# person with trach on vent



## ladyMj (Jun 24, 2011)

Hello all, I was just wondering when you answer a call for someone who has a trach and on a vent that they are having trouble getting enough oxygen when you all arrive, do 1st, check what kind of trach they have? remove it and start bagging? or start to suction before you remove the trach? Thank you so much! and if anyone has advanced knowledge on emergency respiratory management for the trached/vented pt, please feel free to enlighten me! Ihave come seeking knowledge!(hey, isn't that in a song?..lol)

Ps I think you emts and Paras are pretty great!


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## abckidsmom (Jun 24, 2011)

I wrote this as an email inservice not long ago:



> You are dispatched to a call for respiratory distress, a 9 yo female with a possible respiratory infection.  Upon arrival, you find the patient, very thin and with spastic extremities, in a hospital bed in the living room of the residence, with mom standing over her daughter, suctioning copious secretions from her trach tube.  The patient is in severe distress, with rapid breathing, accessory muscle use, and is coughing, but doesn't seem to be able to clear her secretions.
> 
> You continue your interview with the mom, and find that this family recently moved into the area (mental note- memorize this address), and the patient has a history of a congenital heart defect that required 4 open-chest surgeries to correct.  During one surgery, she suffered an anoxic event that left her profoundly handicapped.  She now is on meds for seizures and gastric reflux, which are administered via her G-button, along with her tube feeds.  Mom says the patient weighs about 48 pounds, and was last hospitalized about a month ago.  She says that they started noticing increased secretions and respiratory rate yesterday, and things got much worse overnight.
> 
> ...


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## abckidsmom (Jun 24, 2011)

Edit:  Never Minds.  The second part isn't so much trach-applicable.


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## 18G (Jun 24, 2011)

These are just a few basic things I always keep in mind and check right away.  

1) Oxygen Source - make sure the oxygen source is good. That is make sure it's powered on, bottle full/on, etc - make sure the patient is getting the proper concentration of oxygen.

2) Check the circuit to make sure it's connected properly, not kinked, or any other problem. 

3) Check the vent - alarms/indicators? Vent powered on? Settings correct (ask caregiver/parent). 

4) Suction the patient - not all vent patient's require deep suctioning with advancement of the catheter down to the carina. Although if having distress and oxygenation issues I would say deep suctioning is indicated. But sometimes suctioning of the trach itself is enough. 

5) Remove the patient from the vent and ventilate with a BVM. This narrows down one possible cause of the problem. If patient status improves, sats come up, anxiety decreases, than prob some sort of issue with the ventilator. With a BVM, you can feel compliance and know for sure the patient is being ventilated with proper tidal volume, rate, and pressure.   

6) All vent patients should have extra trach tubes for replacement if necessary. Some trach's have an inner lumen that comes out and can be replaced without pulling the entire trach. If no extra trach then insert an ET tube. 

I still get intimidated by trach patient's but starting to become more comfortable since my exposure to them has started to increase. 

Hope this helps ya a little.


Take a look at this from Maryland EMS... some good, concise information on managing trach patients - http://www.miemss.org/home/LinkClick.aspx?fileticket=oiMqx1lWxAE=&tabid=58&mid=451


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## ladyMj (Jun 24, 2011)

*Thank you*

for helping me understand! would O2 ever be attached to the bag?


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## 18G (Jun 25, 2011)

If the pt. is hypoxic then yes, O2 would be connected to the BVM.


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## MrBrown (Jun 25, 2011)

People on ventilators are much more likely to get sepsis, pneumonia and other respiratory compromising infections.  Could very well be an oxygenation problem.  

Remember, ventilation and oxygenation are not the same thing otherwise she would be on an "oxygenator"


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## WTEngel (Jun 25, 2011)

*Dope*

When you have a vented patient who is not oxygenating well, the DOPE mnemonic can help isolate the problem. With trach/vent kids, it will almost always be O. D & E are not totally unlikely candidates, but O is a good place to start.

Also, I will mention, one of the first things I always do when I have a patient on a vent who begins to drop there sats, is remove them from the vent and provide bag mask ventilation. This isolates E and rules it out or in immediately. This is also situation dependent. So here is DOPE:

D- Displacement if tube or trach
O- Obstruction
P- Pneumothorax
E- Equipment failure/malfunction

Normally when you are encountering an issue with a trach/vent patient, obstruction is the cause. Heavy secretions form a mucous plug in the tube insert of the trach. Generally a good lavage with NS and deep suction will alleviate this issue. 

Most trach/vent kids can tolerate a moment or two off the vent for suctioning. They hate it (who wouldn't?) but ultimately, clearing the plug is going to make them so much happier. If they are in pretty bad shape you may need to suction and then bag them back up with 100% o2 before placing them back on the vent.

