What do I do if a trach gets dislodged?!

A nurse runs into the workroom: “Ms. X’s trach is two inches out! She’s desatting to the 70’s on 60% FiO2!”

What do you do for a dislodged trach? This is the situation I faced a week ago, on a patient who wasn’t mine on the floor where I was working.

First, to clarify, dislodged=trach partially out of the stoma, decannulated=trach is all the way out of the stoma. Immature stoma is <1 week, mature stoma >1 week.

I love this slide from Vanderbilt, because it works for me, personally: keep it simple
  1. Your nurses and respiratory therapists are your life line!! Most institutions have protocols to page Anesthesia or a surgical team of some kind for these situations.
  2. Bag valve mask=Ambu bag: whatever you call it, if a patient with a trach is in distress, stabilize them with manual respiration. Apply the bag to the trach itself. If you meet “resistance” while bagging, STOP. It indicates either the trach is in a false tract, or there’s an obstruction, like a plug or extra tissue. (If it’s a false tract, you might be able to feel subcutaneous crepitus develop during bagging!)
  3. If bagging the trach doesn’t work, apply the bag to the patient’s mouth for face bag ventilation. The one caveat is laryngectomy patients: their mouths are not connected to the rest of their airways.
  4. Remove the inner cannula. Insert the suction catheter. If the catheter quickly draws back secretions, it’s still in the right place. If it doesn’t, the trach might be in a false tract.
  5. If you want to be fancy and have the skills, a fiberoptic scope can be passed from the mouth or through the stoma to look for problems.
  6. If the stoma is mature, in an emergency you can replace the trach with one that’s the same size or one size smaller. However, if the stoma is immature, the rate of closure is very high–up to 50% of the hole can close within 12 hours!
  7. Therefore, when dislodgement and definitely decannulation happens in an immature stoma, you may have to reintubate and wait for the surgeons to repair the stoma and reinsert the trach.

In my patient’s case, we ended up bagging her by mouth until respiratory therapy fiddled around with her trach enough to confirm it was in the right place and secured it with the trach collar. Stabilization is always #1! It turned out the patient had a large gap in her stoma, making the trach loose/malpositioned. The thoracic surgery team came by and put in a stitch to close the gap.

References:

What is a Passy Muir or speaking valve?

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A speaking valve, commonly called a Passy Muir valve, is a cap that can be put over the trach cannula to allow patients to vocalize more.

Patients often have to practice wearing the Passy Muir valve, and may be more fatigued or have more coughing at first.

The Passy Muir website has a practical and interesting troubleshooting page. Of course, take the company website with a grain of salt, but I did find it helpful overall for understanding the applications and patient perspective better.

Are there contraindications to using a speaking valve? 

Yes. Patients with an an inflated cuff, fome cuff trach, history of laryngeal masses, stenosis, total laryngectomy, or thick copious secretions should hold off on a speaking valve.

What is the difference between cuffed and uncuffed trachs?

  Cuffed trach Uncuffed trach Fenestrated trach (comes with a cuff)
Indication Patients on a closed ventilator (cuff prevents airleak) Patients who are more stable, getting closer to decannulation Patients on a ventilator who aren’t ready for a speaking valve. Has a cuff but is more “in-between”
Compatible with speaking valve?  

Yes—must deflate the cuff first

 

Yes, speaking valve may not be necessary

 

No—if cuff is deflated can speak using vocal cords or a trach plug

Advantages Provides the most secure airway Is easier for the patient to tolerate Allows air to pass more “normally” through nose and mouth
Things to look out for Pressure necrosis

Tracheal stenosis

Cuffless or deflated cuffs are more prone to silent aspiration Many fit poorly, leading to granuloma formation and infection
Random things to know Cuff pressures are ideally checked twice a day: 20-30 mmHg generally good The decannulation plug is used when patients get decannulated, so hold on it it Patients can still wear a nasal cannula if the trach is plugged

The table above was made using this Hopkins page as a reference.

This guide from OHSU is seriously fantastic. (Except at the beginning I think they switched the labels for pilot line and cuff.)  I am shamelessly borrowing their pictures.   Screen Shot 2018-10-25 at 8.18.23 PM.png

What are the parts of a trach?

 

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What are the most common different brands of trachs?

  • Shiley (plastic/PVC piping)
  • Portex (plastic)
  • Bivona (silicone)
  • Jackson (metal)

See here for pictures and specifics of the above brands.

What do the different trach sizes mean?

