Post on 22-Jan-2018
transcript
Let’s Talk About Trachs, Baby.
Objectives
Indications
Contraindications
Types of Trachs
Design
Materials
Cuffs
Insertion/Trach Change Out
Trach Care
Speaking Valves
Indications
Upper airway deformity or obstruction
Obesity-induced hypoventilation
Not manageable with CPAP/Bipap therapy
Inability to maintain airway
Need for permanent ventilatory support
Severe facial trauma (jaw wired, etc.)
Laryngectomy
What is a laryngectomy?
Surgical removal of the larynx (voice box)
Can be partial (only remove a portion) or
Complete (entire larynx is removed)
Can result in a separation of the trachea from the pharynx
Typically seen with laryngeal cancer cases, but can be seen with:
Other types of head &/or neck cancer
Severe swallowing problems
[complete removal] Since upper airway is now completely bypassed,
they can be dubbed “total neck breathers”
[partial removal] There is still a connection, so they can breath
through their trach & their nose/mouth
Total Laryngectomy Patient Education Materials. UPMC. http://www.upmc.com/patients-visitors/education/cancer/Pages/total-
laryngectomy.aspx
Procedure Types
Standard Insertion
Incision between the 2nd or
3rd tracheal ring
Horizontal is in between
the rings
Vertical cuts through both
rings
Involves removal of small
amount of cartilage
Trach tube is inserted
Percutaneous dilation
tracheotomy
A large leak will be present
when ETT is pulled back
A needle & sheath are
inserted between cricoid &
1st tracheal ring - &
advances a guidewire
Larger and larger dilators
are introduced until the
stoma is large enough for a
standard trach tube
Considerations & Cautions Care should be taken with the following pt populations when
considering a percutaneous dilation tracheostomy. [relative
contraindications]
Poor landmarks secondary to body habitus, obnormal anatomy, or
occluding thyroid mass
PEEP >15cmH20
Coagulopathy
Pulsating blood vessel over tracheotomy site
Limited ability to extend cervical spine
History of difficult intubation
Infection, burn, or malignancy at tracheotomy site
Egan’s Fundamentals of Respiratory Care, 10th Edition.
Types of Trachs
What does SJMC Carry?
CS
Stocks all standard Shiley trachs w/disposable inner cannulas
Inner Cannulas
Suction packs
Pulmonary Services
Stocks Shiley XLTs and Bivona TTS
Shiley XLT inner cannulas
In-line suction catheters
Trach Tubes
Typically made of plastic
There are still a few pts floating around Tulsa with metal, Jackson, trachs
If your patient has a Jackson trach and needs to go on the vent: you need to
change out the trach
Jackson trachs do not have a cuff and typically don’t have the 15mm end adaptor
Obturators
Come with ALL Trachs, no matter what brand/material/etc.
Inner Cannulas
Seen with all Shiley trachs
Not every brand has inner cannulas (Bivona TTS, for example)
Cuffs Not every trach tube has a cuff
Cuffs can require any of the following for inflation:
Air
Sterile Water
Pilot line open
Bivona TTS Cuffs:
Fit very snug to shaft of trach tube.
Can be water or air filled – check the labeling on the flange
Can insert a bigger size tube as cuff doesn’t impede advancement of airway
Shiley Cuffs:
Can be bulkier (even when deflated) at the cuff
Water-based lubricant on cuff can help with insertions
Cuff Pressure
If your patient has a cuffed trach tube, you need to monitor & document the
cuff pressures at least once per shift
Pressures are (typically) 20-25cmH20, but can vary depending on
Size of the tube compared to airway, swelling, etc.
Cannot use cufflator on sterile water or foam cuffs
Instead, use the Minimal Leak Technique (MLT) or
Minimal Occluding Volume (MOV)
Breaking it down… Shiley Style!
…now Bivona’s Adjustable Hyperflex
Tubes… This is a temporary trach.
It can be used when you have a patient who a ‘normal’ sized trach does not meet the needs
Could be really tall w/a long trach
Could have a large neck or mass that requires a trach to protrude more
Physician that placed it SHOULD HAVE measured the lengths.
2 custom trachs (based on measurements) should be ordered through CS
Backup Trach?
Place standard bivona TTS in same size in room until customs come in
Shiley XLTs
These are longer than the average Shileys
Can have extra length either proximal to the pt or distal to the pt
XLT Inner Cannulas are one-size fits all
XLT Inner Cannulas are disposable/one-time use
All XLT supplies are kept in the Pulmonary Department
Make sure you have the right back up (ie. Distal, Proximal, Cuffed, etc.)
Trach Change OutsDon’t be scared…
General Tips: If sutures are still in place &/or the trach is only a few days old:
Have the Physician at bedside to perform the initial change out
ALWAYS use the obturator when placing a trach
It only takes a few seconds to grab it & it will help tremendously
ALWAYS tape the obturator in a bag at the HOB
Call for help if having issues
Always confirm that placement is in the trachea
Ask pt how it feels/if they can breath
(if pt is unresponsive) bag a few times (you’re feeling how hard it is to bag and
someone should be auscultating over the lung fields)
If there is resistance – you may be in a false pocket
Sometimes passing a suction catheter (with the thumb port removed) into the
stoma can serve as a guidewire for your trach tube to slip over
Ideal pt positioning:
Flat & in an exaggerated SNIFF position
Can modify the SNIFF position using
pillows behind the shoulders/neck
Remain Calm
It can be a very scary experience for you
and everyone in the room
Just take a breath – you have all your
supplies and help is just a phone call away.
