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.
Wednesday, January 12, 2011
Saturday, January 1, 2011
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.
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.
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