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Show Notes

Pearl One: Trach Basics

  • What is a tracheostomy?
    • A tracheostomy is a surgical airway that bypasses the nasopharynx in order to deliver oxygen directly to the trachea
    • Review the anatomy here
  • What components make up a tracheostomy tube? 
    • The outer cannula makes up the body of the trach. 
    • The outer cannula connects to a flange or face plate which contains key details about the trach (e.g. size, brand etc)  
      • Tracheostomy tubes are each assigned a number that represents its size, which usually correlates with the inner diameter of the outer cannula  
        • OD can refer to the outer diameter of the trach (outer cannula) or the outer diameter of the inner cannula
        • ID can refer to the inner diameter of the trach (outer cannula) OR the inner diameter of the inner cannula
        • Compare different trach sizes and details using this tool
    • The disposable inner cannula exists to be exchanged, preventing secretion buildup without requiring a full trach change.
  • What are the variations of a tracheostomy tube? 
    • There are different brand names of tracheostomy tubes, such as Portex and Shiley
    • “XLT” stands for “extra long tube” and is an optional adjustment for tracheostomy tubes. 
      • Proximal XLTs are longer proximal to the bend and useful in patients with more neck tissue. 
      • Distal XLTs are longer distal to the bend and useful in patients with tracheal stenosis or other abnormalities in the trachea. 
      • Adjustable length trachs with locking mechanisms also exist for patients with complex anatomy.
    • Trach tubes may have cuffs, i.e. a balloon at the end
      • When inflated, the cuff:
        • creates a seal for positive pressure ventilation 
        • may protect from large aspiration events in the short-term
      • Downsides to cuff over-inflation include:
        • Tracheal necrosis and 
        • Impaired swallowing (which could increase aspiration risk long-term).
    • Finding the happy medium of cuff pressure is key.

Pearl Two: Bedside Triage & Complications

  • Ask yourself the following questions:
    • What are the indications for a tracheostomy?
      • One indication is chronic ventilator dependence (e.g. neuromuscular weakness, difficulty weaning off ventilator). 
        • Treat trach tube malfunctions as an airway emergency in patients who are ventilator dependent.  
      • Another indication is secretion management (e.g. vocal cord paralysis, stroke).  We have more time to problem-solve around trach tube malfunctions in these patients.
      • Patients not on ventilators are often transitioned to trach collar (or sometimes called trach masks), which is essentially a humidified nasal cannula through the trach.
    • When was the tracheostomy tube first placed?
      • Timing of initial trach tube placement guides management of common complications.
      • An early trach tube is the first trach placed. This will be sutured in, is typically in place for about 2 weeks , and is higher risk to manipulate because the tract has not fully epithelialized. 
      • A trach is mature about 2 weeks (can be as early as 5-8 days) after placement, and is much safer to manipulate because the tract has epithelialized. Sutures are generally removed around time of trach maturation.     
  • The big 3 complications (see ICU OnePager)
    • Accidental Decannulation (Trach tube “fell out”)
      • Early Trach: reinserting a trach tube has a high risk of creating a false tract (ending up in the wrong place) potentially causing pneumomediastinum and other complications. 
        • Instead, prepare to “ventilate from above” ie from the nasopharynx such as with non-rebreather or intubating if necessary. 
      • Mature Trach: trach tube can be safely replaced because the tract has epithelialized.
        • Replacement is done with the obturator, an insertable rigid plastic piece that stiffens the trach tube to facilitate insertion. 
          • Know where to find the obturator in your patient’s room!
        • As a precaution, stock 2 spare tracheostomy tubes in the room: 1 of the same size, and 1 a size smaller 
    • Obstruction
      • Early Trach: 
        • Suction inside the trach tube
        • Replace the inner cannula (but not the whole trach) 
        • If obstruction not relieved, ventilate from above
          • When ventilating from above in a patient with a cuffed trach tube, the cuff must be deflated for oxygen to make it down to the lungs
      • Mature Trach: same options as with an early trach, with the addition of full trach replacement if needed 
    • Bleeding
      • Early Trach:
        • Bleeding from the trach tube is typically mucosal and can be treated with pressure or silver nitrate
      • Mature Trach:  
        • Feared (but rare) cause of bleeding is a tracheoinnominate fistula
          • Caused by erosion through anterior tracheal wall into the innominate artery
          • Brisk airway bleed and requires immediate surgical treatment. 
          • Try to achieve tamponade by either over-inflating the trach cuff or using a finger occlusion technique 
    • Bonus: Tension Pneumothorax
      • Rare complication but always one to consider in the immediate post-procedure period 
  • Caveat to Ventilating From Above
    • In patients who have had laryngectomy or who have fixed upper airway obstruction, the tracheostomy is their only airway (i.e. cannot be intubated).
      • Instead of ventilating from nasopharynx, provide oxygen through the tracheostomy stoma 

