Trach and secretions

xtxrn, ASN, RN · Aug 17, 2011

Looking back, I'm pretty sure every trach patient I ever had also had humidified 02 or air.... that's going to loosen up the loogies...

NurseLoveJoy88, ASN, RN · Aug 17, 2011

Looking back, I'm pretty sure every trach patient I ever had also had humidified 02 or air.... that's going to loosen up the loogies...

Ditto! Since people with trachs don't have the ability to make natural humidification they do have humidified air and thus more secretions.

I'm interested in all responses too !

CBsMommy · Aug 17, 2011

I always thought it was because you have a foreign object in the airway. And what are secretions there for? To help get rid of foreign objects! That's why we cough up sputum when we're sick!

SpecialK38, ASN, RN · Aug 17, 2011

Yes- the trach irritates the trachea causing more mucus to be produced- the humidification is necessary because the air doesn't go through the nasal turbinates for humidification. I've heard of patients who weren't humidifed well enough getting mucus plugs in their trach and coding!!!! The trick with suctioning is to do it enough to help clear the airway but not too much to irritate and cause more secretions to be formed.

GreyGull · Aug 17, 2011

Patients may have trachs because of their disease process which creates secretions. Due to a weakened state or the advancement of their disease they are no longer able to cough, spit or swallow as others would. They are probably colonized with every bacteria imaginable which will rise occasionally for sputum producing infection.

If anybody here has ever had PNA or bronchitis, it may seem like you are coughing up stuff for weeks or months later. Your body is just able to rid itself of the secretions more effectively. You also don't have a plastic hollow tube amplifying the sound of the secretions which may sound like a bucket full but really might be just a tiny but annoying amount that takes effort to clear the tube.

The other reason for a trach is chronic aspiration or impaired swallow. These patient will of course end up with more secretions, and infections, as they aspirate their own saliva. Cuffed trachs also do NOT prevent aspiration. They only slow down the inevitable or create one very nasty mess around or on the cuff. This is why some trachs now have subglottic suction ports just like the ETTs which are supposed to prevent VAP.

Patients can sometimes be weaned to a small trach and one without a cuff for them to be able to cough up and expel or swallow the secretions in a natural way despite a large piece of plastic.

And then there is even a bigger reason for secretions than the trach itself. That is over zealous "really deep" suctioning every two hours whether they need it or not and just because it is a check in the box. Also, the way some are taught is to push the catheter in until you meet resistance and that resistance is tissue which becomes irritated. BE CAREFUL when suctioning.

Most humidification systems are inadequate and cold air blowing around a trach can also be just irritating. Using a little donut heater on the top of a bottle or having 10 foot of tubing to lose whatever heat was produced is just not going to do much except irritate especially if the person has any asthma or reactive airway component. There is newer technology available for humidification systems which can prevent some of these issues. When the humidification is inadequate, patients retain secretions regardless of how vigorously you suction and that will lead to an infection and more secretions.

Poor patient hydration is also another factor which cause secretions to thickend and put them at risk for infection and more secretions.

Finally, there is malpositioning of the trach or excessive movement which created irritation. Care is not given when securing the trach or when turning them or just allowing the humidifier circuit to dangle heavily pulling the trach into a poor fit. The trach then irritates the wall of the trachea. BE CAREFUL of the trach's position.

Usually when a patient is in control of his or her own trach or is alert enough to tell his provider to be careful, they will have less secetions.

The trach itself gets an undeserved bum rap but then the most efficient trach for preventing colonization was the one made with real silver.

Double-Helix, BSN, RN · Aug 17, 2011

The trachea is coated with a mucous secreting cells and ciliated epithelial cells. The purpose of mucous in the trachea is to help trap bacteria and dirt that don't belong there. The cilia sweeps this dirt and bacteria out of the airway. This process happens constantly without out knowledge. When we are healthy, we can raise and swollow the extra mucous and debris without ever noticing. Conditions and illnesses that cause inflammation of the trachea lead to an increased production of mucous, such as a cold, pneumonia, bronchitis, etc.

In the hospital, patients with trachs often have them because they have been in respiratory distress and needed ventilation for an extended time. They may have had a trach before being admitted. Either way, the stress of the illness that they were admitted for and the trauma of a trach being inserted leads to increased production of mucous. Since the body is already weak, it becomes very difficult for these patients to control their own secretions. If the trach is cuffed, it is impossible for the patient to cough and raise the secretions into the mouth so they can be swollowed or spit out. Secretions can be stuck in the lungs or plug the trach and obstruct the airway, so they need to be suctioned.

I hope this helped!

daveintexas8 · Aug 17, 2011

Ughhh, trachs. My nemesis. I graduated almost 2 years ago, and work in one of the bigger hospitals in Dallas. I work on a very busy med-surg floor (I know, they are all busy, but ours can tend to turn into "ICU light"). My worst night was a couple of weeks after finishing orientation, and already had a full load of heavy patients. I got an admission, and this guy was THE WORST trach patient I've had. It was my first trach, he spoke only spanish (although I don't remember him ever really responding) and had terrible, projectile, secretions. It being my first trach, I was petrified, and thought I was gonna do something to kill him. It was the night that all new nurses have at some point. I was drowning, and I knew it. After I went into the med room and melted down, I pulled myself together, and got the charge nurse (who is now me :eek: ) to help me.

Anyway, we are lucky in that we have an ENT floor, and most trachs end up there. For the last couple months, tho, we have had at least one, and usually two trach patients (one of which is a DNR now).

