10-Year Outcomes Study on Trachs

This was a 10-year study done at a tertiary care teaching hospital in Tanzania and included 214 patients. Male to female ratio was 3:1, with a mean age of 38 years.  In their study, the most common indication for tracheostomy was upper airway obstruction secondary to trauma or neoplastic causes. Eighty-six percent of tracheostomies were temporary, and 14% were permanent tracheostomies.  Most (80%) of these tracheotomies were performed as an emergency and the complication rate was higher in that group, compared to the overall complication rate (74% vs. 21.5%).   Twenty-two percent of complications occurred in the first  postoperative week, and 65% occurred after the first postoperative week. Of the patients who had a tracheostomy placed for prolonged mechanical ventilation, the duration of intubation before tracheostomy ranged from 4-62 days, with a median of 26 days.  Duration of cannulation was 8 days to 46 months, with a median duration of 4 months.  Decannulation was successful in 72% of patients who survived.  Mortality rate was 13.6% and was due to the underlying illness, not the tracheostomy itself.

As the authors stated, and I would agree, that the majority of the complications can be prevented by meticulous attention to technique and postoperative care.

Source: Gilyoma, J.,Balumuka, D, Chalya, P. (2011). Ten-year experiences with tracheostomy at a university teaching hospital in northwestern Tanzania: A retrospective review of 214 cases. World J Emerg Surg, 6:38.

Trach for Prolonged Mechanical Ventilation

A survey was done of intensive care units in Italy to learn about the clinical characteristics of patients with a tracheostomy, including types, complications, criteria for performing decannulation, and outcomes. They received responses from 22 intensive care units with 846 admissions of 719 patients. Reasons for admission included acute respiratory failure with underlying chronic co-morbidities (24.4%), exacerbation of COPD (34.4%), neuromuscular diseases (27.8%), surgical patients (10.7%), and obstructive sleep apnea (2.2%). They found a very low incidence of major complications (fistula or stenosis, 2%). Twenty-two percent of patients were decannulated prior to discharge; and 41% were discharged with home mechanical ventilation, while 26.5% maintained the tracheostomy despite being weaned from the ventilator, and 10% died or were lost (either transferred to other units or refused treatment). Those who maintained the trach without mechanical ventilation were either over age 70 or had co-morbidities, or both.
In this study, the criteria to indicate decannulation included: stable PaCO2, absence of swallowing problems, type and severity of disease, presence of effective cough, stability of respiratory parameters such as dyspnea, respiratory rate, SaO2, PaO2, PaCo2, pH, and successful capping.

Source: Marchese et al, (2010). Tracheostomy patients with long-term mechanical ventilation: A survey. Resp Med (104), 749-753.

First Trach Change

There is very little research regarding when it is safe to do the first tracheostomy tube change.  Commonly, the first tube change is done between post-op day 7-14. A study was just published in Critical Care Medicine and showed that it is safe to do the first tracheostomy change prior to post-op day 7.

The authors at Mass General in Boston enrolled 130 patients after a tracheostomy placement.  Thirty-eight patients received a trach change prior to Day 7 (early group) and 92 patients received a trach change after Day 7 (late group).  They found that the early group was more likely to be liberated from the ventilator on Day 7 (100% vs. 45%, p=0.0001), tolerate speaking valve earlier (7 vs. 12 days, p=0.001), more likely to tolerate earlier oral feeding (10 vs. 20 days, p=0.04), and had shorter length of stay (11 vs. 17 days, p=0.001).  There was no difference in mortality and no complications associated with the trach change.

Source: Abstract: Fisher et al., (2011). Early tracheostomy change is associated with earlier use of speaking valve and earlier oral intake, Crit Care Med, 39(12), 515.

Air Transport with Trachs

R.H. asks, "We have a tracheostomy patient who is being airlifted to a different facility in another state.  Should we have any concerns with air transport?"

Answer: The biggest concerns with transport of any kind is dislodgement.  So the usual precautions for ensuring tube security should be in place.  These include ensuring snugness of the trach ties and limiting traction against the tube.  However, air transport poses additional concerns with cuffed tracheostomy tubes.  Boyle's law states that a fixed volume of gas will expand as pressure decreases.  So when the cuff is inflated with air, barometric pressure will decrease with altitude, and cuff pressure will rise as the cuff expands.  Studies have measured cuff pressures of well over 200 cm water pressure during air transport!

