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.
Monday, March 14, 2011
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.
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.
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