This is just one of those things that I never thought about until it happened. When someone is on a vent,at what point do you just use the ambubag? When the sats drop in the 30s? Or when they stop breathing?confusing,because technically air will still be going in them even if they stop breathing?
My situation today is that I had a child who is being weaned from the vent. He is on a mist collar with 30% o2. All of a sudden his sats drop to the 30s and he turned blue. After checking to see his trach was in, I immediately put him on the vent.Mom says I should have used the ambubag. I'm thinking you only use the ambubag when some isn't breathing at all.(he was still breathing) who is right?
Afetr I put him on the vent he went to the high 90s immediately.
Also,please no one bash me or make me feel ashamed,as I'm on this site to learn.
Yeah, it might have a high pressure alarm sound if the pressures overcame the alarm settings. but until we investigate a high pressure alarm could be anything from a plug, ptx or a kink in the vent circuit.
I would have bagged the patient, just because that's the quickest method when you have a child in trouble. I would've suctioned the patient next, and if I didn't get the response I wanted (pink, good sats) I would've changed the trach. As long as you get the sats up and the kiddo was ok, that's all that matters.
I would have reached for the BVM first especially if it is hooked up to oxygen. The ventilator may be running at a low Fi02 or even set at 21% and may also be in a weaning mode with low or spontaneous settings. With the BVM you may be able to feel the resistance or compliance to determine the cause better. Listening to breath sounds will also give you a clue and may even isolate the lobe in question.
If a ventilator high pressures, it stops the ventilation cycle. If the alarm is sounding with each breath, the child probably will not be ventilated.
For those using a ventilator with a manual breath button, use with caution. Stacking breaths or those in a decreased I:E ratio in an attempt to "hyperventilate" the child may lead to over expansion or air trapping caused by the mucus with the increased rate and can cause harm by creating an air leak or compromising hemodynamics resulting in a BP drop.
I would not suggest pulling a trach unless you can not pass a suction catheter. The mucus plug may be in or near one of the bronchi below the trach and losing the airway is not the answer. Listening for breath sounds may again help you determine that. You may also risk false tracking the trach in your haste to get the SpO2 up. However, false tracking can also be the initial problem and a serious one. Always make sure the mask of the BVM is at bedside. Some toss it thinking it is of no use with a trach patient. If the patient is a permanent stoma from a tie off with the trachea as the opening, the appropriate mask and tubes should also be at bedside.
But yes, definitely start at the patient first to make sure the airway is patent and to look at the clinical presentation to determine the best intervention.
I would not suggest pulling a trach unless you can not pass a suction catheter. The mucus plug may be in or near one of the bronchi below the trach and losing the airway is not the answer. Listening for breath sounds may again help you determine that. You may also risk false tracking the trach in your haste to get the SpO2 up. However, false tracking can also be the initial problem and a serious one. Always make sure the mask of the BVM is at bedside. Some toss it thinking it is of no use with a trach patient. If the patient is a permanent stoma from a tie off with the trachea as the opening, the
I strongly disagree. If you have a kid who is blue with low sats and ambu/suction doesn't work, you change that trach and you do it fast. Generally kids in homecare have established and healed tracheostomies. They can handle an emergency trach change. If you're in a child's home and they're going down you do everything and fast, and call 9-1-1. Kids clamp down and sometimes changing the trach helps. I also disagree about lung sounds. Sometimes you can hear diminished air movement, but a child can sound perfectly clear and have a plug.
I strongly disagree. If you have a kid who is blue with low sats and ambu/suction doesn't work, you change that trach and you do it fast. Generally kids in homecare have established and healed tracheostomies. They can handle an emergency trach change. If you're in a child's home and they're going down you do everything and fast, and call 9-1-1. Kids clamp down and sometimes changing the trach helps. I also disagree about lung sounds. Sometimes you can hear diminished air movement, but a child can sound perfectly clear and have a plug.
You are also making very general statements and taking for granted that you might have a full team with many devices, skills and experience at your side in the hospital. In over 35 years of working with infants and peds, it is very rare that I have ever had to pull a trach. You also do not know the skill level of someone on a forum that you are advising to pull a trach on. If that airway is lost, the child may not do well especially if there is an anomaly or stenosis above that trach. Not all children handle trach changes the same and you may have another complication to complicate what is already going on. Be very, very cautious about pulling out any airway. Calm down and try a little lavage with the suction. Take a deep breath and do a quick assessment before removing something you may not be able to replace especially if the trach is still patent. Pulling a trach with a child in bronchospasm or who is "clamped down" may just complicate the situation as will the possibility of bleeding especially if the trach is cuffed for an adequate ventilator seal. What you may have seen is a trach that has become malpositioned where the tip gets against the wall. Checking the allignment can often alleviate that situation. This is definitely common in adults also whose circuit pulls the trach to an angle.
We teach parents not to panic in these situations but it is usually the health care provider who does.
There are also limitations to what 911 can do which is why we do teach parents about almost every emergency possible so they are the calm ones. If the child has an anomaly, they may not be able to be intubated orally so that trach is their primary airway. Some EMS agencies no longer allow pediatric intubation by Paramedics. BVM with mask to face may also be difficult with upper airway problems.
If there is a child with a trach in your care in a home situation, learn as much as you can from the home care agency and the parents before an emergency happens. We also try to include if a child tolerates suctioning without preoxygenation or recruitment with a bag in the care plan.