If it isn't an obstruction (90% of the time it is) then my money is on a displacement. The cuff has likely failed and allowed the trach to displace, or possibly there has been some sort of physical insult to the trach (we are dealing with kids here) and it has been forced out of place. If this happens, you have a few options, depending on patient status. If the patient was in very bad shape, I would not try to deal with trouble shooting the trach. I would physically occlude the ostomy and bag the patient at the mouth as normal. Transport to the ED for evaluation and replacement. If the patient is not in extremis, then you can try removing the entire trach and re inserting, generally with one size smaller. Once you remove the trach, you will have difficulty and it will be uncomfortable for the patient to try and insert the original size. 

This is just my advice on the issue. Generally these patient have very involved home care, either parents or a "nurse." These people are usually in the know about what's up, and often are calling for a ride. Allow them to help as much as possible, especially if you aren't comfortable. If you can tell they do not have a clue, then intervene and deal with it as appropriate.

Oh, and plus one on what Brown said. These kids are extremely prone to pneumonia and other respiratory infections. If it is a problem that has been coming on for the past 24 hours with associated fever, my money is on pneumonia most likely. If it an acute onset that you were called to deal with, I would consider O and D.


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## usalsfyre (Jun 25, 2011)

WTEngel said:


> This is just my advice on the issue. Generally these patient have very involved home care, either parents or a "nurse." These people are usually in the know about what's up, and often are calling for a ride. Allow them to help as much as possible, especially if you aren't comfortable. If you can tell they do not have a clue, then intervene and deal with it as appropriate.


+1 and probably the best advice on this thread. 

Most EMS providers (myself very much included) are simply not going to have the experince with technology dependent kids to effectively deal with anything but the simplest issues. The parents of these kids are usually an amazing resource on their kids specific condition. Listen to them.


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## ladyMj (Jun 26, 2011)

*Thanks again!*

I just wanted to say thank you to everyone who answered. I was contacted by a moderator(?) on this site about why I was asking these kinds of questions, so I will no longer ask anything on here. Believe me, it was for no other reason than knowledge, NOT for medical advice nor to sue anyone or to make sure someone was doing their job! I guess we live in a society where everyone is suspicious of everything and whatever you say or ask is scrutinized. oh well, I will just make sure I ask the healthcare professionals that I know of and not on here. But really, thank you all. It seems at though you really know your stuff and even if I do become a paramedic, I will just keep it local.(asking any questions)

lady MJ


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## Handsome Robb (Jun 26, 2011)

Don't stop asking questions because someone questioned your motives...If they are truly educational then why stop? Why remove yourself from the wealth of knowledge available through many of the brilliantly, yet sometimes obnoxiously  smart people on this site?


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## ladyMj (Jun 26, 2011)

NVRob said:


> Don't stop asking questions because someone questioned your motives...If they are truly educational then why stop? Why remove yourself from the wealth of knowledge available through many of the brilliantly, yet sometimes obnoxiously  smart people on this site?



Awww thank you! I guess I was taken aback by that person's questioning of my intentions with my post:wacko:. I was so impressed with the knowledge of the EMS people on this site, I knew that I could ask something I wanted to know about some things I may need to deal with in the very near future. haha I had a somewhat of a difficult night and then came home and read this and...was like darn it!, so many paranoid people! ARGH!!!!


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## 18G (Jun 26, 2011)

ladyMj said:


> I just wanted to say thank you to everyone who answered. I was contacted by a moderator(?) on this site about why I was asking these kinds of questions, so I will no longer ask anything on here. Believe me, it was for no other reason than knowledge, NOT for medical advice nor to sue anyone or to make sure someone was doing their job! I guess we live in a society where everyone is suspicious of everything and whatever you say or ask is scrutinized. oh well, I will just make sure I ask the healthcare professionals that I know of and not on here. But really, thank you all. It seems at though you really know your stuff and even if I do become a paramedic, I will just keep it local.(asking any questions)
> 
> lady MJ



A moderator actually took time and messaged you to inquire why you were asking a question about trach patients???? really??? 

Yeah, don't even know what to say to that. Perhaps they thought you were planning on killing someone on a vent...lol... who know's.

Don't stop asking questions!


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## AlphaButch (Jun 26, 2011)

Indeed, keep asking questions. It's one of the best ways to learn. I love this site for the mass of knowledge folks here have.

re; the OP question. I use the DOPE method myself. However, like most of what we do, the actual response is dependant on the presentation of the patient and on the abilities of the provider on scene as well as many other variables.

If I encounter a trach vent pt who is cyanotic - I'm not going to waste my time checking the machine out. My first priority is ensuring ventilation (and hopefully oxygenation). For me, the fastest way to check ventilation is to use a BVM and observing the results. This eliminates the vent and the circuit from the equation. I prefer oxygen attached, but sometimes it's not ready until after I've hooked up - especially when I have a new partner. If it's a blockage or displacement (the two of highest probability), whether you have oxygen hooked up for the initial airway check is irrelevant. If it's a complete obstruction, I can't preoxygenate the pt anyway.

