You have to remember, never try to replace a fresh tracheostomy in the ICU, ever. I don’t care it there’s a suture hanging out and you can see the hole. If you’re in the E.D. and somebody comes in, they’re a chronic trach patient, that’s fine. But in the unit, for somebody who’s on a ventilator, never, never try to replace a fallen out tracheostomy tube, just orally intubate them and put the trache back under controlled conditions (of course this does not apply if their pharynx and larynx were removed, you may have to try to get that one back in, but if it doesn’t go in easily, and if theyre breathing, put supplemental oxygen over the hole and call for ENT help).
Everybody thinks that when you put a trach in that’s the end of the airway, trachs are put in for convenience unless somebody gets a laryngectomy. If the trach’s not working you pull it out and you put them back on the ventilator using an endotracheal tube. Not remembering that has probably led to the demise to quite a few patients, because people just keep messing around with the trach and trying to suction through it and trying to repositioning it and trying to do this and trying to do that. Bottom line, if you don’t think the trache is in the right place, just pull it out, and just go ahead and endotracheally intubate them. 99% of the cases, the trach was not placed because there was a problem with the airway, the trach was placed because you were trying to get them off the vent. Most important, you’re not going to have a lot of time think in those situations, a lot of times what you can do is just pull the trach out and bag. Just put your finger over the hole and just bag them. The other thing you can do in this situation is let the balloon down. And then see if the patient can ventilate if you were too scared to pull the trach out. You can let the balloon down and see if there was some problem with that. A lot of times when that happens the trach is dislodged and is blocking the airway, so until you get the trach out, they’re not going to get any better.
Archive for category Clinical Pearls
Assisting Respiration and Airway Control:
When you have somebody with an airway issue, if they don’t have a tube in them, they have to be able to protect their airway, be able to exchange oxygen and release carbon dioxide, if they can’t do that, you need to control their airway. If you’re uncomfortable controlling their airway, you need to know how to bag mask ventilate patients. That does not mean hold the mask and press it down on their face and squeeze the bag. There’s a specific technique that you need to use to bag mask and ventilate someone and you should learn it since it will save someone’s life someday. If you are with an anesthesiologist or respiratory therapist, ask them to show you, and then have them watch you try to do it.
Diagnosing Acute Airway Issues in the Intubated Patient:
If the patient does have an airway, you need to make sure that the path from the outside into their lungs is clear and you need to think about it that way. So, if they’re unable to ventilate someone and they have an endotracheal tube in, the first thing you need to do is, bag ventilate them and listen to breath sounds. That will tell you whether the path to the lungs is clear. If there are no breath sounds, you need to stick a suction catherer down the endotracheal tube to ensure that path is clear. If that path is clear, you need to make sure there’s not a mechanical obstruction with a physical exam and then a stat chest x-ray. If the path from the outside to the lungs is clear, and the lungs have no pneumothorax or hemothorax or other mechanical issues, then you need to start thinking about ARDS, severe pulmonary edema, pulmonary embolism, and other intrinsic lung issues. If that’s going on and the patient can’t be ventilated adequately, you need to quickly get some experienced help to the bedside.
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