The usual clinical methods of ensuring safe cuff pressure--namely, minimal occlusive volume and minimal leak technique, are ineffective in air transport because the noise level is too high.  Some recommend using saline to inflate the cuff, but there are no devices currently on the market that will continuously monitor and automatically adjust cuff pressure.

For a detailed discussion on this topic, see Chapter 5 in Tracheostomies: The Complete Guide.

Home Supplies

Dr. C.R. asks, "What kind of home supplies do my tracheostomy patients need?"

Answer: Patients need many supplies to manage their tracheostomy.  They need plenty of suction catheters, suction machine, tubing, inner cannulas (if disposable), tracheostomy cleaning kits, trach holders, and an extra trach of the same size, and one size smaller.  It is essential that these supplies are delivered to the patients home before the patient is discharged. 

Keep in mind that Medicare and most insurance companies provide a cap on the number of supplies.  For example, the maximum allowance for suction catheters is 90 per month.  The patient can use the same suction catheter all day by rinsing it completely and allowing it to dry between uses.  But this may not be optimal, especially if the patient is prone to frequent infections.  In that case, it would be wise to write a letter of medical necessity so that they can receive more than the usual maximum number of supplies.

Maximum monthly allowance for other tracheostomy supplies are as follows: one new tracheostomy tube, 12 rigid Yankauer suction catheters, 30 disposable inner cannulas, 30 tracheostomy holders, and 30 cleaning kits per month. 

Patients need to be taught how to use these supplies before they are discharged from the hospital so that they are comfortable with the basic care of the tracheostomy.  This includes suctioning, changing or cleaning the inner cannula, care of the stoma, and managing the cuff (when present).  They also need to know how to identify the signs of infection and how to manage an emergency, such as a mucus plug.

Tracheal Bleeding

W.C. asks, "I've noticed a small amount of bleeding from my trach recently. Should I be worried?"

Answer: The two most frequent causes of tracheal bleeding are due to frequent suctioning and lack of humidity.  Regarding frequent suctioning, one should not decrease the frequency of suctioning just because of the appearance of some blood.  Rather, this should be a cue to switch to softer suction catheters.  I usually recommend red rubber catheters, which are not suction catheters, but are actually they are urinary catheters, technically called "coude" catheters.  These are especially helpful because the tip is closed, rather than open, so there is less trauma to the tissue with the use of these catheters.  Because the tip is closed, they may not be quite as effective as the standard suction catheters, but complete healing of tracheal tissue has been observed in as little as 24 hours after the switch, so this is an option.  Please note: Red rubber catheters cannot be used in the patient with a latex allergy.

The other frequent cause of tracheal bleeding is lack of proper humidity.  This is especially true in the fall and winter in colder climates....or other places that have low humidity (like hospitals!).  This dried blood can collect within the tracheostomy tube and begin to occlude the airway.  In fact, one patient had no trouble at home, but came to the hospital and required almost daily trach changes because of the accumulation of dried blood within his tracheostomy.  The problem resolved as soon as humidity was added to his ventilator circuit.

Now that fall and winter is approaching, you may need some extra help with humidity.  This can include room humidifiers, soaking a gauze in water or saline and placing lightly over your trach, using an HME (heat moisture exhanger), spritzing some atomized saline (Ocean nasal spray) into the trach and mucous membranes, increasing water intake, and more frequent changes.

If there is a large amount of bleeding, contact your health care provider for further evaluation.

Capping a Trach

J.D. asks, "I heard that there are many benefits for capping a trach.  Can you explain?"

Answer: Yes, capping a tracheostomy tube can provide many benefits; the primary benefit is usually allowing a patient to speak.  First, not all tracheostomy tubes should be capped.  A standard cuffed tracheostomy tube should never be capped, even if the cuff is deflated.  When the cuff is deflated, it still provides a great deal of bulk and resistance in the airway.  Even if a patient appears to breathe comfortably at one moment, things can change suddenly.  In addition, patients may not be able to fully expectorate their secretions, as they may get caught on the folds of the deflated cuff.

