Ventilator-Assisted Living©

Winter 2005, Vol. 19, No. 4

(continued)

Care of a Tracheostomy

Larry Kohout, Edina, Minnesota, lkohout@mn.rr.com
and Tony Nadeau, Saint Louis, Missouri, soberstill@juno.com

Readers who have used noninvasive ventilation for years have reported to IVUN that they have been offered a tracheostomy because of their increased respiratory insufficiency and the need for more hours of breathing assistance. They have asked, "What is a tracheostomy and how do you take care of it?" Two survivors of polio tell how they care for their "trach" to help others who may be contemplating this option.

Connect here to read Tony and Larry's
unedited version of this article.

Tony's Experience

photo of Tony NadeauI contracted polio in Los Angeles in 1948 when I was 13 years old and have had two tracheostomies. The first came six weeks after the initial onset of the mild form of polio when I relapsed into the more severe spinal-bulbar type. When I awakened from the coma two weeks later, I was in an iron lung and had been trached. At that time, being unconscious and a minor, I had no say in the decision. Today, I'm extremely grateful to those who made that decision.

I was transferred to Rancho Los Amigos in Downey, California, and was gradually weaned from the iron lung. The trach tube was removed shortly thereafter. A month later, I was released from the hospital and, even with limited arm and leg strength from polio, I led a fairly normal life – 40 years of marriage, two children and 30+ years in the workforce.

In the mid ''70s, I began to experience new muscle weakness and breathing problems. In December 1984, I ended up in the Emergency Room. My pulmonologist said my ability to breathe had deteriorated to the point where, if I wasn't re-trached so I could use a mechanical ventilator on a regular basis, I would most likely die shortly. This time it was my decision and a no-brainer. I told him to do it ASAP.

I've used three different ventilators with my trach, and currently use a Pulmonetic Systems LTV®800, their volume vent. I use a two-nights-on and two-nights-off routine.


Larry's Experience

photo of Larry KohoutI'm a newcomer to ventilation. Although I was in an iron lung for a short time during my acute polio experience at age 13, I have spent the greater part of the last 52 years denying that breathing problems exist. After 15 months using a BiPAP® at night, I ended up using Pulmonetic Systems LTV®950 fulltime.

The shift from part-time to full-time ventilation left me unable to tolerate any of the interfaces that I tried. My face and particularly my nose was so sore that it was three months after I had my trach before I could touch it comfortably.

At that time, I had not subscribed to Ventilator-Assisted Living and I am not certain that I knew all of my options. Even now, knowing all of the options available, I am happy with my decision. While I can breathe on my own for 20-30 minutes, essentially I use the vent 24/7.


Tony's Trach Care Routine

Since 1984, I've used Shiley® (Size 8) fenestrated disposable trach tubes. (See Figure 1.) This type allows me to talk normally when the trach's opening is plugged, either with my finger or with a trach cap. When first home from the hospital, I tried to follow the recommended trach care routine I'd learned from my nurses. After a few months, following the strict sterile procedure began to seem extreme, time consuming and expensive, so I changed it. No health consequences occurred and I still use that routine.

My 3-4 times daily trach cleaning technique, depending on accumulated mucus, involves loosening any hard-to-clear mucus from the outer or inner cannula* walls by spraying Ocean Saline solution inside them. I then "heave" up the loosened mucus into a clean inner cannula or use my suction machine. Routinely, I only insert an inner cannula into my trach when cleaning the outer wall or when using my ventilator for the night.

My ENT, Laurence A. Levine, MD, Saint Charles, Missouri, and I agree with changing my trach tube only two or three times a year, which he does in his office.

Several months ago, some nonmalignant growths appeared in my upper trachea wall directly above the fenestration. These growths were very troublesome and very painful when clearing mucus from the tube. After a few attempts to remove the growths, Dr. Levine decided to take a non-fenestrated trach tube and custom cut (with a Dremel tool) a single fenestration hole a bit below where the other holes had been cut. Success! Since then, the growths have disappeared and have not returned.

Figure 1. Airflowing moving through the fenestration of a cuffed fenestrated tracheostomy tube.

Figure 1. Airflow moving through the fenestration of a cuffed fenestrated tracheostomy tube.

Diagram ©1995 Singular Publishing Group, Inc. for Communication and Swallowing Management of Tracheostomized and Ventilator-Dependent Adults by Karen Dikeman, MA, and Marta S. Kazandjian, MA.

Editor's Note: Trachs can also be uncuffed and nonfenestrated; cuffed and nonfenestrated; and uncuffed and fenestrated. The hole or window is called the fenestration.