Pearl Three: Airway Clearance

  • Hydration and Airway humidification
    • Rationale: Tracheostomies bypass the nasopharynx which typically humidifies air. As a result, secretions may become thicker and drier.
    • What helps with airway clearance in a patient with trach?
      • Adequate hydration 
      • Humidification keep secretions from drying out
      • Trach collar (essentially humidified nasal cannula) provides humidified oxygen through the trachea 
      • Heat moisture exchanger, which contains thin pieces of paper  within plastic casing that traps and recycles moisture. 
      • Suctioning
        • Use a flexible red rubber catheter for suctioning, which is less likely to cause airway irritation and bleeding than a rigid suction
        • Preventive suctioning can remove secretions before they dry out
  •  Pharmacologics
    • Albuterol is standard.
    • Avoid medications that can further dry secretions, such as ipratropium and glycopyrrolate
      • However, this is not a hard and fast rule in managing secretions.  Sometimes, patients who have trouble with drooling or have copious secretions (e.g. hospice, parkinson’s, other neurologic disease), you may want to use agents that thicken secretions.
      • Hypertonic saline can thin existing secretions by drawing water into mucus
    • Don’t reinvent the wheel – ask the patient!
      • Patients may have already found a regimen that works for them (particularly in patients with chronic use of tracheostomy).. Ask!

Pearl Four: Passy Muir Valves (Speaking valves)

  • Determining readiness for phonation
    • Patients progress from larger trach tubes to smaller trach tubes to uncuffed trach tubes and finally to a speaking valve
    • Ideal candidates are awake, alert, off positive pressure and have controlled secretion burden
      • Technically, we can actually get patients speaking BEFORE they are fully weaned from ventilation (especially since the inability to speak can be so troubling for patients) but requires considerations of other factors
  • Mechanics of speaking valves
    • Speaking valves are one-way valves that open on inhalation and close on exhalation.
    • Since the speaking valve closes on exhalation, outgoing airflow must go through the vocal cords and nasopharynx (and that air movement through the vocal cords generates sound and allows for phonation!)
      • Usually performed with cuffless trachs
        • An inflated trach tube cuff with a speaking valve leads to air trapping. Some amount of air trapping may occur even with cuff down. Incoming airflow cannot exit, which presents a safety risk.
        • For this reason, speaking valves are generally avoided in a trach tube with a cuff (with a few expectations of cuffdown)
  • Additional Support
    • When in doubt, consult your neighborhood respiratory therapist and speech and language pathologist

Pearl Five: Decannulation

  • Determining readiness for decannulation
    • This is similar to determining readiness for phonation. Patients progress from larger to smaller trach tubes to uncuffed trach tubes and eventually to a capping trial
    • In a capping trial, a cap is placed over the trach tube for up to 48 hours. 
    • The capping trial blocks all airflow through the trach tube and forces all airflow to go through nasopharynx
    • A capping trial is a test run before decannulation: 
      • Use it to assess work of breathing and secretion tolerance
  • Decannulation Process
    • Straightforward process wherein the trach tube is removed and the stoma covered with gauze.
    •  The stoma typically heals over weeks to months.

For more information on tracheostomies, check out Dr. Morris’ book: Tracheostomies: The Complete Guide.

Transcript

S: Hi Everyone! The Core IM episode this month will count for CME credit with ACP. We will link to the URL in the show notes – so follow the link, complete the 3 questions and get CME credit. Without any further ado, cue the intro! 

Dr. Nick Mark: I was at home Depot getting some plumbing stuff, and there’s this giant wall of all these pipes and like L bend T bend this to this adapter. And I was like, oh my God, this is what it feels like for people when they go into that respiratory therapy supply room, right? Like, I feel like an idiot buying plumbing supplies. And until you’ve actually like gotten comfortable with all of these things, it’s like, oh my God, which one of these do I need? You know, which one of these goes with which one? 

S: That’s Dr. Nick Mark, Seattle intensivist, creator of ICU OnePager and contributor to COREIM – POCUS Series. Welcome to Core IM 5 Pearls Podcast, bringing you high-yield, evidence based pearls. I am Dr. Shreya Trivedi, a internist at BIDMC. And today I am joined by…  

M: Hi, I am Dr. Matt Tsai, second year internal medicine resident at BIDMC   

T: and I am Dr. Tim Rowe, pulmonary & critical care fellow at Northwestern in Chicago. And I’m so glad to be back and cover a topic near and dear to every pulmonologist – tracheostomies.   

S: Okay, let’s get into what we’ll be covering in the episode. Test yourself by pausing after each of the 5 questions. Remember, the more you test yourself, the deeper your learning gains.  

M: Pearl 1: Trach Basics  

S: What are the main components of a tracheostomy tube to know?   

M: Pearl 2: Bedside Triage and Complications  

S: What are the 3 main complications with tracheostomies? How does timing of trach placement affect how we manage these complications?  

M: Pearl 3: Airway Clearance  

S: What airway clearance therapies should we reach for and which should we avoid in patients with tracheostomies?  

M: Pearl 4: Phonation  

S: How do we assess readiness for speech? How does a speaking valve work?  

M: Pearl 5: Decannulation  

S: What are the steps towards tracheostomy removal, or decannulation?   

PEARL 1

What are the main components of a tracheostomy tube? What variations should internists be aware of? What is the difference between a cuffed and uncuffed trach?  

S: Tim/Matt, i gotta be honest because every time a patient gets admitted that has a trach in the one-liner, i kind of do a little prayer that there be no trach complications on my watch.   

T: Oh man, I’d be lying if I said I’ve never had the same thought. I’ve gotta say that before I started my fellowship trachs were just kind of a black box to me. And it really doesn’t have to be that way! So I think the best place to start is with some basics Now that we’ve clarified that point, what is a tracheostomy?    

