Understanding trachs??

[danceyrun]

I am not really fully understanding how trachs work. I understand the normal physiology of the esophagus and larynx but I'm confused about a few things. Is the reason that pts with tracheostomies are at risk for aspiration because they are not used to breathing in and out of their noses and therefore the epiglottis does not cover the opening of the larynx? I'm also confused about cuffs and why they are there. Also don't understand why you uncuff the trach when you put a speaking valve on. If anyone can answer my questions or point me to a website that can break it down for me I'd really appreciate it, thanks!

[Rose_Queen, BSN, MSN, RN]

What Is a Tracheostomy? - NHLBI, NIH

[chare]

Is the reason that pts with tracheostomies are at risk for aspiration because they are not used to breathing in and out of their noses and therefore the epiglottis does not cover the opening of the larynx?

Patients with tracheostomies don't breathe through their nose, they breathe through the tracheostomy tube. Generally speaking, the anatomy of the upper airway should be intact for most patients with a tracheostomy. As such, patients who are neurologically intact should be able to protect their own airway.

I'm also confused about cuffs and why they are there.

The cuff serves two purposes. First, if the patient is being mechanically ventilated, the cuff is frequently inflated to prevent an air leak around the tracheostomy tube. Also, the cuff might be inflated to help prevent aspiration, although it is still possible to aspirate around the inflated cuff.

Also don't understand why you uncuff the trach when you put a speaking valve on.

While the cuff is inflated, exhalation occurs through the tracheostomy tube. Deflating the cuff when the speaking valve is placed on the tracheostomy tube, occludes the tracheostomy tube. This allows the exhaled gases to exit through the larynx. It is important to remember when placing the speaking valve on the tracheostomy tube, that the cuff must be deflated, otherwise the patient will not be able to breathe effectively, if at all.

You might find the National Tracheostomy Safety Project website helpful, as they provide several resources. If you are unfamiliar with tracheostomies, you might find their NTSP Manual 2013 (PDF file) helpful.

[danceyrun]

Thank you both so much!!!

[nurseprnRN, BSN, RN]

Another problem that people with trachs have is related to the fact that they have no air movement through their noses. Therefore the air they breathe must be warmed and humidified (the functions of the nasopharynx and sinuses) or the secretions in the trachea will turn to rock.

They will also not be able to smell anything with no air going through the nose. This affects the sense of taste, because, as we know, smell is a huge component of taste. The classic experiment of pinching off the nose and being unable to tell the difference in the taste of a slice of apple and a slice of onion is illustrative. So many of these people have nutrition problems; getting them to eat when everything is tasteless is a challenge.

Finally, know the difference between a temporary tracheostomy (larynx is intact, but above the tube and cuff, so air does not go through the vocal cords and no voice or whisper is possible until the tube is removed (except if Passy-Muir speaking valve is added) ) and a trach after laryngectomy, in which the larynx and surrounding structures are removed, completely and permanently obliterating any air passage between the trachea and pharynx/mouth/nose.

If you can find a sagittal (cut away) view of the neck this will be a lot clearer to you. Here's a good one.

http://www.elsevierimages.com/image/27724.htm

[Esme12, ASN, BSN, RN]

This may help.....http://www.tracheostomy.com/resource...rachHandbk.pdf

[danceyrun]

Thanks for the excellent resources!!:)

[Esme12, ASN, BSN, RN]

You're welcome

[smartnurse1982]

I just read this,but from an RT told me is that some patients with trachs still breathe through their nose and mouth,along with the trach.

He explained that my patient is using both her trach and mouth. He told me to feel under her mouth,which I did.

I felt respirations inhalation and expiration.

He also explained why the Pulmo started Flonase on some patients......because it would be uncomfortable for her to breathe through a stuffy nose.

The patient also was switched from nebulizers to MDI for this reason.

The nebs were just going not going in her lungs full strength.

We tried the MDI through the trach and we could see the aerosol escape through her mouth. It was strange.

The Pulmo then wrote additional orders for us to close her mouth and then use the MDI.

[AliNajaCat]

Look at the illustration linked above. Do you see how the trachea extends below the larynx? If there is a tube entering the front of the neck below the larynx air will go in and out of that tube-- but the airway is still open to the larynx and up into the mouth and nose, because the tube itself isn't so large that it completely closes off the trachea from the higher structures. There is an inflatable cuff at the end of the tube to make a seal to prevent aspiration from above, and this will also prevent air from going around the tube, up (exhalation ) or down (inhalation).

If that cuff is not inflated, air can still pass in both directions around the tube and into the upper airway. That's what you're feeling when you feel air going in and out of her upper airway even though she has a trach tube in place.