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A ventilator-dependent home patient is currently using a HME inline with his vent. Is this adequate or should we go to a Heated Humidifier? The patient is requesting a Heated Humidifier.
Mechanical ventilation involving an artificial airway should include humidification and supplemental heat to deliver gas containing at least 30 mg/L of water at 31-35 degrees Celsius (Wissing, 2004, p. 93, para 6). The level of humidification within this range described should be adequate to prevent dehydration of airway secretions, destruction of airway epithelium, and atelectasis. According to Wissing, Heat and Moisture Exchangers (HMEs) produce humidity levels in the range of 10-31 mg/L at a temperature of 30 degrees Celsius. They are therefore best suited for patients during short periods of mechanical ventilation (i.e 96 hours/4 days or less), with minute volumes less than 10 lpm, limited secretions, and normal body temperature (Wissing, p. 98, para 3).
HMEs provide adequate levels of humidification for short intervals such as during transport and when active humidity through high flow systems is not practical, but HMEs do not add additional moisture to the airway or breathing circuit. Applying active heated humidity during the course of the day would add the recommended humidity. Additionally, a heated wire ventilator circuit in conjunction with the active humidifier may reduce labor of system maintenance and assist in keeping the moisture in vapor form preventing 'rain-out' in the circuit tubing.
Wissing, D. R. (2004). Humidity and aerosol therapy. In J. M. Cairo & S. P. Pilbeam (Eds.), Mosby's Respiratory Equipment, Seventh Edition (pp. 87-129). St Louis: Elsevier.
For a patient who is able to eat, can a fenestrated tracheostomy tube be used or must it be the solid inner cannula?
Unless specific recommendations were made by a speech-language pathologist due to results of an X-ray swallow test (modified barium swallow), there is no reason that one type of inner cannula should be better or worse than another when eating. The primary exception would be if the patient wears a tracheostomy speaking valve (e.g. Passy Muir Valve) and needs one type of inner cannula when the speaking valve is in place. Generally speaking, swallowing is safer with the cuff down and the speaking valve on, though specific recommendations should come from a formal swallowing assessment.
What is the use of a tracheostomy plug? How do we use it? Can we use it for all ages? Can we use it as a speaking valve and what kind of trach tube can we use it with?
A tracheostomy plug is used for two purposes. First, it is used for decannulation of the tracheostomy tube. Secondly, it can be used for speech, but not as a speaking valve. A speaking valve is a one-way valve unlike a trach plug that completely obstructs the air flow via the trach tube. For decannulation, we plug the trach tube for 12 hours the first day and 24 hours the second day. If the patient tolerates plugging, then we decannulate. Plugging should be done only when the cuff is down or if the trach tube is uncuffed. We use it for patients who are 18 years and older. We recommend that you contact a pediatric specialist to discuss options for children.
When do we have to downsize the trach tube?
Whenever you think that the patient is tolerating weaning from the mechanical ventilator.
What can we do for children with a trach tube to encourage them to speak if they have a trach without inner cannula?
Please contact a pediatric specialist to discuss this further.
I am a Respiratory Therapy student. We noticed in our clinical experiences in Sub-Acute units that we did not find a single patient with Heated humidification when they were on a T-piece aerosol. My instructor states that is not acceptable. We are unable to find any information that states this is acceptable and that every patient with a "by-passed" airway should have Heated Humdification. If you have any information that would aid in our discussion, it would be truly appreciated.
According to Mosby (1999), gas delivered should be maintained at or above ambient temperature and relative humidity when delivered to the upper airway. When delivered to an artificial airway or an airway that bypasses the upper airway, temperature should be at or near body temp and relative humidity 80-100%. Active or passive humidification devices may be used to accomplish the appropriate levels needed. Reference:
Wissing, D. R. (1999). Humidity and aerosol therapy. In J. M. Cairo & S. P. Pilbeam (Eds.), Respiratory care equipment (6th ed.). p. 96. St. Louis: Mosby.
Why do you need the inner cannula with a tracheostomy?
Inner cannula is very important for patients especially when they have a lot of secretions. First of all, it is easier to pull the inner cannula out and clean it to maintain hygiene of the airway. Secondly, if patients develop a mucus plug, you can pull the inner cannula out and have the outer cannula serve as the airway. You can then either place a new inner cannula or clean the plug out of the old one and reuse it depending on whether the tube is disposable or not. Maintaining hygiene and management of emergent cannula blockages can become difficult if you do not have the inner cannula as changing the whole tracheostomy tube is more work and often uncomfortable for the patients.
What is the anatomy of the trachea relation to the esophagus? I am concerned about how close they are with regards to dangers associated with eating.
The trachea and esophagus share a common wall. The back wall of the trachea is the front wall of the esophagus.
