What is a tracheotomy? What are the indications?

Tracheotomy is one of the oldest surgeries performed by mankind.  There is written evidence the procedure was performed on a person suffocating from an upper airway obstruction as early as 4,000 B.C. The operation was a last ditch effort to save a life.

Today the procedure is safer and more common than ever before.  The following are some of the basic terms to describe the procedure.

What is a tracheotomy:  An opening or stoma made by the incision in the neck.

What is a stoma:  Any opening between an internal body part and the external environment.  A colostomy is a form of stoma because it allows feces to bypass the rectum and anis so it can be removed from the body into a clostomy bag.  A tracheotomy is another form of stoma because air can bypass the upper airway.  Stoma is Greek for mouth, in when we refer to a stoma we are generally referring to providing a "mouth" to some internal part.  Generally speaking, when an RT refers to a stoma he's referring to a tracheostomy of any form, either when their is a trach present or when there is simply a hole in the neck.  A tracheostomy is the opening or stoma made by the incision in the neck.

What is a Tracheostomy:  A tracheostomy is a small hole or stoma in the neck or windpipe that a person can breathe through.  It's usually temporary, yet in some cases it can be permanent.

What is a tracheostomy tube:  This is a small, hollow tube inserted into a stoma created by a tracheotomy.

Who performs the operation of tracheotomy and tracheostomy insertion? The procedure of tracheotomy is usually performed in a sterile environment such as in an operating room by a surgeon, however an emergency trach can be inserted just about anywhere by any trained professional.  Any hollow tube can be used as a tracheostomy in emergency procedures.  An incision is made through the crichoid cartilage between the 2nd and 4th tracheal rings.

What are the indications for tracheostomies? There are a variety of indications:

• To reduce resistance to breathing: Anything that may cause the upper airway to become obstructed increases airway resistance, making it hard to inhale or exhale.  Diseases that may obstruct the upper airway include epiglotitis, cancer, foreign object, paralysis of vocal cords, and trauma. By making the airway shorter resistance is reduced.  By creating a shorter airway and thereby reducing resistance, the procedure may be beneficial to patients with end stage emphysema, chronic bronchitis, severe pneumonia or chest injury
• Long term ventilation is required.  This makes it easier to manage the airway and is more convenient to the patient than having an ETT in the throat.  It's also improves infection control and facilitates weaning from a ventilator. 
• Respiratory muscle paralysis. Various neuromuscular disorders such as polio myelitis, amyotrophic lateral sclerosis,  stroke, muscular dystrophy may inhibit the ability to breathe and closed head injury. 
• Enhance secretion clearance:  Some diseases, such as chronic bronchitis, cystic fibrosis and pneumonia may cause thick secretions that are difficult to expectorate.  A tracheotomy creates an easy access route for expectorating and suctioning the airway.  It may also enhance a cough, making it easier to clear the airway

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What is a tracheostomy?

Your humble question:  What is a tracheotomy and why is it needed?

My humble question:  A tracheostomy is a small hole or stoma in your neck -- your windpipe -- that the person can breathe through.  It's usually temporary, yet in some cases it can be permanent.

Your question:  Who inserts a trach and where and how is it inserted?

My humble answer:  The procedure is usually done in a sterile environment such as in an operating room by a surgeon, however an emergency trach can be inserted just about anywhere.  Any hollow tube can be used in emergency procedures.  An incision is made through the crichoid cartilage between the 2nd and 4th tracheal rings.  

Your humble question:  What are the indications for tracheostomies?

My humble answer:  There are a variety of indications:  

• To create an easy passage for the person to breathe when there is an obstruction of the upper airways caused by disease (epiglotitis, cancer, foreign object, paralysis of vocal cords, and trauma).
• Long term ventilation is required.  This makes it easier to manage the airway and is more convenient to the patient than having an ETT in her throat.  It's also improves infection control.  It also makes it easier to wean some patients off a ventilator.  
• It shortens the airway and makes breathing easier by reducing airway resistance.  This is essential for diseases such as chronic bronchitis, empysema, severe pneumonia or chest injury.
• Respiratory muscle paralysis.  This may be permanent as a result of a disease such as a neuromuscluar disorder such polio or ALS.   It can also be temporary as with head trauma.
• Diseases with thick secretions such as cystic fibrosis or chronic bronchitis associated with pneumonia. This makes it easier to clear secretions.
• Inability to cough and remove secretions, as with a stroke or neuromuscular disorder

Your humble question:  What are the advantages of a tracheostomy?

My humble answer:  There are a variety of advantages:

• More comfortable than an ETT
• Makes it easier to wean a patient off a ventilator
• Reduces need for sedation because it's not as uncomfortable as an ETT
• Reduces risk of trauma to airway as might be causes by an ETT
• Reduces airway resistance to make breathing easier for patients
• Allows patient to breathe when upper airway is swollen or collapses (such as with paralysis caused by neuromuscular disorders or epiglotitis)
• Makes it easier to suction the patient with thick, or copious secretions
• A patient can talk with special trachs

Your question: What does a trach consist of?  What does it come with?

My humble answer:  Most trachs come with three parts:  Outer cannula, Inner cannula, and obturator.  The outer cannula holds the stoma open and it has neck plates that extend on both sides so it can be secured by a velcro trach collar or trach ties.  The inner cannula has a lock to keep it from being coughed out.  It is easily removed so it can be cleaned.  Essentially, the inner cannula makes cleaning easier.  The obturator is used to insert the trach.  It slips into the tube and helps the doctor guide the trach into place.

Your question:  What is a fenestrated trach?  What are the benefits and disadvantages of it?

My humble answer:  It's a trach with holes or fenestrations in the outer cannula that allow air to pass into the upper airway so the patient can cough to remove secretions and talk.  Basically, it allows normal breathing and the ability to speak. It allows a trial of normal breathing and normal talking before a trach is removed, and may also necessary for long term trachs.  To take advantage of the fenestrations the inner cannula must be removed and the cuff (if there is one) deflated.

Your question:  What are the different types of trachs?  

My humble answer:  What trach to use depends on the patient, and trach should be 3/4 the diameter of the patient's trachea.  The following are the types of tracheotomy tubes according to John Hopkins:

• Cuffed with inner cannula:  The inner cannula may be either disposable or reusable.  Cuff should be inflated only for positive pressure breaths.  It must be deflated to use a speaking valve.  
• Cuffless tube with inner cannula:  T'he inner cannula may be either disposable or reusable.  Good trach for people who don't need to be on a ventilator.
• Fenstrated cuffed tracheostomy tube:  This increases the risk for aspiration due to the fenestrations.  The fenestrations also make it difficult to ventilate these patients.  However, good for weaning off trachs and for some patients who want to use a speaking valve. This type of tube is good for long term ventilator patients.
• Fenestrated cuffless tracheostomy tube:  Only used for patients who have difficulty using a speaking valve with the other trach tubes. There are risks associated with using fenestrations, such as aspiration and glanulation formation around the site of the fenestrations
• Metal tracheostomy tubes:  Rarely used.  Cannot use during MRI, and will cause alarm during airport security checks.  

