Tracheostomy and Oxygen

Amanda in Omaha, Nebraska said: I am wondering if using a nasal cannula to deliver O2 is effective with someone with a tracheostomy (assuming the cuff is deflated).

Hi Amanda, For tracheostomy patients, it is best to use a trach mask for oxygen delivery. We risk patient aspiration with a deflated cuff. And a nasal cannula would be ineffective for those patients whose upper respiratory anatomy has been surgically removed due to cancer... etc. I hope this helps. I wish you well. Good journey.

It depends on if this trach is going to be permanent or if it will be removed in the future. If plans are to remove it eventually, the cuff is deflated, the trach capped with the red trach button, then a cannula would be used for O2 requirements, but if its a more permanent trach or the issue causing the trach to be inserted in the first place is not yet resolved there would be no 'weaning' and a trach mask should be used as Rolinda stated above. Prior to permanent removal of a trach (decannulation), it would be capped and the patient would be assessed to see if they tolerate this well. If that goes well, after a period of time the trach tube is removed leaving an open stoma (hole) which would be cleaned and bandaged regularly and then the stoma would close naturally.

If the trach is going to be permanent for the patient, many trach tubes commonly used by home patients do not have a cuff at all, but some do. Some home trach patients require oxygen while others do not. While I recommend that all trach patients use aerosol humidifying devices, many home trach patients who do not need O2 use HME's or no humidification at all.

Thanks for the great information. What about if the person is utilizing a Passy Muir valve? Do you recommend that the cuff be inflated when the Passy Muir is not on, or does it just depend on the person.? I work in a skilled nursing facility and there does not seem to be any consistency as far as when the cuff is deflated (and HOW much it is inflated) Are there guidelines they should be using?

I've seen the cuff both ways when the PM valve is not being used. Everywhere I have worked it was pretty much the way the doc wanted it with consideration to how the patient tolerated it.

P.S. About the amount of cuff inflation, use minimal leak technique to prevent necrosis of endotracheal tissue.

even if the cuff is deflated the trach tube itself would increase resistance oxygenation would be inadequate.

phillip in West Covina, California said: even if the cuff is deflated the trach tube itself would increase resistance oxygenation would be inadequate.

Duh.. well of course breathing through ANY tube would cause an increase in resistance vs. breathing normally, but trach or ET tubes certainly do not make oxygenating these patients inadequate and your response wasn't appropriate to the question which was asked. Sorry to be so sarcastic here, but shame on you if you are a therapist and if you aren't one, then why would you even be answering?

I am a nurse and I have been working with a patient who has a tracheostomy, she wears a humidifier and nasal cannula. This woman has copd also. She has an order for 8L via nasal cannula. I asked someone why her o2 was so high and they told me that since she has a trach that she loses half of the o2. I personally think she is be over oxygenated but I'm not sure.

First problem.. You can't give 8 lpm of O2 with a nasal cannula.

since the patient has a trach the pt should be on trach collar/trach mask for oxygen and humidification and ABG would also be nice.

Yes you can...ever hear of a high flow nasal cannula?

Why would an ABG be nice?

kristi in Galion, Ohio said: Yes you can...ever hear of a high flow nasal cannula?

A high flow if the pt is capped but on the same page you could also use
transtracheal augmented vetilation ( aka TTAV)

BonnieJo in Dearborn, Michigan said: Why would an ABG be nice?

to find out if this pt really needs that much oxygen

So you'd opt for an invasive time consuming procedure as opposed to the immediate feedback of pulse oximetry to check if someone is being over oxygenated??? Interesting. Good luck on your clin sims. I assure you the software won't find your choice of ABG as being something that is nice for this particular patient.

Huhh in Woodstock, Illinois said: So you'd opt for an invasive time consuming procedure as opposed to the immediate feedback of pulse oximetry to check if someone is being over oxygenated??? Interesting. Good luck on your clin sims. I assure you the software won't find your choice of ABG as being something that is nice for this particular patient.