Dr. Nick Mark: So a trach is a definitive surgical airway that bypasses the upper airways, the nasopharynx and the oropharynx.   

M: Ok so a tracheostomy, or as will refer to as trach in the episode, is a way to deliver oxygen and ventilate more directly without having to go through the naso-oropharynx and larynx like we typically do with endotracheal intubation.  

Dr. Nick Mark: So it’s useful if you are talking to a respiratory therapist and they ask you what tube, if you know all of that, you’re a hero. You’ll tell them exactly what to get out of their supplier room.  

S: Oh man I still remember when i was an intern and interventional pulm was asking me about someones trach and me fumbling around with the words, 7.0 Shiley, XLT pretending like i knew what any of that actually meant and their implications actually were   T: Ohhh man the struggle! Well lets start out with that first number you just said, Shreya. Trachs are assigned numbers – in this case 7 – which correlate with their sizes.  

Dr. Nick Mark: It’s also useful because let’s say somebody has a, a five, 5.0 tube. You might want to get one size smaller two, because if you have trouble getting the, getting a new five in a four will, will certainly fit.  

T: So for most common numbering conventions – the tube number is the inner diameter of the outer cannula – and don’t worry if I lost you there, we’re going to clarify all of that nomenclature in a second here. But not to get bogged down in semantics, but some manufacturers like Shiley use a different numbering convention which does not have the 1-to-1 relationship between number and inner diameter. Still, the general correlation is still there.. We’re going to link a nifty tool in the show notes that you can use to compare different trach sizes on the fly.   

S: Speaking of Shiley… I’ve heard and written that a thousand times and don’t think I fully appreciated that Shiley is just the trach manufacturer!   

T: Yep, there are quite a few trach manufacturers, but the “big 2” we see most frequently are Shiley and Portex. So it’s helpful to have that information ready when you are troubleshooting with your friendly neighborhood RT or pulmonologist   

S: Okay, that makes sense. Let’s do more trach parts. You mentioned an “outer cannula” – what is that?  

Dr. Nick Mark: There’s this thing called the outer cannula, which attaches to a flange or face plate. This is what you see on the front of the neck, the face plate often it has to strap or sutures that hold in place.   

T: Okay, so the outer cannula is what we see on the outside and think of as the“tracheostomy tube” – its connected to a flange, which is rich with details about the trach… honestly they used to look like hieroglyphics to me but now I use them all the time because at a glance I can tell the size, the manufacturer, the presence of that telltale pilot balloon that lets us know the trach is cuffed.  

Dr. Nick Mark: There’s also an inner cannula, so it’s basically a tube within a tube, a rigid tube with a slightly smaller tube inside of it.  

S: Right so the inner cannula clearly that goes inside but why do we even need that inner piece    

M: Shreya -the inner cannula is the underdog of trach tube components!! That inner cannula is removable which makes it much easier to change when secretions build up. This way you avoid having to go through a full trach change.  

S: Oo nice the inner cannula is like the behind the scenes, come to the rescue when you need MVP – im sure we will talk more about that the next pearl on trach emergencies. While we’re on a roll, what about the phrase I see thrown around in 1 liners “XLT”?   

Dr. Nick Mark: XLT is extra long tube. Um, but there are two types. There’s, what’s called proximal XLT and a distal XLT. Proximal XLT is where the tube is longer before the bend. If you imagine a trach sort of looks like an L, right? And if you have somebody who has a lot of neck tissue or swelling, you need a longer tube to get into the trachea. So that’s where proximal XLT is useful.   

S: It was helpful for me to see a pic in our show notes to cement that proximal XLT are longer on one end to get through more neck tissue  

Dr. Nick Mark: On the other hand if you’re trying to get that tube farther down their trachea, let’s say they have some stenosis or something. Um, then you wanna use a distal XLT tube. Um, and so that, that tube is longer after the band.   

M: So two patients could both have a Shiley 5.0 XLT tube, but one might have a distal XLT due to tracheal stenosis while the other might have a proximal XLT because of more neck tissue?   

T: Exactly!   

Dr. Nick Mark: So to put this all together, I might say that a patient has a five oh cuffed distal XLT tube. And what that means is that means the size of the tube, the inner diameter, five millimeters. It has a cuff, and it’s a longer tube where it’s longer after the bend.     

S: It feels so good to understand most of that. Dr Mark just mentioned a trach being “cuffed” or not – let’s break this down a bit more. What does it mean when a trach is “cuffed?”  

Dr. Nick Mark: What this means is that there is a balloon on the end of the tube, which you can inflate, which holds it securely in the trachea. And this is important for two reasons. Um, one, it creates a firm seal. So you can apply positive pressure. Imagine if you didn’t have that balloon. So if you tried to hook this person up to a ventilator and give them positive pressure, all that air would just come out, out around the sides and out their vocal cords.  

S: And all that leak would be no bueno. So basically when we want to ventilate, cuff up!   

T: One thing to watch out for is when you inflate the cuff, the cuff pressure rises –  BUT if you put too much pressure, it’s gonna cause necrosis, which leads to tracheomalacia, basically making the trachea pretty floppy.   

M: Then this kicks off a vicious cycle.   

T: Because when that trachea is all floppy, what are you going to do to make sure the trach still has that seal you need to ventilate? You’re going to increase the cuff pressure more! That’s going to cause more necrosis, more tracheomalacia.  

