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Please Take Some Deep Breaths

I am a Respiratory Therapy student/intern finishing my last 4 months in school. In my first months as a respiratory intern, I am finding that moments of learning are passing me by with each breath… literally. Why am I writing a blog? Mostly because my husband asked me to. With that said, I am realizing no matter what level of medicine you practice at, there is a difference between exposure and experience.

EXPOSURE “the state of being exposed (not covered or hidden) to contact with something.”

EXPERIENCE “practical contact with and observation of facts or events,”

Experience can be secondary to the exposure, if you want it to be. Not everyone gains experience. Experience is researching the exposure, understanding what you did incorrectly, and how we are going to do it differently next time. We can visualize and come in contact with anything in medicine. It’s easy to believe we did a bang-up job or threw that hail mary and move on to the next patient - forgetting about improving our skills. When we don’t analyze the exposure, we will create the same patient outcome every time (which might be okay if things went well). Or we end up hurting patients unknowingly. My purpose in writing about being a brand new RT will be: What did I miss and how will I avoid that next time?

When I worked in EMS I rarely walked away from a call feeling like I did an amazing job. I typically had a feeling of failure and I often ask myself the question “what did I do wrong back there?” Using my mantra “don’t look stupid” propelled me to prepare to be on top of new evidence based medicine - and in turn I did a better job caring for my patients. I am glad that has not changed now that I changed careers. I still go back and gain experience even if I know what I did was right.

Traipsing through the halls

As I traipse the halls of the hospital, undecided to either drag or push my computer, I know there is a PRN tracheobroncho toilet (TBT) on my assignment list that I will eventually have to assess. My hope is the RN doesn’t summon me to the room early. I am alone, as many RTs are in their daily assignments, and I have never done a TBT before. As I reach the end of my patient workload, I see that “TBT PRN.” No one has called, so I feel like I am in the clear - this may not happen for me today!

What is a tracheobronchial toilet (TBT)? My first instinct hearing this in lecture was, “so we are using a toilet for this procedure.” I have witnessed many dialysis machines hooked up to the bathroom sink with a hose in the toilet in the patient's room, I guess it made sense? What I found out was tracheo-bronchial is simply the trachea and bronchial structures. “Toilet” in french (different spelling) is “hygiene” in many uses of the language, or at least when Eagan’s Fundamentals of Respiratory Care was written. This procedure is not always referred to as "TBT." You may also hear "NTS" (nasotracheal suction) or "Pulmonary toilet."

So, what is it exactly? Hygiene of the trachea and mainstem bronchial structures. How do we accomplish hygiene? Suction. Suctioning someone's trachea and mainstem bronchi using a french catheter by way of the nasal passages. We know suctioning is implementing negative pressure to the airways. In this case RT’s use a catheter on a conscious patient who possesses indications for a TBT. Anything beyond the main stem bronchi requires bronchoscopy. At my facility the catheter is a red soft tip and come in sizes 10f or 12f, I haven’t found the red soft tip to come in other sizes, I am sure they do though. You can also use the clear french catheters - especially when using an NPA (we will talk about that later).

How do I find which size catheter? For starters, a TBT is not comparative to a typical ETT in-line closed Ballard suction kit that can be calculated by taking the ETT size multiplying it by 2 and using the next even number down. I am not assessing ETT approximate sizes for someone whose airway is not being intubated. That situation or calculation won’t help me here. When I initiate orders for the first pass, I bring a wide range of sizes. The curvature of the nasal passage can be too sharp for the larger red soft tipped catheter. However the stability of the 12f tends to not collapse as easy after engaging suction, but the smaller catheter is less invasive. Preference. I write this having done quite a number of TBTs now. For my first TBT, I relied on the kit in the room already stocked.

This is a sterile procedure to avoid contaminating the lower airways; that doesn’t always work. It is best to dedicate 1 hand to being sterile. This should be accompanied by water soluble jelly to prevent chafing and to ease excessive force of the catheter through the nose. Any resistance met can be combated with a twist in the catheter, if that doesn’t work, try the other nare.

Sometimes you will want to place an NPA for TBT. We have people who are scheduled TBT and PRN TBT. Scheduled suctioning is not a nice thing and is not typically recommended. It should be on a PRN bases due to changes in each patients condition. What if the patient doesn’t need suctioning but the order says “Q2 or Q4?" Sometimes the frequency of the TBT due to moderate to copious secretions calls for the placement of an NPA. We do this to avoid causing inflammation or airway biopsy of nasal tissue every time the catheter is introduced or suction is engaged. It seems to be a preference thing where I work. Just keep in mind, you would lubricate the NPA and not the clear french catheters because the lube is for the ease of passing the catheter through the nasal airway. The NPA does that for you. Avoid creating airway resistance and partially occluding the NPA by using lubricant.