How long are newly trached patients in the hospital before they are discharged? How much nursing care do they receive once they get home?
On an ENT floor, newly trached patients remain in the hospital until the first tracheostomy change. This can happen anywhere from 3 - 5 days, when the suctioning machine and supplies arrive, and when the patient and/or caregiver perform competent suctioning skills.
However, in an ICU setting, the first tracheostomy change may be done only after 7 days and the critical illness that brought them to the ICU usually determines how long the patient will stay in the hospital.
The amount of home nursing newly trached patients receive depends on the patient. The home nurse will go in and re-iterate what was taught in the hospital, as well as evaluate if suctioning is done properly. They will usually not be the one to suction the patient. The level of home nursing care may also depend on their insurance plan.
Is it normal for a patient to feel soreness in his/her neck around the tracheostomy tube area?
That is normal and expected after a recent tracheostomy tube change.
What does a T-tube look like and how is it different than the others?
Unlike standard tracheostomy tubes, a T-tube has three limbs and is shaped like a "T." The outer limb is the part that you can see in the stoma. The upper limb extends toward the vocal folds and the lower limb extends into the trachea. T-tubes are used when there is stenosis or reconstruction of the airway. The T-tube is held in placed with rings positioned over the outer limb so that the upper and lower limbs do not move inside of the airway.
Can a person with a tracheostomy and his/her right side impaired due to stroke be able to go on a 3 day cruise?
Yes, a person with a tracheostomy and right sided impairment due to stroke will be able to go on a 3 day cruise as long they have the suction machine, equipment, oxygen and their usual help (if they require a caregiver routinely).
Is a pulsating oxygen delivery system available in airplanes compatible with a self-ventilating patient with a tracheostomy tube in place?
Pulsating Delivery System delivers oxygen on demand from the patient. It means that only if the patient takes a breath, the oxygen is delivered. The system will not be able to sense the effort by the patient if he/she is breathing via tracheostomy. However, if the patient's supplemental oxygen is delivered via HME, the system might be able to sense and deliver the oxygen but it is not guaranteed.
Another option would be to provide oxygen directly to the patient (without using the HME) using a regular oxygen cylinder. The regular transportable cylinder that we are familiar is the E cylinder which has 2000 psi. This cylinder will last for 1120min if you are delivering only 0.5l/min, which means that the cylinder will last for 18 hours. You will need to instill 5-10cc of saline every 2 hours or so to prevent the airway from drying. However, you would need to consider back up oxygen supply if the patient's health condition changes and might require more oxygen. The solution might be to take two oxygen cylinders on the flight. One for use and one for back up.
I read your Living with a Tracheostomy and a Passey-Muir and found it very interesting. Why can we not use the Passey Muir valve with the cuff inflated?
The reason why the valve cannot be used with the cuff inflated is because the speaking valve is a one-way airflow mechanism. The patient inhales air through the speaking valve but exhales it around the tracheostomy tube and then through the nose or the mouth. If the cuff is inflated with a speaking valve, the person will only be able to inhale air and will not be exhale since there will not be any room around the tracheostomy.
How often should a tracheostomy tube be changed?
We recommend changing the tracheostomy tube once a week to remove the dried or old secretions and maintain adequate hygiene of the tracheostomy tube and airway.
Is Tracheostomy and Tracheotomy the same thing?
Is a tracheostomy temporary to permanent?
It can be temporary or permanent. Basically, the tracheostomy is placed for a particular problem. If the problem is resolved, then the tracheostomy can be removed. However, if the problem does not resolve, then it may potentially be permanent.
Can a person with a tracheostomy work around food like a restaurant/cafeteria?
There are no absolute contraindications regarding an individual with a tracheostomy working in food service. Meticulous hygiene and tracheostomy care would be required. The individual with the tracheostomy could wear a speaking valve or cap/plug if medically appropriate; otherwise, a mask, trach bib, or loose scarf could be used to cover/protect the trach site. The individual with the tracheostomy may find that secretion production is increased in an environment in which there are food aromas and warm air/steam from food trays. Consequently, there may be a need for increased suctioning and/or cleaning of the inner cannula.
In addition, individuals with tracheostomy are protected from discrimination in the workplace under Title I and V of the Americans with Disabilities Act. This legislation is civil rights legislation which prohibits discrimination against qualified individuals with disabilities, including limitations of walking, breathing, seeing, hearing, speaking, learning, and working.
Is suctioning 4 – 5 times a day too much?
No it is not too much. Some people even suction every 1-2 hours or even more frequently. However, if you notice a change from suctioning 4-5 times every day to a more frequent need or if you notice any change in color or consistency of the secretions, you should notify your doctor.