You and your brand new partner, both EMT-B trained, are called to the home of a 58 year old male for "difficulty breathing." You arrive on scene to a battered tenement, climb the first set of creaky wooden stairs and enter the back kitchen door into a very small apartment. You ease through the narrow hallway and make the left turn into a small and cluttered living room. There you catch your first glimpse of your patient.

You think to yourself, "He looks older than 58!" And, you notice right away he is in severe respiratory distress, is struggling to breathe, is audibly congested, and is frantically pointing towards his neck. As you approach the patient you are wondering why he is pointing to his neck. He sounds like he's congested as there is audible gurgling from the patient's airway. Could he have aspirated something? Maybe he is choking! Maybe he is in pulmonary edema...

Surprise! It's a Trach!

As you arrive at the patient's side you are able to see his neck and chest and you notice that the patient has a tracheostomy tube. Now you are concerned because this is your first time dealing with a "trach" and realize that you don't really know how to help this patient if there is a serious problem with the trach tube. You start to break a little sweat and your thoughts start to race: "What is the proper procedure for rescue breathing for a patient with a tracheostomy tube? How is the trach properly suctioned? How will I administer oxygen over the trach? We never really covered this in my EMT course!"

The patient's wife is present and tells you he has been feeling weak for several days. He broke out in a sweat last night and had trouble breathing this morning. He has not been able to breathe well without his ventilator today, and is rapidly becoming fatigued. His wife tells you that last time he had pneumonia he acted like this. She has not taken the patient's temperature.

Don't panic! Assess the patient!

While the unexpected discovery of the patient's trach may have caught you off guard, one thing you do know is how to do is assess your patient! You must always begin with your initial assessment and then you can decide how to best assist and figure out how to troubleshoot any problems with your patient's trach tube. You and your partner assess the patient and here are your initial findings:

Develop and Implement an Action Plan!

Airway, Ventilation and Oxygen first!

Based on your assessment above you set out a plan for action. First, you decide to bag-assist the patient through the trach tube. He is in too much distress and is tiring which means he is not breathing adequately. You need to oxygenate and ventilate this patient. The patient's trach tube has a 15 mm adapter so it nicely fits onto your BVM. If the patient had a "Jackson" type trach that is flush with the neck and does not have a 15 mm BVM adapter you will need to attach a pediatric face mask to your BVM and bag the patient over the opening. You will need to get a neck-mask seal by using a smaller face mask piece with an adult BVM.

Timing is everything!

You begin to ventilate with 100% O2. However, the patient begins to cough and you realize that to effectively assist this patient you need to time your BVM ventilations to when he begins his own inspiration. You need to be in "sync" with the patient's ventilatory cycle. This means that you have to watch the patient carefully. After a few ventilations his color improves a little bit and he begins to relax. Your next step should be to suction out the patient's trach to clear his airways of the thick, tenacious yellow mucous that is contributing to his respiratory distress.

Ready for Suction!

You have ventilated and preoxygenated this patient and he is now ready for suctioning. You know he's ready when his color has improved. Remember that you MUST preoxygenate the patient prior to suctioning secretions. This is a very important step to prepare the patient and to prevent serious complications such as bradycardia or even cardiac arrest that can occur when a hypoxic patient is suctioned. Preoxygenation flushes out excess nitrogen and carbon dioxide and builds up the patient's reserve.

A trach provides direct access to the trachea and airways. Keep powder from gloves and any other debris away from the opening. Keep in mind that a common cause of respiratory distress in a patient with a trach tube is obstruction of the trach tube with mucous. You are ready to enter the patient's respiratory tree. This means that you must use sterile gloves and a sterile soft suction catheter. Insert the sterile suction catheter into the trach tube and gently feed it in until you get a bit of resistance. The patient will likely begin to cough indicating you have gone in far enough. You do NOT have to insert the entire catheter. Instilling sterile saline into the airway is not necessary in most cases and has proved in most cases to cause unecessary discomfort for the patient. If the secretions are very thick and dry then a saline lavage may be useful. You must use saline without preservative solution. Only instill saline that is known to be safe for the airway.

Typically the catheter is inserted just a few inches. Some instructors teach to pass the suction catheter until some resistance is felt or the patient begins to cough. This method causes discomfort for the patient and the catheter should be measured for estimated length prior to insertion for an appropriate length. The patient need not be made to cough in order to effectively suction secretions. Apply suction on the way out (never apply suction on the way in!). Suction for no more than 15 seconds. Most suction kits come with some sterile water so you can rinse the catheter and ensure it is not plugged. Don't contaminate the catheter by putting it down or touching anything that is "dirty" with your sterile gloves. You may need to repeat this procedure again. Reassess the patient at this point and see if there is sufficient improvement.

Once may not be enough!

You may need to repeat this procedure because the airways are still too congested. Having to repeat the suctioning procedure is NOT uncommon in trach patients with thick or large amounts of secretions. Simply preoxygenate and ventilate the patient again and repeat the suctioning procedure as above. You will want to use a new sterile soft suction catheter if the one you used or your gloves have been contaminated.

Reassess the patient and determine what other interventions are required. A third time is rarely needed right away. Continue to monitor the patient and resume BVM ventilation with 100% O2.

