Approach to downsizing trach

[VentdependenT]

Seeing as how we are placing lots of perc-trachs ourselves what is your approach to downsizing and decanulating?

I understand intial trach must be in 7-10d for track to mature

I understand to consider downsizing pt must be vent free for several days, be hemodynamically stable (otherwise high risk of needing invasive ventillation), be able to clear secretions (?anybody check MEP? Doesn't seem practical), be able to swallow their secretions (have gag), and not have sky high paco2, not be neuromusculairly impaired significantly.

If I understand this correctly:
-change to 6.0 uncuffed for at least 4 days
-if tolerate this then cap under supervision (eval for glottic stenosis if flop cap) for a day? two days?
-then decanulate

Size 4 has no role unless very tiny person?

WHy use a jackson-pratt? WHen use it?

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[Hernandez]

Why use an uncuffed? Once we hit a 6, we deflate, if doing well then cap and possible decannulation.

 

[VentdependenT]

If you are going down to a 6 arent you comitting to pt being off vent? So would I use a cuffed anything if i was downsizing?

 

[core0]

Why use an uncuffed? Once we hit a 6, we deflate, if doing well then cap and possible decannulation.

We use an uncuffed because of the possibility of the cuff getting inflated on the floor and the patient obstructing. Which has happened with cuffed trachs (multiple times).

 

[VentdependenT]

We use an uncuffed because of the possibility of the cuff getting inflated on the floor and the patient obstructing. Which has happened with cuffed trachs (multiple times).

1000% agree.

 

[Hernandez]

We use an uncuffed because of the possibility of the cuff getting inflated on the floor and the patient obstructing. Which has happened with cuffed trachs (multiple times).

I can see that point, i guess ive been spoiled as Cuffed trachs are only allowed on 2 floors outside of the ICU, both of which have dedicated RT,

 

[redy]

The last patient we decannulated my attending argued for a cuffed trach just in case he decompensated at night and needed to be put back on vent.

If I am understanding it correctly the argument for a cuffless trach would be that if he obstructed the trach from secretions he would still be able to breathe around it? But that would mean that any trach patient off the vent should be cuffless, no? Which would be a problem if he needed to be back on the vent (in the initial stages of weaning off the vent for example)

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[core0]

The last patient we decannulated my attending argued for a cuffed trach just in case he decompensated at night and needed to be put back on vent.

If I am understanding it correctly the argument for a cuffless trach would be that if he obstructed the trach from secretions he would still be able to breathe around it? But that would mean that any trach patient off the vent should be cuffless, no? Which would be a problem if he needed to be back on the vent (in the initial stages of weaning off the vent for example)

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Yes. Once you've downsized the trach (ie the tract is stable) its simple enough to put a cuffed trach back in. You don't change it out until they are off the vent (and you are reasonably sure they aren't going back on.

 

[jdh71]

Most trach decanulation around here gets done at outside facilities. So like most things probably ends up being a bit nuanced, but I leave the cuffed trach in until they can trachdome for ~48hours with any significant respiratory decomp and secretions can be handled. I know patients aren't happy about trachs, but they come out, the hole closes, whatever, so I simply don't rush it. Change out the cuffed to uncuffed and cap as tolerated. Usually by this time they will have gone to a rehab spot and have them removed there, but if still in the hospital and they are strong enough by my estimation, able to clear seceretions, and the reason they were placed on the vent in the first place has resolved, then I take it out.

 

[VentdependenT]

Most trach decanulation around here gets done at outside facilities. So like most things probably ends up being a bit nuanced, but I leave the cuffed trach in until they can trachdome for ~48hours with any significant respiratory decomp and secretions can be handled. I know patients aren't happy about trachs, but they come out, the hole closes, whatever, so I simply don't rush it. Change out the cuffed to uncuffed and cap as tolerated. Usually by this time they will have gone to a rehab spot and have them removed there, but if still in the hospital and they are strong enough by my estimation, able to clear seceretions, and the reason they were placed on the vent in the first place has resolved, then I take it out.

So you put the 6.0 cuffed in vs uncuffed in case they need PPV AND to facilitate
shrinking tract size at same time. Otherwise I dont see the point of dropping an 8 to a 6 cuffed.

But I am learning and I like the approach.

 

[jdh71]

So you put the 6.0 cuffed in vs uncuffed in case they need PPV AND to facilitate
shrinking tract size at same time. Otherwise I dont see the point of dropping an 8 to a 6 cuffed.

But I am learning and I like the approach.

Yeah. That's usually been my thought and approach. You could argue it's overly cautious, but I like that pathological airway control until I'm convinced the airway isn't going to any longer be an issue. If I put in an uncuffed, I like to have a cuffed trach follow the patient into their room, and kept in a neat little box at the bedside.

Though, if at your shop you send out cuffed trachs to the floor, then perhaps maybe not a great idea and just drop the uncuffed trach in. Where I work, you don't get out of the unit with a cuffed trach. There is a floor that can/will handle chronic vent patients but that's not really what we're talking about.

 

[dweinstein]

I am a speech pathologist working in acute care. The benefits of downsizing to a 6 cuffless are numerous. Size 8 are often too big (both the outer cannula and balloon rubbing against the tracheal wall), and when left in too long have negative effects on voicing and swallowing (reduced airflow going up through vocal cords). Once a 6 is put on and a patient can get good voicing with occlusion, then a Passy Muir valve can be placed, which will allow the patient to communicate and will also help with swallowing. So even if you're not going to decannulate right away, at least the patient can be discharged being able to talk and is one step closer to decannulation in the near future. With Shiley, only the cuffless trachs come with a cap, so another reason to switch the cuffless.

 

[Hernandez]

So even if you're not going to decannulate right away, at least the patient can be discharged being able to talk and is one step closer to decannulation in the near future.

Often this is the least if my concerns in most of these PTs. Granted I don't deal with trauma or neuro PTs at this point and most of the medical PTs are older with significant co-morbidities that pt them at increased risk relapsed of new infection. As JDH alluded to, honestly we almost never make it to a cuffless Trach in the acute care setting.

 

[VentdependenT]

Important for me as I will and do see these patients s/p pulm perc trach and must manage them until safe decanulation.

 

[Hernandez]

Important for me as I will and do see these patients s/p pulm perc trach and must manage them until safe decanulation.

Do you cover an LTAC as a fellows?

 

[VentdependenT]

There is a kindred floor in one of our hospitals

 

[idiot07]

We routinely downsize open trach's on postop day 5. I don't think waiting a little longer on the perc trach is a bad idea since you don't have the stay sutures in. If the patient's neck is huge or changing it looks difficult, I find changing the trach out over eschmann via the seldinger technique is helpful. Venty-the floors at the U do fine managing cuffed trachs so that's not a big deal (The RT's, nurses, and speech therapist all know to let the cuff down before sticking anything on it). Patients actually do pretty well on the vent with a 6 in, and I'll put a six in as the initial trach for someone who's getting it for airway control, i.e. massive facial trauma, and I'm expecting to come off the vent rapidly. If they're going to be on the vent for a while and need to be upsized from a 6 to an 8 this can be accomplished rather easily with the blue rhino kit, just put the wire and redilate. I would not attempt to just stick and 8 trach in a hole that has had a six in in it though. I don't always plug before removal. If they're tolerating passimuir, and talking they'll usually tolerate decannulation. This is primarily a trauma patient population though. They also make fenestrated trachs with holes in them to help the patient breath around the tube and clear secessions etc.

 

[bigtuna]

We use this for perc trachs that need to be changed before POD #7

http://www.cookmedical.com/cc/dataSheet.do?id=4012