I dont think that was RTPBALLERS point. 1st, he didnt say he was assessing oxygenation he simply stated "to see if the patient needs that much oxygen". 2nd, where did it say to perform one now? An ABG would be nice could VERY SIMPLY mean any current history of one also!

Now, in regards to the "assessing proper oxygenation of a COPD pt with an ABG". Not all COPD pt's are on O2 sensitive or CO2 Retainers. So looking at an ABG can definitely help properly assess your patient. WHY... well DUH... HUHH! Is the patient PcO2 compensated or acidotic due to... TOO much O2?!? acidotic PcO2 + Superoxygenation= no more hypoxic drive. Hence assessing the need for proper oxygenation.

This should have been the moment to educate someone for you Huhh! A few more patients and a few more years. Then you will KNOW IT ALL!!!

i have a question about trachs. what is the difference between a portex and shiley trach? is one bigger, wider, or longer than the other one and which one?

Huhh in Woodstock, Illinois said: So you'd opt for an invasive time consuming procedure as opposed to the immediate feedback of pulse oximetry to check if someone is being over oxygenated??? Interesting. Good luck on your clin sims. I assure you the software won't find your choice of ABG as being something that is nice for this particular patient.

you are definitley a noob. A pulse oximetery only tells part of the story. A pulse ox does not tell me hemoglobin, Pco2, or Po2 (YES THERE IS A DIFFERENCE) And besides an ABG is more accurate than pulse ox any day. As for the clin sims if you base you assesments on pulse ox you will get it wrong. Here is a typical scenarion. You get a fire victim and has burns around is mouth and nose
he is breathnig 40 bpm, hr= 120 sats= 100% on room air and is bright red and sitting down. The pulse ox will give you a FAlSE reading. Yes the RBC are full, but they are not full of oxygen they are full carbon monixide (hint think affinty). This is known as carbon monixide poisoning. YOU WOULD HAVE FAILED THIS SCENARIO!!!! and props to Sweet Rt. She is 100% correct.

You should have stopped while you only looked slightly fooling RTP.

No disrespect intended Sweet RT but "an ABG would be nice" sure doesn't sound like they want to see the results of an old ABG. The student wanted to stick the patient to find out all sorts of information that simply isn't needed YET. Simple titration of the liter flow and checking that against the SAT would suffice to arrive at the correct liter flow (Pst or a call to the physician who wrote the order as to why they ordered it so high). There was nothing in J Rice's information about this patient that would indicate this patient was in distress and needed to be stuck to see how they are ventilating (or to check they carbox, met, ferrous Hb - RTP stop reading out of text books and get some real life experience – non one said this pt was in a fire). As far as your rant about hypoxic drive, etc, it wasn't needed or indicated either as again, no information was given about the patient's condition. You simply have a trach patient who is on 8 LPM NC, the nurse stated she thinks the patient may be getting too much O2, again, the smartest, fastest, most non invasive way to check that is by turning down the liter flow until it is NOT too much. And again, an ABG isn’t needed in order to accomplish this. But hell, if RTPballer wants ABG’s on all their patients, if they do ever make it past their CRT, RRT, and Clin Sims, more power to them. Going to be some long shifts ahead.

This question is for an RT who knows what they are talking about; VS. Someone who thinks they know....seriously. Can a non-ventilated trach patient get too much humidification? I'm not sure what they exact name of the system used is, but it is heated water delivered via a trach collar.

What you are talking about is simply a heated aerosol, and no the patient won't get too much humidity. Ideally they should get air that's 100 percent saturated at body temp, but that rarely happens in the real world unless you have a closed system (vented) and a humidification system designed to deliver that (IE one of the newer fisher paykel systems)

Thanks for your reply. I am a nurse and have been with my pt. for over 2 years. All the nurses have their own ideas on how much humidification he should get. What you said, is what my pt.s RT said, but some think that he can get too much and he gets all "soupy" and produces copious amount of secretions. I am 99.9% sure that the reason he gets this way sometimes is because he drools allot and is unable to manage this by swallowing. Although he has a cuffed trach, allot still goes down into his lungs. I can see; he has a mouthful of saliva and it is running out of his trach stoma. Anyway, thanks again, I would love to have an RT to talk to, as I have so many questions to ask. I have done allot of research on the internet, but as I'm sure you know, each pt. is a little different. Thanks again:)

