When the Trach tube comes out, how do you ventilate the patient?

[chiuli]

I can't find this in my book anywhere, when the trach comes out accidentaly, and you want to ventilate the patient with the ambu bag, do you ventilate their mouth or their stoma? I always thought you would ventilate the stoma but another student told me they would ventilate the nose and mouth. Please help!

Also, is there any reason why grown adults bite the ET tube? why do they do that?

[DCtraumarn]

People bite on their tubes is they are not getting enough sedation.

You can replace and should replace the trach if able, or you can bag the stoma but may need to hold the mouth and nose closed....or assess the patient and see if they are breathing....moving air, chest rise and fall.

[GreyGull]

If a trach comes out for a patient who is a tracheotomy, have someone occlude the stoma with a nonporous dressing if available and use the regular BVM (Bag and Mask) to ventilate over the face as you would any other patient.

If the patient has a tracheostomy or laryngectomy with a permanent stoma, there is no communication to the upper airways (mouth and nose). There may be a neonatal or pedi mask at bedside for you to do bag/mask to stoma. Or, there may be a trach at bedside. Since a tracheostomy is a permanent stoma, replacing the trach may not be much of an issue but be mindful of internal speaking valves, fistulas and any grafting that may have been recently done.

Never attempt to replace a trach unless you have be trained to do so and have done one under supervision of another professional. False tracking is always a serious complication as is tearing and bleeding. Avoid replacing the same trach. An unopened one should always be at bedside. I really hate when people leave dirty obturators at beside encouraging someone to come along to use this dirty thing to reinsert the used trach. Only in extreme emergencies would you not have time to open a new trach. Always keep lube with the spare trach and a syringe.

And, above all, have a poster (yes those silly posters which some hate so much) above the bed indicating what type of airway patency the patient has and recommended cannulation or intubation. Some patients may be a fiberoptic only intubation or cannulation due to the different surgeries. It is futile (and embarrassing) to hang a NRB mask on someone's face or do a regular BVM method if the patient has no upper airway communication (trachea is brought forward to make the stoma). This is the best information you can relay to an emergency team.

Many laryngectomy patients do not have trachs in their stomas. Some may have nothing or have a laryngectomy tube which looks like a large nasal trumpet in their stoma. In an emergency a regular trach may need to be placed or even an ETT in the stoma. However, the distance from stoma to carina may be very short and don't be surprised to see the cuff just inside the stoma. Also monitor for gastric insufflation if there is a fistula (usually made on purpose by the surgeon for the prosthetic valve.

As far as patient biting their tube,there are several reasons.

* People grind their teeth when they sleep even when they are not intubated.

* Pain

* Grimacing just from overall discomfort or the situation itself.

* Involuntary reactions to other stimuli.

* Involuntary reactions due to injury or medications.

Most ICUs will use a tube guard the prevents damage to the tube. I do not recommend a full size oral airway due to aspiration, VAP and damage to some tissues of the mouth, palate and tongue if left for more than just a very short time. And, it is very, very uncomfortable for an awake patient. There are "shorties" if a tube guard is not available.

[meandragonbrett]

You *should* already have a larger and smaller trach at the bedside. You would insert one of those and then ventilate if needed. You can always stick an ETT tube in the stoma in a pinch to keep it open (while not the best idea..sometimes it can be the only option).

[Asystole RN]

Edit: Grey Gull said it best.

[wtbcrna, MSN, DNP, CRNA]

In an emergency you should be able to place a 5.5 or 6.0 endotracheal tube trough the trach stoma inflate the balloon and ventilate through that.

[opensesame]

Never attempt to replace a trach unless you have be trained to do so and have done one under supervision of another professional. False tracking is always a serious complication as is tearing and bleeding

Thank you for mentioning this specifically. I have had this conversation at work and some of my coworkers are convinced they should just grab the spare and pop it back in. Not so. It is a blind insertion at the bedside and you really don't know what you are hitting and potentially damaging if you have never done it before.

I have seen one patient almost die from a false passage -- relatively new trach (I think 3-4 days) migrated slightly up and slipped through a small tear that was above the trach cuff. Patient ended up orally intubated until they could get the trach replaced, but in the meantime while we were trying to ventilate the patient with a BVM through a partially occluded airway (we put the cuff down, but we still had to get air around the trach tube that was in there) and patient got very hypoxic for several minutes to the point of bradycardia -- near arrest (not to mention it took a few minutes to figure out why the patient wasn't ventilating, etc.) It was very scary. I don't recommend the experience.

[chiuli]

I was still confused by some of the nurses replies, by far, Grey Gull thank you, you said it best without confusing me.

[netglow, ASN, RN]

Thanks for all that detail Gull! It's been copied and placed in my "trach" info archive.

[GHGoonette, BSN, RN]

Thanks, Grey Gull, I too have copied it.

[AtomicWoman]

Awesome, Grey Gull!

[chiuli]

So let me make sure I got this clear:

A tracheotomy is an incision into the trachea to put the tube in while a tracheostomy is a procedure where the doctor takes the trachea and pulls it out through the neck to make a stoma