Respiratory Care Procedures and Troubleshooting

Decannulation Process and Tracheostomy Management

Decannulation Factors

• The three key factors discussed previously regarding decannulation were:

  • Weaning

  • Decannulation itself

  • Trach tube management

Speaking with a Cuffed Tracheostomy Tube

• Challenge: A patient with a cuffed trach tube wants to speak without removing the cuff.

• Solution: A Blom fenestrated tube would allow speech because it can have an inflated cuff.

• Incorrect Option: A Passy Muir valve is not used with a fully inflated cuff. Using it this way would block airflow and be dangerous; the cuff must be deflated for a Passy Muir valve to function correctly.

Decannulation Readiness

• Scenario: A patient with a trach tube is weaning from a mechanical ventilator. The patient is alert, has a strong cough, can clear secretions independently, and a cough leak test shows a strong audible leak. The patient maintains adequate oxygenation on room air.

• Recommendation: Begin the decannulation process. These are all positive indicators for successful decannulation.

Ventilator High Pressure Alarms

• Indication: A high-pressure alarm on the ventilator, accompanied by decreased breath sounds and patient distress, indicates an obstruction in the airway or ventilator circuit.

• Initial Action: The first step as a respiratory therapist is to try to pass a suction catheter. This helps rule out or clear secretions as the cause of the obstruction. This is a crucial troubleshooting step before escalating to other interventions or calling a physician.

Post-Extubation Stridor Management

• Scenario: A patient extubated after 7 days of ventilation develops inspiratory stridor, mild retractions, and decreased oxygenation.

• Initial Action for Mild Stridor: Administer racemic epinephrine or cool aerosol (e.g., cool mist, cool aerosol with saline). This is appropriate for some inspiratory stridor, or mild symptoms of laryngeal edema.

• Cool Aerosol Protocol: Cool aerosol should be readily available and can be initiated immediately without a doctor's order. It's often continued for about 4 hours, then reassessed.

• Distinction between Stridor Severity:

  • If the patient develops marked or severe stridor after extubation, the appropriate action is re-intubation.

  • If only some inspiratory stridor is noted, racemic epinephrine or cool aerosol is the initial treatment.

• Cuff Leak Test and Stridor: The cuff leak test performed before extubation is crucial for determining if a patient is at risk of developing severe or marked stridor post-extubation. If a patient fails the cuff leak test by having little to no leak, extubation should be reconsidered or planned with extreme caution and readiness for re-intubation.

Endotracheal Tube (ET Tube) Intubation Essentials

• ET Tube Sizes: Know the appropriate ET tube sizes for both male and female adult patients.

• Malampati Class: Malampati Class 4 is considered the most difficult for intubation due to poor visualization of the glottis.

• ET Tube Tip Distance from Carina: The ideal distance for the ET tube tip from the carina is between 2 and 6 cm on a chest X-ray. (Note: Clinically, it might be 2 to 3 cm, but for testing purposes, 2 to 6 cm is the accepted range).

• Intubation Setup: When preparing for intubation, a cardiac defibrillator is not part of the standard initial setup equipment.

• Pilot Balloon Purpose: The pilot balloon on an ET tube or trach tube is connected to the cuff and is used to inflate or deflate the cuff, creating a seal in the airway.

Complications of Intubation

• Right Main Stem Intubation: If, after intubation, decreased breath sounds and reduced chest movement are observed on the left side of the chest, it indicates that the ET tube has been advanced too far into the right main stem bronchus. This obstructs airflow to the left lung.

Decannulation Factors

• Q: What are the three key factors concerning the decannulation process?

  • A. Cuff management, speaking valves, and suctioning techniques

  • B. Weaning, decannulation itself, and trach tube management

  • C. Ventilator settings, patient mobility, and hydration status

  • D. Airway patency, secretion clearance, and intubation duration

Speaking with a Cuffed Tracheostomy Tube

• Q: A patient with a cuffed trach tube wants to speak without deflating the cuff. Which device would allow this?

  • A. A Blom fenestrated tube

  • B. A Passy Muir valve

  • C. A standard uncuffed tracheostomy tube

  • D. A speech-generating device

• Q: Why is a Passy Muir valve contraindicated with a fully inflated cuff?

  • A. It would cause dislodgement of the tracheostomy tube.

