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.