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.
Sunday, October 31, 2010
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.
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