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.
Tuesday, April 26, 2011
Monday, March 14, 2011
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.
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.
Wednesday, February 2, 2011
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
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
Wednesday, January 12, 2011
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.
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.
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.
Wednesday, December 1, 2010
Discharge Instructions for the Patient with a Tracheostomy
G.J. asks, "When patients with a tracheostomy are discharged home, what do they need to know to take care of themselves?"
Answer: Patients and families who are being discharged with a new tracheostomy need a great deal of teaching in order to become comfortable with their care. Ideally, this teaching takes place over a period of time, during several sessions and should begin as soon as possible before discharge. Teaching should include guidelines for infection control such as handwashing and proper handling of the tracheostomy and equipment. Patients should be given a list of supplies and instructed to ensure that all supplies have been received in the home before they leave the hospital.
Patients and family members should be taught about airway anatomy and parts of the tracheostomy tube, how they fit together. The most difficult thing for patients and family members to master is suctioning. They realize that suctioning creates discomfort and they are reluctant to cause discomfort for their loved one. However, effective suctioning is an essential skill.
They must also be taught how to clean the stoma and the inner cannula, and how to change the trach ties. When the tube is cuffed, they must also learn how to maintain effective cuff pressure. The tracheostomy tube must be changed at regular intervals (usually every 1-2 months), so they must learn how to change the entire tube. In addition, patients and family members must learn the early signs of infection so that they can report symptoms to their health-care provider.
Emergency management must begin in the home, so patient and family members should know what to do in the event of an obstructed tube and a dislodged tube, which are the most common emergencies.
Upon discharge, family members should place a call to the local fire department to provide information for emergency personnel so that they can be better prepared if dispatched to the home.
Patients and family members should know where emergency equipment is located, including the obturator, extra tracheostomy tubes, and manual resuscitation bag.
It is also important that patients are followed closely by a medical professional to regularly review their plan of care and ensure that needs are met.
More detailed information about tracheostomy care is presented in Chapter 7: Care of the Tracheostomy Patient and Chapter 12: Rehabilitation and Recovery. Emergency management is presented in Chapter 10: Complications and Emergency Procedures.
Answer: Patients and families who are being discharged with a new tracheostomy need a great deal of teaching in order to become comfortable with their care. Ideally, this teaching takes place over a period of time, during several sessions and should begin as soon as possible before discharge. Teaching should include guidelines for infection control such as handwashing and proper handling of the tracheostomy and equipment. Patients should be given a list of supplies and instructed to ensure that all supplies have been received in the home before they leave the hospital.
Patients and family members should be taught about airway anatomy and parts of the tracheostomy tube, how they fit together. The most difficult thing for patients and family members to master is suctioning. They realize that suctioning creates discomfort and they are reluctant to cause discomfort for their loved one. However, effective suctioning is an essential skill.
They must also be taught how to clean the stoma and the inner cannula, and how to change the trach ties. When the tube is cuffed, they must also learn how to maintain effective cuff pressure. The tracheostomy tube must be changed at regular intervals (usually every 1-2 months), so they must learn how to change the entire tube. In addition, patients and family members must learn the early signs of infection so that they can report symptoms to their health-care provider.
Emergency management must begin in the home, so patient and family members should know what to do in the event of an obstructed tube and a dislodged tube, which are the most common emergencies.
Upon discharge, family members should place a call to the local fire department to provide information for emergency personnel so that they can be better prepared if dispatched to the home.
Patients and family members should know where emergency equipment is located, including the obturator, extra tracheostomy tubes, and manual resuscitation bag.
It is also important that patients are followed closely by a medical professional to regularly review their plan of care and ensure that needs are met.
More detailed information about tracheostomy care is presented in Chapter 7: Care of the Tracheostomy Patient and Chapter 12: Rehabilitation and Recovery. Emergency management is presented in Chapter 10: Complications and Emergency Procedures.
Tuesday, November 23, 2010
Frequency of Tube Changes
J.C. asks, "How often should a tracheostomy tube be changed?
Answer: Tracheostomy tubes should be routinely changed on a regular basis to prevent infection and other complications; and in the case of children, to keep up with their growth and development.
Most manufacturers recommend changing their tubes every 30-60 days. Tube changes can be done during an office visit, but many patients prefer to change the tube at home, either by themselves or a caregiver. Some change their tube weekly or biweekly, and some change the tube daily, rotating between two different tubes.
Failure to change the tube on a regular basis can result in severe infection, tube obstruction, or tracheitis.
Answer: Tracheostomy tubes should be routinely changed on a regular basis to prevent infection and other complications; and in the case of children, to keep up with their growth and development.
Most manufacturers recommend changing their tubes every 30-60 days. Tube changes can be done during an office visit, but many patients prefer to change the tube at home, either by themselves or a caregiver. Some change their tube weekly or biweekly, and some change the tube daily, rotating between two different tubes.
Failure to change the tube on a regular basis can result in severe infection, tube obstruction, or tracheitis.
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