Other benefits of capping a tracheostomy tube include restoring subglottic pressure which can in turn restore taste, smell, improve cough and defacation.  Another benefit of capping is that the quantity of secretions tends to diminish.

For more discussion on capping, refer to Chapter 5 on phonation and Chapter 11 on downsizing.

Optimal Tube Length

P.S. asks, "How do I know that the tube is the correct length?"

Answer: It is important to ensure that the tube is neither too short nor too long.  If the tube is too short, it can be easily dislodged.  If too long, the tube can become "mainstemmed" in the right bronchus.  It can also cause other symptoms such as high airway pressures, discomfort, or continuous coughing by its constant irritation against the tracheal wall.

In order to determine optimal position of the tube within the airway, a chest x-ray can be beneficial, but a bronchoscope can be used to directly visualize the position of the tube.

International Conference on Tracheostomies

There is a new international symposium on Advanced Tracheostomy Management and Prolonged Mechanical Ventilation.  It will be held in Melbourne, Australia on September 1-2.  Check out their website at: https://sites.google.com/site/tracheostomyconference2011/.

I'm very excited about this conference as it will be the first conference dedicated specifically to tracheostomies.  I have been invited to be part of the panel on Tricky Tracheostomy Cases.
LLM

Trach Dislodgement

B.L. asks, "How does tracheostomy dislodgement happen?"
Answer: Dislodgement can be one of the most serious complications of having a tracheostomy.  Dislodgement can be even more serious than complete decannulation; because when the tube is completely removed from the stoma (decannulation), the problem is clearly visible.  However, when the tube is dislodged, it may not be so obvious.  In this case, the tube is still in the neck; however, the tip of the tube is not within the trachea and instead is positioned within the tissue anterior to the trachea, most often called a false passage.

Numerous attempts to replace the tube can enlarge the false passage, making subsequent attempts to replace it nearly always unsuccessful. 

There are several risk factors for tracheostomy dislodgement: a tube that is too short, traction against the tube, edema of the neck, obesity or a thick neck, and excessive coughing or agitation. 

Specific techniques of tube replacement depend on the maturity of the stoma and whether or not the patient is able to breathe around the tube.  These are discussed in more detail in our recent article in the "The Dreaded False Passage: Management of Tracheostomy Tube Dislodgement", Morris & Afifi, Journal of Emergency Medicine, 33(8).

Trach Button vs. Trach Tube

Dr. S.A. asks, "I just received a rehab patient with a trach button who has developed pneumonia.  Can I just replace the button with a regular trach?"

Answer: A trach button is often placed to maintain the stoma while the patient is gaining strength through rehabilitation.  The benefit of a button is that it provides no resistance within the airway, yet it maintains the stoma in case an artificial airway is needed.  If there is concern about secretions and the need for frequent suctioning, it is best to replace the button with a regular tracheostomy tube.  Otherwise, one would need to open the button every time the patient needs suctioning, and the introduction of a suction catheter would be directed toward the posterior tracheal wall.

One must realize that the trach button consists of three parts: the tracheal cannula, the closure plug, and a series of spacers to adjust to the exact length of the stoma. In order to remove the button, first remove the closure plug with the spacers.  This will release the tension against the distal petals of the cannula.  The cannula can then be removed easily and replaced with a tracheostomy tube.

Cuff Leaks

R.B. asks, "When a patient is on the ventilator, what causes a leak in the cuff?"

Answer: There are many causes to a cuff leak. First, to clarify, it is rare that a leak within the cuff actually happens. What happens most often is a leak around the cuff.  This leak around the cuff is usually caused by a tube that is too small, or by an overinflated cuff.

When a tube is too small for the airway, most clinicians attempt to compensate by overinflating the cuff.  This may solve the problem temporarily; however,  the problem is that overinflation of the cuff changes a low-pressure cuff into a high-pressure cuff, creating many more problems later on.  A small tube should be changed to one of proper size in order to ensure an adequate seal.