Your question:  What is an inner cannula?

My humble answer: An inner cannula is a cannula inserted into the trach.  It allows for easy maintenance of the trach especially if there are thick secretions.  It also has a universal adaptor on it so the patient can be connected to a Ambubag or ventilator circuit to receive positive pressure ventilation.  

Your question:  How can a person with a trach speak?  

My humble answer:   The patient can speak either if the tube has a speaking valve or if the patient simply covers the opening with a finger.  For this to occur, the outer cuff must be fenestrated.  

Your question:  When should the trach cuff be inflated?  Deflated?

My humble answer:  The cuff, if there is one, should only be inflated during positive pressure ventilation, such as with a ventilator, bagging, or BiPAP.  The only reason a cuffed tracheotomy tube is necessary is when positive pressure breaths is indicated.  A cuff will irritate the trachea, and therefore should not be used unless needed for positive pressure breaths.  It also traps secretions (even when deflated) and can increase rates of infection.  If a patient requires continuous positive pressure ventilation, the cuff should be deflated four times a day to prevent tracheal necrosis and the lowest possible pressure should be used to inflate the cuff.

Your humble question:  What is a stoma?

My humble answer:  Any opening between an internal body part and the external environment.  A colostomy is a form of stoma because it allows feces to bypass the rectum and anis so it can be removed from the body into a clostomy bag.  A tracheotomy is another form of stoma because air can bypass the upper airway.  Stoma is Greek for mouth, in when we refer to a stoma we are generally referring to providing a "mouth" to some internal part.  Generally speaking, when an RT refers to a stoma he's referring to a tracheostomy of any form, either when their is a trach present or when there is simply a hole in the neck.  A tracheostomy is the opening or stoma made by the incision in the neck.

Your question:  So what is a tracheotomy?

My humble answer:    A tracheotomy is the opening or stoma made by the incision in the neck.

Your humble question:  When a tracheotomy is removed, what happens to the hole?

My humble answer:  The hole will seal and seal fast.  It's for this reason if a trach slips out it must be reinserted as rapidly as possible.  A person will continue to have a scar where the incision was.

800-400 B.C.: Greeks define tracheotomy

Knowledge of mouth to mouth breathing and the surgical procedure of tracheotomy would have made it's way from ancient Egypt to ancient Greece. There were many Greek philosophers who studied medicine at one of Egypts fine schools, probably at Heliopolis early on and Alexandria later. The procedure more than likely made it's way to Greece by this means. 

So this knowledge must have appeared via a dream to a priest at the Asclepion at Cos, who must have used it successfully at some point early in Greek's history. Details of the procedure and the diagnosis it was used for would have been surreptitiously etched onto a stone slab that was kept at the temple for future reference. The slabs may also have been used as early medical texts, as such temples also served as schools. 

Sometime around 450 B.C. a boy by the name of Hippocrates (460-370 B.C.) sat with his father, a physician, at the temple, learning as much as he could about medicine, perhaps using the stone slabs as texts. Hippocrates grew to become the greatest physician of the ancient world, and would become the first to write about the procedure in his Hippocratic Corpuus.  He wrote:

"A tube should be inserted into the throat, along the jaws, so that the air may be attracted to the lungs."  (1) 

The procedure is perhaps best detailed by historian Pierre Victor Renouard in his 1867 history of medicine:

When the air passage is stopped by any obstacle, the anguish is extreme, the suffocation iminent, and the patient speedily dies, unless promptly succored. This accident has sometimes occurred in a violent quinsey, but more frequently in the fibrinous effusion in children, called croup. The Hippocratic works indicate as the only resource in this extremity, to pass a leek leaf, or any elastic tube, into the throat of the patient; but this agent is very diflicult of application, and I doubt whether it was ever done advantageously.(2, pages 448-449)

The ancient Greeks would have referred to this procedure as a tracheotomy.  The term, according to dictionary.com, comes from a combination of the Greek terms for "windpipe" (arterios trakheia) and "to cut into" (tom).  It means to cut into the trachea.

Another term, tracheostomy, comes from the combination of the Greek terms for "windpipe" (arterios trakheia) and "mouth, opening, or orifice" (stoma).  It is the creation of an opening in the trachea.  The opening is often referred to as a stoma, which comes from the Greek term for mouth, opening, orifice.  It is the opening created in the trachea or, simply, the hole in the trachea.

However, it should be understood here that, according to Dr. Morrell Mackenzie in his 1880 book "Disease of the nose and throat," the term tracheotomy was first used by Lorenz Heister (1683-1758).  Prior to him the procedure was actually called a bronchotomy.  Mackenzie defined bronchotomy as "the various operations by which the air-passages are laid open."  (3, pages 520,522)

For simplicities sake, I will simply refer to the procedure as a tracheotomy for the purposes of this history.

So while the ancient Greeks definitely didn't invent the procedure, they gave it a name and an identity.

References:

1. Fourgeaud, V.J, "Medicine Among the Arabs," (Historical Sketches), Pacific medical and surgical journal, Vol. VII, ed. V.J. Fourgeaud and J.F. Morse, 1864, San Fransisco, Thompson & Company, pages 193-203 (referenced to page 198-9) 
2. Lee, W.L., A.S. Stutsky, "Ventilator-induced lung injury and recommendations for mechanical ventilation of patients with ARDS," Semin. Respit. Critical Care Medicine, 2001, June, 22, 3, pages 269-280 
3. Mackenzie, Morrell, "Diseases of the throat and nose, Volume I, 1880, Philadelphia, Presley Blakiston

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124-200 A.D.: Roman physicians describe tracheotomies

Knowledg of mouth to mouth breathing and the operation of tracheotomy was carried from ancient Greece to ancient Rome by the physician Asclepiades of Bythinia. (124-40 B.C.).

Prior to Asclepiades the Romans had a negative view of the harsh medicine of the Greeks, although Asclepiades was able to convince the Romans that Greek medicine could be useful for saving lives and soothing the minds of the sick.

Once again I quote Renouard:

Asclepiades of Bythinia, had the idea of opening a passage for the air, by making an incission into the larynx or trachea; but the authors who report this fact do not describe the operation he adopted. After him, no one dared attempt tracheotomy until Antyllus, who practiced it several times, and described his mode of operating.  (1, pages 448-449)

Antyllus, a Greek physician who lived in Rome sometime between the birth of Jesus and the 4th century (and probably in the 2nd century), had a fragment of his writings preserved by Paulus Aegineta (625-690), some of which provides one of our first accounts of the surgical procedure:  

"The incision should be made in the trachea, under the larynx, about the third or fourth ring. This situation is most eligible, because it is not covered by any muscles, and no vessels are near it. The patient's head must be kept back, in order that the trachea may project more forward. A transverse cut is to be made between two of the rings, so as not to wound the cartilage, only the membrane." (2)(3)(also see 5, page 521)

The GrecoRoman physician Galen (120-200 A.D.) stated that Aesculapius (around 100 A.D.) was the first to recommend tracheotomy, so we may speculate Galen also used it.   Both Aeretaeus (130-200 A.D) and Caelius-Aurelianus (5th century) mention the recommendation by Aesculapius, although Aeretaeus condemned the procedure out of fear the cartilage would not heal, and Caelius talked of it as a rash procedure never put into practice.  (2)(5, page 521)

Galen also described tracheostomies, and described inflating lungs with bellows through a hole in the trachea.  (4) 

Chances are Galen performed his experiments on animals, probably pigs, dogs or apes.  Yet even if he never performed it on a human, his efforts may have been the first mechanical breaths. 

