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:

• 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!)

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.

Positioning for Trach Reinsertion

C.L. asks, "If inadvertent decannulation occurs, what is the best patient positioning for reinsertion?"

Answer: Supine positioning with neck hyperextension is ideal for reinsertion. However, this may not be appropriate for all patients. The key is visualization of the stoma and adequate lighting. I have reinserted trachs in all positions, including sitting and standing.

Operator positioning is also important. The operator should be positioned on the side of their dominant hand. For example, I always stand on the patient's left because I am left-handed.

Complications During Tube Replacement

C.L. asks, "What are the chances of esophageal or tracheal rupture, or subcutaneous emphysema with reinsertion of a dislodged tracheostomy tube?"

Answer: I have never encountered esophageal nor tracheal rupture during reinsertion of a dislodged tube. Nor am I aware of any reports in the literature. Theoretically, it could occur if the tube was placed with great force and without an obturator to cushion the tip, or perhaps in combination with friable tissue. However, ruptured esophagus and ruptured trachea have been reported as a complication during the tracheotomy procedure, particularly with the percutaneous technique.

As for subcutaneous emphysema, this can occur if the tube is inserted into a false passage and positive pressure is applied, forcing air into the subcutaneous tissue. During the early postoperative period, tube security should be a priority. When replacing a tube into a mature stoma, and prior to application of positive pressure, it is important to confirm placement by passage of a suction catheter with return of tracheal secretions.

When replacing a tube, technique is also important. An initial 90 degree approach, followed by a caudal turn is the recommended technique. A premature caudal turn can result in placement into a false passage.

What is Downsizing?

P.T. asks, "What is the purpose of downsizing?"

Answer: The purpose of downsizing is to allow the patient to do more breathing around the tube, rather than through the tube. When the initial problem that initiated placement of the trach is resolved, downsizing may begin. For example, when the tube was placed because of prolonged mechanical ventilation, downsizing can begin as soon as the patient has been weaned from the ventilator.

Downsizing should begin with cuff deflation, which allows admixture of room air, lowering overall FiO2. So downsizing should not begin until the patient is hemodynamically stable and can tolerate cuff deflation.

When the patient is able to tolerate cuff deflation, the tube can be changed to one with a smaller outer diameter. Capping can begin at that time (and never with a standard cuffed tube).

The end result of downsizing is usually with the overall goal of decannulation; however, the tube may need to be downsized in order to allow enough air around the tube to reach the vocal cords for phonation. See the Downsizing Algorithm in Chapter 11 for a step-wise procedure on downsizing.

Water or Saline?

A respiratory therapy student asks, "What am I supposed to use to inflate the cuff of a Bivona TTS trach? I've heard they should be inflated with water, but I've also heard saline. Which is it...and why?"

Answer: The Bivona TTS and the Arcadia CTS tubes are both made of silicone with high-pressure, low-volume cuffs. These cuffs are in contrast to the majority of tracheostomy tubes out there (most are low-pressure, high-volume). When inflated, they create pressures greater than 120 cm H2O, even when only slightly inflated. So direct measurement of cuff pressure is not useful. When extended cuff inflation is desired (as for intermittent mechanical ventilation), they should be inflated with sterile water (not saline), using minimal leak technique. Saline has been shown to degrade the cuff over time. Sterile water is preferable for cuff inflation because air can diffuse through the cuff over time and manifest as cuff deflation.

Historically, the first cuffs to appear on tracheostomy tubes were also high-pressure, low volume. These cuffs created significant tracheal damage, and intermittent cuff deflation was recommended to relieve pressure against the trachea. Over the years, low-pressure, high-volume cuffs were developed that helped to minimize tracheal damage due to cuff inflation.

The primary benefit of these high-pressure cuffs is their deflation characteristics. When deflated, the cuff lies snugly against the shaft of the tube, lessening resistance to airflow passing around the tube. These tubes are ideal for a patient who requires intermittent cuff inflation, but they are the only cuffed tubes that can be safely capped when deflated.

Common Trach Emergencies

Dr. E.H asks, "What are the most common emergencies with tracheostomies?"

Answer: The two most common emergencies with tracheostomies are mucus plugs and inadvertent decannulation/displacement. Mucus plugs occur because of inadequate hydration and inactivity, resulting in thickening and stasis of secretions. Initial presenting symptoms of mucus plugs are respiratory distress and/or desaturation. Treatment involves removing/cleaning inner cannula, vigorous suctioning, and/or changing the entire tracheostomy tube. Occasionally none of these measure will relieve the obstruction. In that case, the mature tracheostomy tube may be removed and the stoma suctioned directly, or bronchoscopy may be necessary to relieve obstruction.

Inadvertent decannulation or dislodgement can result from inadequate security of the tube, especially when it is combined with patient movement or a tube that is too short. Decannulation is easy to observe, in that the tube is completely absent from the stoma; however, dislodgement is not so obvious. Sometimes, the tube is still within the stoma, and so, appears in place; however, it is removed from the tracheal lumen. In an immature tracheostomy, this situation is an emergency. The tube should be removed, the stoma covered, and the patient intubated from above. A tracheal revision can then be performed under more controlled circumstances.

In a mature tracheostomy, dislodgement is recognized by a "high-riding tube" (one that cannot be pushed in as far as the neck flange), inability to pass a suction catheter, and the alert patient may be able to phonate clearly. In this case, the tube may be withdrawn and reinserted, taking care to assess the location and orientation of the tracheal stoma.
L.L.M.