Worse-Case Scenario
Pt loses trach, you can’t get it back in, SpO2 starts dropping & pt goes
unresponsive
Initiate emergency response (RRT or Code Blue depending on pt status)
You need to bag
Since you don’t have an airway: you can occlude stoma and bag/mask OR
You can place a smaller ETT from the airway box in & hold it in place
Trach Care & SXN
General
Trach Care is done BID (scheduled at 0800 & 2000) & PRN by RT
If pt states “I do it” – have them do it in front of you and at least check
the stoma site for any signs of infection or skin breakdown
Signs of infection: redness, bleeding, pus, foul-smelling stoma site
It is still our job to make sure our pts are evaluated and taken care of
Items to have in EVERY trach pt room:
Back up trach of same size/brand
Obturator taped at HOB
Suction setup w/tubing
Extra suction catheters or in-line suction*
Trach cleaning supplies
*Which do I use?
Sterile Suction Catheters
Floors/General Care areas
Pt is just on a wall flow
by/trach collar
Majority of pts are discharged
home, to NHs, SNFs, etc with
this set up; so we need to
match what they’ll have in
those settings
Provides consistency for the pt
& caregivers
In-line Suction Catheters
In units or 8West
If pt is requiring any positive
pressure
We do not put on just because
any group is ‘tired of
suctioning’
If pt has documented copious
amounts of secretions, we can
consider in-line on the floors
Must be documented
When secretions start to thin
out: switch to sterile suction
catheters
Getting Started w/Trach Care
Know where all your back up
supplies are before starting trach
care
You’ll need:
New inner cannula (if applicable)
Trach ties
Suction Supplies
Towel/Washcloth
Sterile Water &/or Hydrogen
Peroxide
Cotton-tipped applicators
New drain sponge
Explain to the pt what you are
doing before you start
Try to position pt in a SNIFF
position so that you can see the
trach & stoma site
If pt cannot lay flat – modify the
position using pillows/towel rolls
If pt does not stay still/cooperate –
call for another set of hands
Hydrogen Peroxide should be used
when the pt’s site needs deeper
cleaning.
*signs of infection present
*crusty secretions present
*clinical judgement dictates it
When using Qtips or gauze to clean
away secretions/dirt:
*use motion that leads away
from stoma
*you don’t want to push things
into the stoma/opening
Place a new/clean drain sponge. Typically one side at a time.
*TIP: use the Qtip to help push drain sponge up/through trach ties
Inner Cannulas(assuming this is a Shiley trach that we stock)
If pt has an inner cannula, it needs to be changed out with each trach care
and PRN
The inner cannulas we stock are disposable and are to be thrown away after
each use
IF pt has a different trach than we stock in house, we do not have access to
inner cannulas
We need to either switch out to a trach we carry & have supplies for, OR
Custom supplies can be ordered by that unit for that specific pt, OR
Family can bring some of the home supplies up for us to use while pt is here.
Speaking Valves
General
One-way valve that is placed on the external opening of
the trach tube
Pt inhales around and through the trach tube
Exhales only around the tube through the larynx
The exhalation through the larynx creates phonation
Cuff should ALWAYS be deflated when
speaking valve is in place
Good Candidates for Speaking Valves
Medically stable
Able to communicate
Low risk for aspiration
Can be on spontaneously breathing pt or one that
requires ventilation
(if on a ventilator/positive pressure) Must be able to
have cuff deflated
Egans Fundamentals of Respiratory Care, 10th Edition.
Contraindications
Pt has a foam cuff trach tube
Pt unable to tolerate cuff deflation
Severe upper airway obstruction
Copious, thick, unmanageable secretions
PEEP or CPAP >5cmH20
Bilateral vocal cord paralysis
Tracheal stenosis
Total/complete Laryngectomy
Comatose pt
Positives of the speaking valves
Facilitate communication with the patient
Better function of the vocal cords
Better sense of smell
Fewer secretion problems
(in some) improved swallowing function & less aspiration
Initial Trial
Usually coordinated with Speech
Pt’s ability to exhale around the tube & phonate is assessed
If there is increased resistance or pt cannot breath around it, several
possibilities could be occurring:
(most common) size of the trach tube in relation to the size of the
trachea
Tube position
Inadequate cuff deflation
Upper airway abnormality
Possible solutions:
Change to a smaller size, cuffless, or TTS trach tube
If upper airway abnormality: ENT should be consulted to evaluate the pts
risk for aspiration and tolerance of the speaking valve
Trial on the Ventilator Must use the aqua/blue speaking valve (it is made so that 22mm
tubing can fit over it)
Deflate cuff
Increase set Vt (or PIP if on PCV) until you see good volume return
PEEP off
Reduces excessive flow & auto-cycling
PS may have to be decreased to allow the vent to cycle into exhalation
If on a HME circuit:
Remove HME as it causes increased resistance
Trial can only be for 30min at a time due to lack of humidification
www.passy-muir.com
Treatments & SXN
You must remove the
speaking valve when
giving a breathing
treatment
You must remove the
speaking valve when you
need to suction through
the trach tub
Humidity & O2
Humidity can still be provided
to the trach via trach collar
If ambulating with the speaking
valve in place – sometimes a
nasal cannula can be used for
supplemental oxygen
We do not carry HMEs for any
sized patients
All pts with a
tracheotomy/open stoma
should be on humidity
www.passy-muir.com
Cleaning the Speaking Valve
Swish Valve daily in soapy, warm water (not hot water).
Rinse Valve very thoroughly in warm running water.
Allow Valve to air dry thoroughly before placing in storage container. Do not apply heat to dry Valve.
DO NOT use hot water, peroxide, bleach, vinegar, alcohol, brushes or cotton swabs to clean Valve
www.passy-muir.com
Hands on time.