If a trach comes out for a patient who is a tracheotomy, have someone occlude the stoma with a nonporous dressing if available and use the regular BVM (Bag and Mask) to ventilate over the face as you would any other patient.
If the patient has a tracheostomy or laryngectomy with a permanent stoma, there is no communication to the upper airways (mouth and nose). There may be a neonatal or pedi mask at bedside for you to do bag/mask to stoma. Or, there may be a trach at bedside. Since a tracheostomy is a permanent stoma, replacing the trach may not be much of an issue but be mindful of internal speaking valves, fistulas and any grafting that may have been recently done.
Never attempt to replace a trach unless you have be trained to do so and have done one under supervision of another professional. False tracking is always a serious complication as is tearing and bleeding. Avoid replacing the same trach. An unopened one should always be at bedside. I really hate when people leave dirty obturators at beside encouraging someone to come along to use this dirty thing to reinsert the used trach. Only in extreme emergencies would you not have time to open a new trach. Always keep lube with the spare trach and a syringe.
And, above all, have a poster (yes those silly posters which some hate so much) above the bed indicating what type of airway patency the patient has and recommended cannulation or intubation. Some patients may be a fiberoptic only intubation or cannulation due to the different surgeries. It is futile (and embarrassing) to hang a NRB mask on someone's face or do a regular BVM method if the patient has no upper airway communication (trachea is brought forward to make the stoma). This is the best information you can relay to an emergency team.
Many laryngectomy patients do not have trachs in their stomas. Some may have nothing or have a laryngectomy tube which looks like a large nasal trumpet in their stoma. In an emergency a regular trach may need to be placed or even an ETT in the stoma. However, the distance from stoma to carina may be very short and don't be surprised to see the cuff just inside the stoma. Also monitor for gastric insufflation if there is a fistula (usually made on purpose by the surgeon for the prosthetic valve.
As far as patient biting their tube,there are several reasons.
* People grind their teeth when they sleep even when they are not intubated.
* Grimacing just from overall discomfort or the situation itself.
* Involuntary reactions to other stimuli.
* Involuntary reactions due to injury or medications.
Most ICUs will use a tube guard the prevents damage to the tube. I do not recommend a full size oral airway due to aspiration, VAP and damage to some tissues of the mouth, palate and tongue if left for more than just a very short time. And, it is very, very uncomfortable for an awake patient. There are "shorties" if a tube guard is not available.
Last edit by GreyGull on Oct 9, '10