After that, it's dependant on the results, the agency protocols, level of provider, closest facility, etc. You can help by keeping the patients BVM and suction near the head of the patient's bed, and by learning the basics of home care for the trach from the patient's MD.

As stated, generally the home provider or nurse is able to take care of emergent problems. Generally, by the time I get there, it's an observe and transport call.


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## MMiz (Jun 26, 2011)

18G said:


> A moderator actually took time and messaged you to inquire why you were asking a question about trach patients???? really???
> 
> Yeah, don't even know what to say to that. Perhaps they thought you were planning on killing someone on a vent...lol... who know's.
> 
> Don't stop asking questions!


Sometimes is challenging interpreting someone's intent on the internet, and in this case one of our Community Leaders had questions as to ladyMj's background and intent with such specific questions.  The Community Leader PMed the user asking for clarification, and in turn we received an email stating ladyMj no longer wanted to be a member of the community.

We're people, not robots, and when we have questions as to a member's intent and background we like to inquire further.  We don't permit users to ask for medical or legal advice, and that's why we PMed the user asking for additional information.  It's unfortunate that the member took her complaint to the community instead of to the Community Leader team.


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## WTEngel (Jun 26, 2011)

I will say that I answered this question assuming the OP was in EMS in some way shape or form or a student, or potential student.

If I had any indication that they were asking for any other reason I probably wouldn't have answered. So kudos to the CL team for following up. My thinking is that if the person did not have anything to hide or was genuine in their intention, then they would not have become so offended by the CL team following up to seek clarification on her intent.


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## 8jimi8 (Jun 26, 2011)

The one thing i didn't notice is that no one said the first thing you do is disconnect the ventilator.


1 person bags, the the other person trouble shoots the vent.

No?


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## WTEngel (Jun 26, 2011)

A few people have said remove the patient and bag, but removing the patient is not always the first step for a deoxygenating situation.

Take your patient's status and condition into account. If it is a chronic trach vent patient then the vent is not the likely offender. Typically it is going to be an obstruction in the form of mucous plugging or thick secretions.

Even when it is an equipment issue, normally it is not actually the vent, it is the oxygen source or something with the circuit. There is very little that typically goes wrong with vents that isn't blatantly obvious.

Most of these patients don't have a high FIO2 demand, so oxygen source may be the cause, but probably not. Unless the vent is smoking and leaking air fr every crack it has, if you come up on some snotty trach that's bubbling into the circuit and decide to detach the vent and troubleshoot it while your partner bags, instead of suctioning first and seeing if the oxygenation rises, then your plan of attack is flawed.

Removing the vent first is an excellent strategy for the patient who has just been placed on the vent and begins to deteriorate or the patient who does not have routine plugging issues who becomes acutely deoxygenated.


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## 8jimi8 (Jun 26, 2011)

WTEngel said:


> A few people have said remove the patient and bag, but removing the patient is not always the first step for a deoxygenating situation.
> 
> Take your patient's status and condition into account. If it is a chronic trach vent patient then the vent is not the likely offender. Typically it is going to be an obstruction in the form of mucous plugging or thick secretions.
> 
> ...



Thanks Engel, great clarification.


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## firetender (Jun 27, 2011)

*I'll take the weight*

As CL.s we're all, theoretically, supposed to read each and every new post on the site. Much overlap would be occuring so that more than one person is regarding each post. When we see something unusual, we report it to each other and sometimes take action. There are checks and balances here. We bust each other sometimes.

Functionally, of course, each of us takes our best shot and jumps in when we can. In this case, this post caught my eye. The OP identified herself as interested in becoming a paramedic with no other qualifiers. She then immediately posted a question regarding proper care for a long-term patient.

Why? I asked myself. This is an emergency site.

So I PM'd her and asked for clarification of her intent. I also requested she not post again until she checked in with me. I was seeking conversation to open doors rather than close them. This wasn't even a warning, just a one-on-one expression of concern a request for clarity and a brief time-out. I guess it wasn't taken that way!

She PM'd back, taking umbrage at my questioning, and saying she was out of here.  She ID'd herself as an LPN soon to be assigned such a patient and unable to get the guidance she needed elsewhere. That opened up even more questions for me because her scope of practice is not the same as ours. We can't really advise her. The whole thing felt quite murky to me. I would have asked more

 ...but apparently she brought it back here to you.


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## tacitblue (Jun 27, 2011)

abckidsmom said:


> I wrote this as an email inservice not long ago:



I love your inservice. Perfect! Do you mind if I share this with some of the EMTs who work with RTs at my service? I will credit you (your handle, rather), of course.


