There's a cardiac arrest in progress, and we're coming in as a second crew. The code is taking place at a local nursing home, and CPR is in progress. As we approach with our equipment, we're walking down large halls with rooms on each side. It's a large nursing home, but I can hear the unmistakable sounds of a code being run. There is one strange sound, though. You know that sound the BVM makes when you release it, and it sometimes sounds almost like a quack from the duckbill valve? Well, it was a little like that, but not exactly. That sounds happens with you release the BVM. This sound was occurring during the squeeze of the BVM. The only way I can really explain this sound is as a...
Anyway, we get closer and closer as I'm observing this strange phenomenon and I noticed that the patient has a trach, to which the crew has a BVM attached. Every time the clinician squeezes the bag, the breath is getting lost through the mouth - it's not going into the chest. So, what's the problem? Let's check out the three things we need to know about trachs and then the problem will be very obvious!
And check out the extra part of this blog after the peer review. I try to answer some questions we had in response to our post on social media about trach questions.
There are different Types
I'm not just talking about brands - we usually see the brands Shiley or Portex - but not all trachs are the same in their form and function. As you'll see, varying types can make a big difference in some scenarios.
The original tracheostomy tube was a Jackson Trach. You might be unfortunate enough to run into one of these if you encounter someone who lives in the mountains or something. They're very old and hopefully all replaced by now, but you never know. See the problem with these? There's no BVM connector. Also, that device next to it is an obturator. It's used to blunt the tip of the device during placement into a stoma (modern trachs come with plastic versions of these).
It is interesting, though, that this original Jackson trach is still used as a reference of size in modern trachs in their coding systems.
Another quick point on these codings systems that you can see on trachs. You don't need the code to tell you if it's cuffed or uncuffed, you should have already known that by looking for the presence or absence of a pilot balloon. That last letter "H" and "R" for reusable or disposable inner cannula is also kind of useless. However, that "85" is very useful. Just imagine that there is a decimal in between those two numbers so that it's actually "8.5" - that's the size.
Next comes what most of us typically think of when we think of a trach. After metal devices, plastic came around. These airways are very simple - they have a connector, a flange, a tube, and a cuff. It's essentially like a shorter, more rigid version of an endotracheal tube. You'll often find these in cricothyrotomy kits that lots of people carry, such as a Pertrach kit. But, there's a reason you shouldn't use one of these trachs long-term. What is it?
Tracheostomies with an Inner Cannula
How would you clean that trach mentioned above? It would get pretty gross rather quickly if you think about it. And, what if it gets clogged with a mucus plug? You would essentially have to replace the whole device pretty often. This was a problem, which the new trachs with inner cannulas fixed, and they could be reusable or disposable. The cannula lines the inside of the trach, which can be removed easily for cleaning. This cannula catches all of the germs, dirt, dust, and mucus that get caught up in the tube. Picture the following scenario.
You are the patient and you've just coughed up an incredibly tough mucus plug into your trach, completely occluding it. As hard as you try to breathe, no luck. You grab at your trach and try to pull it out but you can't because the cuff won't allow you to pull it out, and you have no syringe to deflate your own cuff.
Yikes, right? That's a scary situation. Luckily, trach patients don't have to worry about that anymore because they have their disposable inner cannula which they can easily remove, which will bring the mucus plug with it. All modern tracheostomies should have one of these, and they make dealing with obstructions much easier (including the cuffless and fenestrated ones we'll look at next).
Here is an example where the cannula is actually required in order to attach a BVM since the adapter is connected to the inner cannula.
This type is VERY common. This inner cannula sits discretely inside the 15mm adapter and is barely noticeable. Those two 'wings' that you see squeeze together and allow the cannula to unclip and be removed.
