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.
Sunday, May 29, 2011
Saturday, May 21, 2011
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 At that point, 1/2 ml of air is withdrawn from the cuff, enough to seal the airway, but minimizing excess pressure against the trachea.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.
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.
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