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.
Wednesday, January 12, 2011
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.
Sunday, October 31, 2010
Your Most Valuable Tool
B.W. asks, "What does it mean if I start to have trouble passing the suction catheter?"
Answer: Meeting resistance upon passage of a suction catheter usually means one of two things: either the inner lining of the tracheostomy tube is becoming coated with secretions, or the tracheostomy tube has entered a false passage.
The suction catheter is your most valuable tool because it can provide you with much useful information. Not only is it used for removing secretions, but it can be used to predict future problems. If a suction catheter meets some resistance, but can be passed several centimeters, then it usually means that secretions are beginning to coat the inside of the tracheostomy tube. In this case, the inner cannula should be changed. If the tube does not have an inner cannula, the entire tube should be changed.
If the suction catheter can be passed only a few centimeters and no more (i.e., the length of the tracheostomy tube), it usually means that the tube has entered a false passage. In other words, the tube is lodged within the tissues anterior to the trachea. In that case, the obturator should be used to maneuver the tube into the correct position. Alternatively, the entire tube should be changed. After any of these maneuvers, the proper position of the tube should be confirmed by easy passage of a suction catheter and return of tracheal secretions.
One should be aware of the proper sizes of suction catheters to be used for tracheostomy tubes. A size 14 French should easily pass through a size 6 and 8 tracheostomy tube. However, a size 4 tube often requires a size 10 or 12 French suction catheter. The response to difficult passage of a suction catheter should not be a switch to a smaller catheter. Rather, it should be a warning sign to consider the reason for the difficulty.
Another use for the suction catheter is as a "guidewire" to determine the tracheal tract. A tracheostomy tube can then be slid into position over it.
Answer: Meeting resistance upon passage of a suction catheter usually means one of two things: either the inner lining of the tracheostomy tube is becoming coated with secretions, or the tracheostomy tube has entered a false passage.
The suction catheter is your most valuable tool because it can provide you with much useful information. Not only is it used for removing secretions, but it can be used to predict future problems. If a suction catheter meets some resistance, but can be passed several centimeters, then it usually means that secretions are beginning to coat the inside of the tracheostomy tube. In this case, the inner cannula should be changed. If the tube does not have an inner cannula, the entire tube should be changed.
If the suction catheter can be passed only a few centimeters and no more (i.e., the length of the tracheostomy tube), it usually means that the tube has entered a false passage. In other words, the tube is lodged within the tissues anterior to the trachea. In that case, the obturator should be used to maneuver the tube into the correct position. Alternatively, the entire tube should be changed. After any of these maneuvers, the proper position of the tube should be confirmed by easy passage of a suction catheter and return of tracheal secretions.
One should be aware of the proper sizes of suction catheters to be used for tracheostomy tubes. A size 14 French should easily pass through a size 6 and 8 tracheostomy tube. However, a size 4 tube often requires a size 10 or 12 French suction catheter. The response to difficult passage of a suction catheter should not be a switch to a smaller catheter. Rather, it should be a warning sign to consider the reason for the difficulty.
Another use for the suction catheter is as a "guidewire" to determine the tracheal tract. A tracheostomy tube can then be slid into position over it.
Tuesday, October 12, 2010
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:
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!)
Tuesday, October 5, 2010
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.
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.
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