Dr. Nick Mark: The key is you want to find the pressure that allows you to, um, secure the trach in there and get a good seal without having so much pressure that it causes injury  

M: So we want to find that goldilocks zone with cuff pressure, enough to secure the trach but not so much as to cause tracheal necrosis.  

S: Yeah, all for finding that goldilocks zone. Besides allowing for a seal for positive pressure ventilation, is there any other purpose for that tracheostomy cuff?  

Dr. Nick Mark: It protects them a little bit from secretions, from above. Not a lot secretions will still pool there and still get around it.   

S: Okay that makes sense if we think of the cuff as kind of a balloon that sits in the trachea, I can see how having that balloon inflated would create a physical barrier and prevent large aspiration events   

M: That’s right. But buyer beware, cuff inflation is sort of a double edged sword with aspiration. Like yes, on one hand an inflated cuff is a physical barrier to large amounts of secretions, but on the other hand, the cuff also interferes with the way our patients swallow which annoyingly can increase their risk of aspiration over time.   

Dr. Linda Morris: Contrary to what  I learned that, um, the cuff inflation helps to prevent aspiration actually, no, it’s, it’s, it’s been found, uh, mainly research done by speech language pathologists have shown that he risk of, of aspiration increases with increasing cuff pressures.  

S: That was Dr. Linda Morris, a clinical nurse specialist in tracheostomy care at the Shirley Ryan Ability Lab, an associate professor at Northwestern and notably the co-author of the book Tracheostomies: The Complete Guide.

T: Okay so that’s a lot of us hyping up cuffed trachs.. But don’t you worry – we’ll be talking about taking the cuff down and cuffless trachs soon enough in pearls 4 & 5  

S: Before we move on, should we do a quick review?  

M: Let’s do it!! Trachs are complicated — that’s prolly my biggest takeaway. But to summarize, we talked about different parts to a trach tube like an outer cannula and an inner cannula which is removable and will be helpful when we are troubleshooting in Pearl 2. Since prepping for this episode, ive been looking out for faceplates that tells us the manufacturer, a number that tells you the trach size and if the trach has extra components like “XLT” or “extra long” proximal or distal segments. Finally, we talked about trachs that have cuffs attached which can be inflated for positive pressure ventilation but comes with its own disadvantages including aspiration risk and tracheal injury when the cuff pressure is too high.

PEARL 2

What are the 3 main complications with tracheostomies? How does timing of trach placement affect how we manage these complications?  

M: Okay now that you understand the different parts of the trach your patient has, let’s say you get a page from the nurse that your patient with a trach does NOT look well and he thinks something is up with the trach and wants you to come take a look.   

S: This is probably the scariest part of trach care for me and many people – my brain just draws a blank trying to remember anything from that one trach complications lecture I got way back when   

M: In that moment of brain going blank, just take a step back and remember…context is key! The very first step is to figure out why they have the trach in the first place.   

Dr. Nick Mark: The most common is somebody who has an endotracheal tube in, and we’re trying to get them off of the ventilator. There are also people who have a chronic need for, um, mechanical ventilation. So people with like neuromuscular weakness where they, they don’t have good control of their respiratory muscles   

T: Alright, so we manage trachs differently if someone is vent dependent. And if I’m trying to figure out why my patient has a trach, the first place I look in the chart is their respiratory flowsheet to see – are they 24 hour vent dependent?   

M: Right – Because if your patient is on the vent 24/7 like with signifcant neuromuscular weakness or someone who failed to liberate from the vent and is waiting for placement in a long-term acute-care hospital (LTACH), then trach malfunction is sort of like an emergent airway – its a big deal.   

S: Yeah so if the patient is 24/7 vent dependent, i should be thinking how to help this patient ventilate from above e.g help them breathe from their nose and mouth  

T: Yeah – but on the other end of the spectrum is a patient who doesn’t need 24/7 ventilation.   

Dr. Nick Mark: Then there’s also people where you’ll see, they have trouble clearing secretions, like people with vocal cord paralysis, stroke,  And for them, the tracheotomy is just preventing stuff from above getting down into their lungs.   

T: Non-vent dependent patients with trachs are maybe those are recovering from COVID infection or are riding out on trach collar all day, getting better, making progress

S: Just to clarify so everyones on the same page, what’s a trach collar?  

T: Trach collar is basically a humidified nasal cannula but through the trach – so if that patient has a trach complication, we may have a bit more time to think before we have to act.  

M: Now an another important branch point to thinking about if they’re vent dependent or not, we also have to ask ourselves when that  patient’s trach was placed and if it’s considered an early or a mature trach  

Dr. Nick Mark: That first trach..  I’ll be in for let’s say 10 days to two weeks and then the, the service or the person who placed it will come to the bedside and they will exchange it after that, after that first exchange, um, pretty much anyone can manipulate it. Cause at the, after that point it’s considered to be a mature tracheostomy.  

T: So in other words a mature tracheostomy is one where trach tract has epithelialized, which usually takes 5-8 days. You can feel safe manipulating or exchanging the trach once it has been in for 2 weeks or so.  

M: You should still check at your institution, because there is probably a safety policy about those tracheostomy changes, and each place handles it slightly differently.   

T: For example at my hospital, my quick and dirty is to look for sutures, which come out around day 10, as an indicator of maturity.  

