is presented in Chapter 10: Complications and Emergency Procedures.
Wednesday, December 1, 2010
Tuesday, November 23, 2010
Frequency of Tube Changes
J.C. asks, "How often should a tracheostomy tube be changed?
Answer: Tracheostomy tubes should be routinely changed on a regular basis to prevent infection and other complications; and in the case of children, to keep up with their growth and development.
Most manufacturers recommend changing their tubes every 30-60 days. Tube changes can be done during an office visit, but many patients prefer to change the tube at home, either by themselves or a caregiver. Some change their tube weekly or biweekly, and some change the tube daily, rotating between two different tubes.
Failure to change the tube on a regular basis can result in severe infection, tube obstruction, or tracheitis.
Answer: Tracheostomy tubes should be routinely changed on a regular basis to prevent infection and other complications; and in the case of children, to keep up with their growth and development.
Most manufacturers recommend changing their tubes every 30-60 days. Tube changes can be done during an office visit, but many patients prefer to change the tube at home, either by themselves or a caregiver. Some change their tube weekly or biweekly, and some change the tube daily, rotating between two different tubes.
Failure to change the tube on a regular basis can result in severe infection, tube obstruction, or tracheitis.
Sunday, October 31, 2010
Your Most Valuable Tool
B.W. asks, "What does it mean if I start to have trouble passing the suction catheter?"
Answer: Meeting resistance upon passage of a suction catheter usually means one of two things: either the inner lining of the tracheostomy tube is becoming coated with secretions, or the tracheostomy tube has entered a false passage.
The suction catheter is your most valuable tool because it can provide you with much useful information. Not only is it used for removing secretions, but it can be used to predict future problems. If a suction catheter meets some resistance, but can be passed several centimeters, then it usually means that secretions are beginning to coat the inside of the tracheostomy tube. In this case, the inner cannula should be changed. If the tube does not have an inner cannula, the entire tube should be changed.
If the suction catheter can be passed only a few centimeters and no more (i.e., the length of the tracheostomy tube), it usually means that the tube has entered a false passage. In other words, the tube is lodged within the tissues anterior to the trachea. In that case, the obturator should be used to maneuver the tube into the correct position. Alternatively, the entire tube should be changed. After any of these maneuvers, the proper position of the tube should be confirmed by easy passage of a suction catheter and return of tracheal secretions.
One should be aware of the proper sizes of suction catheters to be used for tracheostomy tubes. A size 14 French should easily pass through a size 6 and 8 tracheostomy tube. However, a size 4 tube often requires a size 10 or 12 French suction catheter. The response to difficult passage of a suction catheter should not be a switch to a smaller catheter. Rather, it should be a warning sign to consider the reason for the difficulty.
Another use for the suction catheter is as a "guidewire" to determine the tracheal tract. A tracheostomy tube can then be slid into position over it.
Answer: Meeting resistance upon passage of a suction catheter usually means one of two things: either the inner lining of the tracheostomy tube is becoming coated with secretions, or the tracheostomy tube has entered a false passage.
The suction catheter is your most valuable tool because it can provide you with much useful information. Not only is it used for removing secretions, but it can be used to predict future problems. If a suction catheter meets some resistance, but can be passed several centimeters, then it usually means that secretions are beginning to coat the inside of the tracheostomy tube. In this case, the inner cannula should be changed. If the tube does not have an inner cannula, the entire tube should be changed.
If the suction catheter can be passed only a few centimeters and no more (i.e., the length of the tracheostomy tube), it usually means that the tube has entered a false passage. In other words, the tube is lodged within the tissues anterior to the trachea. In that case, the obturator should be used to maneuver the tube into the correct position. Alternatively, the entire tube should be changed. After any of these maneuvers, the proper position of the tube should be confirmed by easy passage of a suction catheter and return of tracheal secretions.