So, like ancient Greek physicains, ancient Roman physicians were knowledgeable of the operation of tracheotomy, and performed experiments that would be picked up by later physicians who would have had better knowledge of anatomy.   

References:

1. Lee, W.L., A.S. Stutsky, "Ventilator-induced lung injury and recommendations for mechanical ventilation of patients with ARDS," Semin. Respit. Critical Care Medicine, 2001, June, 22, 3, pages 269-280
2. Fourgeaud, V.J, "Medicine Among the Arabs," (Historical Sketches), Pacific medical and surgical journal, Vol. VII, ed. V.J. Fourgeaud and J.F. Morse, 1864, San Fransisco, Thompson & Company,  pages 193-203  (referenced to page 198-9)
3. "Biographical Dictionary of the society for the diffusion of useful knowledge," Longman, Brown, Green and Longmans, volume III, 1843, A. Spottingwood, London, page 124-5
4. Szmuk, Peter, eet al, "A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age," Intensive Care Medicine, 2008, 34, pages 222-228
5. Mackenzie, Morrell, "Diseases of the throat and nose, Volume I, 1880, Philadelphia, Presley Blakiston

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What are the parts of a tracheostomy tube?

In 1543, Andreas Vesalius (1514-1564) described how he breathed for a animals by blowing into a reed inserted into their necks through a tracheal opening. This was one of the first descriptions of a tracheostomy tube.  By the 19th century the operation of tracheotomy was perfected, and tracheostomies resembled those used today.

Since we have already discussed the procedure of tracheotomy and the basic indications for them, this post will cover the basics of the tracheostomy tubes themsevles.

1.  What is a tracheostomy tube?  This is a small, hollow tube inserted into a stoma created by a tracheotomy.

2.  What does a tracheostomy tube consist of?  What does it come with?  My humble answer:  Most trachs come with three parts:  Outer cannula, Inner cannula, and obturator.  The outer cannula holds the stoma open and it has neck plates that extend on both sides so it can be secured by a velcro trach collar or trach ties. The inner cannula has a lock to keep it from being coughed out.  It is easily removed so it can be cleaned.  Essentially, the inner cannula makes cleaning easier.  The obturator is used to insert the trach.  It slips into the tube and helps the doctor guide the trach into place.

3.  What is a fenestrated tracheostomy?  What are the benefits and disadvantages of it?  It's a trach with holes or fenestrations in the outer cannula that allow air to pass into the upper airway so the patient can cough to remove secretions and talk.  Basically, it allows normal breathing and the ability to speak. It allows a trial of normal breathing and normal talking before a trach is removed, and may also necessary for long term trachs.  To take advantage of the fenestrations the inner cannula must be removed and the cuff (if there is one) deflated.

4.  What are the different types of tracheostomies?  What trach to use depends on the patient, and trach should be 3/4 the diameter of the patient's trachea.  The following are the types of tracheotomy tubes according to John Hopkins:

• Cuffed with inner cannula:  The inner cannula may be either disposable or reusable.  Cuff should be inflated only for positive pressure breaths.  It must be deflated to use a speaking valve.  
• Cuffless tube with inner cannula:  T'he inner cannula may be either disposable or reusable.  Good trach for people who don't need to be on a ventilator.
• Fenstrated cuffed tracheostomy tube:  This increases the risk for aspiration due to the fenestrations.  The fenestrations also make it difficult to ventilate these patients.  However, good for weaning off trachs and for some patients who want to use a speaking valve. This type of tube is good for long term ventilator patients.
• Fenestrated cuffless tracheostomy tube:  Only used for patients who have difficulty using a speaking valve with the other trach tubes. There are risks associated with using fenestrations, such as aspiration and glanulation formation around the site of the fenestrations
• Metal tracheostomy tubes:  Rarely used.  Cannot use during MRI, and will cause alarm during airport security checks.  

5.  What is an inner cannula?  An inner cannula is a cannula inserted into the trach.  It allows for easy maintenance of the trach especially if there are thick secretions.  It also has a universal adaptor on it so the patient can be connected to a Ambubag or ventilator circuit to receive positive pressure ventilation.  

6.  How can a person with a trach speak?  The patient can speak either if the tube has a speaking valve or if the patient simply covers the opening with a finger.  For this to occur, the outer cuff must be fenestrated.  

7.   What is a tracheostomy cuff? When is it needed and when should it be inflated?  When should it be deflated?   A cuff will irritate the trachea, and therefore should not be used unless needed for positive pressure breaths. It also allows a place for secretions to pool, and therefore increases the risk of micro-aspiration of secretions, increasing the risk for lung infections.  The only reason a cuffed tracheostomy is necessary is when positive pressure breaths are indicated. When a person is receiving positive pressure breaths, whether by AMBU-bag, BiPAP, or mechanical ventilator, it is necessary to inflate the cuff. This is necessary to prevent air from leaking around the tube in order so the patient receives an adequate breath or tidal volume.  If a patient is not receiving positive pressure breaths the cuff, if there is one, should be deflated.  For patients who require positive pressure ventilation, the lowest possible cuff pressure should be used to inflate the cuff, and it should be deflated four times a day to prevent tracheal necrosis

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Check out these tracheostomy tubes from 1866

If you guys thought tracheostomy tubes were a modern tool for physicians, think again.  The following is an advertisement from the a physician's catalog of S. May and Son from 1866:

DOUBLE TRACHEOTOMY CANULAS, of silver, three axes, improved, as Pig. 6.

each 22/-, 23/-, and 1 4 0 The outer canula of this instrument can be introduced quite flat.

£ s. rf.

IMPROVED DOUBLE TRACHEOTOMY CANULAS, of silver, three sizes, improved,

as Fig. 7 24/6, 26/6, and 1 8 0

This instrument allows the patient free motion of the head. 

Reference:

1. S. Maw and Son, Manufacturer of respiratory equipment, "A catalogue of surgeon's instruments, air and water beds, pillows, and cushions, bandages, trusses, elastic stockings, inhalers, galvanic apparatus, and other appliances used by the medical profession," 1866, London, 11 Aldersgate St., Buttler and Tanner, The Selwood Printing Works, page 85

4000-2000 B.C: The birth of artificial breathing and tracheotomy

Perhaps as far back as 4,000 years before the birth of Christ some mother grappled for something to do as she watched her child gasp for air.  She had already chanted incantations, and even called the medicine man, so she placed her mouth over the boy's mouth, and exhaled.  As she did so she saw that his chest expanded.