M:  Thats a neat trick! So with that set up of thinking of it as an early or a late trach, let’s go through 3 major complications – first on deck, let’s say you are called to the bedside for an accidental decannulation, which is a fancy way of saying the whole trach came out of the stoma    

Dr. Nick Mark: The key thing to understand is that if somebody has an early trach, it has not yet been exchanged and that trach comes out. You should ventilate them from above. You should prepare to intubate them from above. You should not try to put that tube back in yourself. And the reason is is that if you try to do that, you will put that tube in the wrong place and you will end up ventilating their mediastinum knock their lungs.  

T: So if this new or an “early” trach falls out and you reinsert the trach you run a high risk  of creating a false tract. And if you ventilate through the false you’re going to cause pneumomediastinum or a tension pneumothorax, and worst of all, you wouldn’t be providing effective respiratory support to your patient.  

S: Okay, so bottom line: new trach falls out – best to avoid replacing, and if this patient is ventilator dependent we should prep to intubate them. What about a mature trach, what if trach comes out in a patient with a mature tract?  

Dr. Nick Mark: Compare that to if somebody DEC cannulate and it’s a mature trick, it’s already been changed. Um, this is a situation where it’s, it’s also an emergency. You need to secure their airway. Um, you should ventilate them, oxygenate them from above, but you can attempt to replace it. Um, you may want to use a one size smaller tube, cuz it may be easier. Um, but this is a situation where, you know, this is, this is potentially not an airway code emergency, where you need to get everybody to the room really fast. This may be a situation where, you know, people who are appropriately comfortable with a trach can fix the problem right there  

S: So basically losing a mature trach is safer to replace because the tract has actually epithelialized.  But how do we replace the trach, just pop it back in?  

M: That gets into a component of the trach we didn’t talk about in pearl 1, the obturator!   

T: YES. This is something I always emphasize on rounds in the MICU – I point out the obturator to all my residents because no one ever knows what it is – but it’s SUPER IMPORTANT!   

M: The obturator.. That’s the rigid piece of plastic you put inside the trach for an easy insertion  

T: Yes!! You gotta know where to find that obturator.    

M: Let’s move on to our second complication. Say you get a page about a patient with a trach. This time, they are desatting and the nurse is concerned about a trach obstruction.   

Dr. Nick Mark: Let’s talk about obstruction. So let’s say now you get called to the bedside. Oh, Ms. So-and-so’s trach is, is blocked. We can’t, we can’t ventilate her. All right. Well, this is, this is bad. This is an emergency, people need to breathe. So what are, what can we do? Um, if it’s early things that we can do so we can try taking out the inner cannula and suctioning through there. Um, we can also say, Hey, let’s, let’s, uh, deflate the cuff and ventilate from above

M: Okay so recap with a new trach  – if there is an obstruction, we can think about switching out that inner cannula and suctioning  

S: And the last key thing that Dr. Mark mentioned again – when in doubt, ventilate from above! As in, help the patient breathe from their nose or mouth  

T: Okay, since we’re ventilating from above we need to think about the cuff. Pop quiz shreya when you are ventilating from above – like using an ambu bag – should the cuff on the trach be up or down?  

S: humm well you did say in pearl 1, that the cuff in the trach has to be “up” to have a good seal for positive pressure  

T: Right but there we are talking about positive pressure through the tracheostomy tube. Now we are talking about ventilating from above the trach with ambu bag, so you actually want the cuff deflated so that the breath can make it from the patient’s nasopharynx, around the trach and down to the lungs.   S: ahh i see makes a lot sense. So if we’re ventilating from above like with an ambu bag, cuff on the trach is down – noted. So how does managing obstruction differ in a mature trach?  

Dr. Nick Mark: If somebody is obstructed and it is a mature trach. Now you have a few more options. So again,   You can remove the inner cannula. You can suction… sometimes what happens when somebody obstructs is they have secretions that have become really dry. And they’re kind of crusted on the endotracheal tube, the sorry, crusted on the tracheostomy tube sometimes the answer is to, um, just take out the whole thing and put in a new one.  

S: wow changing out whole trach — — it feels invasive but i guess it makes sense if its mature and the tract is already epithelialized   

T: Right, this is sorta like rebooting a computer that isn’t working. If something has gone wrong and you can’t troubleshoot with the inner cannula and sunctioning, just change the trach!  

M: Nice, okay, now for the nightmare scenario. The third big trach complication- you get a page that your patient has some bleeding at the tracheostomy site.   

S: Let me guess just like with obstruction or accidental decannulation, the management of bleeding then differs depending on whether it’s an early or mature trach.  

Dr. Nick Mark: If somebody has bleeding early, most likely that is bleeding from small from the skin or small vessels, usually that can be stopped by just pressure. Um, sometimes that bleeding is not from the trach itself, but from the airway. So the person might have suction trauma. They might have some tracheitis. Um, these are situations where generally, um, this will stop on its own with supportive measures. Um, you should be mindful that maybe what you’re seeing is not bleeding from the trach, but bleeding from farther down …the other thing I remember is, you know, any bleeding in the airway could also be from above. So, I mean, this could also be like epistaxis.  In many cases it’s bleeding at the skin around the trach. And in many cases you can control that pressure or, um, some topical silver nitrate or some other measure like that  

S: Sounds like if the bleeding is coming from a recently placed trach itself, it is usually controllable and usually resolves with pressure or silver nitrate. Pfeff!  I can breathe a bit easier.So im curious, how does that compare to bleeding in a mature trach?  