Trachs do not have to have cuffs. In fact, many patients you'll encounter will not have a cuff. This should be part of your doorstep assessment of the patient. What are you looking for? A pilot balloon. If there's no pilot balloon, there's no cuff. The presence or absence of a cuff is something you'll want to note immediately, because without a cuff, how will you ventilate this person if you need to? You might wonder why someone would receive a cuffless trach in the first place - didn't the prescribing physician think of a case where this patient would need a ventilator? Cuffs make phonation more difficult even when deflated, and if the patient does not require any type of ventilation during the day or night (some trach patients are only on ventilators for portions of the day) then a cuffless tracheostomy will likely be used.
A cuffless tracheostomy, inner cannula, and obturator.
There is an exception to this rule about needing a cuff to ventilate a patient. If the patient has had their larynx removed (laryngectomy), you can use a cuffless trach for positive pressure ventilation (because there is no passageway from their trachea to their mouth or nose). You can usually tell if someone has had a laryngectomy just by palpating their neck. The stoma is also usually different in a patient with a laryngectomy. Because the trachea is being entirely rerouted, not just cut into, the stoma is larger and will sometimes simply have a filter attached to a LaryTube (pictures below). If the patient doesn't have any sort of 'trach' to attach to, just use an endotracheal tube. And keep in mind how easy it would be to right main-stem one of these patients since you're starting the ETT at almost the sternal notch (the carina isn't much further).
Here is a LaryTube - this is what sits in the stoma of a laryngectomy patient. As you can see, there is no adapter for a BVM or ventilator. This patient is cleaning their LaryTube with swabs. LaryTubes, for whatever reason, do not have inner cannulas (at least that I've ever seen).
A fenestration is an arrangement of holes, so a fenestrated trach must have holes in it. This is might seem a little confusing at first because it seems counterproductive to have holes in a trach. So, what's up with these devices?
Again, imagine that you are the patient with the tracheostomy. You're stuck with it, but you would like to be able to talk to people when you want to. So, how do you accomplish this? You would deflate your cuff, and then either plug the trach with your finger or attach a speech valve. This forces air past the vocal cords during exhalation and allows you to phonate. However, how well do you think you'll be able to speak with a trach partially occluding your airway? Not very well. This is why fenestrated tracheostomies were developed - to reduce the airway resistance and allow air to flow through the tracheostomy instead of around it (although they can be prone to certain problems). Pretty cool! Unless you're trying to bag one...
This is the type of tracheostomy that the patient had at the outset of this blog. The fenestrations were allowing air to take the path of least resistance, which was away from the chest that was receiving compressions. We ended up swapping out the trach for a 6.0 endotracheal tube, ensuring not to place it too deeply. We did not trim the tube, because it's often easier to simply secure the extra length of the tube.
This type of trach has an exception to this 'no ventilation' rule as well. If the fenestrated trach has a cuff, you may be able to find a non-fenestrated inner cannula to cover the holes. If they have a cuffed fenestrated trach, it's very likely that they have a non-fenestrated inner cannula sitting around somewhere nearby.
Here's an example of a simple typical fenestrated tracheostomy. The inner cannula is what is actually attached to the 15mm adapter, and there are large clips on the side that allow removal of the inner cannula. The cannula in the example below says "Do not clean or reuse" but they will also typically say "Not for ventilators" if they're fenestrated.
Here is a different type of fenestrated tracheostomy tube. This illustration is showing what's occurring during inhalation (left) and exhalation (right). This particular fenestrated trach is fitted with a bubble valve and flap on the cannula.
There are a couple of others that you might see, but they're not of great consequence to our specialty. There are devices that have sub-glottic suctions attached, which help prevent secretions from sitting on top of the cuff. There are also larger/longer tracheostomies that look a little different as well, these are used for thicker necks, or if the trach cuff has to sit lower in the airway (past tracheal malacia or stenosis).
Here are examples of proximal and distal Shiley XLT placement. This type of trach is also used in very tall people who could dislodge a normal-sized trach if they move their head and neck excessively.
Here is a tracheostomy with subglottic suction attached just superior to the cuff. This allows secretions sitting between the cuff and the vocal cords to be suctioned. This is especially useful for those who have lost some function of the upper airway are likely to aspirate into the trachea.