One should be aware of the proper sizes of suction catheters to be used for tracheostomy tubes. A size 14 French should easily pass through a size 6 and 8 tracheostomy tube. However, a size 4 tube often requires a size 10 or 12 French suction catheter. The response to difficult passage of a suction catheter should not be a switch to a smaller catheter. Rather, it should be a warning sign to consider the reason for the difficulty.
Another use for the suction catheter is as a "guidewire" to determine the tracheal tract. A tracheostomy tube can then be slid into position over it.
Tuesday, October 12, 2010
Emergency Equipment
Nurse C.D. asks, "What type of emergency equipment should I have at the bedside?"
Answer: One must always be prepared for an emergency, and the key is to have essential items always available. These items include: extra tracheostomy tubes of the same size and type, as well as one size smaller, suction catheters (and a functional suction system), and the obturator.
The purpose of the obturator is to assist with insertion, and is especially helpful when the tube is partially or completely removed from the stoma. The tube can be easily guided into place when the obturator is handy.
Extra trachs should always be present and can be used if the tube comes out or if the tube needs to be changed. The smaller sized tube can be used if you encounter difficulty getting the larger tube in. For example: In one patient, the trach fell out during the night. When the problem was discovered, the larger tube could not be placed because the stoma had shrunk; and so, the smaller tube was inserted.
Your most important tool is the suction catheter. It should be used to suction as often as necessary. Suctioning is done for removal of secretions, but it also has other purposes:
Answer: One must always be prepared for an emergency, and the key is to have essential items always available. These items include: extra tracheostomy tubes of the same size and type, as well as one size smaller, suction catheters (and a functional suction system), and the obturator.
The purpose of the obturator is to assist with insertion, and is especially helpful when the tube is partially or completely removed from the stoma. The tube can be easily guided into place when the obturator is handy.
Extra trachs should always be present and can be used if the tube comes out or if the tube needs to be changed. The smaller sized tube can be used if you encounter difficulty getting the larger tube in. For example: In one patient, the trach fell out during the night. When the problem was discovered, the larger tube could not be placed because the stoma had shrunk; and so, the smaller tube was inserted.
Your most important tool is the suction catheter. It should be used to suction as often as necessary. Suctioning is done for removal of secretions, but it also has other purposes:
- To stimulate a cough (especially important in patients who are unable to generate an effective cough).
- To ensure proper placement of the tube. (If you can only insert the suction catheter 2-3 inches, it may be in a false passage, or there may be a mucus plug.)
- The suction catheter can be used as a "guidewire" if there is difficulty in placement of the tube.
In addition to the emergency supplies, I also recommend a bedside kit to include everyday items such as drain sponges, trach ties, saline, trach cleaning kit, 10-ml syringe, oropharyngeal suction catheter, and hydrogen peroxide and saline. It's very helpful to have everything you need at your fingertips. In case of emergency, you will be glad you were prepared (and the patient will be, too!)
Tuesday, October 5, 2010
Bloody Secretions
B.L. asks, "What should I do if the secretions become bloody? Am I suctioning too much?"
Answer: Secretions can become bloody because of tracheal irritation. And yes, this can be caused by frequent tracheal suctioning or strong coughing. However, the presence of bloody secretions should not cause you to suction less often. Rather, you should consider switching to red rubber catheters. These catheters are very soft and have a blunt tip (because they are actually urinary catheters). The use of these catheters has shown complete healing of tracheal lesions in as little as 24 hours.
The problem with these catheters is that one must use a separate adapter in order to connect it to the suction tubing. If you use a Y-shaped adapter, you can use your thumb over the open end to create intermittent suction. If you use a straight adapter, you will be unable to create intermittent suction.
Another solution is to ease off on the suction pressure. Too much negative pressure against the lumen of the trachea can also be an irritant. A few studies suggest that -200 cm H20 pressure should be the upper limit; however, this depends on the ratio of the size of the suction catheter to tube size.
