What do you do when a transtracheal oxygen patient shows up in your emergency room, and no one's ever seen one before?".
While the vast majority of these patients have been in the COPD group, an increasing number of patients with severe ILD are being placed on TTOT both for the immediate benefits, and perhaps to keep the patient alive long enough for lung transplantation. While a great deal of information has been published regarding the day to clay management of transtracheal catheters, very little has been published regarding the special concerns or questions that might arise when a transtracheal oxygen patient (TTO) patient is admitted to the hospital for an exacerbation of their underlying disease. This may be complicated by the fact that there may he very few (if any) TTO patients within the hospital's service area. Add to this the average turnover in a modern Respiratory Care department, lack of fundamental knowledge or exposure to TTOT, and the fact that TTOT is unevenly covered in already jammed RT curriculums, and you can see why a newly admitted patient may cause a bit of a stir both in the RT department and on the nursing floor to which the patient is admitted. The level of concern obviously increases if the patient is "sick" enough to be admitted to the ICU and perhaps intubated and placed on a ventilator.
In fact, problems unique to TTO patients can begin even before the patient gets to the Emergency Department (ED). The typical scenario goes something like this. It is 3:00 am Saturday morning, and you have just sat down for the first time all night. You have just retrieved your "dinner" from the vending machine, and made all the usual jokes about it coming from the lab. Your beeper goes off as you take the first bite of tonight's mystery meal. The nurse down in the ED is asking you to come down and evaluate a trach patient who is having severe respiratory distress. Usually, no mention is made of the fact that the patient has a transtracheal oxygen catheter (TTOC) in place. ... not a trach tube! EMT's, paramedics, ED physicians and nurses, who have no experience with ITO patients may well think that the cause of the patient's difficulties is the TTOC itself. Believing the catheter is part if not the whole problem they pull the transtracheal catheter out of the trachea. This is even more likely to happen if they feel they must intubate the patient. This unfortunately, has happened many times over the years. But you've got a little luck on your side tonight. When you get down to the ED you do indeed find a patient with a TTOC in place and the patient is in acute respiratory distress.
Hospital policy usually dictates who on the hospital staff is allowed to intubate. In fact, if an airway must be established, whichever individual is doing the intubating should go right ahead and intubate over the TTOC. The catheter is soft enough and pliable enough that no case of tracheal wall trauma has ever been published in the literature even with the cuff inflated to the correct pressure. It is best to treat the catheter as if it were not there until the underlying problem can be corrected. Generally, since there is no gas going through the catheter while the patient is intubated, there is no maintenance required. Routine cleaning and maintenance of the catheter can be re-initiated once the patient is extubated. Assuming the most positive outcome possible, the patient gets through this hospitalization and will be discharged home on his/her transtracheal oxygen settings. You can appreciate the extreme frustration of a patient whose TTOC was pulled either in the field, or perhaps even in the emergency department. Pulling the catheter out will inevitably lead to closure of the tract. This is especially true if the patient had the Modified Seldinger Technique to establish their transtracheal tract instead of the Fast Tract procedure. This necessitates a repeat procedure for the patient, which is both costly and time consuming for the patient and the health care team. So the rule bears repeating ... "if you have to intubate, intubate right over the catheter and treat the catheter as if it were not there."
If your TTO patient is admitted in a more elective fashion, the cleaning and maintenance of the catheter itself becomes one of the more important tasks that may need to be assumed by the respiratory care department in conjunction with the nurses who will be taking care of the patient. Most TTO patients have been taught to have their routine cleaning supplies with them at all times, and this would be especially true of a TTO patient who knew they were going to be hospitalized. However, like many things in medicine we can't assume anything. A TTOT "stash" is a good thing to have just in case a TTO patient is admitted to the hospital. The stash should include one set of replacement catheters, a TTO connecting hose, and a couple of wire guides to help retrieve a lost tract, or do a routine catheter stripping. In this way, should a patient forget to bring his TTO supplies in with him, there will he no interruption of his TTO therapy. A patient should never use a guide wire on themselves. Guide wires should only be used by experienced clinicians as they are for routine catheter strippings.
