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.
Wednesday, November 30, 2011
Friday, November 25, 2011
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.
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.
Saturday, November 12, 2011
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.
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.
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