Unknowingly, she became the first person ever to perform mouth to mouth breathing.  Her attempt probably failed, and amid her anguish as she grieved for her child she made no effort to reveal to others what she had done.

Similar efforts were made from time to time, and mostly by mothers making panicked efforts to save their children.  Most of these efforts probably failed, although each would have at least given a child a chance to go on living.

And, lo and be hold, one of these efforts must have resulted in the child gasping and opening his eyes, and this would have been reported to a medicine man who made note of it deep in the back of his mind.  Several years later he was called to a young patient who appeared to be dead.  He breathed three times into the child's mouth and the child breathed life.

Such success would have brought great joy to the parents and family members, and the medicine man hailed as a hero.  This hero would have shared this wisdom with his sons, one of whom shared it with an ancient Mesopotamian messenger, who shared it with a prophet, who shared it with his scribe, who recorded it in some ancient medical texts.

For the first time ever, instead of being relayed from word of mouth, it was privy wisdom shared with the select few who were privileged to attend the few schools that then existed.

This wisdom was used from time to time by ancient physicians, magi, and profits. More often than not such attempts failed to bring people back from the dead, but from time to time it worked.  And with each success some new wisdom was learned.

One day, after a failed attempt at mouth to mouth breathing, a young physician took a sharp knife and created an opening into a suffocating man's neck.  This would have been the first tracheotomy.  Such knowledge would have been recorded by scribes and taught at schools.  This would have been done sometime around 4,000 B.C. (1, page 222)

In 2000 B.C. Ancient Hindu medicine mentioned "throat incision," and about 1500 B.C. the ancient Egyptian architect, scribe and physician Imhotep became the first mention the procedure in writing. While his original works are lost to history, we learn about his thoughts by later writers who would have had access to his original works.  (1, page 222)

The rare patients brought back to life by mouth to mouth breathing were probably merely revitalized by the efforts.  The rare patients who survived early tracheotomies probably died later on due to the unintentional introduction of pathogens to the blood stream during the operation.

References: 

1. Szmuk, Peter, eet al, "A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age," Intensive Care Medicine, 2008, 34, pages 222-228
2. Price, J.L., "The Evolution of Breathing Machines," Medical History, 1962, January, 6(1), pages 67-72; Price references The Bible, Kings, 4: 34 
3. Fourgeaud, V.J, "Medicine Among the Arabs," (Historical Sketches), Pacific medical and surgical journal, Vol. VII, ed. V.J. Fourgeaud and J.F. Morse, 1864, San Fransisco, Thompson & Company,  pages 193-203  (referenced to page 198-9)
4. "Biographical Dictionary of the society for the diffusion of useful knowledge," Longman, Brown, Green and Longmans, volume III, 1843, A. Spottingwood, London, page 124-5
5. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1922, Philadelphia, W.B. Saunders Company
6. Lee, W.L., A.S. Stutsky, "Ventilator-induced lung injury and recommendations for mechanical ventilation of patients with ARDS," Semin. Respit. Critical Care Medicine, 2001, June, 22, 3, pages 269-280
7. Tan, S.Y, et al, "Medicine in Stamps:  Paracelsus (1493-1541): The man who dared," Singapore Medical Journal,  2003, vol. 44 (1), pages 5-7
8. Ball, James B, "Intubation of the Larynx," 1891, London, H.K. Lewis
9. Hill, Leonard, Benjamin Moore, Arthur Phillip Beddard, John James Rickard, etc., editors, "Recent Advances in Physiology and bio-chemistry," 1908, London, Edward Arnold

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Pulmonary Toilet Lexicon

Bronchial Pulmonary Hygeine: Use of a variety of procedures and medicines to try to help the patient expectorate thick secretions, or to help losen secretions from the bronchioles to the upper airways so the patient can more easily spit it up.  The goal is enhance secretion clearance to help prevent lung infections, enhance ventilation, improve pulmonary function and gas exchange.

Expectorate:  To spit up

Pulmonary Toilet: It's a generic term to describe any effort, medicinal or other, to help loosen or break up thick secretions that are causing respiratory distress, to help bring secretions to the upper airway so they can be either swallowed or expectorated.  The most common therapies here are albuterol and mucomyst nebulizer treatments, followed by either use of flutter valve or postural drainage and chest percussion.

Who needs it?  The patient feels like they have something to cough up, but are unable to generate enough flow to expectorate it.  Rhonchi is a common lung sound heard upon auscultation.

What are Indications for Pulmonary hygiene or toilet?

• Thick secretions (may be heard in large airways by auscultation (rhonchi)
• Retention of secretions
• Difficulty clearing the airway (trouble getting phlegm up)
• Artificial airways (intubation or tracheotomy)
• Atelectasis caused by mucus plug or obstruction
• Conditions that increase amount and thickness of secretions (COPD, Cystic fibrosis, asthma)

Rhonchi.  This is the sound of air moving through large airways.  It is commonly described as coarse. Sometimes it is mistaken for a wheeze, especially as it resonates throughout the lung fields. Sometimes it may present as a forced, expiratory wheeze, and may even be audible.

What does the pulmonary toilet involve? 

Bronchodilator.  Inhaling this medicine will help to open up air passages, releasing trapped secretions so they may be expectorated.  The most common medicine is albuterol, although  xopenex may also be prescribed.

Mucolytic: Inhaling these medicines will help to break up secretions so they may be expectorated.  It makes phlegm more liquid and easier to spit up. This medicine may cause bronchospasm, so it should always be given with a bronchodilator. The most common medicine used in the hospital setting is Mucomyst (acetylcysteine). Pulmoyme (dornase alfa) is commonly prescribed for cystic fibrosis patients.  Other mucolytics may include ambroxel, carbocisteine, and erdosteine.

Chest physiotherapy (CPT): This describes the various techniques a therapist might use in order to help knock thick secretions loose so they may be more easily expectorated.  Procedures may include chest percussion, mechanical percussors, postural drainage, PEP valves, and flutter valves.  Ideally, CPD should be performed prior to meals, or 60-90 minutes after meals.  If the patient is on pain management, it should be performed 30-60 minutes after pain medicines are given.

Chest Percussion: A therapist uses cupped hands and applies rythmic clapping on a patient's chest in order to break up secretions so they can be more easily expectorated.  It may be performed over the entire chest, although is more commonly performed only over the infected area.

Vibration: This is where you put one hand over the other over the infected area and generate vibrations during expiration to help loosen secretions. This is generally done after percussion, and particularly for patients with thick and copious secretions.

Mechanical Percussor

Mechanical Percussor:  Due to the trauma that may be caused by CPT, mechanical percussors are thought to accomplish the same goal as CPT. Constant vibrations from the device are thought to break up thick secretions so they may be more easily expectorated.

