Frequently Asked Questions (FAQs):
Q. Why must TTO products be routinely replaced every 90 days?
A. SCOOP products are made of plastic. All plastics are subject to oxidation, exposure to light, and the action of patient body oils and secretions. They may become discolored and brittle resulting in tract trauma. Reliability beyond 90 days has not been determined. For comfort and safety reasons, all SCOOP catheters and hoses should be routinely replaced every 90 days.
Q. What causes subcutaneous emphysema (air), what is its significance, and how is it treated?
A. When a hole is created in the trachea, coughing immediately after the procedure can blow air into the tissues of the neck. This may result from obstructing the skin incision or lumen of the Stent. With the FastTract Stent, air escape through the lumen protects against developing subcutaneous emphysema, but well-intended medical staff may unknowingly provoke the dissection of air into tissues by instructing the patient to occlude the tube when coughing or speaking. Medical staff should be specifically ordered not to obstruct the lumen of the Stent or use dressings that block the escape of air through the skin incision. A gauze dressing taped under the Stent like a bib is recommended. Since the pathogenesis of the subcutaneous air is from positive intrathoracic pressure caused by coughing, the air presents in the extrathoracic neck and face. This contrasts with the pathogenesis of subcutaneous emphysema caused by positive extrathoracic pressure (e.g., mechanical ventilation). Hyponasal voice quality is common, and subcutaneous air can even cause swelling and closure of the eyelids. Negative intrathoracic pressure with normal breathing can draw some of the extrathoracic air into the upper mediastinum, but we are unaware of any cases of pneumothorax or compromised ventilation caused by a transtracheal procedure. It is generally appropriate to observe patients overnight in the hospital while reassuring them that the condition is transient and not serious. The physician should give strict orders to the hospital nursing staff observing the patient that the skin incision and lumen of the Stent should never be occluded before the tissues about the new tract have had a chance to seal.
Q. What is the difference between the Fast Tract procedure and the Modified Seldinger technique?
A. The Modified Seldinger technique is the original procedure used since 1986 to create the tract that will eventually accommodate a transtracheal catheter within the trachea. In 1996, a new procedure called Fast Tract was developed in concert with the surgical community. It is a true surgical approach that must be performed by a qualified surgeon.
Q. What is the length and diameter of the transtracheal catheter?
A. The internal segment of the standard adult length catheter is 11 centimeters. The diameter is 9 french. Outside diameter is 3.3 mm or .131 inch. Inside diameter is approximately 3.0 mm or .118 inches. Transtracheal catheters are available in 9 cm, 11 and 13 cm lengths. A perfectly positioned catheter is normally 2-4 cm above the carina. The post procedure chest x-ray is used to determine which length catheter is best for each patient.
Q. What material is the transtracheal catheter made of?
A. Polyurethane, with thermoplastic properties. That is, at body temperature it will take a “set.” This occurs approximately one hour after insertion, and explains why the vast majority of patients report that they cannot even feel the catheter in their trachea.
Q. What is the highest liter flow permitted through a transtracheal catheter?
A. TTO catheters (Part Numbers C-9, C-9-2, C-11, C-11-2, C-13, and C-13-2) are FDA approved up to 12 L/min. Be aware of increased humidification requirements at flow rates much above 6 L/min.
Q. Where do most transtracheal catheters lie in the trachea relative to the carina?
A. A properly placed catheter is normally 2-4 centimeters above the carina.
Q. How does one determine if transtracheal tract is fully mature?
A. When the catheter is introduced into the tract opening, there is no snugness, tightness, or any unnecessary manipulation required to get the catheter to enter the trachea. Other than twirling the catheter, it should not require any extra effort or take an inordinate amount of time. There should be no pain or tenderness associated with catheter insertion or removal. The catheter should feel as if it were “dropping into air.”
Q. How is the actual Phase III cleaning protocol determined for each patient?
A. All patients begin Phase III by cleaning their catheter in place with saline instillation and the cleaning rod two times per day. This is established during the first scheduled visit of Phase III. When the patient subsequently returns for their next visit, a careful history is taken with regard to mucus balls. If the patient reports that they have been producing mucus balls, two steps are immediately taken. First, they are told to increase their cleaning frequency to four times per day. Second, they are started on the mucoevacuent per the physician’s prescription. (They may already be on this medication).
The patient is scheduled for their next scheduled visit which will include a catheter stripping. Encourage the patient to increase their intake of systemic fluids (assuming no contraindications). It is very likely that over the time period that covers Phase III, you will further customize the patient’s cleaning regimen. Patients with weak cough and higher flow rates are more likely to get in trouble. Weekends are particularly suspect. Trust your clinical instincts. It is always better to bring a patient in on a Friday afternoon for a catheter stripping, then to find out the patient was admitted to a local hospital over the weekend.
Q. Do all patients have to remove and reinsert their catheter twice a day for cleaning?
A. No. This is part of the customization process. Most patients do very well with BID removal. Other patients may only need to remove their catheter once per day or every other day. Each patient’s ultimate cleaning regimen is based on a number of factors. These include: baseline secretions, oxygen flow rate, cough effort, medications, as well as environmental factors. Many patients will need to clean their catheter in place several times per day in addition to catheter removal and reinsertion. There is a great deal of flexibility in the recommended cleaning protocols for TTO patients. After a period of time, all patients determine which cleaning schedule works best for them.
Q. What do you tell a patient who has just called and says they “can’t get their Transtracheal catheter back in?”
A. Ask them how long it has been out. If more than 5 minutes, have them put their nasal cannula back on at the prescribed flow rate and come in to the transtracheal follow-up unit as soon as possible. Time is critical, as an immature transtracheal tract can close in less than an hour.
Q. How do you convert a tracheostomy stoma to a usable TTO tract?
A. Downsize the patient to a #4 trach tube. Insert the transtracheal catheter into the stoma. Consider the patient to be in Phase III. After a few days, the stoma should “snug” down around the catheter. Advance the patient per standard published protocols. See our manuals containing the appropriate protocols.
Q. What is Chondritis?
A. An inflammation of the tract, probably secondary to colonization of cartilage at the base of the tract. It results in a swollen, reddened, knot of tissue around the tract. They almost never contain pus, and do not typically drain. Treatment consists of a 2-3 week course of antibiotics. Cephalexin 250mg TID has worked very well over the years, but any anti-staphylococcal antibiotic that the physician orders should work. Chondritis usually appears early in Phase III, but may occur at any time. Chondritis is much more common with the MST procedure.
Q. Can I suction a patient through the transtracheal catheter?
A. No! The catheter cannot be configured to suction the patient; furthermore the catheter cannot be advanced any further into (towards) the lungs to promote vigorous suctioning.