M: In someone with a mature trach, there is one rare but life-threatening bleeding complication to be aware of, called a tracheo-innominate fistula (or TIF).  

Dr. Linda Morris: The incidence is less than 1%, but the mortality is close to a hundred percent.  

S: Yikes, that does sound like a nightmare scenario. But what causes a tracheo-innominate fistula?  

Dr. Nick Mark: Remember that you have this, um, brachiocephalic or a innominate artery, which crosses in front of the trachea and what can happen. if you have a tracheostomy cuff up against the trachea and it erodes in the trachea and puts pressure on this artery, it can cause this artery to bleed. And this will cause a very brisk, very red, very scary airway bleed.  

T: This type of bleed will not be subtle, and the patient needs to go to the operating room immediately.  

M: Oh for sure! But what can we do for the patient at the bedside to temporize them on the way to the OR?  

T: ​​The first thing to do for any worrisome  bleeding: STEEP TRENDELENBERG AND OVER-INFLATE CUFF  

Dr. Linda Morris: One is if you see a, a blood shooting out of a trach, um, the first thing to do is hyperinflate the cuff and try to manipulate the tube so that you can possibly tamponade that area of bleeding. If that doesn’t work. The only other thing to do is to remove the tube completely, which seems crazy, but to remove the tube completely and put a finger in the, to try to pull forward toward you, the clinician, to try to clamp off that bleeding artery, meanwhile, of course it’s gonna be a bloody mess. So someone has to then take over mask ventilation, of course, suctioning, suctioning, the airway mask ventilation, and then of course, intubation and then worry about the, the, then get them to the operating room immediately.

M: So you’re telling me that i can hyperinflate the cuff and if that doesn’t work, stick my finger in the trach site and pull forward to try and stop the bleed? That is wild  

T:  Yes! Bottom line here is that in a tracheo-innominate fistula, you have to do everything you can to achieve tamponade for this bleed. And what works for one person may not work for everybody. Fortunately this is an uncommon scenario, but if you happen to find yourself in that situation you might be the one to save a life.   

S: Gosh i hope i’m never in that situation but if i am i do think im gonna freak out a bit less. Let’s recap what we learned. For me the biggest takeaways are that i have to ask 2 Qs after I get a page about a trach complication: 1) if the patient is vent dependent or not  and 2) if its early trach <2 weeks old or a mature  trach   

T: The first big trach complication to know is accidental decannulation where the trach comes out – big teaching point there, if an early trach falls out, do not try to replace the trach. And if they are vent dependent, ventilate above from the mouth and nose and intubate if you have to.  

S: With obstruction we can try changing the inner cannula and suctioning. And if that does not work and its trach is mature, you can consider replacing the whole trach.   

T: And finally the third complication is bleeding, which is usually mild and resolves with pressure or silver nitrate BUT the thing to watch out for is a rare complication called a tracheo-innominate fistula which happens in mature trachs. In an emergency, consider ventilating from above while providing direct pressure to try to stop the bleed.   

M: One big exception before we move on, there is one scenario where you wouldn’t want to ventilate from above, which are in people without a larynx

Dr. Nick Mark: We see a lot of people who, who no longer have a larynx. eople who have like a head neck cancer and they undergo like aary inject, they’ll, they’ll have a tracheotomy because they need, they need an airway and they don’t have an airway from above.   

T: Okay let’s repeat that because it is a key concept. In a patient who has had a laryngectomy, there is no connection between the nasopharynx and the trachea.   

Dr. Nick Mark: And it’s actually really important to call out. This is separate from those others because when you don’t have an upper airway, it really means that the tracheotomy is your only airway option..  

T: Right so in patients with laryngectomy or trauma to their larynx,  the tracheostomy tube is their only airway and so we are not able to ventilate from above –  if you intubate this person through their mouth, all you’ll do is insufflate their stomach. So if there is a trach emergency in a patient with a laryngectomy, and they need respiratory support, you should provide it through the stoma while you wait for help.   S: Now that we explain the anatomy out like that, that helps it stick a lot more: No ventilation through the mouth/nose in a patient with laryngectomy.

PEARL 3

How do we approach airway clearance in patients with tracheostomies?  

T: Okay, after that adrenaline rush of emergencies, let’s shift gears and focus on the day to day trach care – this  stuff really matters for quality of life! First, let’s just talk a bit about secretions in the patient with a trach.  

S: Ugh yes I just had a patient tons of crusting around the trach and wondering what causes it  

Dr. Nick Mark: So one of the main purposes of our upper airways and nasopharynx is to humidify air. When you bypass the upper airways and you have a direct connection between ambient air and your trachea, um, your trachea is now exposed to really dry air and that can dry secretions there, which is why you get this crusting problem.  

S: oh so our nasopharynx is essentially helping with humidification but with a trach, by definition we are bypassing that our body’s humidification system   

T: And those dry secretions can thicken up and cause the trach to get obstructed, which is why we approach secretion management a little bit differently in patients with a trach than in other patients.  

