Tell Me About A Trach Before I Need One

1/10/2013
PEDIATRIC VENTILATOR APPLICATION OF PASSYPASSY-MUIR® VALVE
“TELL ME ABOUT A TRACHEOSTOMY
BEFORE I NEED ONE”
Linda Dean, RRT
Clinical Specialist
Passy-Muir Inc.
ldean@passy-muir.com
(949) 833-8255
Disclosure: Financial — Employee of Passy-Muir Inc.
Nonfinancial — No relevant nonfinancial relationship exists.
PEDIATRIC VENTILATOR APPLICATION OF PASSYPASSY-MUIR® VALVE
Is There Anything I Can Do To Postpone
A Tracheostomy?
Is There Anything I Can Do To Postpone
A Tracheostomy?
There are many forms of non-invasive ventilation
• Noninvasive Ventilation
• Airway Clearance
Is There Anything I Can Do To Postpone A
Tracheostomy?
Today’s options are much smaller
Is There Anything I Can Do To Postpone A
Tracheostomy?
There are multiple mask types
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1/10/2013
Is There Anything I Can Do To Postpone A
Tracheostomy?
Is There Anything I Can Do To Postpone A
Tracheostomy?
Airway Clearance Devices
Sip and Puff Ventilation
Is There Anything I Can Do To Postpone A
Tracheostomy?
Airway Clearance Devices
Is There Anything I Can Do To Postpone A
Tracheostomy?
Airway Clearance Devices
Left: PEP Valve
Right: Bronchial Hygiene acapella® Vibratory PEP Therapy System-Portex
The Vest-Airway Clearance System http://www.thevest.com/
Why Do Some People Need A
Tracheostomy?
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Prolonged mechanical ventilation
NIV no longer meets your needs
Upper airway obstruction (temporary or permanent)
Secretion management (neuromuscular disease)
Improved patient comfort
What Are The Advantages of a
Tracheostomy?
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Can save your life
Quality of life can be great
Frees up face/hands for eating, etc.
May decrease need for continuous ventilation
Provides direct access to your lungs for:
– Secretion removal
– Mechanical ventilation
– Medication delivery
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1/10/2013
What Are The Disadvantages of a
Tracheostomy?
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Increased risk of infection, bleeding, scar tissue
Requires a surgical procedure
Emotional and psycho-social issues – altered body image
Communicating and swallowing may be altered
Sense of taste and smell can be lost
The natural warming, humidification and filtering of air that
usually takes place in the upper airway is lost
Need for home health services/skilled caregivers
Increased equipment needs
Cost of care can be a burden
Upper Respiratory Tract
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Nasal Cavity
Oral Cavity
Pharynx
Larynx
Nasal Cavity
Oral Cavity
Pharynx
Larynx
***MOST IMPORTANT: you decide
Lower Respiratory Tract
Tracheostomy or Tracheotomy?
Which One Is It?
• Trachea
• Bronchi
– right and left mainstem
• Bronchioles
• Alveoli - air sacks
• Tracheotomy is defined
as the surgical opening
of the trachea.
– lined with surfactant,
filled with air to prevent
collapse/ atelectasis
Tracheostomy or Tracheotomy?
Which One Is It?
• Tracheostomy also refers
to a surgical procedure:
the creation of a stoma
at the skin surface, but
most often is referring to
the tube that is inserted
How Is A Tracheotomy Performed?
• Percutaneous – at the
bedside (usually while
the patient is in critical
care)
• Open – in an operating
room
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1/10/2013
Open Tracheotomy
What Does The Tube Look Like, And Where
Does It Go?
• The oldest surgical
procedure
• The patient goes to the
operating room
• Vertical incision is made
between 3-4 or 4-5
cartilage rings
• Tube is inserted and
sutured in place for
safety
There are many choices of tubes!!!!!
Parts of a tracheostomy tube - ISO STANDARDS
Neck flange
Tube shaft
Cuff
15 mm connector-hub
Inflation line
Pilot balloon
Pilot port with one way valve
Tracheostomy Tubes
• Single Lumen/Cannula
Fenestrated Tracheostomy Tube
• Double Lumen/Cannula
Image used by permission from Covidien
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1/10/2013
Extra Length Tubes
distal
Adjustable Flange Tube
proximal
Tracheal Malacia or Stenosis
Increased skin-to-tracheal-wall distance
Image used by permission from Nellcor Puritan Bennett LLC, Boulder, Colorado, doing business as Covidien.
