Trouble with Trachs - Recannulating the Stenosed Trach Site
/The Problem
TracheOTOMY sites can close up rapidly (within hours). Why is this? Essentially, there is (usually) no missing tissue with this procedure. Occasionally the procedure does involve cutting a small section of the tracheal ring out but this is much less common now that percutaneous techniques are more in vogue The percutaneous technique involves, essentially, dilation of the skin, soft tissue, and trachea and, as such, these sites can close up very rapidly.
TracheOSTOMYsites are less of of problem as they do involve the removal of tissue. If they are fresh, however, these sites can also close relatively quickly.
What is a fresh site? The site should be pretty well matured by 40 days out from the time of the procedure. If the site is fresh, and you have the resources, you should probably consult ENT or the surgeon who performed the procedure as the risk of creating a false passage will be much higher.
So the Trach is Out, Now What?
You’ll need to get something back in there but because the hole is rapidly closing, you aren’t likely to be able to put in the same size tracheostomy tube. Oftentimes a tracheostomy tube one size smaller will even be too big to put in its place. You could always just put a very small ET tube or tracheostomy tube in place temporarily, but the patient is going to be better off if you can dilate the tract and replace the same size tracheostomy tube.
Dilating the tract:
Get all your equipment together
You’ll need a tracheostomy tube match the patients original, a tracheostomy tube one size smaller, multiple ET tubes of increasing size (up to the size of the patient’s tracheostomy tube), lidocaine, chlorhexidine, lubricating jelly, and some form of introducer (see below).
Clean and Prep: Start off the procedure by cleaning the skin around the tract with chlorhexidine. Chlorhexidine is preferable to betadine in this instance as its action is unaffected by moist environments or blood.
Anesthesia:
This is not comfortable procedure (for you or the patient), but you can do something about this. You should endeavor to make the patient as comfortable as possible through the generous and appropriate use of local anesthesia. You can use local infiltration of lidocaine with epinephrine to anesthetize the skin surrounding the tracheostomy hole. And, you can deliver atomized lidocaine into the airway to provide anesthesia of the respiratory mucosa and to blunt the patient cough reflex (which would otherwise be in overdrive during this procedure).
Use an Introducer:
If the tract is especially narrow, if there is high concern for a false passage, or if you just feel more comfortable doing so, you can use an introducer to get the initial ET tube in the patient’s airway. The best option for this is a flexible fiberoptic scope. This allows you to minimize local trauma and ensures that you are in the airway before and after you pass the initial ET tube into the tract. If you don’t have a flexible fiberoptic scope readily available, your next best bet is going to be suction tubing. Much love exists for bougies, but they are a bit stiff and unyielding in comparison to suction tubing.
Sequential Dilation:
Put a small amount of water soluble, sterile lubricant on the tract prior to the passage of the initial tube.
Now you should have a collection of various sized ET tubes. Start with the smallest that will easily fit into the tract. Insert it just into the airway, blow up the ballon and slowly withdrawal through the tract. Repeat this process with ever-increasing sizes of ET tubes until the tract is large enough to accommodate the same sized tracheostomy tube the patient came in with.
At this point you can look back through the tracheostomy tube with the fiberoptic scope if you have it available to confirm it’s placement in the airway.
Here's what the procedure looks like...
References:
- Russell, A. (1986) Chlorhexidine: Antibacterial action and bacterial resistance. Infection. 15 (5), 212-215. http://link.springer.com/article/10.1007%2FBF01644264
