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.
Her vitals:
HR: 130
RR: 48
SpO2: 89%
BP: 104/60
Temp: 101.7
What’s your initial read on her problem? What can you do for her? What’s the proper technique for ventilating a patient with a trach?
As always, your first priority is airway. With secretions blocking the trach and the large upper airways, this patient is having trouble moving enough air. You’ll need to preoxygenate her and suction her to clear these secretions. Getting out the adult BVM, you desperately hope that it will fit the adaptor of the trach. Phew! 15mm! If the trach had an 11 mm adaptor, you could use the family’s BVM or use a pediatric face mask placed over the trach and sealed on the patient’s neck to ventilate the patient.
Once she’s preoxygenated (hopefully you were able to get her sats up above 92-94%), you need to suction her again. The patient’s mom may have an opinion on what you use in the trach, it’s great to involve her in the discussion. We carry french catheters, which are probably a bit too rigid for her delicate airways, so if you decide to use what you have instead of her standard equipment, just know that you have to be very gentle. Flushing with saline bullets is not advised unless the secretions are so thick that they can’t enter the catheter. Use a new, sterile catheter and do your best to maintain sterility on the tip and the length of the catheter that enters the trach. When you insert the catheter, leave the thumb hole uncovered as you slowly advance until the patient starts to cough. The catheter is sitting at the carina of the trachea, stimulating the cough reflex. Now you can cover the thumb hole and swirl the catheter around as you slowly withdraw it. The same catheter can be used for several passes in a row, but watch the O2 sats, and stop to ventilate if her sats start to drop.
Just a few minutes on dry, cold, high-flow oxygen can cause a nightmare for her lungs. When patients have trachs, the standard anatomy that functions to warm and humidify the air we breathe is bypassed by the hole in the neck. Cold, dry air can actually cause injuries like burns to the airways. So, make sure you grab whatever humidified oxygen setup they may have in the house, if one’s available. Our standard BVMs are not compatible with humidified oxygen setups, so ventilate her if she needs it, otherwise just use the trach collar or a nonrebreather placed over the trach.
Would you want to use the ventilator for this patient? Only if you want to hear the alarms the whole way to the hospital. There are too many variables with this patient to be able to use the simple transport vent that we carry. Use the BVM if you think she needs ventilatory help.
So now we spent this week’s email talking about her airway and breathing, next week we’ll focus on IV therapies and the rest of the special considerations you’ll need to have for this patient.
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