Postural Drainage.  This is using gravity to aid in draining secretions from various areas of the lungs.

• Postural drainage and CPT or mechanical percussors are often used in tandem to enhance secretion removal
• Ideally, the infected side should be up to allow gravity to enhance movement of secretions to trachea to enhance removal.  
• After postural drainage is complete, the infected side should be down so that secretions do not drain into good areas of the lungs to make breathing more difficult.  If a patient's SpO2 suddenly drops, this is something that might be considered.  
• To learn more check out the AARC Clinical Practice Guidelines. 

Positive Expiratory Pressure (PEP) valves:  These are small, hand-held devices that a patient exhales into.  A positive pressure is thought to enhance secretion production and prevent and treat atelectasis.

Flutter Valves:  The most common one is referred to as an Accapella Flutter Valve.  It combines PEP therapy with gentle vibrations.  The small, hand-held device consists of a mouthpiece connected to a cylinder in which a stainless steel ball rests in a cone shaped valve. The patient exhales through the cylinder and causes the ball to move up and down during the exhalation. The effect is threefold

1. Vibrate the airways to facilitate movement of mucus
2. Increase endobronchial pressure to avoid air trapping
3. Accelerate expiratory airflow to facilitate the upward movement of mucus.

Many hospitals are now using these instead of the more invasive chest percussion and postural drainage. Although, sometimes a combination of the two are used.  Just about any alert patient can do this regardless of lung capacity. It takes about half the time of CPT and postural drainage.

Suction: This involves using negative pressure to suck secretions from the airway.  

• Upper Airway:  A common device for suctioning the upper airway is a Yankaur. It helps facilitate secretion removal of upper airway, and is similar to devices used in dentist offices.  
• Lower Airway.  Various suction catheters may be inserted through the mouth, or one of the nostrils, into the large airway (usually to just above the corina).  Negative pressure helps suck secretions blocking the airways.  This is generally referred to as deep tracheal suctioning. It should rarely be performed on an awake and alert patient.  It is most commonly performed on a patient who is intubated.  
• Suction pressure: This is usually determined as follows:
• Adults = -100 to -120 Hg
• Children = -80 to -100 Hg
• Infants = -60 to -80 Hg
• Catheter Size: A common formula for choosing the ideal suction catheter for a patient who is intubated:
• Double the internal diameter (ID) of the endotracheal tube (ETT) and multiply by 2, then use the next smallest catheter size. For example, if the patient has a size 8 ID ETT, 8*2=16 or a size 14 suction catheter.

Yankaur: As noted above, this is a device that fits into the patient's mouth, and can be used to suction secretions in the mouth to the back of their throat. This is generally considered to be non-invasive.

Deep tracheal suction: As noted above, this involves inserting a catheter beyond the trachea to just above the corina.  Ideally, a catheter should never touch the corina in order to prevent trauma.  Also, this procedure should never be performed on a non-intubated patient who is awake and alert, as it is considered extremely traumatic.  It should be performed as needed on intubated and trached patients in order to clear the airways of secretions.  It's ideal for generating a sterile sputum sample for analysis.

Closes suction system: The most common one used is called a Ballard. This is used on intubated patients so you don't have to break the circuit to suction the airway. This prevents loss of PEEP and reduces risk of Ventilator Acquired Pneumonia.

Incentive Spirometer:   During normal breathing, people sigh 3-5 times per hour.  This is a natural mechanism to clear secretions from airway to prevent pneumonia and alveolar recruitment to prevent atelectasis.  This natural mechanism is blunted due to pain from abdominal or chest operations.  It is also blunted due to pain medicine.  Ten inhalations per hour using an incentive spirometer is meant to encourage secretion removal and alveolar recruitment.  Volume spirometers provide some resistance to inhalation, and allow therapists to monitor a patient's progress. It is usually followed by cough and deep breathing exercises.

Cough and deep breathing exercises: A patient should be encouraged to take in a deep breath to fill the lungs with air, and then to cough.  This is yet another means of enhancing secretion clearance and alveolar recruitment.

Abdominal Thrust: This is performed only on quadraplegic patients. This is where you push in and up on the abdomin to force up the diaphragn to facilitate a cough. You'll need to do this in sync with the patient.  I find that the best teachers of this procedure are the patients themselves.

Mechanical Insufflation-Exsufflation: It's a machine that alternates positive and negative pressure to the airway to help increase expiratory flows and remove secretions. It's a non-invasive procedure that can be performed with a mouthpiece or mask for spontaneously breathing patients, or with an adapter to an artificial airway. It's usually used with patients with neuromuscular disorders.

When should pulmonary hygiene be discontinued?

• Improvement in chest x-ray
• Improved vital signs
• Improved oxygenation (monitored by pulse oximetry or ABG)
• Less demand for oxygen (less supplemental oxygen required, lower FiO2s)
• Sputum production (patient coughing up sputum without assistance)
• Auscultation (improved lung sounds)
• The patient can generate an effective spontaneous cough

Originally published on 5/20/09 on respiratorytherapycave.blogspot.com; Edited and updated for accuracy by Rick Frea

Ventilator bundle to prevent Ventilator Associated Pneumonia

By the late 1990s it was known that about 15% of patients intubated and placed on a ventilator acquired what was then termed ventilator associated pneumonia (VAP), and that about 30% of those with VAP would ultimately die.  A major effort was then begun to try to reduce these numbers.

Solid data was now available that allowed the Centers for Disease Control and Prevention (CDC) to compile guidelines for combating VAT.  Considering the limited options for treating pneumonia, the main effort was aimed at prevention.

The initial guidelines included many of the following.  These are often referred to as the essential parts of a "Ventilator Bundle."