Vapotherm-high flow nasal canula

I have an 87 y/o male who is at home on a ventilator. I attempted prior to dc home to have the LTAC switch trach's out so he could talk. Of course they did not do that. Now I need some direction as to how much of an issue is it to do this. He is pretty much homebound so going out for multiple appointments is not going to work. Is it as simple as changing the trach? If not what else does it involve. I don't want to suggest this to the patient and family before I feel it may be a realistic option.
Thanks for any insight. Sandy

I have severe sleep apnea, cannot tolerate the CPAP after 10 years of use, and have had the UPPP surgery which didn't work. My options now are to shave the back of my tongue and try to remove more from my mouth and throat, or to have a Tracheostomy. My question to you is do people maintain gainful employment after having a permanent tracheostomy or are they considered disabled?

the patient has lung cancer stage 4 is it of if you stop the oxygenation if the patient has a tracheostomy what is the preffered liters of oxygen??

Curious in Clifton Heights, Pennsylvania said: I have severe sleep apnea, cannot tolerate the CPAP after 10 years of use, and have had the UPPP surgery which didn't work. My options now are to shave the back of my tongue and try to remove more from my mouth and throat, or to have a Tracheostomy. My question to you is do people maintain gainful employment after having a permanent tracheostomy or are they considered disabled?

Well you should seek second opinion. There are more modalities than just CPAP your OSA could be worse or miss diagnosed the first time around and you could have more of a CENTRAL SLEEP APNEA PROBLEM... and in most cases when a person cannot tollerate CPAP they are tried on BI-PAP. You should consider getting another study to see if your settings are even appropiate then getting a second opinion about your options. From my expierence surgery is always a coin toss and more often then not do not help.

Far as I know your are not on diability because you have trach that is something you could speak to your physician about.

Also, you should adress other factors that are affecting your OSA and speak to a DR about common causes beyond anatomy.

Curious in Clifton Heights, Pennsylvania said: I have severe sleep apnea, cannot tolerate the CPAP after 10 years of use, and have had the UPPP surgery which didn't work. My options now are to shave the back of my tongue and try to remove more from my mouth and throat, or to have a Tracheostomy. My question to you is do people maintain gainful employment after having a permanent tracheostomy or are they considered disabled?

I work for a DME setting pt.'s up on cpaps and bipaps. So , please before you have surgery that serious, let me ask you a few questions. What kind of mask do you have? Have you had a new sleep study lately? What about a bipap or cpap with a flex setting? Some dentists also have dental appliances that can treat sleep apnea.

When taking a trach pt. (recently got trached) off the vent in CPAP mode, and placing them on a trach collar is it necessary to deflate the cuff.

if they are on mechanical ventilation the cuff must be inflated. if the are on Cool Aerosol then deflated

RRT in Tulsa in Broken Arrow, Oklahoma said: I work for a DME setting pt.'s up on cpaps and bipaps. So , please before you have surgery that serious, let me ask you a few questions. What kind of mask do you have? Have you had a new sleep study lately? What about a bipap or cpap with a flex setting? Some dentists also have dental appliances that can treat sleep apnea.

What is a "flex setting"? They want to do a trach on my mom because they have not been able to wean her off vent in ten days. She has too much pulmonary secretions and her CO2 level is too high when off the vent now. Is there any alternative to a trach?

Mary don't confuse the CPAP mode on a vent with CPAP/BIPAP. It's not the same thing. Listen to your doctors. 10 days on the vent without the ability to wean is time to start thinking about traching the patient for all the reasons I am sure the docs clearly explained to you. There is a no need to try and get 2nd opinions here. They aren't trying to hinder your Mom's recovery.

tweetRT in Lexington, South Carolina said: When taking a trach pt. (recently got trached) off the vent in CPAP mode, and placing them on a trach collar is it necessary to deflate the cuff.

dont listen to the other girl on or off the vent if they are aspiration precaution the cuff is inflated only deflate the cuff with a PMV on to talk or eat.