These are speech valves (sometimes called Passy Muir valves due to a popular brand). They are one-way valves that let air in, but not out. When the patient inhales, air goes through the valve, into the tube, and into the lungs. When they exhale, the valve closes, forcing the air to go around the tracheostomy tube and up through the vocal cords, allowing for phonation. Sometimes patients simulate one of these valves by covering the tracheostomy with their finger during exhalation.
Sometimes you have to replace them
Just like I outlined above with the coded patient, sometimes you need to replace the tracheostomy tube if there is no way you can use it for positive pressure ventilation. Here's a quick mental map to figure out if you need to swap out the trach for something different.
Most people will swap out a trach with a bougie. This isn't ideal, but it can work as long as the bougie fits through the trach and the tube you're using. However, here's a quick word of caution with the bougie. If you feel resistance, do not force it. You can easily perforate the tracheal wall with a bougie, and that would create a whole new set of problems. The ideal device you would want to use is a Cook Airway Exchange Catheter, but not a lot of services carry those. Just be very careful. You could exchange the trach without the aid of 'guidewire', and many people do, but it could be risky (especially if the stoma is less than a couple of weeks old). If that stoma is new, or the trach has been out for a while, you might not get back through. This would likely be a case for orotracheal intubation. I would just like to reiterate that a fresh trach can close rapidly. It is never ideal to swap a trach, but when you cannot oxygenate or ventilate a patient, you do not have a choice - you have to find another option if their current device will not work.
There were a couple of questions on social media that I don't feel were addressed anywhere else in this blog, so I'll address them here. The first question was:
'When should you BVM the stoma vs. BVM the mouth and cover the stoma?'
Here's the best answer I can give... Placing the BVM on a stoma is assuming some things. We're assuming that the stoma is patent, that the air is not going into a false passage or just leaking, and that the air will go into the lungs and not out of the mouth/nose. By using the BVM at the head, we're also assuming at least a couple of things. We're assuming the patient has a larynx and no anatomical disruption that would preclude the BVM from being effective. Because of all of these assumptions, it's difficult to give a straightforward recommendation. I would say the least of the evils is likely attempting traditional BVM ventilation at the head and covering the stoma with perhaps a Tegaderm. However, I would check the patient for a larynx first. Unless it's a low, wide-open stoma from a laryngectomy, I would have serious doubts that the ventilation would be effective through a typical stoma without a tube.
The other question was kind of multi-part:
What about vent modes / what if there are leaks / what about max leak compensation?'
Each vent has its own max leak compensation, so I cannot speak to how many LPM your vent will tolerate. You can use any mode of ventilation with a trach as you would an ETT, but this brings us back to the leaks topic. For some reason, trachs seem to have more leaks than endotracheal tubes. This may be due to the type of cuffs that are used. A lot of modern endotracheal tubes use high-volume low-pressure cuffs, which are more rectangle-shaped, allowing for more surface area of the cuff to be in contact with the tracheal wall. Tracheostomy tube cuffs are usually traditional spherical or tapered cuffs, that only tough the trachea at the far ends of the sphere or cone. This makes leaks occur more easily. Also, trachs can be kind of positional, and movement of them can cause a leak, whereas endotracheal tubes usually maintain their position rather well as long as they're secured. To come back around to that ventilator mode question, leaks will be less likely with lower pressures. So any mode that requires prolonged high pressures would be more likely to cause a leak, such as APRV. I would also include in this any setting that causes high peak pressure, such as a very short inspiratory time / high flow.
I hope that answered those questions! Thank you for posting those online!
Alright, now for our last point!
There’s a specific way to clear a Trach
Yes, we've all heard the joke. Have your partner stand right in front of the trach and instruct the patient to cough. But, seriously, a clogged tracheostomy can be a scary thing. Here are a few things you'll want to keep in mind. A lot of these items take place in rapid succession, but I did my best to try and prioritize them in a logical order - things change depending on the severity of the obstruction. If the patient is moving some air, you'll probably follow this order. If the patient isn't moving any air, you'll have to advance further down the list more quickly or skip some steps altogether.