Tracheal suctioning is one of the most important things that you can and must do for your tracheostomy patients. To suction less frequently is to do your patients a disservice, and may create harm by inspissation of secretions and obstruction of the tube.
Caution: Do not use red rubber catheters in a patient with a latex allergy.
Answer: Secretions can become bloody because of tracheal irritation. And yes, this can be caused by frequent tracheal suctioning or strong coughing. However, the presence of bloody secretions should not cause you to suction less often. Rather, you should consider switching to red rubber catheters. These catheters are very soft and have a blunt tip (because they are actually urinary catheters). The use of these catheters has shown complete healing of tracheal lesions in as little as 24 hours.
The problem with these catheters is that one must use a separate adapter in order to connect it to the suction tubing. If you use a Y-shaped adapter, you can use your thumb over the open end to create intermittent suction. If you use a straight adapter, you will be unable to create intermittent suction.
Another solution is to ease off on the suction pressure. Too much negative pressure against the lumen of the trachea can also be an irritant. A few studies suggest that -200 cm H20 pressure should be the upper limit; however, this depends on the ratio of the size of the suction catheter to tube size.
Tracheal suctioning is one of the most important things that you can and must do for your tracheostomy patients. To suction less frequently is to do your patients a disservice, and may create harm by inspissation of secretions and obstruction of the tube.
Caution: Do not use red rubber catheters in a patient with a latex allergy.
Friday, July 30, 2010
Positioning for Trach Reinsertion
C.L. asks, "If inadvertent decannulation occurs, what is the best patient positioning for reinsertion?"
Answer: Supine positioning with neck hyperextension is ideal for reinsertion. However, this may not be appropriate for all patients. The key is visualization of the stoma and adequate lighting. I have reinserted trachs in all positions, including sitting and standing.
Operator positioning is also important. The operator should be positioned on the side of their dominant hand. For example, I always stand on the patient's left because I am left-handed.
Answer: Supine positioning with neck hyperextension is ideal for reinsertion. However, this may not be appropriate for all patients. The key is visualization of the stoma and adequate lighting. I have reinserted trachs in all positions, including sitting and standing.
Operator positioning is also important. The operator should be positioned on the side of their dominant hand. For example, I always stand on the patient's left because I am left-handed.
Wednesday, June 23, 2010
Complications During Tube Replacement
C.L. asks, "What are the chances of esophageal or tracheal rupture, or subcutaneous emphysema with reinsertion of a dislodged tracheostomy tube?"
Answer: I have never encountered esophageal nor tracheal rupture during reinsertion of a dislodged tube. Nor am I aware of any reports in the literature. Theoretically, it could occur if the tube was placed with great force and without an obturator to cushion the tip, or perhaps in combination with friable tissue. However, ruptured esophagus and ruptured trachea have been reported as a complication during the tracheotomy procedure, particularly with the percutaneous technique.
As for subcutaneous emphysema, this can occur if the tube is inserted into a false passage and positive pressure is applied, forcing air into the subcutaneous tissue. During the early postoperative period, tube security should be a priority. When replacing a tube into a mature stoma, and prior to application of positive pressure, it is important to confirm placement by passage of a suction catheter with return of tracheal secretions.
When replacing a tube, technique is also important. An initial 90 degree approach, followed by a caudal turn is the recommended technique. A premature caudal turn can result in placement into a false passage.
Answer: I have never encountered esophageal nor tracheal rupture during reinsertion of a dislodged tube. Nor am I aware of any reports in the literature. Theoretically, it could occur if the tube was placed with great force and without an obturator to cushion the tip, or perhaps in combination with friable tissue. However, ruptured esophagus and ruptured trachea have been reported as a complication during the tracheotomy procedure, particularly with the percutaneous technique.
As for subcutaneous emphysema, this can occur if the tube is inserted into a false passage and positive pressure is applied, forcing air into the subcutaneous tissue. During the early postoperative period, tube security should be a priority. When replacing a tube into a mature stoma, and prior to application of positive pressure, it is important to confirm placement by passage of a suction catheter with return of tracheal secretions.
