T.H. asks, "What is the purpose of a fenestrated tracheostomy tube?"
Answer: The word fenestration comes from the French word, "la fenetre", meaning 'window'. So a fenestrated tube is one with a window, or a hole, on the dorsal shaft of the tube. The purpose of this hole is to decrease the resistance of the tube when breathing around it, usually allowing the patient to speak.
The biggest problem regarding fenestrated tubes is that most clinicians do not realize that these tubes must be fit precisely so that the fenestration lies centrally in the airway. If it does not, granulation tissue will grow within the fenestration, making removal of the tube a surgical challenge. Only those with specialized training should attempt to remove a fenestrated tube, or hemorrhage could result.
Most fenestrated tubes require a custom fit. It is rare that an off-the-shelf fenestrated tube will fit an average patient. Because of these precautions, it is usually easier and safer to fit a different type of tube to allow a patient to speak. If a fenestrated tube remains the best option, then it is imperative that it is precisely measured to fit to the patient.
Sunday, May 29, 2011
Saturday, May 21, 2011
Inflated or Deflated?
Respiratory therapist, S.S., asks, "If the patient has been weaned from the ventilator, should the cuff be inflated or deflated?
Answer: The inflated cuff provides a seal of the airway in order to effectively ventilate and oxygenate the patient. When the patient no longer requires the ventilator, it is usually best to deflate the cuff because of other problems that an inflated cuff can cause (tracheomalacia, tracheal stenosis, etc.). However, the exception to this rule is the patient who cannot protect his airway. Those who pose a risk for aspiration should have an inflated cuff because their cough and/or swallow reflex is not strong enough to prevent secretions from entering the airway.
When patients require cuff inflation, we need to ensure that the cuff is inflated enough to prevent leakage around the cuff, but not exert too much pressure against the trachea. Measured cuff pressure should be in the range of 20-25 cm H2O.
In the absence of measured cuff pressure, a good clinical technique is minimal leak technique. In this case the cuff is completely deflated (first, use a soft suction catheter to remove secretions from the oropharynx), then inflated until a leak is no longer heard. At that point, 1/2 ml of air is withdrawn from the cuff, enough to seal the airway, but minimizing excess pressure against the trachea.
It is important to note that clinical opinion varies on this point. If the patient is in the ICU and managed by the critical care team, their goal is to ventilate the patient and may not be as concerned with high cuff pressures in the short term. However, to prevent more long term complications, it is wise to minimize cuff pressure as much as clinically warranted.
Answer: The inflated cuff provides a seal of the airway in order to effectively ventilate and oxygenate the patient. When the patient no longer requires the ventilator, it is usually best to deflate the cuff because of other problems that an inflated cuff can cause (tracheomalacia, tracheal stenosis, etc.). However, the exception to this rule is the patient who cannot protect his airway. Those who pose a risk for aspiration should have an inflated cuff because their cough and/or swallow reflex is not strong enough to prevent secretions from entering the airway.
When patients require cuff inflation, we need to ensure that the cuff is inflated enough to prevent leakage around the cuff, but not exert too much pressure against the trachea. Measured cuff pressure should be in the range of 20-25 cm H2O.
In the absence of measured cuff pressure, a good clinical technique is minimal leak technique. In this case the cuff is completely deflated (first, use a soft suction catheter to remove secretions from the oropharynx), then inflated until a leak is no longer heard. At that point, 1/2 ml of air is withdrawn from the cuff, enough to seal the airway, but minimizing excess pressure against the trachea.
It is important to note that clinical opinion varies on this point. If the patient is in the ICU and managed by the critical care team, their goal is to ventilate the patient and may not be as concerned with high cuff pressures in the short term. However, to prevent more long term complications, it is wise to minimize cuff pressure as much as clinically warranted.
Tuesday, April 26, 2011
Trach Progression
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.
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.
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.
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