Oxygenate (if you can). Ventilators usually have some sort of 'oxygen' button that you can press that will turn the FiO2 up to 1.0 for a set amount of time. The reason for these buttons is so that you can preoxygenation prior to a procedure that will likely cause the patient to desaturate. This would include things like a tube swap, bronch, or suctioning. If you're not using a vent, at least crank up some flow on an oxygen tubing and aim it at the tracheostomy. If you're struggling to get the oxygen aimed at the trach, you can also take a little piece of tape and secure the tubing to your glove while you're working with the patient. Just don't forget about and leave the patient without oxygen.
Check for the inner cannula. This should exclude the trach as a source of obstruction (but there could still be mucus on the distal tip of the trach or a large amount in the trachea itself).
Suction, suction, suction (but don't kill them). Sometimes we forget that when we're suctioning, we're literally taking the air out of someone's lungs, which is why I brought up the oxygenation point above. For suctioning, there is a simple formula for choosing the correct size of the suction catheter.
ID x 2 (then go down one size).
Example: ID ('size') = 7.0.
7 x 2 = 14, so use a 12 french. (This also works for endotracheal tubes.)
How far do we suction? We measure approximately from the adapter of the trach to the sternal notch. And, if you meet resistance, or the secretions are very thick, use saline. Flush ~3mL into the trach to help loosen things up. What if none of that works?
If you've removed the inner cannula, suctioned, irrigated with saline, suctioned again, moved the trach to see if it was positional, etc... are you're still not fixing the problem, you'll probably move to a BVM next and see if you can deliver a breath with it. This may move obstructions further down the lungs, kind of like what we do with a choking victim when we do breaths during CPR (better to have one lung blocked than two). I'll let you decide where the bougie goes in this scenario. For me, it would likely be after the BVM, and only if I was completely unable to pass a suction catheter. I would be very nervous to perforate the tracheal wall.
Trachs are a little more nuanced than we might think. They might have holes, no cuff, a cannula, or varying adapters or suction attached. When it comes to the airway, we want to be just as familiar with these devices are we are with our endotracheal tubes and SGAs. Troubleshooting a trach can be stressful (and messy). I hope this blog helped you get ready for your next tracheostomy emergency!
Thanks for reading!
Kristin Ireland, BAS, RRT, EMT
One thing I would like to mention is while you are assessing to remove a trach or not for emergent ventilation/oxygenation, I would advise people to look at the site. Many trachs have quite a bit of variability in the movement of the trach itself, that is one reason why people are afraid it will pop out, and yes without the ties keeping it in, that variability will cause you some trouble. You can actually pull the trach forward a bit and see under the flange that the site is fresh. This is indicated by the redness, bleeding, or even stitches that are placed to allow stability while the new fistula heals. Knowing this will prepare you and stop someone from pulling a trach emergently without thinking. Someone might think, oh this will just take a second. Well, it only takes a second for the site to close up enough for you not to get a new trach in or an ETT. Your bougie won't help you if the once dilated area is now so closed you're traumatizing the site and risking a false passage if the insertion was forced. It's been my experience that bedside percutaneous stomas close faster than stomas performed in the operating room. This may not be universal, but typically I've seen that in the OR, they excise a portion of the trachea to create a window. This is opposed to the bedside percutaneous stoma creation where there is a simple incision into the trachea which is then dilated.
Please excuse the lack of in-text citations, with this type of material there would have been a citation for every other sentence. Here are some books that cover this information about trach patients:
Kacmarek, R., Stoller, J., Heuer, A., Chatburn, R. & Kallet, R. (2017). Egan's fundamentals of respiratory care. St. Louis, Missouri: Elsevier.
Cairo, J. (2014). Mosby's respiratory care equipment. St. Louis, Mo: Elsevier.
Chang, D. (2014). Clinical application of mechanical ventilation. Clifton Park, New York: Delmar Cengage Learning.