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.
Friday, November 25, 2011
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.
Thursday, October 20, 2011
Tracheal Bleeding
W.C. asks, "I've noticed a small amount of bleeding from my trach recently. Should I be worried?"
Answer: The two most frequent causes of tracheal bleeding are due to frequent suctioning and lack of humidity. Regarding frequent suctioning, one should not decrease the frequency of suctioning just because of the appearance of some blood. Rather, this should be a cue to switch to softer suction catheters. I usually recommend red rubber catheters, which are not suction catheters, but are actually they are urinary catheters, technically called "coude" catheters. These are especially helpful because the tip is closed, rather than open, so there is less trauma to the tissue with the use of these catheters. Because the tip is closed, they may not be quite as effective as the standard suction catheters, but complete healing of tracheal tissue has been observed in as little as 24 hours after the switch, so this is an option. Please note: Red rubber catheters cannot be used in the patient with a latex allergy.
The other frequent cause of tracheal bleeding is lack of proper humidity. This is especially true in the fall and winter in colder climates....or other places that have low humidity (like hospitals!). This dried blood can collect within the tracheostomy tube and begin to occlude the airway. In fact, one patient had no trouble at home, but came to the hospital and required almost daily trach changes because of the accumulation of dried blood within his tracheostomy. The problem resolved as soon as humidity was added to his ventilator circuit.
Now that fall and winter is approaching, you may need some extra help with humidity. This can include room humidifiers, soaking a gauze in water or saline and placing lightly over your trach, using an HME (heat moisture exhanger), spritzing some atomized saline (Ocean nasal spray) into the trach and mucous membranes, increasing water intake, and more frequent changes.
If there is a large amount of bleeding, contact your health care provider for further evaluation.
Answer: The two most frequent causes of tracheal bleeding are due to frequent suctioning and lack of humidity. Regarding frequent suctioning, one should not decrease the frequency of suctioning just because of the appearance of some blood. Rather, this should be a cue to switch to softer suction catheters. I usually recommend red rubber catheters, which are not suction catheters, but are actually they are urinary catheters, technically called "coude" catheters. These are especially helpful because the tip is closed, rather than open, so there is less trauma to the tissue with the use of these catheters. Because the tip is closed, they may not be quite as effective as the standard suction catheters, but complete healing of tracheal tissue has been observed in as little as 24 hours after the switch, so this is an option. Please note: Red rubber catheters cannot be used in the patient with a latex allergy.
The other frequent cause of tracheal bleeding is lack of proper humidity. This is especially true in the fall and winter in colder climates....or other places that have low humidity (like hospitals!). This dried blood can collect within the tracheostomy tube and begin to occlude the airway. In fact, one patient had no trouble at home, but came to the hospital and required almost daily trach changes because of the accumulation of dried blood within his tracheostomy. The problem resolved as soon as humidity was added to his ventilator circuit.
Now that fall and winter is approaching, you may need some extra help with humidity. This can include room humidifiers, soaking a gauze in water or saline and placing lightly over your trach, using an HME (heat moisture exhanger), spritzing some atomized saline (Ocean nasal spray) into the trach and mucous membranes, increasing water intake, and more frequent changes.
If there is a large amount of bleeding, contact your health care provider for further evaluation.
Sunday, October 2, 2011
Capping a Trach
J.D. asks, "I heard that there are many benefits for capping a trach. Can you explain?"
Answer: Yes, capping a tracheostomy tube can provide many benefits; the primary benefit is usually allowing a patient to speak. First, not all tracheostomy tubes should be capped. A standard cuffed tracheostomy tube should never be capped, even if the cuff is deflated. When the cuff is deflated, it still provides a great deal of bulk and resistance in the airway. Even if a patient appears to breathe comfortably at one moment, things can change suddenly. In addition, patients may not be able to fully expectorate their secretions, as they may get caught on the folds of the deflated cuff.
Other benefits of capping a tracheostomy tube include restoring subglottic pressure which can in turn restore taste, smell, improve cough and defacation. Another benefit of capping is that the quantity of secretions tends to diminish.
For more discussion on capping, refer to Chapter 5 on phonation and Chapter 11 on downsizing.