Progress!

What a little airway management can do! Your patient is now relaxed, pink, less irritable. and is breathing comfortably. However, he is tired and can not breathe adequately on his own. You will simply need to continue ventilating the patient and timing your assisted breaths to his own. The patient's rate is adequate - so let him take the lead. You are there to help him conserve his energy and ensure he is breathing deeply enough. Remember it is rate and depth of respiration that lead to adequate breathing. If he is too tired to take a deep enough breath he needs to be ventilated mechanically.

You reassess the patient's vital signs and the patient's heart rate is 104/min. and his blood pressure is now 170/96. An improvement! His mental status, a key indicator of oxygenation and perfusion is markedly improved as well. With no other complaints to deal with you decide it's time to package your patient and transport to the Emergency Department for further evaluation and treatment. You smile to yourself...that wasn't so bad after all!

An Overview of Tracheostomy Tubes

Dealing with tracheostomies should have been covered in your EMT-B course when artificial respiration was covered. It should have been included when you discussed patient's with a stoma. The patient with a trach tube in place has a stoma, or artificial opening at the base of the neck. A tracheostomy may be a temporary or permanent. Trach tubes are made of either plastic (Portex and Shiley are common brands), silicone or metal (Jackson type)and they may look like small opening that is flush with the neck, or it may be the type where a ventilator can be hooked up to. They may also be cuffed or un-cuffed.

Here are some pictures of common types of trach tubes:

The patient with a trach tube will be ventilated using a Bag-valve mask device that can either attach directly to the trach tube, or if the trach is a small opening flush with the neck, the patient may be ventilated by attaching a small face mask (pediatric size usually works) to make a seal over the opening. In the latter case, treat it like any patient with a stoma. The BVM is designed to attach directly onto the trach tube opening if a "Portex" or "Shiley" brand/type of device is being used. Unless the patient is on a home ventilator, most likely you will see the trach being flush with the neck. You will note that either type of trach tube is held in place by Twill ties or Velcro ties. These ties prevent the tube from being dislodged during coughing or moving about.

Another Trick of the Trade:

Here's a trick that might work if you are faced with needing to ventilate a patient that doesn't already have an adapter that will fit onto the BVM: With a trach tube that is flush with the neck, a plastic endotracheal tube adapter may be sized to fit a low profile metal tracheostomy tube to create a 15mm hub. Presto! You can now use the Bag-valve-mask to ventilate! Never try to place anything into a plain stoma - if there is not a trach tube in there - don't put anything in to the opening.

How come some patients with a trach can talk while others can't?

If the patient can talk with the trach tube, then the type of trach is called a "fenestrated" tube. This means there is a special opening that allows air inspired through the nose and mouth to pass through the tube. When the tube is plugged, or capped, air can pass over the vocal cords allowing the individual to talk. NOTE: This is important to know because if the chest does not rise when you try to ventilate, there is a possibility that there may be an air leak from the nose or mouth. If this is the case, you can manually close the mouth and pinch the nose. This can occur if there is an "uncuffed" or "fenestrated" trach tube being used.

Summary:

Here's a summary of the key points covered in this article.

A trach provides direct access to the trachea and airways. Keep powder from gloves and any other debris away from the opening. Keep in mind that a common cause of respiratory distress in a patient with a trach tube is obstruction of the tube with mucous. It is a good idea to suction using a sterile soft catheter. Preoxygenate the patient and insert a sterile soft catheter. Apply suction only when the catheter is being removed. Suction for no more than 15 seconds, or what your local protocol dictates. Here's the basic procedure:

1. Keep the head and neck in a neutral position. Since you have a direct "hole" into the lungs, there is no need for a head-tilt-chin-lift or jaw thrust maneuver.

2. Attach the BVM to the opening of the trach tube. Or, if the opening does not accommodate the BVM, use the trick above to create a 15 mm adapter hub, or simply ventilate using a pediatric mask with a neck-mask seal. Mouth-to-mask, or mouth-to-stoma can be performed as well.

3. The rate for rescue breathing is the same rate as with any other patient - 1 breath every 5 seconds for an adult and 1 breath every 3 seconds for an infant or child. Remember that you have direct access into the lungs so watch for chest rise to insure that you don't overinflate the lungs. Ventilate for 1.5 - 2 seconds and allow for exhalation following each ventilation. (Note: You do NOT need to remove the BVM for exhalation to occur.)

4. If the chest does not rise, there is a possibility that there may be an air leak from the nose or mouth. If this is the case, you can manually close the mouth and pinch the nose. If the tube is cuffed you can also try to inflate the balloon.

Discovering that the patient who calls 911 lives at home with a tracheostomy is more and more common. Adult and pediatric patients with a tracheostomy may be cared for in the home environment with or without a ventilator in the home. Examples of patients who may be in the home include laryngectomy patients, trauma patients, or spinal cord injuries. Elderly patients who have cardiac or pulmonary diseases who required mechanical ventilation for a prolonged time and could not be completely weaned off the ventilator and who, otherwise, are well. Be prepared and equipped to deal with patient's unique problems by being familiar with the types of equipment, tubes and special interventions that they may require.