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## CAOX3 (Jun 27, 2011)

I thought the original post was pretty benign.

Regardless, I think is a great topic for discussion.  With more and more vent dependent patients being managed at home, chances are we will be crossing paths on a more  regular basis.

The DOPE acronym is fantastic, thanks.

Now as EMTs does your area allow deep trachial suctioning or is that strictly an ALS skill?


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## medicdan (Jun 27, 2011)

CAOX3 said:


> Now as EMTs does your area allow deep trachial suctioning or is that strictly an ALS skill?



In MA, it's a BLS skill for a basic working on an ALS truck, so performed under the order (and supervision) of a medic. 

My default (if theres ever a problem) before immediately bagging a patient is to turn to FiO2 up on the vent-- and see if that corrects the problem. It's what we would do to a non-vented patient, who is on existing oxygen (turning up an n/c, switching to a NRB). From there, of course, transfer to a BVM while troubleshooting vent with staff/family, or preparing our vent with consultation of family/facility RT. RTs are generally an excellent resource, if available, I encourage you to take advantage of their wisdom and problem solving magic.


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## ladyMj (Jun 27, 2011)

emt.dan said:


> In MA, it's a BLS skill for a basic working on an ALS truck, so performed under the order (and supervision) of a medic.
> 
> My default (if theres ever a problem) before immediately bagging a patient is to turn to FiO2 up on the vent-- and see if that corrects the problem. It's what we would do to a non-vented patient, who is on existing oxygen (turning up an n/c, switching to a NRB). From there, of course, transfer to a BVM while troubleshooting vent with staff/family, or preparing our vent with consultation of family/facility RT. RTs are generally an excellent resource, if available, I encourage you to take advantage of their wisdom and problem solving magic.



Thank you I am trying to set up a day where I can shadow an RT. I can only read so much, so I would love to see resp. side in action;-) Thanks for a great idea! I am an LPN, but I going to see also if I can get into EMT work and eventually become a medic. I think the emergency side of care is intriguing, so I would love to pursue that avenue. I do have a client currently who has a trach and is vented, family is awesome, but I do have questions...but when you talk of worst case scenario...I like to be prepared and the family says 911 will be there in minutes and I am sure they will, but I just  want to know exactly what to do in any event. You all have really given me some good info! I did leave a message for the NCM to see if I can spend a day with an RT, so we will see....wish me luck;-)


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## squrt29batt12 (Jun 28, 2011)

if you have ANY trouble with the trach patient on a vent, d/c the vent and bag with 100% o2 (i would make sure the cuff on the patient's tube is inflated if necessary). i would suggest that you NEVER, let me repeat, never, remove the patient's tube. you run the risk of causing a laryngospasm, and have yourself in a bucket of s**t

just make sure the patient is being oxygenated, administer high flow diesel and let the er physician and rrt deal with clearing the obstruction


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## 8jimi8 (Jun 28, 2011)

squrt29batt12 said:


> if you have ANY trouble with the trach patient on a vent, d/c the vent and bag with 100% o2 (i would make sure the cuff on the patient's tube is inflated if necessary). i would suggest that you NEVER, let me repeat, never, remove the patient's tube. you run the risk of causing a laryngospasm, and have yourself in a bucket of s**t
> 
> just make sure the patient is being oxygenated, administer high flow diesel and let the er physician and rrt deal with clearing the obstruction



A trach insertion is below the vocal chords...  Are you sure that is what you Meant to say?  Are you talking about an ET tube?


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## squrt29batt12 (Jun 28, 2011)

You caught me in a brain fart, that's what I get for multitasking and half-reading the OP. For some reason I pictured the pt with an et, but it's actually a stubby trach tube, as you said below the larynx. Thank you for the heads up lol. Disregar:wacko:d my original post, wow


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## usalsfyre (Jun 28, 2011)

squrt29batt12 said:


> just make sure the patient is being oxygenated, administer high flow diesel and let the er physician and rrt deal with clearing the obstruction



With a seriously obstructed trach, you won't be able to oxygenate the patient no matter what you do. Knowing how to replace a trach, or clear a mucous plug is literally a lifesaving skill. 

"High flow diesel" very, very rarely a good treatment plan.


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## squrt29batt12 (Jun 28, 2011)

usalsfyre said:


> With a seriously obstructed trach, you won't be able to oxygenate the patient no matter what you do. Knowing how to replace a trach, or clear a mucous plug is literally a lifesaving skill.
> 
> "High flow diesel" very, very rarely a good treatment plan.



Of course always handle the ABCs even if it means having to remove/replace the trach IF you have poor compliance or the pt remains in resp distress, but where I live, transport times are 4-6min, and if I can properly oxygenate the pt, I will leave it to the specialists.


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