Advice on stable vents/trachs.

Pediatric Critical Care Columnist · Dec 29, 2009

You really should insist on a trach CPR class, and don't do a trach change alone until you've done several with help. Get in the practice of always securing the new ties before removing the old ones. When suctioning the trach the first few weeks, try holding your breath so that you'll have a sense of passing time. Know the distance from the opening of the connector to the tip of the tube so that you can properly gauge how far to insert the suction catheter... not more than 1/2 to 1 cm past the end otherwise you risk sucking up against the tracheal wall and causing trauma. Remember that babies have no necks and will obstruct their trach if they pop the ventilator circuit off. Since children are more sensitive to desaturation than older people and that's usually the cause of cardiac arrest, it's important to keep an eye on that. Never go anywhere without a spare trach and ties, portable suction and catheters, a self-inflating resus bag and a cell phone.

Ask if you can have a class on vents too. The usual home vent is pretty straight-forward and you can set the alarms as tightly as you're comfortable, but someone should show you how to do it. Find out how to change the battery in the vent, or to ensure that it's adequately charged so that you won't have to worry about it running out of juice when you're out and about. You'll quickly become used to the normal sounds of a properly-functioning vent, so you'll often hear and recognize a change in the sounds it makes before the alarms go off. It won't take you long to be comfortable with your new job. The day that you notice that awake kids need to be suctioned a LOT more often than sleeping kids, you'll be there!

NeoPediRN · Jan 6, 2010

Thank you thank you for all of your advice! I had my first day on the floor today and it helped so much. I was able to relax, take a step back, and really assess the kids to know who needed interventions and who did not. I forced myself not to take a step forward at every beep of the vent alarms, but it was hard! I also forced myself not to panic every time I saw a sat in the 70s and 80s with a poor pleth. I looked at the patient, color, their respiratory effort and rate. By the end of the shift it was easier to tell which kids needed suctioning and which are going to sound junky and coorifice. I also learned how to feed and pace a stubborn baby with increased O2 requirements. We are going to have a vent day sometime next week with the director of respiratory therapy. Im still scared, but I can tell its going to eventually be a different kind of scared. I love it so far!

Pediatric Critical Care Columnist · Jan 6, 2010

Good for you! A little fear is never a bad thing. I've often said that the day I look after a sick child and don't have a moment where I feel just a little scared is the day I need to move on. Alarms are useful when they're for real, but just like the little boy who cried wolf, nuisance alarms, which make up about 85% of them, tend to desensitize us. Your decision to look at the patient first when you hear an alarm is a very good one. But realize that there's a 10 to 15 second delay from the time a desat starts until the alarm goes off. So look at the kid, but look quickly and intently! If they're wiggling and the wave is really wonky then it's a pure nuisance alarm. If they're laying quietly and are pink when you look, they still might have had a desat, but so brief that by the time the monitor noticed, they were already recovering. Oh, and don't automatically believe the bedside monitor when it alarms for apnea on a child with a set ventilator rate - the ventilator will alarm first if the limits are set appropriately. Your bedside monitor is measuring chest wall movement and if the electrodes aren't in the right places for the position the kid is in, you'll get those nuisances. One tip I didn't give you related to suctioning is that you can easily feel secretions in the kid's chest by putting your hand on their ribcage. It's faster and sometimes more accurate than your stethoscope. And sometimes you can vibrate those tenacious puddles of junk to where you can get them with the suction catheter just by pressing gently over the rumbly area and rapidly moving your hand back and forth.

Sounds like your first day was a success!

NeoPediRN · Jan 7, 2010

Those are some excellent tips, thank you! When you say the vent will alarm first, do you mean because it's delivering a set number of breaths there could technically be no true apnea? Also, If a child was arresting secondary to something other than a plug would you see the low pressure alarm go off instead? I think it will all make much more sense after the vent education day next week.

Pediatric Critical Care Columnist · Jan 7, 2010

The alarms on the vent are usually set so that if the rate falls below a certain number, it will alarm for low rate and/or low minute ventilation (tidal volume x rate). As I said, there's a lag time between the onset of a desat, apnea or bradycardic episode and the monitor beginning to alarm, but with the ventilator, as soon as its alarm limits are violated, it's going to go off. If the circuit pops off, there will be a sudden drop in peak inspiratory pressure and volume because it's now blowing into the air and not into the trachea and will alarm. Coughing causes a rapid spike in peak inspiratory pressure and an alarm, as will a plug. If there's a lot of rainout in the circuit, the ventilator may autotrip and then the high rate alarm will go off. (It interprets the sloshing of the condensate to be inspiratory effot and it will deliver a breath.)

A cardiac arrest may not cause a ventilator alarm; the ventilator will continue to deliver breaths at the preset rate whether the heart beats or not. Respiratory arrest will be due to mechanical issues such as a plug, a kink in the circuit, failure of the vent to deliver any breaths (power failure, motor failure, dead battery, etc) chest wall rigidity from rapid injection of fentanyl, circuit disconnects and the like. Tension pneumothorax will also do it.

I think you're going to dazzle the RT that gives you your vent education, because you already have learned so much!

RunningRNBSN · Jan 26, 2010

I always keep in mind that no matter how "stable" a trached patient (especially infants/toddlers) is, a plug can happen when you least expect it. I've seen a few occasions where a patient plugs without any warning and we have to actually do chest compressions.

Aside from the PICU, I do some pediatric home health work and work with "stable" trached and vent dependent children. The last home I went to had an epsidode the week before where the mother was at home by herself with no home health nurse and her infant plugged... she was unable to bag the child and her child's heart rate was dangerously low... she did the right thing and pulled the trach and did BMV, chest compressions, and called 9-1-1.

NeoPediRN · Feb 22, 2010

I'm off orientation the second week of March. This week I'll be up to 4 patients, the max we're allowed to take. I absolutely love my job. Jan, you couldn't have been more right when you said I'm there when I realize children who are asleep usually need to be suctioned much less frequently than those who are awake! I feel much more comfortable with trachs and vents now, not 100% but I'm not sure I'll ever be. I feel like I can handle an emergency though, and can kick into gear automatically to know what to do whenever I walk in to a disconnected vent or a baby who's color is off. I also have a basic understanding of vent alarms and which require what kind of intervention. I'm challenging myself to know what kind of support each baby is on and making sure they're getting their volumes (most are on pressure control/support). It takes time to remember everything, but I'm getting there. It's not bad for 6 weeks in. I hope as I learn and grow my skills will get stronger. I've seen a lot of really interesting situations and a couple of emergencies in the past month alone which has helped me get a better understanding of how to prepare. My preceptor has given me a strong foundation to build on too. I will never take safety for granted because of her. Every morning always and forever the first thing I'll do is check on the kids and make sure they have a spare trach, ambu bag, suction, catheters, and scissors. I always calculate my meds out the first time and get a witness for narcs/controls even if they don't require one. I've learned it's these little things that take one extra minute but can make all the difference in the world for safety, especially on those crazy days when you're in a hurry. I've also learned to slow down and do one extra med check those days when I am crazy busy, just because the days my mind is going at warp speed are the days a mistake could happen, especially when almost all the meds are multi-dose liquids that we draw up into syringes, and there's no Pyxis or auto med dispense system. I never want to be the nurse that could've prevented harm if she just did those routine safety things. These kids are so fragile and are all one foot out of the NICU/PICU - some should still be in the ICU. It's amazing to see the little gains they make, to see their FiO2 needs decrease even just 5%, to watch them sit up for two seconds before they topple over, for their mist to be extended by a half hour. I really, really love my job!