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weaning from trach.
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weaning from trach.

my mother is 69.she had a trach tube installed because of extended hospital stay.(post operation complications-infections).she breathes fine with room air (she does have some sputtum discharge at times)but when the trach is capped she can go maybe thirty minutes before she starts to breath irregular and almost starts to hyperventillate.the doctors are puzzled.they have examined her for an upper airway obstruction but found nothing.they say she may have to live with the trach.does any one have any experiences?
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251132_tn?1198082422
When capped the tracheostomy tube (trach tube) itself may be blocking your mother
5 Comments
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Avatar_n_tn
Hello there. I have extensive experience with tracheostomy tubes.

I have found that different facilities have different "strategies" when it comes to weaning patients from tracheostomy tubes. Some places are more aggresive (aggressive) than others.

Now, there are three reasons why someone would need a trach.

1.) Airway obstruction
2.) Respiratory failre/prolonged mechanical ventilation
3.) Pulmonary toilet

When these three are, for a lack of better words, "fixed" weaning from the trach can begin.

When we start weaning patients from their tracheostomy tube, some things we need to keep in mind. I am guessing that you mom is at home now? If so, she needs to be on aerosol therapy at ALL times. A trach collar which emits humidified air (or oxygen). This will keep her secretions mobile. VERY IMPORTANT when it comes to trach patients. She CANNOT breath with just her open trach to room air. This is because her tracheostomy is bypassing her uypper airway. The job of the upper airway is to warm, HUMIDIFY, and filter the air we breath. When you poke a hole in someones neck, you bypass that function. She will breath dry, cold, dirty air. This makes the body work harder to warm her inspired air, and because the air she breathes is dry, it will dry out her existing secretions making them more think and vicid. This puts her at risk for mucous plugging.

Why did your mother recieve her tracheostomy. (I need more medical history, ie cancer, respiratory failure, etc) How old is her tracheostomy tube? What kind of trach is it? What size is it? Fenestrated or non-fenestrated? Cuffed or uncuffed? Does she have an inner cannula? HAs she been evaluated by speach and swallow yet? Have they tried to use a Passy-Muir valve? When capped, did the respiratory therapist measure her tracheal pressures? (Only a respiratory therapist is qualified to do this procedure) YOU CANNOT CAP SOMEONE WITH OUT MEASURING TRACH PRESSURES! If this has not been done, it is my judgement that your mother is recieving poor practice from her caretakers.

All of these questions need to be answered. Looking forward to your reply.

Andy RRT, CPFT
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Avatar_n_tn
Andy thanks for your comments.my mother could not be immediately weaned from the ventillator after upper GI surgery back in october,2003.the doctor in ICU kept the vent.on full support all the time causing her to weaken.after a couple weeks,a trach was installed.sepsis set in.she got over the infection in two months.meanwhile,the doctor kept her on full vent support.the nurses told us to get another doctor because they disagreed with her treatment.we changed doctors,who set the vent.on partial support,allowing her to do some of the breathing.he was able to wean her off the vent in three weeks.they continued with 30%moisturized oxigen applied with a small mask over the trach.by the third week in january,she was discharged from ICU to a step down hospital room which had oxigen for her to breathe.the next day,she developed a "plug"which went too long causing her to go into cardiac arrest.she was semi comatose for two weeks during that time she was on partial vent sppt.since then,she hasbeen downsized to a 4mm.cuffless trach with inner cannula.i do not know if it is fenestrated or not.she can softly speak with some difficulty and can drink "nectar"consistant liquids and solid foods.for the last month,she has been in a nursing/rehab center.
she has had the 4mm trach for the last two months.as far as i know,trach pressures were not measured even in the hospital.she is currently rehabing with speech and swallow therapists.she is currently on 25%oxigen with mid to upper 90's saturation.sorry for the long story but i wanted to be specific.thanks
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Avatar_n_tn
No-no, its good you told me all that information. I'm happy to hear she has a cuffless trach in. And you already mentioned that she can somewhat vocalize. Thats a good sign.

I would suggest speaking to the ENT, Speach & Swallow, and especially her Respiratory Therapist about using a Passy-Muir valve. Ask them to measure her tracheal pressures prior to using the device. Start off using it supervised, then gradually longer periods.

Having a 4mm trach is also promissing to hear. Its the smallest trach we'll use in an adult prior to decannulation. I am particularly not fond of using inner cannulas because they make the inner diameter of the trach even smaller. But it does prevent the trach from plugging up (if you clean it daily) Remember, she needs to wear that aerosol mask at all times. Emphacize the need for Coughing & Deep Breathing exercises. Be sure she is hydrated efficiently as well. Mobilization of her secretions is VERY important.

Another test that also can be perfomed is an esophageal balloon study. This can measure the efficiency of her diaphragm. To my knowledge, rehabilitation facilities do not have the technology to do this. But you can still inquire with her pulmonologist.

Keep me posted. I think the PMV is her best bet!

-Andy, RRT, CPFT
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Avatar_n_tn
To my knowledge, they dont make adult trach tubes smaller than Shiley/Portex #4. Nonetheless, if they did, it would be useless for secretion or airway manegemnt. A 10 Fr. suction catheter is wide enough to fit down the center lumen of a #4 Shiley with the innter cannula in.

Futhermore, removing the trach without even measuring tracheal pressures with a button is extremely poor practice. This is why we use the Passe-Muir valve prior to buttoning/decannulation.

Remember, once you decannulate from a petent stoma, the stoma can close 2/3 its size in about 60 minutes. And completely close within 24 hours. I have even observed stomes close minutes after decannulation. This of course depends on how old the stoma wound it.

Please ask your refrences about the PMV and tracheal pressures. I'm sure they will agree.

Andy, RRT, CPFT
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