Question about spacer use with trach pts

Double-Helix, BSN, RN · Oct 8, 2011

I've never heard of using spacers for trach patents. But I've also never given an inhaler to a patient with a trach. I suppose the concept would work, since the principle of dispersing the medication is the same. However, a patient that can't follow instructions related to inhaling deeply and holding their breath should really be getting a nebulizer treatment, not an inhaler.

VickyRN, MSN, DNP, RN · Oct 8, 2011

When I do this, I gently attach the spacer directly onto the tracheostomy, give a puff from the MDI into the opposite end of the spacer aerochamber, and then wait 20 seconds or so for the patient to breathe in a few breaths of the meter-dosed inhalant from the spacer, before gently removing the spacer from the trach. If a second puff is needed, I allow the patient to ventilate for approximately one minute, then reattach the spacer to the trach and repeat the process.

Before attaching the spacer to the trach, you should already have the MDI attached to the opposite end of the aerochamber and ready to give the puff. You don't want to place any unnecessary force or traction on the trach and be as gentle as possible.

There is good information here (see page 22):

http://www.cincinnatichildrens.org/assets/0/78/1067/1395/1957/1959/1961/98555d88-d30c-4fda-a8a7-b2f3df74b762.pdf

nurseprnRN, BSN, RN · Oct 9, 2011

think about this: when you are asked to hold your breath, what structures in your airway make it possible to do that?

where is the trach tube?

how easy is it to hold your chest full of air when you can't ... (fill in the blank, which you learned by answering the first two questions)?

Double-Helix, BSN, RN · Oct 9, 2011

think about this: when you are asked to hold your breath, what structures in your airway make it possible to do that?
where is the trach tube?
how easy is it to hold your chest full of air when you can't ... (fill in the blank, which you learned by answering the first two questions)?

not entirely true. it is not necessary to close the mouth in order to hold your breath. the diaphragm is a voluntary muscle as well as an involutary muscle. when you inhale, the diaphragm contracts and pulls air into the lungs. in order to hold your breath, you have to keep the diaphragm contracted. it's quite possible for patients with trachs to hold their breath.

nurseprnRN, BSN, RN · Oct 11, 2011

not necessary to close your mouth (or to do a glottal stop, which is more to the point) but i challenge you to inhale with your diaphragm and hold it without using your glottis. sure, it can be done, but it requires active use of the muscles of inspiration beyond their usual activity to hold that chest position.

when you breathe in, you actively contract your diaphragm, and may also use accessory muscles to open your chest, to pull air in. at the end of inspiration comes exhalation, when the diaphragm relaxes and the natural recoil of the diaphragm, chest wall, and lungs contract to push the air out. exhalation is passive (yes, you can exhale forcibly, but most of the breaths you take in your life are passively exhaled).

holding a chest full of air -- holding your breath-- is most easily accomplished by the glottal stop (which occurs above the trach, so it cannot prevent air from leaving the chest). if i tell you right now, "deep breath and hold it!" that's how you'll do it. holding the chest in full inspiration without this means the diaphragm cannot relax, and the accessory muscles cannot relax. this is a lot to ask of someone who is already compromised in a respiratory sense.

the other classic maneuver for chronic lungers, pursed-lip exhalation, also cannot be done by trached persons for the same reason: there is no anatomic structure between the lungs and the outside world to restrict air flow, it having been bypassed by the tracheostomy.

now consider what the spacers are for, and ask yourself whether someone with less dead space needs one. wouldn't a nebulizer be more effective?

Sehille4774 · Jan 1, 2012

Nice info Grntea...never heard anyone explain it like that. Makes perfect sense.

Here is a link on how to give a MDI to a trach with an Ambubag and give a few breaths to get the med in.

I have a feeling we are going to have to rig something like this up because noone can seem to find us the actual attachment or even a name.

Here is one link that explains the proceedure.

Shepherd Center Learning Connections

Also I agree the same dose in Neb form, regardless of the patient, is sometimes alot more effective then the MDI. Who would have thought 3cc's of NSS would make such a difference! My nebs at home now have kept me from getting major resp. infections for several years now. They also calm my asthma attacks better!

nurseprnRN, BSN, RN · Jan 1, 2012

the ambu might work as a prosthetic epiglottis to give you a valsalva, only if the exhalation valve stays closed while you hold the bag compressed. but if memory serves i think there has to be active airflow out of the bag to hold that valve closed. if it opens even if you are holding the bag, when you have stopped pushing air in, then as soon as you stop pushing air in, the med you pumped in will come out. check to see and you'll have your answer.

Sehille4774 · Jan 3, 2012

Well.....Yep...I looked at the exhalation valve. I see what you mean. We attached a bacteria filter (like the one from the vents) to the ambubag, then the mdi adapter, then a short piece of corrugated tubing that connects to the trach. (Hopefully the filter helps the med from back-flowing out of the bag). Seems ok and.. the best solution at this time..at least you can get more of the MDI down into the small passages.

The Doc's did away with all of our NEBS so now it's just just the MDI available for use.

I gave a puff the other day through this humidification setup that was what we were told to use..and literally watched as medication went Right out the exhalation side, bypassing the lungs entirely.

And now this epiglottis thing too! Well thanks kindly for the good info.. I think its going to help me with this case and give me a decent rationale to help with advocating for pt's in the future.

Funny thing is I came into this house tonight and see that they just now got an MDI spacer with a mask for the nose/mouth Ahhhh. So frustrating sometimes.