Dr. Linda Morris: And that’s because when we start to think about trying to stop secretions with things like glycopyrrolate, or, some of the other things that, that, uh, we can use that that gets into a possible pulmonary problem, because we’re gonna make the secretions thicker and with a trach patient, you don’t want thick secretions. You want to have the secretion thin and mobile so that the patient can cough them out easily, or we can suction them out easily. Cause once we start to try to, um, stop the secretions by some of those agents, then we can, we get ourselves into more trouble  

S: Wait, what? I always thought we give things like glycopyrrolate to help with secretions. But I guess i was wrong and what we just learned is that patients who have trachs are already prone to drier secretions with glycopyrrolate. This will just be fire on fire  

M:  Exactly! And one of the best ways to put out that fire and keep those secretions nice and flowing is H and H.  

S: I think ur prolly not referring to hemoglobin and hematocrit?  

M: Nope – hydration and humidified air!  

Dr. Linda Morris: Hydration is important, so that, so that it does help to thin secretions. Um, and then there’s humidity… we can do the humidity with the trait collar humidified trait, collar, And the other thing that’s, that’s very low tech, but very effective is the HME, the heat moisture exchanger.  

S: Ok 1st of all, I’m glad Dr. Morris brought up trach collar because i didn’t know the reason patients were on trach collar is basically helping with that humidification. And 2nd of all, what in the world is a heat moisture exchanger?  

Dr. Linda Morris: It’s an attachment to the trach. It can be circular, but it, you, if you look inside, it’s got little layers of filter paper inside. And what that does is it traps the moisture of the exhaled air so that you can re inhale with the next breath, that trapped moisture it’s quite effective. And  I never used to have a whole lot of respect for the HME because it’s just, you know, a little bit of filter paper in a housing essentially, but it can be really effective  

T:  So the takeaway here is that if your patient is breathing through a trach, they need to have some mechanism to humidify their secretions – so give them humidified air whether through a trach collar or the Heat Moisture Exchanger with the filter paper. And also make sure your patient is adequately hydrated – whether they’re drinking, getting through the J tube or IV.   

S: And what about nebs?  

T: With nebs, simplicity is key here – don’t try to reinvent the wheel.  I usually just use albuterol   

S: Wait not duonebs?  

T: Duonebs can be great – more is more, right?? But i think twice about using it if there isnt a clear indication like COPD because the anticholinergic activity of ipratropium can really dry out secretions. And here our goal is just to use bronchodilation to mobilize secretions  

M: Yeah it’s interesting right? I mean most people think duonebs are better because it’s two bronchodilators rather than one. But knowing what we know now, you don’t have to feel bad if a patient without COPD is just on albuterol alone.   

S: But what if your patient is getting adequate hydration, on HME, only on albuterol neb, without any glycoprolate on board and the patient is still having  thick secretions? What do we now?  

T: So THIS is where I’m thinking about hypertonic saline. The high salt content draws more water into the mucus, thinning those thick, stubborn secretions and allowing for clearance.   

S: interesting! I never thought about why hypertonic saline nebs is helpful but makes sense its using its tonicity to shift around fluids and thin those secretions. You know I kind of wish there was an “ideal regimen” for a patient with a tracheostomy. Like a bundle that i can click for all trach patients that will keep their airway nice and humid and prevent those secretions from getting too thick  

T: If only there was a one-size fits all order set, but alas. You can always ask your friendly RT and pharmacist for input but for my money, the best place to start is by talking with the patient themselves!  

Dr. Nick Mark: So often people who have had a trach for years know how to manage their trach. And so keeping them on the same regimen, whether that’s NEDs, suctioning using saline and then suctioning, humidify air, like there are so many things that they have probably figured out. So don’t reinvent the wheel.  

T: Remember you can also use  most airway clearance devices you would use in a non-trach patient like cough assist or acapella – these produce oscillatory positive airway pressure to shake things up and keep those secretions moving   

M: Got it. So my takeaways from this pearl were that patients with trachs are at risk of developing dry and thicker secretions. The teaching point as to why is that air that goes through the trachs bypasses the nasopharynx which typically helps with the humidification bit.  So we can work with RT and nursing to make sure they are getting enough hydration and humidified air – whether that’s with a trach collar or a cool filter device called the heat moisture exchanger.   

T: Other things we can try include bronchodilators like albuterol and airway clearance devices to loosen up thick secretions. Finally, don’t forget that patients might already have a regimen that works for them, so make sure to ask.  

PEARL 4

How do we assess readiness for speech? How does a speaking valve work?

S: Alright  patients or family ask me, you know, when am I going to be able to speak? And it can be hard to know how to answer that! When do we know that a patient with a trach is ready to speak? 

Dr. Nick Martin: If they’re awake, if they’re alert, if they’re able to, if they’re able mechanically to speak and if they’re also, if they don’t require the continuous positive pressure, then you could consider, you know, replacing a larger trach with a smaller trach and giving them an uncuffed trach and then letting them use a pasture valve so that they can speak.  

T:  Ok couple of really important things Dr. Mark pointed out there – we progress the patient from a larger trach to smaller trach and finally to an uncuffed trach. By the way, all these steps fall under the big pathway to decannulation (which is taking the trach out,  which we will talk about in the next pearl) –  

S: That sounds good, but wait  I got stuck on he said “if the patient can mechanically speak?” What does that mean? How do we know that?  