The table below is taken from a very comprehensive paper on trachs in Respiratory Care. As you can see, even trachs that are the same size according to the company actually have different dimensions. So I would recommend discussing with your friendly respiratory therapist if you think a trach needs downsizing and what the right size to go to might be.Screen Shot 2018-10-25 at 9.14.20 PM.png

 

 

What is a capping trial?

A capping trial is performed when you are considering decannulating (removing) a patient’s tracheostomy tube. It is often the final step before someone is able to breathe completely on their own again. It is a test of whether the patient can control secretions and feel comfortable breathing “normally.”

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Literally, it is a cap over the trach. 

Who can undergo a capping trial? 

  • Anyone who has been successfully weaned from the vent for a good amount of time
    • At most, they should be on 40% O2
    • Secretions are not excessive
  • Patients’ cuffs must be deflated (an inflated cuff will not allow ANY passage of air)

How does the capping trial work? 
There is no standardized protocol. Like many aspects related to vent management, this varies by institution. This was a QI study at Hopkins on the creation and implementation of a capping trial protocol. There were two different options:

  • Cap x24 hours and decannulate if successful (2 days)
  • Cap x12 hours, rest, cap x24 hours, then decannulate if successful (3 days)

Patients should be monitored for signs of respiratory distress during the capping trial.

This trach weaning form created by St. George’s Hospitals gives you a sense of how to think about the final steps towards decannulating a trach:

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How to manage chest tubes (5-minute version)

I am no expert in chest tubes, and will add the caveat that for this particular post I really hope everything is correct! If it’s not, let me know! See this post on the different kinds of chest tubes. This is a great but long nursing resource from RN.com.

You’ve placed a chest tube: great! Now you hook it up to some weird box thing that is called a drainage system…now what? Knowing how chest tubes used to work helps you understand the box thing.

This picture is taken from a truly excellent little video on how chest tube drainage works:

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ThScreen Shot 2017-01-26 at 6.01.21 PM.pngere used to be 3 separate bottles hooked up to the chest tube itself: Bottle #1 is where the patient’s empyema fluid or blood leaked into. Bottle #2 is the waterseal: air is forced to travel through water and can only move in one direction (it cannot move back into the patient). Bottle #3 sets suction power based on how much water is in the bottle–more water=less suction, less water=more suction, and you need to make sure the suction power is just right. You can see how the drainage system has evolved over time on the right.

Should patients be “placed to waterseal” or “placed to -20 suction?” 

“Place to waterseal”= don’t be too crazy with drainage, which is appropriate for most pleural effusions or a mild pneumothorax. If the lung is not fully expanded, you can “turn up the suction.”If you apply suction too aggressively, you put the patient at risk for re-expansion pulmonary edema.

How do I know if there is an “air leak” and what the heck does it mean? 

An air leak is present if there is bubbling in the waterseal chamber when the suction is clamped/on waterseal–this indicates there is still air flowing from the chest to the tube. Positive pressure coming from the pleural space=air getting into the pleural space. Intermittent bubbling with expiration (when pleural pressure is highest in the non-ventilated patient) may be normal, but a continuous air leak is pathological and means the patient is not ready to have their chest tube pulled! 

You can “clamp” the tubing, which should stop an air leak. If the air leak persists even with clamping, consider:

  • ruptured bleb (severe emphysema)
  • simple traumatic pneumothorax (from placing the chest tube)
  • a leak in the actual tubing system
  • mechanical ventilation (may see decreased tidal volumes, failure of PEEP increase)
  • bronchopleural fistula (usually more severe or continuous)
  • lung entrapment vs. trapped lung

NB: if your patient has a persistent air leak, think twice about pulling their chest tube because if you do, you may cause a recurrent pneumothorax.

What is “tidaling?” 

You may see movement in the waterseal chamber with respiratory variation. It’s the water being sucked back towards the lung with inspiration due to negative inspiratory pressure. (In mechanically ventilated patients, it’s the opposite.)

How do I know when the tube can be taken out? 

In a 2013 study out of Michigan State, the team found it is reasonable to remove chest tubes when drainage <200 ml/day, on waterseal, with no air leak. In stable patients on the floor, theoretically you don’t need a chest x-ray after removal, but given our litigious society, everyone gets one. In mechanically ventilated patients, you should get a chest x-ray 1-3 hours after removal. However there is no need for regular surveillance chest imaging while a patient has a chest tube in. 

What do I do if the tube falls out? 

Use common sense: cover the area and prepare to re-insert a chest tube. Maintain sterility. The patient is at risk of a tension pneumothorax, so someone should stay with them for close monitoring. More troubleshooting at this nursing website.