1. Mandatory Education:  Everyone involved in the care of the patient should be aware of VAP and how to prevent and treat it.
2. Mandatory Infection Control:  Everyone taking care of the patient, including visitors, should be aware of the hospitals infection policy.  The best method of spreading infections is by frequent and vigorous hand washing. This may also include wearing masks and gowns when necessary. Sterile technique should be followed when inserting lines or drawing blood.
3. Routine Oral Hygiene:  Since bacteria from the upper airway may pool over the cuff, it is essential to keep the upper airway clean.  Many guidelines recommend oral suctioning and cleaning at least every two hours. 
4. Regular Change-out policy:  Closed suction systems and suction canisters and tubing should be changed every 24 hours.  Ventilator circuits should remain closed at all times, and changed at least once a week.  
5. Maintain Closed circuit:  The ventilator circuit should remain closed at all times.  Special adapters can be added to the circuit to introduce breathing treatment and metered dose inhalers.  Closed suction systems such as a ballard can be introduced between the ETT and the "Y" to prevent the need to break the circuit in order to suction.  Heated circuits prevent condensation inside the circuit and reduce the need to open the circuit for water removal. Changing ventilator circuits weekly instead of daily may also help reduce the introduction of bacteria to the patient. 
6. Limit normal saline introduction:  The introduction of normal saline into the ETT to assist with the removal of thick secretions should not be routinely performed by nurses, and should only be done by respiratory therapists on an as needed basis. 
7. Stress ulcer prophylaxis:  Since gastric contents may work their way to the upper airway and into the lungs, efforts must be made to prevent this.  Since all patients on a ventilator are at increased risk for stress fracture, they should all be treated for this. 
8. Ventilator extubation protocols:  Creation of weaning protocols are shown to speed up time from intubation to extubation. This forces clinicians to start thinking about weaning the moment a patient is intubated. 
9. Maintain cuff pressure:  Studies show that a cuff pressure of 30 or greater prevents the micro-aspiration of secretions that pool over the cuff.  To read further about this read the post "What tracheal cuff pressure measurement is ideal?" Cuff pressure should be measured and recorded each shift. While the ETT should be rotated each shift, unnecessary maneuvering of the tube should be avoided.  Also, the cuff pressure should never be less than 20 in adults as this significantly increases the risk of aspiration.  Vigorous suctioning should be performed before rotating the cuff and prior to deflating the cuff.  (1, page 8)
10. Elevate head 30-45 degrees:  This should prevent the aspiration of stomach contents.  This should be required in all ventialtor care policies. 
11. Prevent early extubation:  ETT should be adequately secured, and the patient adequately sedated or watched in order to prevent inadvertent or purposeful early patient extubation.  Ventilator protocols should help guide clinicians as to the best extubation time.  
12. Consider tracheotomy:  If a patient should need to be on a ventilator more than a week, the patient should be trached. Trachs also allow for normal physiologic swallow mechanisms which prevent secretions and stomach contents from being inhaled.  They also make it easier to wean patients, make it so less sedation is required, reduced airway resistance, and enhances secretion removal. It allows application of speaking valves to allow patient to speak, even while on ventilator.  Studies show they also improve overall patient morale.  
13. Avoid heated moisture exchangers (HME):  Do not use HMEs unless absolutely necessary, such as when you need to transfer the patient. Studies have linked them with an increased risk for VAP. 
14. Limit sedatives:  This topic continues to be controversial and debated.  Some experts recommend limiting the use of sedatives in the early mornings to make sure the patient awake enough for weaning trials.  Ideally, sedatives should be stopped at least four hours prior to doing weaning parameters or weaning attempts.  However, some experts suggest that some sedatives allow patient to be alert enough to follow commands.  
15. Daily Chest X-Ray:  Since it is very difficult to know when a patient is developing pneumonia, it is important to have a chest x-ray every morning in order to monitor patient's lungs for signs of pneumonia.  
16. Prophylactic antibiotic therapy:  Some experts recommend automatically starting patients on a broad spectrum antibiotic to prevent the development of infection.  This is also recommended as the top line treatment for VAP.  
17. Obtain sputum ASAP after intubation:  Obtaining a sputum sample immediately after intubation will help determine if the patient already has pneumonia, or confirm that the patient did not have pneumonia.  This will help determine if a pneumonia is pre-existing or caused by the ventilator. 
18. Cleaning equipment: Equipment must be efficiently cleaned between patients in order to prevent contamination from one patient to the next. 
19. Lower tidal volumes:  These may reduce the inflammatory response seen by higher tidal volumes.  
20. Serial Lab tests:  Daily laboratory testing can help determine if white blood cell counts are increasing, or other markers, which will show that a patient has an infection. 

This post will be updated as new wisdom is obtained.  The following graphic from the CDC pretty much sums it up.

References:

1. Van Hooser, Theron, "Ventilator Associated Pneumonia: Best Practice Strategies for Caregivers," 2002, http://en.haiwatch.com/data/upload/tools/VAP_CEU_Booklet_Z0406.pdf, Kimberly Clark Co., accessed 4/21/14
2. "Protocols and Definitions Device-associated Models: Ventilator Associated Pneumonia," Centers for Disease Control, http://www.cdc.gov/nhsn/PDFs/slides/VAP-DA_gcm.pdf, accessed 4/21/14
3. "Intubation And VAP: A Complex Condition Requires Bundled Solution," rtmagazine.com, http://www.rtmagazine.com/2014/04/intubation-vap-complex-condition-bundled-solutions/, accessed 4/23/14

Preventing Ventilator-Associated Pneumonia

How to prevent Ventilator-Associated Pneumonia has been extensively studied. Here are the most common recommendations. Chances are your hospital has already incorporated most of these.

1. Ventilator Bundles are protocols based on best practice medicine. These should be incorporated in all critical care units to assure all of the following guidelines are met. 
2. Good handwashing
3. Sterile technique (as much as possible)
4. Implementing a ventilator extubation protocol to speed up time from intubation to extubation. 
5. Making sure the cuff pressure is always 30 CWP or greater. The idea here is that this will prevent secretions from leaking around the cuff. Higher pressures are acceptable so long as intubation is short term, which is the goal of any intubation.
6. Tracheotomy should be considered for anyone requiring greater than seven days of mechanical ventilation. 
7. Heated wires should be used to limit opening of the circuit (this seems to be no longer an issue)
8. Inline suctioning (such as a Ballard) should be used instead of tracheal lavage and suctioning. Lavage and suctioning can still be used, although this should be left to the discretion of the respiratory therapist. 
9. The head of bed should be raised 45 degrees at all times to prevent aspiration of stomach contents. This should be started as soon as possible, and may even be started in the emergency room prior to the patient being transferred or admitted to critical care.
10. A feeding tube should be inserted to assure adequate nutrition. 
11. The mouth should be washed with a Chlorhexidine Oral Rinse and suctioned out every two hours (as appropriate). Studies have shown a good mouth cleansing can greatly reduce the chance of VAP.
12. Do not use heat and moisture exchangers unless absolutely necessary, such as when you need to transfer the patient. Studies have shown HMEs tend to increase likelihood of VAP.
13. Sedatives should be limited. There have been a lot of studies and discussions on the use of sedatives on intubated patients. Some suggest limiting sedation in the morning to make sure the patient is awake, cooperative, and understands the plan. Ideally, sedatives should be stopped at least four hours prior to beginning any weaning screen.
14. Studies show that it is most effective if the circuit is changed weekly, as opposed to daily as the best way of preventing VAP.
15. Daily chest-x-ray to monitor for signs of pneumonia
16. Sterile technique and proper technique when inserting lines. We are all instructed to monitor physicians to make sure they use this proper technique.
17. Stress-ulcer prophylaxis (this would be part of the ventilator bundle, and would be a nursing protocol. Ours includes a daily proton pump inhibitor like Prilosec (omeprazole)
18. Prophylactic antibiotic therapy (of course there is controversy here too). This is to prevent infections such as pneumonia and sepsis. 

These are some ideas that have been researched over and over the past several years. Newer studies are changing some of the older ideas we had regarding intubation. For instance, back in 1997 when I attended RT school, we were taught never to exceed a cuff pressure of 24 cwp to prevent the occlusion of blood flow. So, as you can see, this has changed considerably, although it's supposedly all for the better. 