  • B. It would block airflow and be dangerous.

  • C. It would prevent the patient from swallowing effectively.

  • D. It would lead to an increase in vocal cord paralysis.

Decannulation Readiness

• Q: Which of the following indicators suggests a patient is ready to begin the decannulation process?

  • A. The patient is dependent on mechanical ventilation for oxygenation.

  • B. The patient requires frequent suctioning due to inability to clear secretions.

  • C. The patient is alert, has a strong cough, clears secretions independently, and has a strong audible cough leak.

  • D. The patient experiences mild hypoxia on room air but has stable vital signs.

Ventilator High Pressure Alarms

• Q: A high-pressure alarm on the ventilator, accompanied by decreased breath sounds and patient distress, most likely indicates:

  • A. A leak in the ventilator circuit.

  • B. Patient hyperventilation.

  • C. An obstruction in the airway or ventilator circuit.

  • D. Low oxygen saturation due to insufficient FiO2 settings.

• Q: What should be the initial action by a respiratory therapist when a high-pressure alarm sounds due to suspected airway obstruction?

  • A. Increase the inspiratory pressure settings on the ventilator.

  • B. Immediately call for a physician's assessment.

  • C. Attempt to pass a suction catheter.

  • D. Administer a bronchodilator through the ventilator.

Post-Extubation Stridor Management

• Q: A patient extubated after 7 days of ventilation develops mild inspiratory stridor and decreased oxygenation. What is an appropriate initial treatment?

  • A. Immediate re-intubation.

  • B. Administer racemic epinephrine or cool aerosol.

  • C. Increase oxygen flow via nasal cannula to 15 L/min.

  • D. Start intravenous corticosteroids.

• Q: What is the standard duration for reassessment after initiating cool aerosol for mild post-extubation stridor?

  • A. 1 hour

  • B. 2 hours

  • C. 4 hours

  • D. 24 hours

• Q: If a patient develops marked or severe stridor after extubation, the appropriate action is:

  • A. Administer high-dose nebulized albuterol.

  • B. Re-intubation.

  • C. Initiate non-invasive positive pressure ventilation.

  • D. Place the patient in a prone position.

• Q: What is the primary purpose of performing a cuff leak test before extubation?

  • A. To assess the patient's vocal cord function.

  • B. To determine if the patient is at risk of developing severe or marked stridor post-extubation.

  • C. To confirm the patient's ability to maintain a patent airway without a tube.

  • D. To evaluate the patient's swallowing reflex.

Endotracheal Tube (ET Tube) Intubation Essentials

• Q: Which Malampati Class is associated with the most difficult intubation due to poor glottis visualization?

  • A. Malampati Class 1

  • B. Malampati Class 2

  • C. Malampati Class 3

  • D. Malampati Class 4

• Q: What is the ideal distance for the ET tube tip from the carina on a chest X-ray?

  • A. 0 to 1 cm

  • B. 2 to 6 cm

  • C. 7 to 10 cm

  • D. 11 to 15 cm

• Q: When preparing for intubation, which of the following is not part of the standard initial setup equipment?

  • A. Laryngoscope

  • B. Suction equipment

  • C. Cardiac defibrillator

  • D. ET tube of various sizes

• Q: What is the primary function of the pilot balloon on an ET tube or trach tube?

  • A. To provide oxygen to the patient.

  • B. To monitor the patient's end-tidal CO2 levels.

  • C. To inflate or deflate the cuff, creating an airway seal.

  • D. To act as a safety release valve for excessive pressure.

Complications of Intubation

• Q: After intubation, if decreased breath sounds and reduced chest movement are observed on the left side of the chest, what complication does this indicate?

  • A. Esophageal intubation.

  • B. ET tube dislodgement.

  • C. Right main stem intubation.

  • D. Left pneumothorax.

Answers

• Decannulation Factors: B

• Speaking with a Cuffed Tracheostomy Tube: Q1: A, Q2: B

• Decannulation Readiness: C

• Ventilator High Pressure Alarms: Q1: C, Q2: C

• Post-Extubation Stridor Management: Q1: B, Q2: C, Q3: B, Q4: B

• Endotracheal Tube (ET Tube) Intubation Essentials: Q1: D, Q2: B, Q3