I believe that every TTO patient admitted to the hospital should at least be known to the RT department. Having said that, I also know from experience that this probably happens less than 5% of the time. Since TTOT involves both a knowledge of both upper airway anatomy AND oxygen therapy, the RT department should assume overall responsibility for the ongoing care and evaluation of these unique patients. In many cases the patient will know more about their catheter than the staff attending them. Bedside in-services where the patient shows the nursing staff how they clean their catheter are more the rule than the exception.
While most patients are taught how often to clean their catheter, in the real world, probably no two patients follow the exact same cleaning regimen. This would be complicated further by an exacerbation that increased both the volume and viscosity of mucus production. Another transtracheal rule that has held true for these many years is the fact that it is not a good idea for catheter to be removed and reinserted more than 2 times a day for cleaning. This is because experience has shown us that it is easy to induce some tract trauma such as tenderness or chondritis by overdoing catheter removals and reinsertion. What can be varied however is the number of times per day the patient may irrigate their catheter and clean out the lumen with the cleaning rod. This is called cleaning in place. Patients can clean in place up to 4 times a day, and may irrigate virtually at will. This may be done with either saline "bullets," or by using the preferred pressurized cans of saline to help dislodge any mucus that may be at or near the tip of the catheter. If the patient is too sick, or incapacitated to the point they cannot do their own daily care, it should be done by respiratory care personnel. Removing, inspecting, and cleaning the TTOC are the hallmarks of transtracheal care and most certainly reflect the community standard. If a respiratory therapist strips the catheter over the wire guide and the catheter comes out perfectly dean, but the patient is still (for example) coughing, you have at least ruled out the catheter as the cause of the problem. The source therefore must be somewhere else and may indicate a new pulmonary problem that is beginning to develop. However, if you strip the catheter and the patient coughs up or produces a mucus ball the size of a grape or bigger, well you have identified the problem as catheter related. Once the mucus ball is dealt with, your patient should very quickly return to their previous saturation baseline.
Patients with TTOC's may develop blood tinged mucus from time to time. It can even be a bit worrisome as to the volume lost, and of course it scares the patient who just doesn't know what is going on. The most common cause of blood tinged sputum or actual hernoptysis is tracheal mucosa! erosion. The mucosa of the trachea is very fragile and if there is a mucus ball near the tip of the catheter, it will make the patient cough. This may set up a vicious cycle I call cough-causing irritation-causing cough and so on. If this goes on for any period of time it is possible to develop a small area of erosion, or an ulceration as the tip of the catheter bangs up against mucosa. One quick tip to get control of tickle cough of any origin is to instill 2cc of 1% plain lidocaine directly down the catheter. You should get immediate relief from the cough and this will buy you some "cough-free" time to continue your evaluation. The lidocaine effect can persist for up to 40 minutes and may be repeated pen. If however, you have gone through your TTO checklist and the patient is still coughing, it seems to me that it is jurisprudent medicine to do a quick bronchoscopy to identify the source of the bleeding. If indeed there is an area of erosion or ulceration, the treatment of choice is to place a shorter catheter (usually the 9cm catheter) in the tract. This will change the foci of the catheter tip, and allow the area of involvement time to heal. Typically this takes 2-3 weeks. Whether or not to go back to the original catheter is a clinical tossup. If the patient continues to do well with the shorter catheter, it is perfectly fine to stay with that catheter. In all the original research done in the early 1980's, it was determined that the closer the tip of the catheter is to the carina, the better the efficiency or oxygen saturation. One caveat here; if the catheter tip gets too close to the carina, it may cause a tickle cough that is almost impossible to treat. If the catheter is too long it might even end up in the right main stem bronchus. Even if the tip of the catheter is sitting just above the carina, the flow of oxygen alone may be enough to induce tickle cough. That's why as a clinical rule, on standard CXR, we like to see the tip of the catheter 2-4 cm's above the carina.