Air Filled Cuffs
• Cuff Inflated
• Cuff Deflated
Day to Day Needs Of A Tracheostomy
Patient
• Patient Information – “Neck Breather Alert”
– Reason for tracheotomy/date of initial tracheotomy
– Brand, type, size tube – spare tubes at bedside
– Local fire and rescue, police, and your electric company
should be alerted to your needs
• Assessment:
– Sputum characteristics – signs of infection
– Cough strength, mucus production
– Check security of tube holder/ties
Water Filled Cuffs TTS
• Cuff Up
• Cuff Deflated
Day to Day Needs Of A Tracheostomy Patient –
Swallowing
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Presence of a tracheostomy
tube may:
– Make swallowing more
difficult
– May increase the risk of
aspiration (as high as 85%)
Assessment, evaluation, and
therapy by a Speech
Language Pathologist may
make oral intake possible
If oral intake is not an option,
alternative feeding options
should be discussed
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1/10/2013
Day to Day Needs Of A Tracheostomy Patient
Humidification
Trach Collar – used with
aerosol generating device
HME – artificial nose
Day to Day Needs Of A Tracheostomy Patient
Humidification
• Drink plenty of fluids, eat
sensibly, and avoid
people who have colds
and flu
• Take care nothing enters
the tracheostomy
(leaves, bugs, hairs, shaving
cream, cotton swabs,
powders, dust, fumes, etc)
STOMA CARE
Day to Day Needs Of A Tracheostomy Patient
Day to Day Needs Of A Tracheostomy Patient
Humidification
Trach Care
• NaCl Nebulizer therapy
• NaCl instillation
• Bibs that heat and filter
• Bronchiol-pulmonary Hygiene
– Suctioning
– Assistive coughing and breathing techniques
– Devices
• Acapella/PEP/Therapy Vest
• Cough Assist
• Inner Cannula Change Cleaning
– Disposable inner cannula is changed daily and PRN
– Non-disposable inner cannula is cleaned 2 X day and PRN
Day to Day Needs Of A Tracheostomy Patient
Oral Care
Day to Day Needs Of A Tracheostomy Patient
Stoma Care
• Trach site must be cleaned daily
• Give special care to nose and mouth
• Unable to sense mouth odor
• Good mouth care stimulates salivation and taste
buds
– After the trach stoma has healed, plain soap and water can be
used to clean the skin around the trach
• NEVER USE: powders, lotions
• Antibiotic ointment may be used for redness
• Moleskin can be wrapped around ties to prevent
rubbing
• Change/wash fabric tube ties daily – can use twill
tape, Velcro fasteners
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1/10/2013
Day to Day Needs Of A Tracheostomy Patient
Personal Hygiene
Day to Day Needs Of A Tracheostomy Patient
Routine Tracheostomy Tube Changes
When showering:
• First tube change is done by a surgeon (preference)
• Cover tracheostomy with HME or shower guard
• Angle spray away from stoma
– To assure stoma and tract established
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Routine change of tube - physician will advise:
• Change monthly if double lumen tube
• Change weekly if single lumen tube
– To reduce complication of granulation tissue
– To decrease risk of infection
– To comply with tube manufacturers guidelines
NOTE*** There is no current consensus/guideline for adults (local
practices)
How Will I Communicate?
Airflow With A Tracheostomy Tube
Alternative Communication Devices
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Intercom system
Bells on ankles/shoes to hear a child
Tricycle horn, squeaker toy, bell
Finger occlusion
Call system, light or bell (adapted as necessary)
Picture, word and/or alphabet communication board
Facial expression or eye gaze board (limited mobility)
Magic slate writing board
Pencil and paper
Simple gesture
Signing
Lip reading
Speaking Valves
PEDIATRIC VENTILATOR APPLICATION OF PASSYPASSY-MUIR® VALVE
Leak Speech For Ventilator Patients
The Passy-Muir® Tracheostomy & Ventilator
Swallowing and Speaking Valve
• Cuff is deflated to allow airflow through the mouth
• May be some loss of ventilation, adjust volumes to
compensate
– to much volume can be harmful to the lungs!
• Vocalize during inspiration – why is this unnatural?
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1/10/2013
PEDIATRIC VENTILATOR APPLICATION OF PASSYPASSY-MUIR® VALVE
Physiologic Benefits of Passy-Muir ® valve
Passy-Muir® Valve Placement
• Restores
Voice/Communication
• Improves Swallowing
• Restores Physiologic PEEP
• Improves Secretion
Management
• Improves Oxygenation
• Promotes Weaning and
Decannulation
• May Decrease Risk of
Aspiration
• Improves Smell & Taste
PEDIATRIC VENTILATOR APPLICATION OF PASSYPASSY-MUIR® VALVE
Other Resources:
www.passy-muir.com
www.hopkinsmedicine.org/tracheostomy/living
www.Tracheostomy.com
http://www.ventusers.org
http://www.upmc.com/patientsvisitors/education/documents/tracheostomycare.pdf
• http://www.kchealthcare.com/media/67088/product%
20information%20and%20tool_trach%20care_home%20
care%20guide.pdf
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Linda Dean, RRT
Clinical Specialist
Passy-Muir Inc.
ldean@passy-muir.com
(949) 833-8255
Disclosure: Financial — Employee of Passy-Muir Inc.