Answer: Yes, capping a tracheostomy tube can provide many benefits; the primary benefit is usually allowing a patient to speak. First, not all tracheostomy tubes should be capped. A standard cuffed tracheostomy tube should never be capped, even if the cuff is deflated. When the cuff is deflated, it still provides a great deal of bulk and resistance in the airway. Even if a patient appears to breathe comfortably at one moment, things can change suddenly. In addition, patients may not be able to fully expectorate their secretions, as they may get caught on the folds of the deflated cuff.
Other benefits of capping a tracheostomy tube include restoring subglottic pressure which can in turn restore taste, smell, improve cough and defacation. Another benefit of capping is that the quantity of secretions tends to diminish.
For more discussion on capping, refer to Chapter 5 on phonation and Chapter 11 on downsizing.
Tuesday, September 13, 2011
Optimal Tube Length
P.S. asks, "How do I know that the tube is the correct length?"
Answer: It is important to ensure that the tube is neither too short nor too long. If the tube is too short, it can be easily dislodged. If too long, the tube can become "mainstemmed" in the right bronchus. It can also cause other symptoms such as high airway pressures, discomfort, or continuous coughing by its constant irritation against the tracheal wall.
In order to determine optimal position of the tube within the airway, a chest x-ray can be beneficial, but a bronchoscope can be used to directly visualize the position of the tube.
Answer: It is important to ensure that the tube is neither too short nor too long. If the tube is too short, it can be easily dislodged. If too long, the tube can become "mainstemmed" in the right bronchus. It can also cause other symptoms such as high airway pressures, discomfort, or continuous coughing by its constant irritation against the tracheal wall.
In order to determine optimal position of the tube within the airway, a chest x-ray can be beneficial, but a bronchoscope can be used to directly visualize the position of the tube.
Tuesday, August 9, 2011
International Conference on Tracheostomies
There is a new international symposium on Advanced Tracheostomy Management and Prolonged Mechanical Ventilation. It will be held in Melbourne, Australia on September 1-2. Check out their website at: https://sites.google.com/site/tracheostomyconference2011/.
I'm very excited about this conference as it will be the first conference dedicated specifically to tracheostomies. I have been invited to be part of the panel on Tricky Tracheostomy Cases.
LLM
I'm very excited about this conference as it will be the first conference dedicated specifically to tracheostomies. I have been invited to be part of the panel on Tricky Tracheostomy Cases.
LLM
Saturday, July 23, 2011
Trach Dislodgement
B.L. asks, "How does tracheostomy dislodgement happen?"
Answer: Dislodgement can be one of the most serious complications of having a tracheostomy. Dislodgement can be even more serious than complete decannulation; because when the tube is completely removed from the stoma (decannulation), the problem is clearly visible. However, when the tube is dislodged, it may not be so obvious. In this case, the tube is still in the neck; however, the tip of the tube is not within the trachea and instead is positioned within the tissue anterior to the trachea, most often called a false passage.
Numerous attempts to replace the tube can enlarge the false passage, making subsequent attempts to replace it nearly always unsuccessful.
There are several risk factors for tracheostomy dislodgement: a tube that is too short, traction against the tube, edema of the neck, obesity or a thick neck, and excessive coughing or agitation.
Specific techniques of tube replacement depend on the maturity of the stoma and whether or not the patient is able to breathe around the tube. These are discussed in more detail in our recent article in the "The Dreaded False Passage: Management of Tracheostomy Tube Dislodgement", Morris & Afifi, Journal of Emergency Medicine, 33(8).
Answer: Dislodgement can be one of the most serious complications of having a tracheostomy. Dislodgement can be even more serious than complete decannulation; because when the tube is completely removed from the stoma (decannulation), the problem is clearly visible. However, when the tube is dislodged, it may not be so obvious. In this case, the tube is still in the neck; however, the tip of the tube is not within the trachea and instead is positioned within the tissue anterior to the trachea, most often called a false passage.
Numerous attempts to replace the tube can enlarge the false passage, making subsequent attempts to replace it nearly always unsuccessful.
There are several risk factors for tracheostomy dislodgement: a tube that is too short, traction against the tube, edema of the neck, obesity or a thick neck, and excessive coughing or agitation.
Specific techniques of tube replacement depend on the maturity of the stoma and whether or not the patient is able to breathe around the tube. These are discussed in more detail in our recent article in the "The Dreaded False Passage: Management of Tracheostomy Tube Dislodgement", Morris & Afifi, Journal of Emergency Medicine, 33(8).
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