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?
I'd take it out.
ReplyDeleteYou 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.
ReplyDeleteI would be pretty conservative with this guy.
ReplyDeleteI 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.
Well, if he has a smallish deflated trach and can phonate and breath around the capped trach he would still generate good flows.
ReplyDeleteHe 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.
ReplyDeleteAs 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...