Intubation and mechanical ventilation is not a science: it is an art based on a science. So, as you will learn (or have learned) in this profession, we do the best we can with what we know today, and as we learn more we do better. This is the case with advancements in intubation and extubation, as it is in other areas of healthcare. 

4000-2000 B.C: The birth of tracheotomy

Perhaps as back as 4,000 years before the birth of Christ some mother grappled for something to do as she watched her child struggle for breath and stop breathing.  She had already chanted incantations, and even called the medicine man, so she placed her mouth over the boy's mouth, and exhaled.  She watched as his chest expanded.  This would have been the first attempts at mouth to mouth breathing.

This first effort probably failed, although it would have at least given the child a chance, albeit a small a small chance.  The medicine man watching this was touched by the mother's efforts, and he used it on a child a year later, only this time it worked.  Yet it never worked again.  Still, he shared this information with his son, who passed it along to his children.

The above story is fictional, although it shows how such wisdom may have been obtained and shared through the annals of time. Such stories, and such medical knowledge, would have been recorded as soon as a written language was invented, first in ancient Mesopotamia and later in Egypt.  Now, for the first time ever, such wisdom could be taught in schools, and later expounded upon.

There is some written evidence that tracheotomies were performed as early as 4,000 B.C. (1, page 222) This is a procedure where a small opening was cut into the trachea of a person who was suffocating, usually due to an upper airway obstruction.  The procedure was usually a last ditch effort to help someone breathe better.

In 2000 B.C. Ancient Hindu medicine mentioned "throat incision," and about 1500 B.C. the ancient Egyptiann architect, scribe and physician Imhotep became the first mention the procedure in writing. While his original works are lost to history, we learn about his thoughts by later writers who would have had access to his original works.  (1, page 222)

This operation would have been among the first ever performed, although chances are there was a low success rate.  Patients who survived the operation probably died later on due to the unintentional introduction of pathogens into the blood stream.  Still, if nothing was done the patient would have died anyway, so this at least gave the patient a fighting chance, albeit a small one.

References: 

1. Szmuk, Peter, eet al, "A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age," Intensive Care Medicine, 2008, 34, pages 222-228
2. Price, J.L., "The Evolution of Breathing Machines," Medical History, 1962, January, 6(1), pages 67-72; Price references The Bible, Kings, 4: 34 
3. Fourgeaud, V.J, "Medicine Among the Arabs," (Historical Sketches), Pacific medical and surgical journal, Vol. VII, ed. V.J. Fourgeaud and J.F. Morse, 1864, San Fransisco, Thompson & Company,  pages 193-203  (referenced to page 198-9)
4. "Biographical Dictionary of the society for the diffusion of useful knowledge," Longman, Brown, Green and Longmans, volume III, 1843, A. Spottingwood, London, page 124-5
5. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1922, Philadelphia, W.B. Saunders Company
6. Lee, W.L., A.S. Stutsky, "Ventilator-induced lung injury and recommendations for mechanical ventilation of patients with ARDS," Semin. Respit. Critical Care Medicine, 2001, June, 22, 3, pages 269-280
7. Tan, S.Y, et al, "Medicine in Stamps:  Paracelsus (1493-1541): The man who dared," Singapore Medical Journal,  2003, vol. 44 (1), pages 5-7
8. Ball, James B, "Intubation of the Larynx," 1891, London, H.K. Lewis
9. Hill, Leonard, Benjamin Moore, Arthur Phillip Beddard, John James Rickard, etc., editors, "Recent Advances in Physiology and bio-chemistry," 1908, London, Edward Arnold

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50-400 A.D.? Antyllus describes asthma remedy

Of his writings we have none. Of his life we know nothing. When he lived we know nothing. When and where he practiced medicine we know nothing. Yet we do know he was a physician and surgeon who lived in the 2nd century, and that he wrote about asthma. His name was Antyllus.  

Claudius Galen (130-200 A.D.) diligently collected the works of all medical writers who came before him, yet of Antyllus he wrote nothing. So if he lived before Galen as some speculate, one might wonder why Galen ignored him. So another theory is he lived after Galen.

For preserving the ideas of this surgeon we owe thanks to Oribasius of Pergamus (320-403 A.D.). He quoted many medical authorities prior to his time, including the works of physicians we would otherwise know nothing of, such as Antyllus. (5, page 129)

Some speculate he lived as late as the Roman Emporor Velerium who ruled Rome from 260-264 A.D. (1, page 129, (3, page 11). Still others speculate he lived as late as the fourth century. (2, page 124-5)
Regardless, he must have held a reputable reputation in the medical community because he was written about by many authors, including Oribasius, Aetius, Rhazes and Paulus Aegineta. Oribasis was the first to write about him, so this used as a baseline for dating his life. (2, page 125)

What he did for the medical community we can gather some hints. Aegineta was the first to mention a technique for performing the operation of tracheotomy, and credits Antyllus for educating him on the best method of doing this. (2, page 124)

He's also credited as being among the first to describe a method of surgically treating aneurysms. Overall, his "works seem to be useful and interesting, as it contains some of the most valuable surgical observations that have come down to us from antiquity." (2, page 124)

Regarding asthma we have gathered some knowledge from Antyllus, and for this we are thankful to John Watson for bringing this knowledge to us in his book, "Medical Profession in Ancient Times," as noted here:

He treated humid asthma with suffumigations, placing the patient in such a position as readily to inhale the fumes from particles of aristolochia (treats edema) or clematis (mild diuretic) previously sprinkled over burning coals in a chaffing-dish or brasier. (4, page 129)

So if you had asthma an Antyllus, or one of his followers, was your doctor, this is what you might expect as your treatment.

References:

1. Watson, John, "Medical profession in ancient times: an anniversary discourse delivered before the New York Academy of Medicine November 7, 1855," 1856, pages 128-129
2. "Biographical Dictionary of the society for the diffusion of useful knowledge," Longman, Brown, Green and Longmans, volume III, 1843, A. Spottingwood, London
3. Peters, John C., "On Sects in Medicine read before the Medico-Legal Slociety of New York, 1870," 1874, New York, J.R. McDivitt, Law Publisher
4. Watson, John, op cit, see page 129, and also see reference 3 above (Peters, John C., page 11)
5. Withington, Edward, "Medical History from it's earliest times," 1894

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Negative pressure ventilation come full circle?

The respiratory therapy profession basically began with the iron lung, or negative pressure ventilator. Wouldn't it be ironic if this type of therapy made a comeback, and negative pressure ventilators were the wave of the RT future.

The latest negative pressure ventilator is called the Biphasic Cuirass Ventilation, and one such ventilator is the Medivent Hayek RTX Biphasic Cuirass Ventilator made by Medivent International, and involves a simple shell placed over the patient's chest, instead of over the entire body as was the case with the inconvenient iron lung of the 1950s.

