person with trach on vent

[ladyMj]

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!

 

[abckidsmom]

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.

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.

 

[abckidsmom]

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

 

[18G]

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

 

[ladyMj]

Thank you

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

 

[18G]

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

 

[MrBrown]

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"

 

[WTEngel]

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.

 

[usalsfyre]

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.

 

[ladyMj]

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

 

[Handsome Robb]

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?

 

[ladyMj]

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!!!!

 

[18G]

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!

 

[AlphaButch]

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.

 

[MMiz]

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.

 

[WTEngel]

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.

 

[8jimi8]

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?

 

[WTEngel]

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.

 

[8jimi8]

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.

Thanks Engel, great clarification.

 

[firetender]

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.