Chronic overinflation of the cuff, even in a tube of proper size, can cause the tracheal tissue to stretch in the area of the cuff.  This is called tracheomalacia.  In this case, the tube should be changed to a longer one to extend past the area of tracheomalacia.

Fenestrated Tubes

T.H. asks, "What is the purpose of a fenestrated tracheostomy tube?"

Answer: The word fenestration comes from the French word, "la fenetre", meaning 'window'. So a fenestrated tube is one with a window, or a hole, on the dorsal shaft of the tube. The purpose of this hole is to decrease the resistance of the tube when breathing around it, usually allowing the patient to speak.

The biggest problem regarding fenestrated tubes is that most clinicians do not realize that these tubes must be fit precisely so that the fenestration lies centrally in the airway. If it does not, granulation tissue will grow within the fenestration, making removal of the tube a surgical challenge. Only those with specialized training should attempt to remove a fenestrated tube, or hemorrhage could result.

Most fenestrated tubes require a custom fit. It is rare that an off-the-shelf fenestrated tube will fit an average patient. Because of these precautions, it is usually easier and safer to fit a different type of tube to allow a patient to speak. If a fenestrated tube remains the best option, then it is imperative that it is precisely measured to fit to the patient.

Inflated or Deflated?

Respiratory therapist, S.S., asks, "If the patient has been weaned from the ventilator, should the cuff be inflated or deflated?

Answer: The inflated cuff provides a seal of the airway in order to effectively ventilate and oxygenate the patient.  When the patient no longer requires the ventilator, it is usually best to deflate the cuff because of other problems that an inflated cuff can cause (tracheomalacia, tracheal stenosis, etc.).  However, the exception to this rule is the patient who cannot protect his airway.  Those who pose a risk for aspiration should have an inflated cuff because their cough and/or swallow reflex is not strong enough to prevent secretions from entering the airway.

When patients require cuff inflation, we need to ensure that the cuff is inflated enough to prevent leakage around the cuff, but not exert too much pressure against the trachea.  Measured cuff pressure should be in the range of 20-25 cm H2O.

In the absence of  measured cuff pressure, a good clinical technique is minimal leak technique.  In this case the cuff is completely deflated (first, use a soft suction catheter to remove secretions from the oropharynx), then inflated until a leak is no longer heard.  At that point, 1/2 ml of air is withdrawn from the cuff, enough to seal the airway, but minimizing excess pressure against the trachea.

It is important to note that clinical opinion varies on this point.  If the patient is in the ICU and managed by the critical care team, their goal is to ventilate the patient and may not be as concerned with high cuff pressures in the short term.  However, to prevent more long term complications, it is wise to minimize cuff pressure as much as clinically warranted.

Trach Progression

B.F. asks, "What is the usual progression of trachs?  My mom got her trach after being in the ICU on a ventilator.  Now she is off the ventilator...so what happens next?"

Answer: The usual progression for tracheostomies depends upon the reason why it was initally placed.  For patients who received their trach because they had difficulty weaning from the ventilator, once they become free from ventilator support, they can begin what we call "trach progression". 

Trach progression is the process of gradually allowing the patient to do more breathing around the tube, rather than through the tube.  Frequently, this requires a tube with a smaller outer diameter--or usually, one without a cuff.  The eventual goal of trach progression is usually removal of the tube.

The first step in trach progression involves deflating the cuff of the tube and assessing the patient to ensure that cuff deflation is tolerated well.  Some patients do not tolerate cuff deflation because they cannot manage their secretions, or because they don't have an effective cough or swallow.  

When the patient is able to tolerate cuff deflation, the tube is usually changed to a cuffless tube and then capping trials can begin.  Capping has many benefits, including voice restoration, smell, taste, improving cough and swallow, etc.

When the patient is able to tolerate capping for 24-48 hours, he or she is evaluated for decannulation--that is, the ability to function safely without the trach.  This involves measuring cough strength to ensure that the patient can cough up all their secretions.  When cough strength is strong enough and the patient can manage their secretions, the tube can be removed.  After decannulation, the stoma usually closes up completely within a few days.