Mucus management of the transtracheal in-patient is of utmost importance. Adequate humidification of oxygen via the transtracheal route must be supplied as the location of a TTOC bypasses the upper airway entirely. High flows of dry gas directly into the trachea can not only cause the development of clinically significant mucus balls, but can also lead to tracheal mucosal bleeding. Even patients on very low transtracheal flow rates must be adequately humidified. A standard bubble humidifier is probably sufficient until transtracheal flow rates get up to 5-6 L/min. Patients who have flow rates above 5-6 L/min. benefit greatly from the addition of heated humidity. The TTC is FDA approved up to 12 L/min. Patients with severe ILD often require TT flow rates in this range. Some patients maybe so hypoxic they need to combine high flow nasal cannula therapy with their HOT to maintain oxygen saturations. Combining these two therapies may buy you the precious 24 hours often needed to stabilize the patient and prevent an unnecessary intubation and period of mechanical ventilation. We have had very good clinical results using heated humidifiers made by Fisher-Paykel and Vapotherm.
One additional advantage of higher flow rates through a TTC in addition to oxygenation is a possible reduction in the patient's work of breathing. This has been identified as Transtracheal Augmented Ventilation or TTAV. By definition TTAV is the application of a heated, and blended flow of oxygen at flow rates of 6-12 L/min though a transtracheal catheter. The effect is probably more pronounced in the COPD patient population, but even the ILD patients may get at least some reduction in their WOB. TTAV has been used with regular success to wean long-term (trached) mechanical ventilation patients since the early 1990's.
In well selected patients TTOT is a life changing therapy. But considering these are patients with lung disease already advanced enough to warrant TTOT, they do still have occasional exacerbations, and are either directly admitted to the hospital, or may be brought via the 911 system. In either event if nursing personnel see a patient with a "twirly piece of plastic" hanging out of their neck, being pulled into their emergency department, or admitted to their floor, who do you think they are going to call first? Of course, it will be the Respiratory Care department.
Which brings us back to our typical scenario. In review, although it was difficult to leave your vending machine mystery meal, you did go down to the ED and as we said earlier you did find a TTO patient in severe respiratory distress. Your mental checklist should go something like this:
What is the patients 02 saturation on arrival?
* Is this patient known to the hospital staff
* Has he cleaned the catheter out within the hour before his visit to the ED?
* Is he coughing more than usual? Has he had a change in the character, volume, or consistency of his mucus? Has he been febrile? A family member can be helpful here.
* How long has he had his catheter? Was his TTO procedure recently done or is he a long standing experienced TTO patient?
* Has he been coughing up blood tinged mucus, or having actual hernontysis?
* Has the clinical picture been developing over the past few days, or is this an acute onset?
If you are real lucky your patient will have remembered to bring all his TTO supplies with him, but still it would be a hit unusual for a patient to have a wire guide with him. In any event, to rule the catheter in or out as the primary problem, the catheter must be removed, inspected, and reinserted. This is nothing more than a routine catheter stripping and should be familiar to all respiratory therapists either though previous experience, or information received freely available at the Transtracheal website (www.tto2.com). Patients with long standing tracts, say over 6 months, can normally have the catheter removed, cleaned and reinserted without fear of the tract closing. Patients whose procedures were more recent should only have their catheter removed and reinserted over a wire guide for fear of losing the tract. Anytime the catheter is to be removed, remember to put the patient on their nasal cannula at their prescribed flow rate. It is helpful to put the cannula on from behind, so you have full access to the cervical area and catheter itself.
As stated above, you are now operating with the knowledge of your recent patient history, and the results of the catheter stripping. Whether or not the patient needs to go on to be intubated and ventilated will depend on all the usual indications of acute ventilatory failure. Hospital policy or RT protocols should dictate what happens at that point of the decision tree. There are simply no data to report on the number of TTOT patients who have had an exacerbation of their underlying disease requiring intubation and mechanical ventilation. Couple this with the very small number of TTOT patients in the general oxygen patient population, and you can easily see how the above patient scenario can occur anywhere a transtracheal patient happens to live. With a little luck, and some RT critical thinking, our hypothetical RT can get back to the cafeteria with just enough time to get paged to go back to the ED for that all important scat IS treatment!
by John R. Goodman BS RRT
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|Title Annotation:||CLINICAL RESPIRATORY CARE|
|Author:||Goodman, John R.|
|Publication:||FOCUS: Journal for Respiratory Care & Sleep Medicine|
|Date:||Jun 22, 2012|
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