Unedited Version

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.

Tony's Experience

photo of Tony NadeauI've had two trachs since contracting polio in Los Angeles, in September 1948 when I was 13 years old. The first came as the result of relapsing, six weeks after the initial onset of the mild form of polio, into the more severe spinal bulbar type of polio. When I came out of the coma two weeks after the relapse, 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 about being trached or not. Today, I'm extremely grateful to those who did make that decision. Shortly after coming out of the coma, I was told about the "whys" of my trach. I was told I'd also had chicken pox and double pneumonia while in the coma. I think I realized then that "Somebody up there likes me." After several weeks, I was transferred to a rehabilitation hospital, where the steady physical therapy started. After several more weeks, I was able to be weaned off the iron lung and the trach was removed shortly after that. Even with my limited arm and leg strength from the polio, I led a fairly normal life.

 

Then the Post Polio Syndrome (PPS) started affecting me in the mid 70's, when I started experiencing some muscle weakness and breathing problems. In December 1984, as the result of my worsening respiratory insufficiency, I ended up in the Emergency Room. There, my pulmonologist told me my condition 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 mostly likely die shortly. This time it was my decision, and a no brainer. I told him to do it ASAP. Since then, I've used three different ventilators with my trach. My current one is a Pulmonetic Systems LTV 800. I continue to use my ventilator, on a 2 nights on and two nights off routine. While I'm not as active as I was 20 years ago, my life is mostly still good and interesting for me, and I'm grateful for that.

 


Larry's Experience

photo of Larry KohoutI'm a newcomer to ventilation. While I was in an iron lung for a short time during my acute polio experience at the age of 13, I have spent the greater portion of the last 52 years denying that there were such things as breathing problems.

 

After 15 months using a BiPAP at night and after meals through noninvasive interfaces, I ended up having to go to full-time volume ventilation. The shift from part-time to full-time ventilation left me unable to tolerate any of the interfaces that we tried. My face and particularly my nose was so sore that it was three months after I had my trach before I could begin to 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'm not at all unhappy with my decision to be trached. My breathing is a whole lot better and I have been much healthier over-all. While I can breathe on my own for between 20 minutes and a half hour, essentially I use the vent 24/7.

 


Dr. Oppenheimer's* Observations

 

When asked about trach care, Dr. Edward A. Oppenheimer offered:

"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."

"There is detailed information on 'tracheostomy care' on the Internet that can be found by doing a Goodle search. However, 'hands on' training and advice from professionals who know you is advised, in addition to reviewing this information."

 

*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.

 


Tony's Trach Care Routine

 

Since my first trach was removed before I was discharged from the rehab hospital, I didn't need a trach care routine. That all changed with the second trach, so I'll start with it.

 

Since December 1984, I've used Shiley No. 8 fenestrated 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. However, after a month or so, using the sterile conditions began to seem extreme, time consuming, and expensive, so I cut down on them. When no health consequences occurred, I kept using the routine I started then. I still use that routine. My 3-4 times daily trach cleaning technique, depending on accumulated mucous, involves loosening any hard to clear mucous from the outer or inner cannula walls by spraying Ocean Saline solution inside them, then "heaving" up the loosened mucous into a clean inner cannula or using my suction machine. For many years, I only inserted an inner cannula into my trach when cleaning the outer wall, or when going on my ventilator for the night. Recently, after reading Dr. Oppenheimer's comments, I've started inserting an inner cannula, even on those nights I don't use my ventilator. This change has made my morning mucous clearing much easier. (Thanks Doc.) For many years, my ENT and I were okay with changing my trach tube only two or three times a year. Recently, however, some non-malignant growths have occurred in my upper trachea wall, directly above the fenestration holes. Now, either my daughter, a nurse, or my wife, change my trach tube every week or so, inserting a fresh clean one, wrapping a 1/2-inch wide strip of Xeroform gauze dressing to cover the proximal fenestration holes. We've learned to make these exchanges quickly, to prevent the stoma from closing and making the insertion more difficult. The Xeroform "wrap" is preventing these growths from going into the distal fenestration holes, and has also resulted in a better stoma seal when I use my ventilator.