I am much more comfortable managing and suctioning trachs now, as I've had each of these patients many times.

It seems like when you ask people for advice, everyone gives you a different answer. How often to suction? I've been told if a patient is satting well, don't suction. I've been told to do it if it sounds like they have a lot of secretions.

How many people go in until they feel resistance, and how many only go about the lenth of the trach, or an inch or so longer? I never go until I feel resistance. I've seen nurses and RT go deep and frequently enough that the secretions are pink, which I suspect is blood.

Esme12, ASN, BSN, RN · Aug 17, 2011

Patients may have trachs because of their disease process which creates secretions. Due to a weakened state or the advancement of their disease they are no longer able to cough, spit or swallow as others would. They are probably colonized with every bacteria imaginable which will rise occasionally for sputum producing infection.
If anybody here has ever had PNA or bronchitis, it may seem like you are coughing up stuff for weeks or months later. Your body is just able to rid itself of the secretions more effectively. You also don't have a plastic hollow tube amplifying the sound of the secretions which may sound like a bucket full but really might be just a tiny but annoying amount that takes effort to clear the tube.
The other reason for a trach is chronic aspiration or impaired swallow. These patient will of course end up with more secretions, and infections, as they aspirate their own saliva. Cuffed trachs also do NOT prevent aspiration. They only slow down the inevitable or create one very nasty mess around or on the cuff. This is why some trachs now have subglottic suction ports just like the ETTs which are supposed to prevent VAP.
Patients can sometimes be weaned to a small trach and one without a cuff for them to be able to cough up and expel or swallow the secretions in a natural way despite a large piece of plastic.
And then there is even a bigger reason for secretions than the trach itself. That is over zealous "really deep" suctioning every two hours whether they need it or not and just because it is a check in the box. Also, the way some are taught is to push the catheter in until you meet resistance and that resistance is tissue which becomes irritated. BE CAREFUL when suctioning.
Most humidification systems are inadequate and cold air blowing around a trach can also be just irritating. Using a little donut heater on the top of a bottle or having 10 foot of tubing to lose whatever heat was produced is just not going to do much except irritate especially if the person has any asthma or reactive airway component. There is newer technology available for humidification systems which can prevent some of these issues. When the humidification is inadequate, patients retain secretions regardless of how vigorously you suction and that will lead to an infection and more secretions.
Poor patient hydration is also another factor which cause secretions to thickend and put them at risk for infection and more secretions.
Finally, there is malpositioning of the trach or excessive movement which created irritation. Care is not given when securing the trach or when turning them or just allowing the humidifier circuit to dangle heavily pulling the trach into a poor fit. The trach then irritates the wall of the trachea. BE CAREFUL of the trach's position.
Usually when a patient is in control of his or her own trach or is alert enough to tell his provider to be careful, they will have less secetions.
The trach itself gets an undeserved bum rap but then the most efficient trach for preventing colonization was the one made with real silver.

I'd listen to GreyGull.....very smart and knowledgeable! :up:

dudette10, MSN, RN · Aug 17, 2011

Thank you for that, Grey Gull. I recently had a patient with a trach, and some of what you are saying here is NOT what I was taught on her. I knew that what I was being taught didn't sound quite right based on what I learned in school (the frequency of suctioning, inserting to resistance, etc.), so you've confirmed my thoughts and helped me improve my practice considerably.

My future patients thank you. :nurse:

birdie22 · Aug 17, 2011

It seems like when you ask people for advice, everyone gives you a different answer. How often to suction? I've been told if a patient is satting well, don't suction. I've been told to do it if it sounds like they have a lot of secretions.
How many people go in until they feel resistance, and how many only go about the lenth of the trach, or an inch or so longer? I never go until I feel resistance. I've seen nurses and RT go deep and frequently enough that the secretions are pink, which I suspect is blood.

Just wanted to clarify something - just because a patient is satting well, they still need suctioned. A mucous plug can form while a patient is satting in the 90s, then they throw a plug, and they immediately drop, turn blue, and you are calling a code. I dont care if the lungs are clear, sats 100% on humidified room air - I am going to suction the patient. If a patient doesnt need suctioned that often, I do it a minimum of qshift. And definitely document if a patient refuses suction - that way you are covered if they do throw a plug and code......based on previous experience on my floor, happened to another nurse.

And if the patient is giving me trouble, I say something like I want to make sure your lungs are clear so that the mucous doesnt build up down there and cause problems. And always ask when they were last suctioned and how frequently in report - that way you can time it out right if they dont need suctioned that frequently.

I always do a normal saline lavage first (breaks up the secretions so the pt. can cough them up more easily), then go down til the patient coughs, go a little further, then suction outward intermittently. Having pink/blood tinged secretions is not a bad thing. I always say better out than in. A mucous plug often times develops because the patients aren't being deep or frequently enough - so if you are only going the length of the trach, you really arent getting everything out.

tyvin, BSN, RN · Aug 17, 2011

Our bodies are designed to reject foreign objects. Certain disease processes can cause more secretion but for part of it the high mucus rate involving tracks is due to our bodies defense mechanism. This is how I explain it to patients when they ask. The weakened state, disease etc... do contribute as well.

If you've ever know anyone who has gotten dentures you will probably know that at first the amount of mucus their mouth created was large and constant when wearing the dentures. After awhile it calms down usually. Same thing; the body is reacting to a foreign object in it.