T: So if you think a patient is ready to speak- the first thing you wanna do is deflate the cuff or as some ppl say go “cuff down,” and then you have the patient put their finger over their trach and attempt to cough, and if that goes okay, speak. This is my favorite part because there’s this magic moment where the patient hears their own voice again, it’s really special.  

M: If all that goes okay and you’re not worried about secretion burden, then you can think about progressing that patient to a speaking valve trial  

S: Great. Speaking of speaking … valves – How does the valve actually work?  

Dr. Linda Morris: A speaking valve allows air in through the trach, but it, the valve closes on exhalation. So it forces air around the tube on exhalation. So you’re breathing in through the trach, breathing out through the mouth and nose.  

M: So with the valve, the patient breathes out through their mouth and nose. Since the valve redirects air flow up through the vocal cords, instead of out the trach, a patient is able to make sounds, or phonate.   

T: Yes and now just to reinforce that point one more time. When a patient is phonating, the cuff should be deflated or straight up cuffless trach  

Dr. Nick Mark: Imagine what happens if you accidentally put a Passy Muir valve on a cuffed trach and that cuff is up. Now they can breathe in through the trach, but they can’t breathe out by blowing air around the trach. Right? So with every breath they just inflate more air and they can’t get it out. So as a safety thing, I really, really, really don’t like it. If there is a cuffed trach and a Passy Muir valve in the same room, right? Like in general, if somebody is, is using a pasture valve, I wanna make sure that they have an uncuffed trach   

T: So in most cases we want to avoid using a speaking valve with a cuffed trach. There are important exceptions, in fact there are cuffed trachs that are designed for speaking valves but important to remember that even with these special trachs the cuff must always be down to safely use the valve. Whenever in doubt, consult your neighborhood pulmonologist, respiratory therapist and speech and language pathologist for assistance.    

S: Exceptions to everything! So to summarize: Trach patients who are off positive pressure, awake, alert and generally who have an uncuffed trach are good candidates for a speaking valve trial. And the reason why the one-way speaking valve works is that it closes on exhalation and redirects air flow through the vocal cords and allows patients to speak.

PEARL 5

What are the steps towards tracheostomy removal, or decannulation?   

M: This last pearl focuses on a super interesting topic – the progression to trach removal. That process is called decannulation!  

Dr. Linda Morris: Once the patient tolerates cuff deflation, then we can start to think about getting them on the pathway toward de cannulation. And that first step after that is, um, doing capping trials, capping their trach  

S: So if someone can tolerate breathing with a deflated cuff, the speaking valve trial we talked about in pearl 4, and a smaller size trach, the next step is then to cap, and just to make sure we are all on the same page, what is a capping trial?  

M: A capping trial is exactly what it sounds like. You put a cap over the trach, sometimes for up to 48 hours!   

S: Nice its as simple as it sounds  

M: And remember how we said a speaking valve is a one-way valve that is open during inhalation? Well a capping trial is harder because it’s a two way valve that effectively forces all the airflow during inhalation and exhalation to go through the patient’s nose and mouth  

Dr. Nick Mark: So put a cap on it. And that basically gives the patient a chance to breathe through their normal. And you can do this for 15 minutes. You can do this for a few hours. You can do this for half a day. Um, and this is a great test run to see how they’re gonna do with the trach out because physiologically it’s just like that trach isn’t there. In fact, it’s actually a harder test than when that trach isn’t there because they’ve got this thing and their trachea obstructing flow. So their resistance is a little bit higher with that small trach in than it will be when you take it out. So if the person is able to go, let’s say, let’s say 12 hours with no evidence of, um, difficulty breathing and no suctioning issues. That’s a sign that they’re ready to be fully decannulated.  

S: So capping trial on the trach to see if a patient can tolerate breathing without any airflow through the trach at all, like a test run. That sounds like a pretty big deal. How do we know when someone is ready for that?   

Dr. Nick Mark: How do we know if they’re ready? Well, they have to not be on the ventilator. Um, they have to be alert, oriented, able to clear secretions, and they generally have to have a very manageable level of tracheal secretions and, and blow suctioning needs. So if somebody is needing to be suctioned more than once a day, that may be kind of a yellow light or a red light on Decannulation, because you worry that, you know, you’re not gonna be able to clear those secretions if, um, if you take the trach out  

T: So big takeaway here is secretion management has to be optimized before we think about decannulation.   

M: That seems like a fitting way to end this episode.   

T: And the perfect time for a recap — thats a perfect trach joke, get it capping recapping?! Patients who are off the ventilator, alert and with manageable secretions could be good candidates for trach removal, or decannulation. The sequence of events to know when a patient is ready for decannulation is first to see how they breathe with cuff deflation, then try downsizing and a speaking valve, and finally cap the trach for up to 48 hours. If they pass all of that with flying colors, it’s time to take the trach out!  

S: And that’s a wrap for today’s episode. If you found this episode helpful, please share with your team and colleagues and give it a rating on Apple podcasts or whatever podcast app you use! It really does help people find us! If you want to add any of your own tips or share challenges, tweet us and leave a comment on our website page, on instagram or facebook page. Thank you to our peer reviewer Drs. David Roberson and  Michael Brenner.   Thank you to  Daksh Bhatia for the audio editing and Dr. Preeyal Patel for the accompanying graphics. As always we love hearing feedback, email us at hello@coreimpodcast.com. Opinions expressed are our own and do not represent the opinions of any affiliated institutions.


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