Larry's Trach Care Routine

While still in the hospital for the tracheostomy, my wife and I were trained in the routine cleaning of the skin around the stoma. This consists of starting next to the stoma and wiping in concentric circles away from the stoma with a single-tipped cotton applicator soaked first in distilled water and then in peroxide. Once the area has been thoroughly washed with peroxide, the same routine is followed with an applicator soaked in plain distilled water to rinse the area. Finally, the area is dried with a dry single-tipped cotton applicator. A fresh, clean drain-sponge is placed under the neck plate and around the stoma, and everything is re-secured with a trach collar. I use the MARPAC One Size Fits All Series soft foam collars. They have smooth edges and Velcro™ tabs for a secure closure.

Within six weeks of the minor surgery to perform the tracheostomy, I was switched from a cuffed trach tube to a cuffless tube. (See comment with Figure 1.) Now, I use a Shiley® (Size 8) disposable tube with disposable cannulas. My ENT, Mark Satz, MD, Saint Louis Park, Minnesota, recommended that the tube be changed every three to four weeks. However, I had a lot of difficulty with secretions building up between the end of the trach tube and the wall of the trachea where it would require the suction tube to make a U-turn to get at them. These secretions would bubble when I talked and caused me to cough and choke. Normal lavaging (washing out) seemed to open the airway a little but it would not stay open long. My wife and I finally stumbled on the routine of changing the trach tube daily.

Even though we use the disposable trach tube and inner cannulas, we pull out the tube and replace it with the one from the prior day which has been washed in peroxide, thoroughly rinsed in distilled water, and dried. Pulling out the tube and replacing it with a clean tube seems to break the hold that the secretions that build up between the trach tube and the trachea wall have on the trach tube. If necessary, I can lavage again and huff out any remaining secretions. We use a pair of trach tubes for two months and then throw them out. Typically, I will change the inner cannula several times during the day as I feel the need.

It is rare that I have to suction anymore, but occasionally there is a need, particularly when I have an upper respiratory infection. I use the Ballard Trach Care Closed Circuit Suction System for adults (Kimberly-Clark REF 22103), a set-up that allows me to suction myself, even with lack of hand strength and dexterity.

When breathing in after a tracheostomy, air passes directly into the trachea and bypasses the nose and upper airway (See Figure 2.) and there is no way to warm and humidify that air. Enter the HME (heat/moisture exchanger), also known as an artificial nose. This little device is a plastic shell containing a spongy material which is very absorbent for moisture that is inserted in the circuit (the hose) right next to the trach tube.

artwork for Figure 2, showing airflow after tracheostomy.

Figure 2. Airflow after tracheostomy. Diagram ©1995 Passy-Muir, Inc.

When exhaling, the moisture in the air coming out of the lungs is trapped in the sponge. The next breath of air being forced in from the ventilator passes back through the sponge, picking up that moisture and carries it back in again. The device does work well for about 10 to 12 hours before there is a need to go back on a supply of heated humidified air, though I have known of some people who have used nothing but HMEs around the clock. (The HME that I use is a Hydro Therm with Flex Tube manufactured by Intersurgical, 1853-T.) I replace the HME daily.

My wife and I have now been following these routines for at least three years. I make yearly visits to my ENT and my pulmonologist, A. Stuart Hanson, MD. Both physicians have commented that whatever it is we are doing, we ought to keep on because they have never seen such a fine-looking stoma. Also, I am clearly maintaining my health.


What Works

Both of us think that the items outlined by Dr. Oppenheimer are right on the mark. He provided the checklist of items that needs to be accomplished without giving the specific details or the timetable for accomplishment.

Too often, we read or hear that "such-and-such" needs to be accomplished every three months, or "do this every three days." People are different. Larry was very uncomfortable until he started changing his trach tube daily, and then started feeling great every day. Tony's routine is markedly different from Larry's, but it has worked for him for many years.

We feel that the details of a trach routine are peculiar to an individual, and that all trach users need to figure out what works best for them. It may take a while to establish an effective trach routine, so patience is very important. The reward is better breathing and better health overall.

*Parts of standard tracheostomy tubes include:
Want to know more about trach tubes?

Read "Tracheostomy Tubes" by Louie Boitano, MS, RRT, in the Winter 2003 issue of Ventilator-Assisted Living (Vol. 17, No. 4).


Dr. Oppenheimer's* Observations

"Tracheostomy care includes:

Dr. Oppenheimer went on to say, "Tracheostomy care (and tracheal suctioning) should be taught by an experienced healthcare professional. Sometimes it is advised that a trained healthcare professional should do the tracheostomy tube changes. My preference is to train the tracheostomy user and his/her caregiver to do this properly and then be sure that they can give a return demonstration of their skill and competency.

"This has the advantage that a tube change can be done in an emergency, e.g., if the tube becomes blocked or comes out, even on weekends or in the middle of the night. This avoids emergency trips to a medical center, which may result in too long a delay for safety.

"Two or three tracheostomy tubes should be available. I recommend the reusable tracheostomy tubes, and rotate them so that there are always 1-2 clean and dry ones available. However, many people do well using disposable tubes."

*Editor's Note: Dr. Edward A. "Tony" Oppenheimer died in November 2005. We are grateful that we were able to obtain his advice for this article.

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