Dr. S.A. asks, "I just received a rehab patient with a trach button who has developed pneumonia. Can I just replace the button with a regular trach?"
Answer: A trach button is often placed to maintain the stoma while the patient is gaining strength through rehabilitation. The benefit of a button is that it provides no resistance within the airway, yet it maintains the stoma in case an artificial airway is needed. If there is concern about secretions and the need for frequent suctioning, it is best to replace the button with a regular tracheostomy tube. Otherwise, one would need to open the button every time the patient needs suctioning, and the introduction of a suction catheter would be directed toward the posterior tracheal wall.
One must realize that the trach button consists of three parts: the tracheal cannula, the closure plug, and a series of spacers to adjust to the exact length of the stoma. In order to remove the button, first remove the closure plug with the spacers. This will release the tension against the distal petals of the cannula. The cannula can then be removed easily and replaced with a tracheostomy tube.
Friday, June 24, 2011
Saturday, June 4, 2011
Cuff Leaks
R.B. asks, "When a patient is on the ventilator, what causes a leak in the cuff?"
Answer: There are many causes to a cuff leak. First, to clarify, it is rare that a leak within the cuff actually happens. What happens most often is a leak around the cuff. This leak around the cuff is usually caused by a tube that is too small, or by an overinflated cuff.
When a tube is too small for the airway, most clinicians attempt to compensate by overinflating the cuff. This may solve the problem temporarily; however, the problem is that overinflation of the cuff changes a low-pressure cuff into a high-pressure cuff, creating many more problems later on. A small tube should be changed to one of proper size in order to ensure an adequate seal.
Chronic overinflation of the cuff, even in a tube of proper size, can cause the tracheal tissue to stretch in the area of the cuff. This is called tracheomalacia. In this case, the tube should be changed to a longer one to extend past the area of tracheomalacia.
Answer: There are many causes to a cuff leak. First, to clarify, it is rare that a leak within the cuff actually happens. What happens most often is a leak around the cuff. This leak around the cuff is usually caused by a tube that is too small, or by an overinflated cuff.
When a tube is too small for the airway, most clinicians attempt to compensate by overinflating the cuff. This may solve the problem temporarily; however, the problem is that overinflation of the cuff changes a low-pressure cuff into a high-pressure cuff, creating many more problems later on. A small tube should be changed to one of proper size in order to ensure an adequate seal.
Chronic overinflation of the cuff, even in a tube of proper size, can cause the tracheal tissue to stretch in the area of the cuff. This is called tracheomalacia. In this case, the tube should be changed to a longer one to extend past the area of tracheomalacia.
Sunday, May 29, 2011
Fenestrated Tubes
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.
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.
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
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