Could someone tell me why to not bag a patient with trach when cuff is deflated?

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I recently had a trach patient who was on the blender receiving up to 90% oxygen, with sats in mid 80's, had pneumonia, COPD and many other diagnoses.( I understand the whole oxygen issue with COPD patients.) We were suctioning her as needed and still she was having a hard time breathing, very anxious too. (I probably would be too if I couldn't get my breath.) Of course I had called the doc on call and he had assessed her (she eventually moved to the ICU from telemetry/step-down unit), ordered blood gas and chest xray that revealed total white-out in her lungs from pneumonia. We had bagged her (with help of more experienced nurses on floor), but evidently the cuff was deflated and the RT got really mad about this. Why exactly does the cuff need to be inflated with bagging? I don't really understand totally, so patient doesn't aspirate, what else? The patient transferred to ICU and put on vent. Anyway, respiratory issues are scary and I plan on following a RT to learn more. Thanks for any input.:bugeyes:

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Specializes in NICU, PICU, PCVICU and peds oncology.

When the cuff is down and you're bagging a patient, most of the air/oxygen you're attempting to push into their lungs will take the path of least resistance... around the trach tube. So really, bagging them that way isn't going to do much good. Another potential is inflating the stomach, which will be really unpleasant when whatever is down there isn't down there any more. To say nothing of the lack of room for the lungs to expand when the stomach is full of air and pushing the diaphragm up.

Respiratory crises can be very frightening to everyone in the room. I think you're making a good decision to spend some time with the RT. They have a lot to share about managing airways, effective ventilation and oxygenation and how to do it all without panicking.

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Specializes in Trauma ICU, Surgical ICU, Medical ICU.
When the cuff is down and you're bagging a patient, most of the air/oxygen you're attempting to push into their lungs will take the path of least resistance... around the trach tube. So really, bagging them that way isn't going to do much good. Another potential is inflating the stomach, which will be really unpleasant when whatever is down there isn't down there any more. To say nothing of the lack of room for the lungs to expand when the stomach is full of air and pushing the diaphragm up.

Respiratory crises can be very frightening to everyone in the room. I think you're making a good decision to spend some time with the RT. They have a lot to share about managing airways, effective ventilation and oxygenation and how to do it all without panicking.

Yep, what he said. We had to spend a day with RT when we started on the unit, very helpful to understand whats going respiratory wise (we get a lot of lung stuff) I would DEFINATELY recommend spending some time with RT! :nurse:

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Thanks for the reminder about air in the stomach, I totally overlooked that. However, working in homecare I have had issues with a trach being difficult to insert. If you are unable to place the trach and therefore unable to bag the patient what is your next step?

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to the op, it sounds like you did a good job in a difficult situation. as jan mentioned, a respiratory crises is definitely frightening, and can be very difficult to manage. it was totally inappropriate for the rt to be angry at what you and your coworkers were doing. a respectful member of the team would have taken the opportunity to explain the reason the cuff needed to be inflated while he/she did so, rather the projecting her/his anger on the rest of the team.

thanks for the reminder about air in the stomach, i totally overlooked that. however, working in homecare i have had issues with a trach being difficult to insert. if you are unable to place the trach and therefore unable to bag the patient what is your next step?

first, if you haven't done so, call 911. if your patient has lost their airway, you have an emergency and you need to get more help sooner rather than later. speaking as a paramedic, i would rather get called early and cancelled en route if you are successful in replacing the airway rather than later and showing up on a cpr in progress.

i'll assume from your post you're referring to an established, rather than new trach. if so, i would try the following:

  1. reposition to ensure proper positioning for insertion.
  2. suction the stoma to ensure you don't have a mucus plug blocking entry.
  3. try inserting a size smaller tube if available.
  4. try passing a small suction catheter through the stoma (for an established trach) and inserting a smaller size trach without inner cannula over the catheter.

if none of the above worked and you now need to ventilate your patient you can try one of the following:

  1. hold the patient's mouth/nose closed and ventilate through the stoma using either an infant or child mask. after ventilation allow the mouth to open for exhalation.
  2. cover the stoma with gauze and/or an occlusive dressing and ventilate through the mouth/nose as you would a patient without a stoma.

if the patient has a fresh trach, i would probably cover the stoma and ventilate through the mouth/nose with the resuscitation bag if possible, rather than getting too aggressive and creating a false passage attempting to replace the trach.

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Thanks for all the tips!!

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