Trach/PEG special

Not sure about the exact number of days a pt has to be on a vent before a trach is added but yep, we do them in pairs at the same time.. After several attempts to wean the pt from the vent, the family is approached about a trach and peg.. We have had many that were reversed. Some pts need longer to wean off..

I really don't have a problem with the pair unless it is done on a lil old lady/man that have a long list of comorbidities with little to no chance of recovery..

My ICU used to wait too long.... however, the docs can see if they are going to be a long wean. If they are, they are better off with a trach and peg, less risk of VAP, aspiration, easier to wean, better communication.... they can go to a facility where they can work on an agressive wean. With an ET tube, you can't switch to trach collar and rest on vent at night. You can't cap during the day and put on trach collar at night. You can't do the things you need to do to wean a patient off on an ETT. I went from ICU to LTACH and let me tell you, it was great to see pt's capped or decannulated. They are both very reversible, and it's awesome to see them reveresed.

In our ICU they are both encouraged after about 10 days on a vent if the pt is nowhere near being able to wean. And they are done on the same day to prevent multiple stressors on multiple days.

as has been stated the trach is very much reversible - you also don't need to continue sedating ( or alternatively as is deemed acceptable in the USA tie them to the bed) someone once they have a trach - as has been said you can go very easily between capped off spontaneous breathing to cuff up and invasively vented with a trach ...

Putting a PEG in as early as necessary is also a good idea so you can make sure people are getting a good food intake and that they gut is kept working ... as long as people have a decent swallow they can eat normally and you can use the peg to top -up feed / give the lots of meds they might be on etc...

give me a patient with trach and a peg who we've maintained a decent body mass and nutritional status vs someone who is wasted and/or has a gut that has not been worked for weeks and has all the problems associated with prolonged ETT placement.

its interesting to see the differences in adults vs babies...in the NICU babies can go upwards of 4-5 months of being intubated before a trach is even placed on the table, and most parents take weeks to agree to that decision...and then for some reason the gtube is a totally different ballpark, rather than putting the baby through one surgery, parents ALWAYS want to try feeding the baby (who likely has a strong oral aversion d/t being intubated for so long) with a bottle for weeks w/ therapy before allowing a gtube - when in reality the baby could get both and if stable, work on both vent weaning and PO feeding at home

I have worked in the same ICU for thirteen years, and here it depends on the opinions of your attendings.

Where the attendings are quick to do trach and G-tube early, that becomes standard practice until the attendings leave and your next attending doctors are willing to keep a patient on an endotracheal tube for an extended period of time.

I do not work in ICU so I am not sure about the occurrence rate at our hospital but my Grandmother was given 12 days on a regular vent before they placed the trach (basically to help reduce VAP). She was much more alert and comfortable after that. Then they placed the PEG and she was able to go to rehab (where they let her backslide so bad from poor care that she came back in with full blown pneumonia).

Unfortunately right after she was fully weaned off the trach and it was out of her neck she was treated for an infection with Levaquin and bled out with an INR of 13.4.

So I guess it was working, there were just a lot of complications for my family as well.

Tait

PS. Sorry, probably too much story, but it's a different perspective.

In my unit, after about 10 days on the vent, the family is approached about a trach after multiple failed weaning attempts. It's just easier to wean a patient from a trach than it is from an ETT. We don't always do a trach/peg special though. A lot of times we'll continue to let the patient have a dobhoff for a while.

In our ICU pretty much the same protocol. After 10-12 days with multiple failed weaning the Trach is approached as wekk as the PEG. We used to do both at once, but now wait a few days as some people do well affter the trach with just the need for overnite vent support. Unfortunately many are done as family pressure to do everything and the patient dies anyway as they are to often stage 4 of some disease with multiple comorbidities and almost all are obese.

Thanks everyone for your responses! I can see now that perhaps it IS the best thing at the time, although many of our patients are over 70 but also I don't see them when they leave for an LTAC/SNF and see them weaned from the vent & decannulated