Since the poster's info says homecare and she is discussing a conversation with the mother, I think it's safe to assume this was in a home without full team resources, otherwise she coulda called for help and generally RTs handle putting pts back on a vent in a hospital setting. I have seen a trach change resolve an acute situation when nebs, bvm, suction have failed, more often than not. Saline lavage is fine to try, but if you've bulleted and bagged and you're not getting anything but your kid is looking bad, you try everything and changing the trach is one of them. Neither me nor the docs or any of my coworkers have ever lost an airway during a routine or emergent trach change, and we deal with teeny tiny airways with severe subglottic stenosis and tracheomalacia. In several cases there have been long snakelike plugs the end of trachs we changed out when other efforts failed, including cough assist and lavage. Maybe it's not something that works for your facility, but we have great success and I'd rather change a trach as a risk than know I'll have a full blown code because my kid is blue with poor sats and nothing else is working. When you're in the home setting you absolutely call 911 if you can't fix that kid fast. Youre not a doctor and its not your job or your place to launch a full investigation alone in the home if you have a decompensating kid and the interventions you know how to do, don't work. It's your job to save their life and if you can't figure it out get them to someone who can. It's in the contract you sign when you start. EMS may not be able to fix the patient but they can transport them to a hospital that will have more resources than you as a single person can do. Sometimes the best thing to do with certain patients is to paralyze and sedate for optimal ventilation when all other options have been exhausted. I've had it happen with multiple patients, especially those with CLD and pulmonary hypertension. Kids with brainstem dysfunction or neuro injuries also can also have spells without a precipitant. For those kids, sometimes changing the trach helps too. Yes, there's always a risk with a trach change, but if is a choice between a certain code or doing something that may fix the problem, I'd rather try.
We are discussing a child who desats, may need suctioning and if bag vs vent is better. We are not discussing a coding child or a hospital situation although most of the information can be used in the hospital.
Since this is a home situation, you can not be changing a trach everytime a child desats. Some children take longer to recover than others. Some may have a very sensitive airway which will cause them to cough like they are never going to stop for a couple of minutes. If you are watching them, it may seem like hours. The child could be cardiac with something like TOF. Their blue spell will probably not improve with a trach change unless you confirm the trach is plugged.
Per your previous post
but a child can sound perfectly clear and have a plug.
If you hear good breath sounds, I would NOT advise you pulling the trach until you have at least looked for another common cause. In the ICU it is usually the self inflating BVM is disconnected from the O2 source. If the child has pulmonary hypertension, pulling the trach will not change that unless the trach is plugged. You need that trach to administer the appropriate medications in some situations to alleviate the symptoms. The sooner the meds are delivered the sooner the child can be on their way to recover. Yes, there may be some trachs that require changing but I would check position first. Learn more about how a trach sits in the trachea. Each trach is a little unique so its quirks are good to know also.
Again I will emphasize; DO NOT panic. If you panic you will of little use to the child and 911 may not arrive fast enough to save the child from you. If you get over zealous with the bagging, changing a trach will not fix a pneumothorax.
your place to launch a full investigation alone in the home if you have a decompensating kid
It is your job to be able to troubleshoot for common causes or to know from a report either from another health care provider or the family how the child responds to everyday basic care which includes suctioning. You should also know other signs such as a fever, dehydration or irritability that may lead to more problems. That is your job.
When you accept an assignment, ask the parents how their child responds to suctioning and if the child prefers to be bagged with suctioning. Have the family guide you in getting to know the child's responses. If a child with home care needs enters the hospital, ask the parents what the child prefers. We try not to change the child's routine too much.
Research and refresh the child's medical condition so you are familiar with how patients with this disease respond to stress such as suctioning. A blue child does not always need the trach to be pulled. Find out from the family when and why and how long it takes to recover.
Do NOT try to freak out the parents with horror stories. They have probably already seen some of the worst by having a child in the NICU/PICU and have heard what they needed to know in their training for transition to home. The parents will also be very well informed about their child's disease and will know what tracheomalacia or stenosis is. It's up to you to do your own homework to be an well informed as the parents.
We send these kids home with their parents all the time and they usually do very well.
If you do not feel comfortable taking care of a technology dependent child in the homecare situation and are not comfortable providing routine care of the trach and airway which may include suctioning, bagging and a ventilator, do NOT accept this type of assignment.
The first step in any emergency is to check your own pulse...and take a breath.
Grey Gull, are you offering this advice to me or to the poster? If it's to me, I didnt ask for it and I'm already well aware of what you posted. I'm not brand new to nursing, green but not brand new, and I manage my patients and my homecare kids very well. Perhaps you should become some kind of clinical instructor instead of preaching to the choir on a message board.
Some of the information you were providing was running together with "pull the trach" being a cure for all situations.
I do teach which is why I give many different options with reasons to back up my statements and/or sources to confirm them.
However, since you have stated your place of employment pulls trachs alot, I do have some recommendations.
Your physicians and staff might consider evaluating hydration and nutrition closer. This area is often not considered as the child becomes more active with vent weaning.
Mucolytics might be considered.
Direct instillation of mucomyst, NaHCO3 (diluted) or Pulmozyme might be an option. We do this for transport, especially flight, where we do not want to risk just pulling a tube.
Your RT staff might want to re-evaluate the humidification systems they are using for the ventilators and trachs. If the child is off the collar or vent for any length of time, an HME might be considered.
The inline suction devices might also need to be re-evaluated for proper use and setup. Technique should be observed for both inline and open.
Investing in some coude suction catheters might also be in order.
You can take the advice in my posts or not. Someone might benefit from some things I have mentioned. One of the things about forums is that you can share ideas. However, one must be careful since some may take what you post to heart when you declare yourself as an authority and attempt to do what you have suggested without knowing there is more to the story than just pulling a trach. This is why I do try to post links and/or reasons.
getoverit, BSN, RN, EMT-P
432 Posts
Yeah, it might have a high pressure alarm sound if the pressures overcame the alarm settings. but until we investigate a high pressure alarm could be anything from a plug, ptx or a kink in the vent circuit.