 

While my older and more current routines may not work for everyone, except for these recent unexplained growths, they've worked well for me for over 20 years now, so unless I find another good suggestion, I'll stick with them.

 

Diagram copyright Singular Publishing Group, Inc. 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 on 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 tip cotton applicator. A fresh, clean drain-sponge is placed under the trach tube faceplate and around the stoma and everything is re-secured with the trach ties.

 

Within six weeks, I had been switched from a cuffed trach tube to a cuffless tube and our ENT doctor put us through the training on changing a trach tube. (See comment with Figure 1.) Then, as Dr. Oppenheimer has suggested, he asked us to demo the process. He recommended that the tube be changed every three to four weeks. That was our beginner's routine. 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 make a U-turn to get at them. These secretions would bubble when I talked and caused me to cough and choke. Normal lavaging seemed to open the airway a little but it would not stay open long. We finally stumbled on the routine of changing the trach tube daily.

 

While 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 purchase area for the secretions that build up between the trach tube and the trachea wall. 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 and replace them with new tubes.

 

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 will be a need. This is particularly true on the rare occasions I have an upper respiratory infection. When I first came home from the hospital after the trach we were given kits that contained sterile surgical gloves and a sterile suction catheter. Due to lack of hand dexterity and hand strength this set up did not allow me to suction myself. Because my wife works during the day that was going to put us in a world of hurt. The doctor immediately prescribed the use of the Ballard Trach Care Closed Circuit Suction System for adults (Kimberly-Clark REF 22103). This system encloses the suction catheter inside a clear flexible plastic outer sleeve. The top of this connects directly to the trach tube. The connection for the ventilator is also at the top and at a 90°  angle to the suction catheter. With the suction catheter lying directly in line with the trachea tube, it is a simple matter to feed the suction catheter into the trachea tube for suctioning. The opposite end of the Ballard has a valve and a connector to attach to the hose of the suction machine. With the suction machine connected and turned on you can open the valve, feed the catheter in and do your suctioning without ever touching or contaminating the catheter itself.

 

One other bit of business that needs to be taken care of is the HME (heat/moisture exchanger). When the air you breathe passes directly into your trachea and bypasses your nose and upper airway, (See Figure 2.) you have no way to warm and humidify that air. Enter the HME, also known as an artificial nose. his little device is a plastic shell containing a spongy material that has been treated to be super absorbent for moisture. Therefore, when you exhale, the moisture in the air coming out of your lungs is trapped in the sponge as the air passes through the HME. The next breath of air being forced in from the ventilator passes back through the sponge, picking up that moisture and carrying it back in again. Medical people can figure out how to be very conservative. The device does work well though for about 10 to 12 hours, and then you need to go back on a supply of heated humidified air, though I have known of some people who've used nothing but HMEs round the clock. (The HME that I've been using is a Hydro Therm with Flex Tube manufactured by Intersurgical, 1853-T.) The HME needs to be replaced daily.

  

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

 

I am now approaching the fourth anniversary of my tracheotomy and we have been following these routines for at least three years. I make yearly visits to my ENT doctor and my pulmonologist, both doctors are aware of the routines that we are following and both have commented that what ever it is we are doing, we ought to keep on doing it because they have never seen such a fine looking stoma. Also, I am clearly maintaining my health.

  


Whatever Works

 

Both of us feel that the items outlined by Dr. Oppenheimer are right on the mark. He provides the checklist of items that need to be accomplished without giving the specific details or the timetable for accomplishment. Too often, we have read or heard 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 realized that the day that he changed the trach tube he felt great. When he started changing his trach tube every day, he started feeling great every day. Tony's routine is markedly different from Larry's, but it's worked for him for many years now. We both feel that the details of a trach routine are peculiar to an individual, and that all trach users need to figure out whatever works best for them. It may take a while to establish one, so patience is very important.

 

*Parts of standard tracheostomy tubes include:

  • Outer cannula (outer wall of the trach tube)
  • Inner cannula (comes in various sizes and snugly fits inside the outer cannula)
  • Flange or neck plate

 

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).

 

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