Nonfinancial — No relevant nonfinancial relationship exists.
Definitions:
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Airway: The passage that allows air (oxygen) to get to the lungs
Ashen: A word that describes a pale, gray color to the skin
Bactroban: An antibiotic ointment used for redness or irritation around the
tracheostomy
Breathing: The process of taking air through the airway and into the lungs,
supplying the body with oxygen vital for survival
Canister: A collection device for secretions and saline, attached to the
suction machine
Cannula: The part of the trach tube that is inside the airway
Catheter: A thin tube used to suction secretions out of the tracheostomy.
Catheters come in different sizes (example, 6 French)
Circulation: The process of blood being pumped by the heart and traveling
through the body via blood vessels, arteries and veins
Dusky: A blue color to the skin, lips or nail beds that signifies a decrease of
oxygen in the body
Definitions:
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Flanges: Flat plastic/silicone front of the tube with holes on each side. These
holes are where the trach ties are inserted and secured.
Humidification: The process of putting moisture in the air, done by a
humidifier. Humidification keeps secretions in the tracheostomy from
becoming dried out and plugging the tracheostomy tube
Humidifier: A device that puts water in the air via a machine
Moleskin: A soft material with a sticky backing that can be applied to the
trach ties to prevent or decrease irritation from rubbing trach ties
Mucus: Thick secretions from the tracheostomy. These need to be suctioned
from the trach in order to keep the airway clear and patent
Mummy Restraint: A sheet or blanket, wrapped securely around the child to
hold his arms down and prevent excessive movement during a procedure
Obturator: The stiff piece of plastic shaped like the trach tube with a
rounded end that guides the flexible trach tube into place during a trach
tube insertion. The obturator must be removed immediately after the trach is
in place because it obstructs the airway.
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1/10/2013
Definitions:
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Resusitation Bag: A device that allows you to push oxygen into the lungs
via the airway. The resusitation bag may be connected to an oxygen
tank.
Rescue Breathing: The process of delivering one breath every 5-10
seconds into the tracheostomy because he/she is unable to breathe
independently
Respiratory Distress : A condition demonstrated by difficulty breathing,
retractions, dusky or ashen color, fast breathing
Retractions: Sucking in of the neck and/or chest between the ribs (a
sign of respiratory distress)
Shiley, Bivona, Portex, Tracoe: Brands of tracheostomy tubes
Sterile Water : Tap water that is boiled and stored in sterile container. It
may also be purchased.
Stoma : The opening in the neck where the trach tube is inserted
Suctioning : The process of removing secretions from the tracheostomy
by applying suction through a catheter
Definitions:
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Equipment Recommended For Home:
Trach Safety:
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Use caution around water – shower guards
Foreign objects small enough to inhale
Avoid turtle necks shirts and plastic bibs
Use care with gauze padding – can become an obstruction
Environmental Control: dust, lint, mold , pet hair, and smoke in
the home
Systemic hydration – drink plenty of water
Avoid aerosol sprays
Transport with care on windy, cold days
Practice infection control: vaccines, hand washing, crowds,
screen visitors
Watch for change in secretions – signs of infection
Disinfect toys – dishwasher
Disinfect respiratory equipment – white vinegar
Ties: Twill tape, Velcro® fasteners, or shoelaces that are
threaded through the flanges on each side of the
tracheostomy to keep the trach in place
Trach: Short for tracheostomy
Trach Nose: (HME) A special piece of equipment with a filter
to collect heated/humidified air on exhalation, to
heat/humidify inspiration on the next breath into the
tracheostomy
Trach Size: The particular diameter and length of the trach
tube (varies with the age and size of the patient)
Trach Tube : The piece of the tracheostomy providing the
artificial airway that goes into the patient’s body
Tracheotomy : A procedure that creates an opening for an
artificial airway to maintain your patient’s ability to breathe
Twill Tape: Cotton strings used to tie the tracheostomy in
place
Velcro Ties: Trach ties commercially available that use velcro
to secure around the neck
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Spare Trach Tubes (same size and smaller sizes)
Suction Catheters
Suction Machines (-80 to -100mmHg)
Sterile Water
Resusitation Bag and face mask – proper sized
Bulb Syringes
HME’s (artificial noses)
Compressor for Humidification
Trach Collar and Tubing
Q-Tips
Hydrogen Peroxide
Gloves
Oxygen
Apnea Monitor
Pulse Oximeter
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