Amanda in Omaha, Nebraska said: I am wondering if using a nasal cannula to deliver O2 is effective with someone with a tracheostomy (assuming the cuff is deflated).[/QUOT

Tracheostomy is the option when a patient is candidate for more than 10 days of mechanical ventilation due to failed weaning. It can also prevent trauma to oral cavity and pharynx of the patient.

Tracheal cuff must be inflated at all times, unless when patient is on per oral diet as per Speech Therapist advice/recommendation.

For trial of tracheal tube extubation.....cuff deflation is done plus monitoring of breath rate, O2Sat etc. This should be done during daytime for safe practice. It is also important to consider the neurological status of the patient as well as cardiopulmonary condition.

Amanda in Omaha, Nebraska said: I am wondering if using a nasal cannula to deliver O2 is effective with someone with a tracheostomy (assuming the cuff is deflated).[/QUOT

Tracheostomy is the option when a patient is candidate for more than 10 days of mechanical ventilation due to failed weaning. It can also prevent trauma to oral cavity and pharynx of the patient.

Tracheal cuff must be inflated at all times, unless when patient is on per oral diet as per Speech Therapist advice/recommendation.

For trial of tracheal tube extubation.....cuff deflation is done plus monitoring of breath rate, O2Sat etc. This should be done during daytime for safe practice. It is also important to consider the neurological status of the patient as well as cardiopulmonary condition.

Amanda in Omaha, Nebraska said: I am wondering if using a nasal cannula to deliver O2 is effective with someone with a tracheostomy (assuming the cuff is deflated).

P.S. I'm confident to say that no one would think of delivering O2 via nasal cannula for a patient who has tracheostomy ---- obviously "nasal cannula" is being to deliver O2 via the nose.

Henry in Sydney, Australia said: P.S. I'm confident to say that no one would think of delivering O2 via nasal cannula for a patient who has tracheostomy ---- obviously "nasal cannula" is being to deliver O2 via the nose.

Well in fact have a pt who was a prior decannulation who was retrached who can only tolerate a nasal cannula due to the fact she still uses her nose to breathe cant tol trach collar

Huhh in Woodstock, Illinois said: So you'd opt for an invasive time consuming procedure as opposed to the immediate feedback of pulse oximetry to check if someone is being over oxygenated??? Interesting. Good luck on your clin sims. I assure you the software won't find your choice of ABG as being something that is nice for this particular patient.

an ABG is not time consuming either. i run abg's in less than 5 mins...just for the record

Amanda in Omaha, Nebraska said: Thanks for the great information. What about if the person is utilizing a Passy Muir valve? Do you recommend that the cuff be inflated when the Passy Muir is not on, or does it just depend on the person.? I work in a skilled nursing facility and there does not seem to be any consistency as far as when the cuff is deflated (and HOW much it is inflated) Are there guidelines they should be using?

amanda, i don't know if anyone answered your questions about the speaking valve. but when ever there is anything plugging the trach, allowing someone to use there upper airway, the trach must be deflated so that the pt can breath around the trach. it the cuff is inflated the pt could possibly die. it would be the same as if someone had a sputum plug.

lolo in Anchorage, Alaska said: Well in fact have a pt who was a prior decannulation who was retrached who can only tolerate a nasal cannula due to the fact she still uses her nose to breathe cant tol trach collar

the only thing wrong with that is if the trach is not plugged they do not use there upper airway, causing the nc to not work.

J Rice in Warrensburg, Missouri said: I am a nurse and I have been working with a patient who has a tracheostomy, she wears a humidifier and nasal cannula. This woman has copd also. She has an order for 8L via nasal cannula. I asked someone why her o2 was so high and they told me that since she has a trach that she loses half of the o2. I personally think she is be over oxygenated but I'm not sure.

A NASAL CANNULA ONLY GOES FROM 1-6 LPM NOT 8. I AM A RESPIRATORY THERAPIST. BEING A NURSE OBVIOUSLY HAS NOTHING TO DO WITH IT. A SIMPLE MASK GOES FROM 6-10 LPM.