When replacing a tube, technique is also important. An initial 90 degree approach, followed by a caudal turn is the recommended technique. A premature caudal turn can result in placement into a false passage.
Sunday, May 30, 2010
What is Downsizing?
P.T. asks, "What is the purpose of downsizing?"
Answer: The purpose of downsizing is to allow the patient to do more breathing around the tube, rather than through the tube. When the initial problem that initiated placement of the trach is resolved, downsizing may begin. For example, when the tube was placed because of prolonged mechanical ventilation, downsizing can begin as soon as the patient has been weaned from the ventilator.
Downsizing should begin with cuff deflation, which allows admixture of room air, lowering overall FiO2. So downsizing should not begin until the patient is hemodynamically stable and can tolerate cuff deflation.
When the patient is able to tolerate cuff deflation, the tube can be changed to one with a smaller outer diameter. Capping can begin at that time (and never with a standard cuffed tube).
The end result of downsizing is usually with the overall goal of decannulation; however, the tube may need to be downsized in order to allow enough air around the tube to reach the vocal cords for phonation. See the Downsizing Algorithm in Chapter 11 for a step-wise procedure on downsizing.
Answer: The purpose of downsizing is to allow the patient to do more breathing around the tube, rather than through the tube. When the initial problem that initiated placement of the trach is resolved, downsizing may begin. For example, when the tube was placed because of prolonged mechanical ventilation, downsizing can begin as soon as the patient has been weaned from the ventilator.
Downsizing should begin with cuff deflation, which allows admixture of room air, lowering overall FiO2. So downsizing should not begin until the patient is hemodynamically stable and can tolerate cuff deflation.
When the patient is able to tolerate cuff deflation, the tube can be changed to one with a smaller outer diameter. Capping can begin at that time (and never with a standard cuffed tube).
The end result of downsizing is usually with the overall goal of decannulation; however, the tube may need to be downsized in order to allow enough air around the tube to reach the vocal cords for phonation. See the Downsizing Algorithm in Chapter 11 for a step-wise procedure on downsizing.
Thursday, May 6, 2010
Water or Saline?
A respiratory therapy student asks, "What am I supposed to use to inflate the cuff of a Bivona TTS trach? I've heard they should be inflated with water, but I've also heard saline. Which is it...and why?"
Answer: The Bivona TTS and the Arcadia CTS tubes are both made of silicone with high-pressure, low-volume cuffs. These cuffs are in contrast to the majority of tracheostomy tubes out there (most are low-pressure, high-volume). When inflated, they create pressures greater than 120 cm H2O, even when only slightly inflated. So direct measurement of cuff pressure is not useful. When extended cuff inflation is desired (as for intermittent mechanical ventilation), they should be inflated with sterile water (not saline), using minimal leak technique. Saline has been shown to degrade the cuff over time. Sterile water is preferable for cuff inflation because air can diffuse through the cuff over time and manifest as cuff deflation.
Historically, the first cuffs to appear on tracheostomy tubes were also high-pressure, low volume. These cuffs created significant tracheal damage, and intermittent cuff deflation was recommended to relieve pressure against the trachea. Over the years, low-pressure, high-volume cuffs were developed that helped to minimize tracheal damage due to cuff inflation.
The primary benefit of these high-pressure cuffs is their deflation characteristics. When deflated, the cuff lies snugly against the shaft of the tube, lessening resistance to airflow passing around the tube. These tubes are ideal for a patient who requires intermittent cuff inflation, but they are the only cuffed tubes that can be safely capped when deflated.
