(Removal of a Tracheostomy Tube)
For many individuals it is a
mystery on how and when their tracheostomy tube appeared. Often
during an acute illness where intubation (insertion of an
endotracheal tube through the nose or mouth) has been necessary to
maintain a persons breathing drugs are administered to keep the
patient relaxed and in a dream like state.
Often it is the spouse,
child or significant other that gives physicians permission to
insert a tracheostomy tube.
As mentioned above an
endotracheal tube (one that goes through the nose or mouth into the
lungs) is generally the initial way to ventilate a patient. The
endotracheal tube has a limited use time because of complications.
It is necessary to use tape to secure the tube to the patients face
and this can be very irritating to the patients skin. A patient
cannot eat or drink with an endotracheal tube in place. Also in
patients that have all or some of their teeth biting on the tube can
also pose a hazard. If the endotracheal tube is placed through the
nose there is an increased risk of sinus infection.
Once the decision is made to
place a tracheostomy tube a surgeon is contacted by the attending
physician to perform the procedure. An incision is made in the
patientís neck just below the Adams apple through the trachea or
windpipe. This area in the neck is very vascular with veins and
arteries. There is always some risk of bleeding with this procedure.
Once the incision is made a tracheostomy tube is placed through the
incision site directly into the trachea itself. There is usually a
balloon or inflatable cuff just above the end of the tracheostomy
tube. This balloon or cuff is inflated with a syringe. The inflated
balloon allows a seal for the airway. If this seal were not there
the air from the ventilator would leak out of the patientís nose
and mouth. The tracheostomy tube is secured in position with trach
ties that go around the patientís neck. Now the nose and mouth are
free of the breathing tube. It is important for caregivers to check
under the trach ties frequently to ensure the integrity of the skin.
Once the tracheostomy tube
has been inserted it then allows for the patient to use their upper
airway. For many patients to resume use of the upper airway takes
some rehabilitation. Speech language pathologists or Speech
therapists often assist these patients with exercises for the
airway. By increasing the strength of these muscleís many patients
can resume oral feeding and speaking through the use of talk valves.
Patients with endotracheal
tubes and/or tracheostomy tubes cannot speak. Not because they donít
know how but because the endotracheal tube passes through the vocal
cords and the tracheostomy tube is inserted below the vocal cords. A
simple understanding is we speak because air passes over the vocal
cords and allows them to vibrate thus allow speech. Because no air
is passing over the cords itís moving through the ventilator
circuit or oxygen tubing no vibration. Using devices such as talk
valves or by simply under inflating the balloon of the tracheostomy
tube speech is often possible.
Many times it takes practice
for a patient to become proficient at speech again. What was taken
for granted now requires concentration. Often times when a talk
valve is placed initially there is coughing associated with it. This
is normal, there is now air flowing through the upper airway where
none has been for quite some time. Calm words of encouragement and
coaching to speak normally often help this pass quickly. Many
patients remark that they can smell again once the talk valve is
placed. The airflow through the nose makes this possible again. Many
patients prior to the use of a talk valve have little desire to eat.
We all enjoy certain foods and we smell them cooking or when the
plate is brought to us. Imagine not being able to smell, everything
would taste flat with very little flavor as our ability to smell
enhances our ability to taste. So keep this in mind if someone
states it all tastes like cardboard, it just may.
The use of the talk valve
not only improves the taste of food but can actually enhance the
swallowing effort of the patient by assisting glottic pressures to
return to normal.
As rehabilitation progresses
and the patient weans from the mechanical ventilator many start to
focus on the tracheostomy tube. Patients often worry that in order
for the tube to be removed they will have to undergo a surgical
procedure. If you think about the miraculous properties of the human
body it is easy to see that the bodies' natural tendency is to heal.
If you have a cut or laceration whether or not it required sutures
or stitches it eventually heals. It is the same with the stoma site
of the tracheostomy patient.
Once a patient has made
significant progress and a physician deems it safe for the
tracheostomy to be removed it can be done several ways. Often the
tracheostomy tube is downsized or a smaller sized tracheostomy tube
is inserted. The smaller size tube allows the stoma site to shrink
in size to accommodate the smaller sized tube. The smaller sized
tube may be the same brand as the previous tube or often times metal
tracheostomy tubes are utilized. During this down sizing capping
trials are initiated. A capping trial depending on the physicianís
orders can last from hours to days. A capping trial is simply
deflating the cuff or balloon of the tracheostomy tube if it still
has one and placing a plug or cap in the opening of the tracheostomy
tube. The purpose of the capping trial is to ensure that the patient
is able to clear their own airway effectively without the need for
suctioning and to assess if any stridor occurs. Stridor is a
high-pitched sound from the upper airway that indicates there may be
swelling, stricture or obstruction of the upper airway. If this
occurs the capping trial is immediately discontinued. When stridor
occurs during a capping trial further evaluation of the airway by an
Ear Nose and Throat specialist or ENT is usually ordered.
If there are no
complications and the capping trials have been well tolerated the
tracheostomy tube is then ordered removed by the physician. Once the
tube is removed the stoma site is covered with a dressing and taped
in place. During this phase of healing the patient often experiences
a loss is speech volume and some leaking of air through the stoma
site. Although this initially may be frightening for the patient
reassurance that by applying gentle pressure over the dressing with
their hand the volume of speech returns and the air leak diminishes.
The dressing is usually changed daily and whenever necessary until
the stoma site heals.
Occasionally the stoma site
takes a significant amount of time to heal. The usual handling of
this is simply to allow time to pass and let the site heal. Rarely
will surgical closure of the site be necessary. It would be up to
the physician whether this measure should be pursued.
Once the stoma has healed
unfortunately there will be a scar. The degree of scaring varies
from person to person. If an individual finds the scar uncomfortable
things like necklaces, ties, scarves can easily hide it.