"Lost tracts" are occasionally seen in patients receiving transtracheal oxygen, and may occur any time following insertion of the transtracheal catheter. The best way to prevent lost tracts is to educate the patient about the security systems built into the TTO program. Make sure the bead chain necklace is properly fit to accommodate 2 fingers. Teach the patient to put two fingers between the neck and the chain, so they know what a properly fit chain feels like. Instruct the patient to come in for a proper fitting if the chain loosens or tightens. In addition, a 2-inch piece of clear plastic tape (Op-Site, Tegaderm or Duoderm) placed on either side of the flange, and over the bead chain (especially at night) can dramatically reduce the incidence of lost tracts.
Explain to the patient that the belt clip on the TTO hose must be used at all times, and especially at night when the patient goes to bed. It is important that the section of the TTO oxygen hose that connects to the catheter be kept under upper body clothing. If you educate the patient to the types of situations that may cause the catheter to come out, your percentage of patients who lose their tracts will be very low.
In spite of your best efforts to educate and reassure your patients, you may still encounter lost tracts. If a patient calls and states "My catheter came out and I can't get it back in," instruct the patient to put their nasal cannula on at their prescribed flow rate, and come to the follow-up unit (clinic, physicians office, emergency room, etc.) immediately. Tell the patient not to attempt to try and insert the catheter more than a few times by themselves. Repeated attempts will only cause the tract to become inflamed and edematous which may make it more difficult for the physician to reestablish the tract when the patient does come into the follow-up unit. (It is recommended that patients not spend more than 5 minutes trying to get their catheter back in before calling and seeking treatment at the follow-up unit.) Even if the patient successfully reinserts their catheter, they should be instructed to continue receiving oxygen via nasal cannula until their doctor can confirm their catheter is in its proper position. The earlier in phase 3 the patient is, the shorter the time element involved before the tract begins to close.
What to do before the patient arrives
While you are waiting for the patient to arrive, you should gather and prepare the equipment and supplies you will need, including:
- A Transtracheal catheter
- A Transtracheal wire guide
- A Transtracheal tissue dilator (optional)
- 2% viscous Xylocaine
- Q-tip applicators
- Two 2-inch strips of tape, approximately 1/2 inch wide
What to do when the patient arrives
Patients usually arrive quite anxious about losing their tract and you must reassure them as best you can while working quickly and efficiently to reestablish the tract. Unless a very long time has gone by, you should be able to clearly visualize the external opening, as the transtracheal tract closes from the inside out.
- With the patient sitting comfortably in a chair, place the patient's nasal cannula on from behind and adjust to the prescribed nasal cannula flow rate.
- Dip a Q-tip in the viscous Xylocaine and apply to the tract site.
- Take the transtracheal catheter out of the package and apply a small amount of viscous Xylocaine to the distal end of the catheter.
- Try to insert the catheter into the tract first. It may be that your better line of sight and dexterity is all that is needed. Twirling the catheter may be helpful in finding the tract.
- If the catheter will not enter the trachea, dip the atraumatic side of the wire guide (the side with the black reference mark) into the viscous Xylocaine and try to advance it into the tract (you will in all likelihood have to probe around inside the tract.) If you do locate the tract, the patient will begin to cough immediately and extensively. DO NOT LET THIS DETER YOU from completing the procedure. As quickly as you can, slip the transtracheal catheter over the wire guide and into the tract.
- Withdraw the guide wire, fasten the bead chain necklace, and reconnect the patient's transtracheal catheter to oxygen at the prescribed flow rate.
- Titrate the oxygen to a SaO2 greater than 92%.
- A chest x-ray for confirmation of catheter placement is highly recommended.
A quick tip for determining if the patient has a patent tract is to have them cough or perform a Valsalva maneuver. If you can hear air escaping from the tract, you have a high probability of successfully retrieving the tract. In some patients, the tract will be so snug on the inside that the atraumatic end of the wire guide will bend at the obstruction instead of going through. If this is the case, you may try using the other end of the wire guide. It is more rigid and you should be able to find the tract opening following the steps outlined above.
Minor bleeding at the tract site is a frequent occurrence following use of the wire guide. It is not unusual for the patient to have blood streaked sputum for a few days. Following successful retrieval of the tract, the patient should not remove their catheter, but rather clean their catheter in place for a period of two weeks. This is true even if the patient is well into phase IV. Prophylactic antibiotics such as Cephalexin, 250 mg TID (or another antibiotic effective against staph. aureus) may be prescribed. The patient's tract should be evaluated by trained staff over the next two weeks to determine if the patient may resume removing the catheter for cleaning.
The transtracheal tissue dilator should only be used if it is determined that a gentle dilation of the tract will facilitate catheter reinsertion and should be used only by or under the direction of a licensed physician. In general, if the catheter is not successfully reinserted it is best to wait and reschedule a new procedure when conditions may be better controlled.