When people have been on the ventilator in the ICU for a prolonged period of time, they are usually quite weak and  frequently trach progression must take place over a prolonged period of time.  Sometimes, it takes a long period of time in rehab before the patient has gained enough strength for the trach to be safely decannulated.

Home Supplies

Family member D.S. asks, "Medicare only supplies one cleaning kit per day, and we were told to clean the trach 2-3 times per day.  Is it OK to reuse the cleaning tray and supplies?"

Answer:  It is very important to clean the trach no less than twice per day while at home.  It should be done 3 or more times per day when secretions are plentiful, and no less than twice per day, even when secretions have diminished. This cleaning includes soaking, scrubbing, and rinsing the inner cannula (when present), cleansing the stoma, and changing the trach ties as necessary. 

This trach care is done using clean technique at home, rather than the sterile technique used in the hospital.  The cleaning tray and the bottle brush can be rinsed off and used again.  If secretions are difficult to remove from the bristles, another option is to use a few pipe cleaners to scrub the inside of the tube.

If these methods don't work well, ask your physician for a letter of medical necessity for additional cleaning supplies.

Dangers with Caps and Speaking Valves

T.A. asks, "If a patient uses a cap or a valve in order to speak, should the cuff be inflated or deflated?"

Answer: The purpose of the cuff is to seal the airway, and the ability to phonate depends upon air reaching the vocal cords.  So the ability to speak depends on cuff deflation.  If a cap is applied to a tube with an inflated cuff, the patient will be completely unable to inhale nor exhale.  If a valve is applied to a tube with an inflated cuff, the patient will be able to inhale through the valve, but will be unable to exhale.

Ideally, a cuffless tube should be used when placing a cap or valve.  A cap should NEVER be applied to a cuffed tracheostomy tube, even if the cuff is completely deflated.  A valve may be applied to a cuffed tracheostomy tube, but only when the cuff is completely deflated and when the ability to breathe comfortably has been thoroughly assessed.

This concept is imperative for health professionals to understand:

Cap or valve + Inflated cuff = Asphyxia

Custom Trachs

B.R. asks, "What if a patient needs a trach that is shorter or longer than the standard trach, because of his individual anatomy?"

Answer: A custom trach can be the answer to meet the needs of patients that cannot be met by any of the standard trachs.  Most companies offer a customized service for those patients who require something other than the standard "off the shelf" tube.

It is possible to custom order most any combination of features on a particular trach.  For example, one woman was being weaned off the ventilator and really wanted to speak.  The problem was that she had a severe anatomical defect of kyphosis, causing her trachea to be deviated into a nearly perfect "C" shape.  A standard Hyperflex tube did not work because it abutted the wall of the trachea and acted as an obstruction, so it was quickly clear that she required a custom tube.  I sent the manufacturer her CT scan and they were able to customize the curve of the tube to exactly fit the trachea.  I specified a TTS cuff, a specific length, combined with the custom curve, and it solved the problem.

Recently, I ran into a situation in which a patient could have benefitted from a trach with an inner cannula and with a TTS cuff.  As of now, there is no way to put this combination of features together as the manufacturers of the silicone tracheostomy tubes do not have inner cannulas with their high pressure, low volume cuffs.

Stomal Wounds

T.C. asks, "How do wounds around the stoma occur; and when they do, how should they be treated?"

Answer: Stomal erosion occurs as a result of either inward or outward traction against the tracheostomy tube. Outward traction is exacerbated with the use of added weight within the ventilator circuit, such as in-line suction systems, filters, and heat moisture exchangers. This outward traction can pull against the stoma enough to pull out the tube and can widen the stoma from the inside.

Measures to correct this outward traction include removing the added weight from the ventilator circuit and adequately supporting the ventilator circuit.

Inward traction occurs when the flange of the tracheostomy tube digs into the skin of the neck. This often begins during the first postoperative week when the tube is sutured securely to the neck and with a tube that has a hinged flange. Inward traction is best prevented by ensuring that the neck flange remains in a neutral position and by padding the stoma area with drain sponges, which also will collect secretions.

Stomal wounds can be challenging to manage, especially when they become infected.  It is often necessary to apply a packing, and debridement may be necessary to allow the wound to heal.