Answer: The Bivona TTS and the Arcadia CTS tubes are both made of silicone with high-pressure, low-volume cuffs. These cuffs are in contrast to the majority of tracheostomy tubes out there (most are low-pressure, high-volume). When inflated, they create pressures greater than 120 cm H2O, even when only slightly inflated. So direct measurement of cuff pressure is not useful. When extended cuff inflation is desired (as for intermittent mechanical ventilation), they should be inflated with sterile water (not saline), using minimal leak technique. Saline has been shown to degrade the cuff over time. Sterile water is preferable for cuff inflation because air can diffuse through the cuff over time and manifest as cuff deflation.
Historically, the first cuffs to appear on tracheostomy tubes were also high-pressure, low volume. These cuffs created significant tracheal damage, and intermittent cuff deflation was recommended to relieve pressure against the trachea. Over the years, low-pressure, high-volume cuffs were developed that helped to minimize tracheal damage due to cuff inflation.
The primary benefit of these high-pressure cuffs is their deflation characteristics. When deflated, the cuff lies snugly against the shaft of the tube, lessening resistance to airflow passing around the tube. These tubes are ideal for a patient who requires intermittent cuff inflation, but they are the only cuffed tubes that can be safely capped when deflated.
Thursday, February 18, 2010
Common Trach Emergencies
Dr. E.H asks, "What are the most common emergencies with tracheostomies?"
Answer: The two most common emergencies with tracheostomies are mucus plugs and inadvertent decannulation/displacement. Mucus plugs occur because of inadequate hydration and inactivity, resulting in thickening and stasis of secretions. Initial presenting symptoms of mucus plugs are respiratory distress and/or desaturation. Treatment involves removing/cleaning inner cannula, vigorous suctioning, and/or changing the entire tracheostomy tube. Occasionally none of these measure will relieve the obstruction. In that case, the mature tracheostomy tube may be removed and the stoma suctioned directly, or bronchoscopy may be necessary to relieve obstruction.
Inadvertent decannulation or dislodgement can result from inadequate security of the tube, especially when it is combined with patient movement or a tube that is too short. Decannulation is easy to observe, in that the tube is completely absent from the stoma; however, dislodgement is not so obvious. Sometimes, the tube is still within the stoma, and so, appears in place; however, it is removed from the tracheal lumen. In an immature tracheostomy, this situation is an emergency. The tube should be removed, the stoma covered, and the patient intubated from above. A tracheal revision can then be performed under more controlled circumstances.
In a mature tracheostomy, dislodgement is recognized by a "high-riding tube" (one that cannot be pushed in as far as the neck flange), inability to pass a suction catheter, and the alert patient may be able to phonate clearly. In this case, the tube may be withdrawn and reinserted, taking care to assess the location and orientation of the tracheal stoma.
L.L.M.
Answer: The two most common emergencies with tracheostomies are mucus plugs and inadvertent decannulation/displacement. Mucus plugs occur because of inadequate hydration and inactivity, resulting in thickening and stasis of secretions. Initial presenting symptoms of mucus plugs are respiratory distress and/or desaturation. Treatment involves removing/cleaning inner cannula, vigorous suctioning, and/or changing the entire tracheostomy tube. Occasionally none of these measure will relieve the obstruction. In that case, the mature tracheostomy tube may be removed and the stoma suctioned directly, or bronchoscopy may be necessary to relieve obstruction.
Inadvertent decannulation or dislodgement can result from inadequate security of the tube, especially when it is combined with patient movement or a tube that is too short. Decannulation is easy to observe, in that the tube is completely absent from the stoma; however, dislodgement is not so obvious. Sometimes, the tube is still within the stoma, and so, appears in place; however, it is removed from the tracheal lumen. In an immature tracheostomy, this situation is an emergency. The tube should be removed, the stoma covered, and the patient intubated from above. A tracheal revision can then be performed under more controlled circumstances.
In a mature tracheostomy, dislodgement is recognized by a "high-riding tube" (one that cannot be pushed in as far as the neck flange), inability to pass a suction catheter, and the alert patient may be able to phonate clearly. In this case, the tube may be withdrawn and reinserted, taking care to assess the location and orientation of the tracheal stoma.
L.L.M.
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