This is fr Susan D,

I am relocating to Louisville, ky. Can you recommend a good Trach Doctor for my contuning treatment?

kcnt in Rochester, New York said: an ABG is not time consuming either. i run abg's in less than 5 mins...just for the record

Just for the record, you do NOT get a call, walk across the hospital, check the order, gather the equipment, talk the patient, perform the stick, run the gas in 5 minutes... so go sit back down at the students table. Again, an ABG is not indicated to assess oxygenation in this case.

kcnt in Rochester, New York said: an ABG is not time consuming either. i run abg's in less than 5 mins...just for the record

Just for the record, you do NOT get a call, walk across the hospital, check the order, gather the equipment, talk the patient, perform the stick, run the gas in 5 minutes... so go sit back down at the students table. Again, an ABG is not indicated to assess oxygenation in this case.

Jari in Hosen, Israel said: No disrespect intended Sweet RT but "an ABG would be nice" sure doesn't sound like they want to see the results of an old ABG. The student wanted to stick the patient to find out all sorts of information that simply isn't needed YET. Simple titration of the liter flow and checking that against the SAT would suffice to arrive at the correct liter flow (Pst or a call to the physician who wrote the order as to why they ordered it so high). There was nothing in J Rice's information about this patient that would indicate this patient was in distress and needed to be stuck to see how they are ventilating (or to check they carbox, met, ferrous Hb - RTP stop reading out of text books and get some real life experience – non one said this pt was in a fire). As far as your rant about hypoxic drive, etc, it wasn't needed or indicated either as again, no information was given about the patient's condition. You simply have a trach patient who is on 8 LPM NC, the nurse stated she thinks the patient may be getting too much O2, again, the smartest, fastest, most non invasive way to check that is by turning down the liter flow until it is NOT too much. And again, an ABG isn’t needed in order to accomplish this. But hell, if RTPballer wants ABG’s on all their patients, if they do ever make it past their CRT, RRT, and Clin Sims, more power to them. Going to be some long shifts ahead.

Oh, boy...basically we need more info here because either of you could be right. A trach pt receiving o2 by NC could be doing very well and weaning off the trach heading toward decanulation, or could be highly complicated and using atypical therapy due to complex conditions (or just plain receiving the wrong therapy). In the first case, a pulse ox would likely do nicely. In the second, you really would need an ABG or at least a VBG because determining oxygenation status in a chronically ill pulmonary patient requires consideration ph and CO2

Amanda in Omaha, Nebraska said: I am wondering if using a nasal cannula to deliver O2 is effective with someone with a tracheostomy (assuming the cuff is deflated).

When someone is trached you are bypassing the upper airway. It is not an option to use a n/c with a trach patient unless the patient has a trach plug and is using nose and mouth.

Susan D in Waterloo, Ontario said: First problem.. You can't give 8 lpm of O2 with a nasal cannula.

it is not recommended to give O2 via nasal entry >6lpm but it can be done. It sounds as if you are talking about a chronic patient in home setting. What we do in an acute care setting and what we do in home settings are not always the same. if a pt has a trach and is on a nasal cannula i would think that what you are getting is a percentage of o2 equivalent to a venturi system. I can not tell you what percent fio2 it is, it would be dependant on the the depth of respirations. the main thing is if it works, it works. too often we see things happen that go against what we are taught. if it is working for that patient then fine. you don't need an abg, but if you have an oxymeter you can monitor sats that way. and the arrogant puppy that knows it all and responded with a "duh" should be looked at as a know it all that really does not "know it all"

Can a trach patient go on BiPAP?

Renee.. sorry sweetie... but you cannot force > 6 lpm through a low flow nasal canula. It goes 0-6. That's it. You can try to go higher... but you'll create back pressure and assure you patient isn't even getting 6 any more.

This has nothing to do with home care vs. acute care, this has to do with the very first device you learn when starting respiratory classes in college... a NC. Congrats!