Indications for TBT

This procedure sounds like it suuucks. Why would someone need a TBT in the first place? A few indications for TBT per the authorities that be (AARC clinical practice guidelines) include but are not limited to; visible secretions in the airway, chest auscultation of coarse, gurgling, rhonchi, or diminished breath sounds, increased tactile fremitus (feeling of secretions in the chest), clinically apparent increased work of breathing and sputum sampling if cough isn’t strong enough. *

Contraindications for TBT

There are many contraindications/hazards or complications that we will not go into great detail, always beware of hypoxemia/hypoxia and blood thinner medications. There is nothing like having an uncontrolled bleed in the airway. You want to avoid causing trauma or an accidental airway biopsy in these patients. Here’s the problem with hypoxemia, these patients will get hypoxemia if we don’t TBT at the appropriate times and they will be in danger of hypoxemia if we do TBT at the appropriate times. For our super oxygen hungry patients who rely on that HFNC or NRB, we are entering their airway and sucking their deadspace O2 out of them. For the PRN patient, contraindication are something to continue to be aware as these repetitive TBT-ers can evolve any of the listed reasons to discontinue TBT. In addition, the most apparent complication is a vagal response and it is important to monitor these patients before during and after for any of those responses. *

*For a full list, see the reference to the AARC website.

"Don't Look Stupid" - I enter the room of a 48 y/o male

So I take deep breath, repeat my mantra and I enter the room of a 48 y/o male with profound psychological roadblocks with the inability to cough up his secretions. He had no past medical history for significant pulmonary disorders. He did display poor posture and muscle tone and was incapable of getting the secretions to the hypopharynx to be suctioned by a yankauer. His mouth was not in service (G-tube placement) due to aspiration precautions, and this coupled with a non-productive cough provoked rhonchi. The patient’s sputum production were not even very viscous or copious in production, but he was retaining them thus causing a build up. Yep, he needs a TBT. There are other ways to tackle the build up of secretions for patients who are cognizant and cooperative. However, it is the very act of expectoration that we rely on to remove our secretions and all the crap caught in the goo. In turn a lack of that ability would warrant a TBT. With rhonchi or gurgling notable of attention, you may witness impaired gas exchange and increases work of breathing. This can develop a serious situation of desaturation, hypoxemia, or atelectasis and you would want a device that would clear secretions quickly-TBT.

The Procedure

We have arrived at the procedure! First thing, is he sitting up or not, he is- check. I open the suction kit and lay it out. I check suction pressure by occluding the tip and turning the dial to make sure pressure is between -120 and -150 mmHg. Some people will have that sucker blasting up past -300 mmHg to the threshold line with no reading, that is crazy to me. I like to hook the suction up right away before removing the catheter from its sterile protective sheath. I have a spot of saline for cleaning between passes. Check, check, check, check. Fortunately for me this patient is very familiar with TBT and is cooperative in the sense that he knows it’ll be an instant relief. I asked him to “smell” my catheter as I held it slightly away for his right nare to get him into the sniffing position for a better alignment. I chose the right nare because I was on his left side closest to the suction set up. His left nare was too much of an angle for me, I would have ended up being in the line of fire bent underneath him had he vomited. As I continue down his airway, making it past the curve and into the trachea, his face began to tense up and he was pulling out of the sniffing position. I asked him to breathe in because the vocal cords are totally open during inspiration. I proceed until I induce a cough or meet resistance. A cough ensues and I engage suction, slowly spinning the catheter between my fingers to reach the circumference of the airways. Success!! So much mucus! He asks for another pass and we clear it up in 2 rounds. Not too bad, eh?

What did I miss? For starters, I completely forgot the to lube up the catheter! I was fortunate to slide by because the patient's nares were already pretty lubed up from whoever was TBT-ing before me. They left a lot of the lubrication behind to prevent any irritation of room air passing by raw skin. I could have really made an already uncomfortable situation even more if he had been dryer. I never forgot that again, matter of fact I actually keep a packet of lubricant in my pocket now. Also, when on the floor of the hospital, and I have asked around quite a bit, it is not uncommon for patients to not be a pulse ox. I was a bit shocked. This patient like most, wasn’t in distress nor was he there for any critical respiratory problems. In the facility I work at, “patient care assistants” will come around check vitals including a SpO2 for you. Little scary though when you think about depriving someone of their oxygen during a procedure. Could I have gone and gotten the Dinamap? Sure, didn’t think about it though. In considering how I took this poor man's oxygen away, I also missed preoxygenation and recovery oxygenation. Another preference for each individual RT. Some will say “oh yea, you should have brought a mask with you” others tell me “He didn’t have O2 on or in his room, it was only a few seconds, I am sure he is fine.” Something to consider nonetheless. Since it is a preference, I have brought both items in with me for that reason. In addition, I never kept track of the amount of time I was suctioning. When I had thought about it, I have no idea what 10-15 seconds feels like. When someone isn’t in need of immediate suction, I suppose it would be easier to be aware of that. In my case, I am sure I suctioned too quickly. Could he have benefited from the allotted time? I don’t know, I will need to practice time management. I still haven’t gotten the timing down, I need to work on being more aware of that. Lastly, after talking to a lot of RTs, I was advised that I could actually keep the catheter in the nasal passage if I wanted so I didn’t have to keep reinserting it over and over (which is the worst part).

I learned a lot from that procedure just by going back in my books, notes and asking around to seasoned RTs. I was exposed to the procedure of a TBT and although I was competent in it, I definitely didn’t have experience. I gained experience by correcting my shortcomings. Now when I go in to perform a TBT, I use all the bits and pieces I missed the first, second, third, fourth and so on, to create as comfortable of a situation as I can for me and most importantly the patient.

References within the AARC document:

Video demonstration of TBT procedure:

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