tracheostomy

Nurses General Nursing

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I am fairly new in the home health arena. I have a trach pt. who I oriented with an lvn on. The POC says "change trach tube every 30 days". I noticed it had been a couple of months (almost 3) since it had been changed and asked the lvn why not. He responded that "the other lvn"(a female) had attempted to remove the existing trach tube approx. 3 weeks before, and was unable (claimed it was stuck) and so it was left alone. The trach tube is a cuffed Shiley. When I came back to work with this patient 12 days later I performed trach care, changed the inner cannula, dressing and ties and documented my observations of no s/s of infection or complications. Everything looked and sounded good. The next morning I arrived to be told that the patient's trach tube had become dislodged late in the evening of the day before and he needed to go to ER to have it put back in as the paramedics were unable at home. The patient's family stated that he needed his stoma "cut" and the ER staff "just shoved it (the new trach tube) in". I also received in report that they had been suctioning bloody secretions since he came home that the ER staff told them was normal. I was also told that the cuff had been inflated with fluid instead of air and the PCG showed it to me and there was indeed fluid in the cuff. I have never inflated trach cuffs with anything but air although Binova TTS uses sterile water but this was a Shiley NOT a Binova.

Anyway, I digress. My question is if the trach tube was "stuck" when the lvn tried to remove it 3 weeks earlier, is it plausible that the patient "coughed it out" with a fluid filled cuff intact and the trach ties (when I left anyway) secure?

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I am an ER nurse and I don't routinely do trach care. However, I did do a short stint in outpatient infusion, and we handled feeding tubes. As you may know, doing home health, a lot of feeding tubes have balloons (some don't, as when they use a red rubber catheter, for instance) and can become dislodged even with the balloon inflated and intact. So, I would imagine the same to be true of trach tubes.

What can happen over time, at least with feeding tubes, where the balloon is inflated with saline, is that the balloon can "deflate" over time. I would imagine the same to be true for trach tubes, and since it hadn't been changed for so long, it's possible that the cuff contained less volume than originally, which allowed it to slip out of the stoma.

You are not there 24/7 to observe everything, as is the nature of home health, and a lot can happen that you have no idea about.

I think if you are worried that you somehow contributed to this, I wouldn't worry too much, as you know that the trach ties were secure when you last visited the patient.

That's one of the things about home health- stuff happens that you are not there to observe.

I wouldn't worry too much about it. The trach tube was replaced (and BTW, I would imagine bloody secretions would be to be expected if the stoma had to be widened, and there was trauma to the stoma when the new tube was placed) and the patient is okay.

This is why documentation of your observations and interventions is so important. You can only document what you saw when you were there. What happened while you weren't there is another story.

Relax, it turned out okay. Don't beat yourself up.

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Specializes in Pedi.

I can't answer your question but I'm sitting here dumbfounded at the idea of not doing anything for a month when a routine trach change could not be performed. Why wasn't the ENT called or the patient sent in to have the change done in the office?

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I can't answer your question but I'm sitting here dumbfounded at the idea of not doing anything for a month when a routine trach change could not be performed. Why wasn't the ENT called or the patient sent in to have the change done in the office?

Well, yeah, there is that. I wasn't gonna say anything....

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I had asked the PCG (mom) the same question and was told she was in the process of making an appointment. After reviewing the nurse notes, I discovered that the trach had last been changed 11/2014. I started this case as my first in home health in last half of 2/2014. I work weekends only. This all happened on a Saturday. PCG finally got patient in to Trach specialist 4/3/15. MediCal was slow to approve appt.

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The good news is that the trach has since been replaced once since then with no comps. The trach is now capped and a bronchoscopy is scheduled to determine if the ER caused trauma before permanent removal is considered. Pt. has been capped 7 days now and 02 sats are 98% RA. All things considered, pt. has made good progress.

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Some home care and LTC trachs are changed q 30 days, q 60 days, q 90 days or q 6 months depending on insurance and protocol. Some LTC facilities stretch out changing special order expensive trachs as long as possible. I prefer to change cuffed trach every 30 days. But ,even hospitals get lax and will not change a due trach because they don't carry that type or no one assumes that responsibility on some floors. DOCTORS may not be willing to refer or may have a difficult time finding an ENT for a state insured patient if it is nonemergent.

Cuffed trachs can be difficult to remove sometimes. Experience and a good mentor will guide you in how much force to use.

Fenestrated_ trachs will sometimes have tracheal wall tissue snagged in the holes. Depending on the feel of the cannula going in and meds the patient is on as well as a doctor's blessing will determine if I force the trach out.

Back when RTS were still in subacutes, I would not allow any Paramedic to attempt to reinsert a trach which I could not get in. This was a very rare situation since I could usually get a smaller one in. But if there was a false Trac or some bizarre anatomy, no digging. If it was an emergency, either myself or the Paramedic could intubate orally.

Since this trach was jammed in at the ER, chances are it was not by ENT or RT. The tracheal wall can be damaged as well as the stoma. The ER physician probably saw the blood and thought water in the Shiley cuff would slow the bleeding and they may have even put ice water in the cuff. This is not standard practice but more of an "Oh Sh#t!" reasoning.

In the hospital we can use a stoma dilator_ and usually avoid an OR trip to "cut".

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In the peds world the trachs are changed every 7 days. Just a "fun fact."

Yes it is very possible for a patient to cough out a trach when the ties are secure. I have seen it happen twice, and this on a unit where we have very small nurse to patient ratio, alarms, and RTs and nurses together monitoring patients. One time it happened it was a cuffed trach! The patient was adult sized and had a strong cough, and had a way of arching their head back during the cough that dislodged it.

A small amount of bleeding is normal after a trach is placed or a traumatic change happens. It's not ideal and a doc should be aware. If you can suction enough blood to fill a suction catheter this needs immediate medical attention.

I'm glad your patient is doing well.

Edited because when I typed nurse:patient ratio, that funny little face showed up.

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Thank you all for your replies. I agree with all of your conclusions and had made some of those myself. I am very proud of my pt. for the progress made. Really motivated to get better and I pray for steady progress so remains motivated. Again thanx and bless you.

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Specializes in NICU, PICU, PCVICU and peds oncology.
In the peds world the trachs are changed every 7 days. Just a "fun fact."

This isn't entirely true. I've worked peds for nearly 20 years and can say with complete honesty that the FIRST trach change is done after 7 days - by ENT, then it's once a month and PRN in all of the facilities where I have worked. I've looked after infants as small as 3 kg who have been trached; with proper humidification and frequent assessment there's no need for weekly trach changes.

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Specializes in Complex pedi to LTC/SA & now a manager.
This isn't entirely true. I've worked peds for nearly 20 years and can say with complete honesty that the FIRST trach change is done after 7 days - by ENT, then it's once a month and PRN in all of the facilities where I have worked. I've looked after infants as small as 3 kg who have been trached; with proper humidification and frequent assessment there's no need for weekly trach changes.

I've seen weekly inner cannula changes for teens & adults. Most of my pedi home care patients are every 2 weeks, first change done by ENT surgeon. A select few are monthly. Most have 16hrs/day home care nursing including school hours

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