Thursday, October 24, 2013

Trach 101

Part 1/2

I've received a couple of questions regarding speaking with a ventilator and trach that I wanted to answer. First, I'll talk about me and go over some basic 101 about trachs.  The post after this will talk about speaking after my accident.

I'm considered a vent dependent quadriplegic; I require the use of a ventilator 24/7. This is a result of the level my injury is at, which is C-1 C-2. When an injury occurs at the C-1 level (the vertebrae closest to the skull), most likely it will affect the person's breathing. In this case, intubation is required. A tracheal intubation, commonly known as intubation, is the insertion of a flexible plastic tube that goes down the throat to maintain an open airway. Then with the use of a ventilator a person is able to sustain breathing. While in the helicopter on a way to the hospital they had to intubate me.

Two days later, after finding out the extent of my injury, the doctors took me to surgery to remove the tube and do a tracheostomy. A tracheostomy consists of making an incision in the neck and opening a direct airway through an incision in the trachea. The stoma that results from this can independently act as an airway for a tracheostomy tube (trach) to be inserted, allowing the person to breathe without the use of his or her nose or mouth. A ventilator can be attached to the trach or it can become the actual place a person uses to breathe. People can have trachs for different reasons, not just spinal cord injuries. An example would be someone with muscular dystrophy, someone who had/has throat or lung cancer etc.

My trach stays in the majority of the time, unless it's being changed. In that case, my nurses do a trach change by taking out the old one and inserting a brand-new sterile one. Depending on the person (age and size) depends on how often the trach gets changed. They change mine every three weeks, or unless it's needed before that. An instance where I would have to have my trach changed before the date would be if there was a mucous plug inside of it blocking my airway. This has happened before to me in which someone has had to do an emergency trach change (sometimes suctioning doesn’t clear this secretions as fast as just changing it does).  Trachs are pretty expensive, so many people sterilize them again in boiling hot water and reuse them.  Since I don’t do it very often, I just throw it away every time it gets changed.

I rarely have to suction anymore; usually every couple days or so.  That’s not very much for someone who has a trach and is vent dependent.  I don’t get big mucous plugs anymore and haven’t had to do an emergency trach change in years.  Now I just change it during the scheduled times.  Although my situation is complicated, I try my best to say as healthy as possible.  This includes staying away from smoky environments along with avoiding others with colds or who are sick. 

There is a machine that I have called a cough assist; it attaches to the trach like the vent tubing does.  I use that twice a day.  It blows air into my lungs and then pulls it back out.  The cough assist has done wonders for me, including clearing my lungs.  Usually it brings up secretions which I then either suction or cough out.  This is most of the reason why I don’t have emergency trach changes anymore.

Cough assist machine

There are many different types of traches.  The one that I use has a cuff on it.  The cuff is actually a balloon that gets inflated using air or water.  It is around the stem of the trach.  To better explain this, I have posted a picture below. 
This is a picture of my trach.  The cuff is attached by a string (shown floating above the trach).  The balloon is around the bottom of the trach.  At this point it is not inflated.

This is what it looks like when the cuff is inflated.  It closes off the airway in the trachea so air cannot come out the mouth or nose.  It all gets diverted back down the tubes, making it so that the person cannot speak.

I don't keep enough water in my trach for it to completely close the air from coming out my mouth and nose. The balloon can hold at least 5 mL, however I only keep 3 mL. For me, I have a huge air leak around my trach so if the water is taken out, most of the air escapes around my trach. That's why I keep 3 mL of water in-to prevent air from escaping around my trach instead of out my mouth and nose like it's supposed to. That's how I'm still able to talk. When all or most of the air gets diverted out my mouth, it allows me to speak better and clearer.

Over time my stoma (the hole my trach is inserted in) has stretched so far that the leak has become more prominent even with water in my cuff.  If more water is added, it leaks even further around my trach, diverting it away from my mouth and nose and I’m unable to speak loud enough.  The leak also increases because the air needs someplace to go.

*A tracheostomy is an opening into the trachea (windpipe) that allows air to be pumped directly into the lungs. Many trach tubes are fitted with inflatable cuffs, which, when deflated, allow air to pass over the vocal cords, making speech possible. When the cuff is deflated, air "leaks" up around the tube and less air gets into the lungs, but many people can tolerate this air leak with adjustments to their ventilation system.

Question: Do you know why some people use a vent and a trach that dowake up Dragon esn't allow them to speak? I heard of someone with muscular dystrophy who had a vent and 'cuffed' trache which could be set to allow her to speak or not, but she usually had it set not to (during an interview she had the cuff set so she could). Is it a matter of money or of medical necessity?

Answer: No, it is not a matter of money.  It may be a matter of medical necessity or just a preference.  As I explained above, I use water in my trach cuff to prevent leaking around my stoma and trach.  In this case she uses a cuffed trach and prefers (or needs) to have it inflated fully, which takes away her ability to speak.  Either way, not all people with trachs have a cuffed one.  Like I said, there are many different types of trachs; I just named one kind.

Stay tuned for the continuous to this post coming up soon!

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