nurses who deal with trach's: Procedure for Accidental Trach Decanulation

caliotter3 · Oct 13, 2010

If you have been assigned to work with patients who have trachs, you need to speak with your supervisor for training and ask to see the facility policy and procedures manual for trach care.

TiffyRN, BSN, PhD · Oct 13, 2010

It depends. If the patient has an established mature stoma it's probably better to bag through the stoma. Particularly if the patient had it placed for some sort of airway obstruction. If the stoma is not mature and patent it is better to attempt to bag through the mouth/nose. If one bags through a fresh trach it may force air into the interstitial spaces and cause subcutaneous emphysema further compromising their upper airway.

The one time I had a patient decannulate; she was alert and oriented and did not have a catastrophic airway collapse. She was able to breathe through her natural airway until the RT arrived and placed a fresh trach tube into her thankfully mature track with only some mild desaturations helped by blow-by oxygen.

A few months later on that same unit; a patient did not survive when the trach tube deviated into the soft tissues. I was floated to another floor that night and found out about it later. I was never so happy to be floated. We were always instructed that if we suspected the trach tube had deviated, then we should stop bagging through the trach and instead bag the mouth/nose.

GreyGull · Oct 13, 2010

I think we just went through this topic a few days ago.

https://allnurses.com/nursing-student-assistance/when-trach-tube-509301.html

The main thing is to know what type of stoma and procedure your patient has before a trach falls out.

It could be a permanent stoma with the trachea externalized with no communication with the upper airway. For this one you will have to be mindful of grafts, internal prosthetic speaking valves and fistulas. Either way you should know when the tracheotomy or tracheostomy was done and you should have the appropriate equipment (BVM with appropriate size mask, spare trachs) at bedside which may even include tracheal ring grappers or pullers and stoma spreaders.

With the many different airways and surgeries for necks and trachs, it is difficult to say one method fits all.

I've got a little "I Spy" game for those who love people watching. See how many different airways you can spot in a crowd. If you hear a synthesized voice, which may not even be that obvious now, see if you can spot the synthesizer and the stoma. Also, if you see someone with a plastic tubing that looks like it could belong to a nasal cannula but the person isn't wearing one, see if you can follow to where it is connected. I've also struck up conversations to see what make and model their oxygen tank is especially if it is fitting into something like a very small hand bag.

Many EMS and ED workers have been fooled by missing a permanent stoma that is well hidden by a flesh colored covering or a shirt.

For a "fun" cruise or outting, volunteer to join a Better Breathers club. Or, crash their Christmas party which is usually hosted by the RT department along with a home care company. If you are not that experienced, make sure there is another RN or RRT accompanying you.

GreyGull · Oct 14, 2010

trying to keep track of the trach threads. i also posted this on the other thread.

the main thing is to know is what type of opening the patient has and where it goes or doesn't go. then you can more easily refer to the proper p&p in your manual.

no (horrors! pulling the trachea out..!!!) the tracheotomy is the surgical procedure of making an opening into the trachea for the purpose of establishing an airway in a person whose upper airway is obstructed. you got that right, but the resultant opening is kept patent by insertion of a tube, of which there are different types. this opening is called a stoma, hence the name tracheostomy. the trachea is not pulled out! unless, of course, you have a grudge against that particular patient...

this depends on the type of surgeries done in your hospital. some doctors like to differentiate between -otomy as the incision meant to close when something is not there holding it open and -ostomy with the ostomy being more permanent and will not close once the trach is removed.

i have also posted a photo here of a stoma being formed when the trachea is brought to the surface. it is a horrors! photo and i apologize if some are squeamish. (google images is a great tool - yeah that posters and graphics display thing again)

to form an -ostomy (according to the purist of ents surgeons), after a laryngectomy the trachea is brought to the surface and the stoma is formed. a more permanent ostomy or stoma can also be created without the laryngectomy if the patient needs tracheal access but still has their larynx some upper airway access. of course many use the terms interchangeably and may not actually realize what their patient has.

example of a stoma s/p laryngectomy (you are looking directly into the trachea which has been brought to the surface to form the stoma.)

http://www.dwp.gov.uk/img/laryngeal-cancer.jpg

in the above photo you will see a little tag stick out which is a prosthetic speaking valve (blom-singer) that fits into the fistula between the trachea and esophagus.

below is a neck resection with laryngectomy where the trachea is being prepared to form a stoma at the surface.

http://www.rborl.org.br/conteudo/acervo/images/10-figura2-68-5.jpg

text that goes with that photo:

http://www.google.com/imgres?imgurl=http://www.rborl.org.br/conteudo/acervo/images/10-figura2-68-5.jpg&imgrefurl=http://www.rborl.org.br/conteudo/acervo/print_acervo_english.asp%3fid%3d466&usg=__yr2iqnbvu9ypcqydkkexfqhv30a=&h=254&w=350&sz=9&hl=en&start=94&sig2=ycac3blewn2vmnp2vg72og&zoom=1&itbs=1&tbnid=qmxvj1gmm2kkrm:&tbnh=87&tbnw=120&prev=/images%3fq%3dtracheotomy%2bincision%26start%3d80%26hl%3den%26sa%3dn%26gbv%3d2%26ndsp%3d20%26tbs%3disch:1&ei=ymo2tlreiog2saodopteba

diagram of a tracheostomy s/p laryngectomy.

http://www.macmillan.org.uk/cancerinformation/cancertypes/larynx/treatinglaryngealcancer/laryngectomy.gif

this is a tracheotomy incision that needs a little tlc and bacitracin.

http://amamasblog.com/wp-content/uploads/2008/11/t-infected-incision-2.jpg

tracheotomy incision with a trach

http://www.rch.org.au/emplibrary/ward8west/trache_3.jpg

note that there is still an intact trachea above the trach.

JEDI-RN · May 23, 2016

We received a patient in respiratory distress with a non-rebreather mask to the patient's "new" trach. The pt needed to be on the vent, but the un-cuffed-trach had to be switched out to a cuffed-trach first. That was done and the patient improved dramatically. Unfortunately, at shift change while turning the patient, the cuffed-trach slid out slightly. When reinserted, it forced air into the interstitial spaces, which caused the patient's neck and face to blow up. The patient rapidly de-sated and went pulseless. The charge RN tried to bag the patient through the ETT and cuffed-trach, but that did not resolve the problem. I wish I had read this forum beforehand, because not one of us (even those with 30 years of experience) knew or thought to immediately bag the patient's mouth. I also think the immediate change in the patient's facial appearance was shocking and somewhat horrifying, which created a lot of panic. Thankfully, the MD arrived quickly and intubated the patient and the patient survived. When we debriefed after the code, we all learned a valuable lesson. I'm just thankful this patient survived.