I can certainly see some advantages of the cuirass ventilator. For one thing, you would avoid the barotrauma associated with positive pressure ventilators and the risk of pulmonary infection because you wouldn't have a tube in the patient's airway nor a tracheotomy.

According to this company, since negative pressure ventilation is "more normal," it would be more comfortable for the patient, and allow RTs greater control over tidal volume and respiratory rate, and, ultimately, make weaning easier.

Likewise, the company claims that the vent "helps to maintain and redevelop the respiratory muscles which often wither and waste with respiratory failure and mechanical ventilation (and also) improves cardiac output."

Here are some more uses, as listed on Medivent International's website:

• It can be used as an aid in weaning a patient from conventional positive pressure vents, particularly those difficult to wean patients.
• Assists patient with removal of secretions, and is used as a glorified chest physiotherapy machine. It has been used in this way for Cystic Fibrosis patients and COPD patients.
• Can be used similar to BiPAP to provide treatment for patients before their condition deteriorates, and thus requiring intubation.
• Can be used as an at home vent and in hospitals for neuromuscular diseases and head and spinal injuries.
• It has been used on post-operative patients
• Can be used on Asthma and COPD patients

This type of therapy would be better for the patient in that they wouldn't have to have a tube in their throat, which can be very uncomfortable and annoying, and requires, most of the time, that sedative be used to make the patient more comfortable, or to forget the event all together. Sometimes this can make weaning difficult.

However, despite these claims, I'm not convinced this machine would be anything more than a glorified and expensive BiPAP machine, of course without the annoying and often difficult to get used to nasal or face mask.

I can also think of some cases where this type of ventilator would not be beneficial, especially if you had excessive secretions or pulmonary edema. Of course, even in these cases, nasal tracheal suctioning would always be an option.

However, this type of breathing apparatus would not protect the patient's lungs from aspiration, may not allow for adequate removal of CO2, and may not be effective for obese patients. In these cases, RTs and doctors would have no choice but to opt for the more conventional positive pressure ventilator.

Wikepedia has a nice write up about the curiass ventilator, but it would appear someone from Medivent International transcribed the copy here from their own website, as it's basically the same information not even reworded.

Anyway, that's my review of this ventilator based on some quick research I did. I wonder if this has been used anywhere in the U.S. If so, I wonder what the general opinion of this innovative therapy is, as so far most of what I've learned regarding this vent has been from the company.

What happens when a tracheostomy is removed?

Your humble question:  When a tracheotomy is removed, what happens to the hole?

My humble answer:  The hole will seal and seal fast.  It's for this reason if a trach slips out it must be reinserted as rapidly as possible.  A person will continue to have a scar where the incision was.

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Physician's Creed: How to take care of pesky RTs

Warning: What follows is top secret information surreptitiously leaked to me via one of the nations elite pulmonologists from an elite teaching hospital. Read at your own risk. This is not edited.

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(Section B-2)

Physician's Creed: How to take care of pesky RTs:

To help themselves feel better about spending two stressful years in the silly respiratory therapy program, Respiratory Care Practitioners too often bellow about protocols because they think they know more than Internists and Pulmonologists. This is simply nonsense. The following is a list of how to deal with a foolish RCP who dares speak his or her mind.

1. All respiratory illnesses should be treated as asthma, thus require bronchodilator

2. Or, all that wheezes should be considered as bronchospasm

3. To clarify 1 and 2, all of the following are indications for bronchodilator, no matter what RTs say:

• All annoying lung sounds
• CHF (Pulmonary edema)
• Pneumonia
• Lung Cancer
• pneumothorax
• Obesity
• Rickets
• Any surgery
• Coughing too much
• Not coughing enough
• History of smoking
• Cold symptoms
• Sinusitis
• Lupis
• M.S.
• Stoma
• Tracheotomy
• Bed ridden (MS, ALS)
• MRSA (any origin)
• Mechanical Ventilation

4. The best pressure support is 10. Period

5. Doctors need their rest and should never wean on weekend or between 7pm and 7am

6. Tidal Volumes are best set by keen eye, not kg per ideal body weight bla bla bla

7. Even if patient is using Automode, he is considered to be getting mechanical breaths. Vent changes should be made with this in mind.

8. If RT babbles about therapy no longer being indicated, double frequency, change dose and add IPPB.

9. If RRT annoys you, change Albuterol to Xoponex Q3-4, Atrovent Q6, and consider using Pulmicort, Intal and/or Mucomyst. This will make tx last forever (tee hee hee)

10. By the way, it’s okay to mix Atrovent and Mucomyst into the same treatment

11. Never, ever, ever discontinue breathing treatments.

12. Ignore their silly notes.

13. Complain to cardiopulmonary director that RTs are trying to get out of work

14. Prolocols hahahahahahahahahahaha(See note below)

15. OK, we’ll give them a protocol or two to make them happy. We just won’t order it.

16. If RN calls for treatment, it’s indicated. Period. Besides, this prevents them from calling again.

17. You don’t need to assess patient to know bronchodilator is

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indicated.

18. If you’re worried about side effects, order Xoponex. If RT complains Xoponex is same as Albuterol, see steps 8 and 9.

19. If you have no clue what’s wrong with patient, even if labs and x-ray are normal, the patient has pneumonia.

20. Oh, and if they have pneumonia, then they better get a bronchodilator Q4. Who cares whether or not they have a bronchospasm component.

21. Of course we know the patient will be SOB every four hours. We are that smart you know.

22. If RN and RT work in cahoots to call you because a patient doesn’t look right, and they recommend ABGs be drawn, order Q3 hour treatments and hang up. That will teach them not to bother you.

23. By golly, if you find out a patient has pneumonia and is not on treatments, you better order them right away. Make up for lost time by adding Pulmicort. This speeds effect of bronchodilator.

24. If patient CO2 rises from 40-45, by golly you better order BiPAP regardless of WOB.

25. All COPD patients are retainers. Period. There’s no need to trial patient on higher O2s, because that’s just a waste of time. If the RT complains patient was on 100% FiO2 in ER for 8 hours & was perfectly fine with it, just ignore them, or refer to steps 8 & 9. All of these patients should NEVER receive more than 2lpm or 30% VM, no matter how low their oxygen goes. Yes, we know scientists say fewer than 10% of COPDers are retainers, but they are wrong.

26. Patient should not be allowed to recover in surgery after 7. P.M.; put them on a vent.

27. We don't want our surgical statistics to look bad, so all patient with no hope of survival should be rushed to floor.

28. And, finally, if they call you, act like you are annoyed and in a hurry; grumble, mumble orders, gripe and hang up without saying good-bye.

29. Oh, and as with RN orders (see section B-1, How to take care of pesky RNs), make sure your written orders are illegible.

For further information see section D-3, Why doctors are always right.

Note: Yes, it is true that some of us physicians (myself included) have approved RT protocols at some of our nations elite hospitals in the past. These have proven to be disastrous, and merely work to build up the egos of RTs. Please forgo the insanity, and follow this list to the best of your ability.

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