for a patient on trach collar uncuffed with pessimer valve presenting for non emergent surgery, what is the standard of care? should they all be changed to a cuffed trach prior to anesthesia?
pt on trach collar
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Passy-muir? You run the risk of a big leak around an uncuffed trach with PPV...kinda depends on what case you're doing/how new the trach is etc...
If it's a new trach I would always have ENT or CT surgeon change to a tube through the trach or a cuffed trach tube. If the trach is old then switch to a cuffed trach tube and then it is plug & play. Don't see a lot of trach's where I am now though. Always remember you never know when you will need significant PPV or muscle relaxation.
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If it's got a passy-Muir valve, then it's likely a small trach (6 or less) and uncuffed. Chances are you're safe switching out on your own.
We're taught perc trachs during CCM fellowship, so I also get called for things like downsizing. Super annoying, but a good experience I guess. By the time they get to that stage a long time has usually passed.
We're taught perc trachs during CCM fellowship, so I also get called for things like downsizing. Super annoying, but a good experience I guess. By the time they get to that stage a long time has usually passed.
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1. because they have a trach doesn't mean intubating from above is difficult or an unacceptable means to providing anesthesia, what you have to do for DLT placement
2. PMVs prevent air from coming out the trach, thereby forcing air through the vocal cords.... so do NOT place cuff UP and then leave PMV on. The patient cant exhale
3. A "Fresh" trach will always have a pilot balloon to inflate, i cant think of a reason why a surgeon would put a new trach in without a cuff. Therefore if the patient has a non-cuffed trach in then it has been changed out before.
4. From an ICU guy... DO not assume that a patient with a trach will go back to ICU on a vent. Drives me insane when my partners see a spontaneous breathing patient at the start and then decide to sedate and paralyze back to the ICU. If the patient is on a PMV they likely dont have a vent in their room anymore. Obviously if its a big surgery and patient needs POstop vent for real reasons thats a different story.
5. Anesthesia manages the Airway, if you cant manage a trached patient then you need to get some education. You cant always just call ENT.
2. PMVs prevent air from coming out the trach, thereby forcing air through the vocal cords.... so do NOT place cuff UP and then leave PMV on. The patient cant exhale
3. A "Fresh" trach will always have a pilot balloon to inflate, i cant think of a reason why a surgeon would put a new trach in without a cuff. Therefore if the patient has a non-cuffed trach in then it has been changed out before.
4. From an ICU guy... DO not assume that a patient with a trach will go back to ICU on a vent. Drives me insane when my partners see a spontaneous breathing patient at the start and then decide to sedate and paralyze back to the ICU. If the patient is on a PMV they likely dont have a vent in their room anymore. Obviously if its a big surgery and patient needs POstop vent for real reasons thats a different story.
5. Anesthesia manages the Airway, if you cant manage a trached patient then you need to get some education. You cant always just call ENT.
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When changing an uncuffed trach for a cuffed trach for a procedure, do you need to sedate the patient before the exchange? I would imagine it's pretty stimulating . I've done a few of these but forget the sequence.
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All great points.
1. It's important to have a good sense of the patient's airway with a trach; do they have a trach for obstruction/structural defect or do they have one for respiratory failure/pulmonary toilet? For our trachs, we slap a sign above the patient's bed that states: "Intubatable/not intubatable from above" along with the obturator.
2. Correct; you can kill a patient by ventilating a PMV with cuff up
3. Agreed
4. Doubly agreed. The community hospital ICU is notorious for sedating and venting our post-op trachs done for cancer/obstruction.
5. True. It's not a big deal to change an old trach, and anybody who deals with them regularly should be able to do so.
Lay the patient flat, having flexible suction and new trach ready to go (with cuff down, obturator in, inner cannula at the ready, a little lube, and preferably velcro ties pre-applied). Suction the trach and airway first. Deflate cuff (if it's up), tell patient to cough, pull old trach. Insert new trach into stoma with curve perpendicular to airway, and twist as you insert it. Exchange obturator for inner cannula. Immediately pass flexible suction to assure it's in the airway, inflate cuff, and you're good to go.
D
deleted162650
Any time you have to mess with a trach or do anything else to a neck for that matter use a shoulder roll and give yourself adequate exposure/neck extension. Makes a huge difference. If the case is a relatively minor one that would otherwise be suitable for an LMA/spont ventilation in a pt with an uncuffed trach you can always put an LMA down from above and clamp it to seal the upper airway and just hook up the circuit to the trach. That will also allow you to give PPV if the need arises. You should always have a cuffed trach or coil wound ETT handy though in case you do end up needing to change it out.
