Wednesday, August 10, 2005

Can we remove this trach

Here's a quick one: 78 y/o man presented to my clinic with the question: can we remove my trach? Actually, he doesn't speak English, and the entire history (or what I could get of one) was provided by his family.

Here's the story: He had a presyncopal episode several months ago and was admitted to another hospital. Developed respiratory distress that night, and was intubated. I have no idea why, but the family says he had been getting narcotics for pain related to the foley (which was placed because he was severely hyperglycemic-known diabetic). Anyway, he self extubated a day later, and required reintubation with 30 minutes. There was apparantly a question of airway edema. A trach was placed 1 week later (no other attempts to remove the tube), and he was discharged to a rehab facility (he was off of the vent).

There, his trach was downsized from an 8 -> 6 -> 4. With the #4, he developed respiratory distress (family things it was a mucous plug). The staff took out the #4, but were unable to get a larger trach in, so he was orally intubated again. A repeat trach was placed 2 days later, and he was in the ICU for 3 weeks (again, I get no history of a pneumonia or mechanical respiratory failure, but I'm told he was on the vent for most of that time) prior to transfer back to rehab.

He was in rehab for 2 months, and now home for 1 month. He's got an uncuffed 6-shiley and caps it without difficulty. He's got a Passey-Muir that he uses to speak with family.

Only other PMH is multi-infart dementia. The rest of the history and exam are unremarkable. Spirometry shows a fixed obstruction-classic-if anyone wants it for their teaching files, let me know.

Anyway, what do you tell them? Can we decannulate?

6 comments - CLICK HERE to read & add your own!:

Baleeiro said...

I'd take it out.

Mendez said...

I'm assuming that the fixed obstruction is still there. However, I'm concerned about the repeated failures at weaning of support and/or trach in the past. If there is no clear cardiopulmonary reason for his failures such as p. edema, increased secretions, etc., without a clear etiology, I worry about swallow function.

I would consider downsizing again - also evaluating his airway for tracheal stensosis secondary to repeated trach's and scarring.

Baleeiro said...

You could do a quick fiberoptic laryngoscopy from above and check the obstruction. If he can function with the capped trach you could also get a spiro and check the flow-volume loop for fixed upper airway obstruction (for which it would be very sensitive) and then take it out.

Mike L said...

I would be pretty conservative with this guy.
I would take him to the bronch suite and remove the tracheostomy. Then, I would look fiberoptically to see if there is a stenosis. If so, I would put the trach back in and send him to T-surg. If not, I would leave it out.
CEOB- wouldn't a sizable majority of patients with a tracheostomy and a normal trachea have a fixed UA obstruction? The capped trach would serve as said obstruction.

Baleeiro said...

Well, if he has a smallish deflated trach and can phonate and breath around the capped trach he would still generate good flows.

Jeff H said...

He has a fixed obstruction on his spirometry with the trach capped. Question is: is the fixed obstruction due to the trach, or is there a stenosis above the trach site.

As he's been doing well, I doubt there is a significant problem DISTAL to the trach.

I was thinking along the same lines as you guys. I considered taking it out in the bronch suite and then taking a look, but decided that, as I don't think there is anything distal, he needed a look proximal to the trach. And, since we're (or I'm) not so good with the upper airway, I'm sending him to ENT for laryngoscopy. If they feel it's safe, I have no problem removing the trach...