Good evening, everybody, and welcome to another Thursday night members webinar. My name is Bruce Stevenson, and I have the honour and privilege of chairing tonight's webinar. I don't think we have any new members in tonight, so not, no need to run through the housekeeping.

You know how it works. Questions into the Q&A box, and we will hold those over to the end. So tonight's presentation is a good one.

I've seen the slides, so you're in for a treat. And of course, our presenter tonight is also more than qualified to talk us through this. So Chloe graduated as a veterinary nurse in 2012.

She gained her Wits now ECC certificate in 2016 and her VTS ECC in 2018. She has a strong background in ECC and referral nursing, and she's currently the head of Priy emergency treatment services, the out of hours ones in Brighton in the UK. She also provides cardiorespiratory and internal medicine referral services.

Chloe is on the review board for the RCVS In Focus Veterinary Journal and is involved in peer reviewing material for the Australian College of Veterinary Nursing ECC certificate. Chloe is highly experienced and passionate about all aspects of emergency and critical care nursing, but her specific interests include critical care, critical care patients, including renal and septic patients, as well as cardiorespiratory patients. Chloe, welcome to the webinar vet and it's over to you.

Thanks very much Bruce. So yeah, we're gonna talk about tracheostomy tubes tonight, and basically just go over the indications of placement and the kinds of tracheostomy tubes that we're gonna be looking at placing on our patients, general care, and, upkeep of the tracheostomy tubes and then a little look as well at . Like contraindications as well just to keep that in the back of our minds.

So it's not super common to place tracheostomy tubes but there are indications. I'm gonna go over quickly the physiology. I'm sure you all are aware of it, but it's just good to keep it fresh, in your mind when you're thinking about where we're placing tracheostomy tubes and, you know, indications as well.

So the pea is composed of 35 to 45 cartilaginous C-shaped rings. And these are connected by muscle, mucosa, ligaments, and connective tissue. So it creates this flexible structure, that connects the larynx to the bronchi, so it's really important if we have any damage to it, any obstruction, we're gonna be, .

Creating an obstruction to the air that's been trying to be delivered as well as that debris that is been coughed up to the larynx so if there's any part of it that's damaged, obstructed, and swollen, we're gonna notice differences in our ventilation perfusion mismatch, so our VQ mismatch. I we can look at that on our. Arterial blood samples, our blood gases, you know, doing our, PA, .

Ratio to, you know, to our room air and looking at seeing whether our patients are appropriately ventilating from the air that they're getting. So often trauma is a primary cause of tracheal injury. You know, we see to kill tears from things like, dog bites, often that's where they'll go for the throat, .

Might see it in an abulsion from a, road traffic accident and we may even see things like abuse, which is very rare, but I've seen one where, you know, owners have stomped on, a trachea, not very nice, but it happens and it's just something to be conscious of, so yeah, for example, traquilled her from a dog fight. It's gonna result in a leak, because the air is now leaking out of that, trachea and gonna cause, subcutaneous emphysema around the cervical thoracic areas, so they've got crisp packet feel to the skin, and it's usually aematous. So when we're thinking about, patients.

That are key candidates for placement of tracheostomy tubes. I'm gonna go straight to this patient on the right, are brachycephalic breeds, often, you know, they'll have laryngeal paralysis, they might have tracheal collapse. I've seen them often with edoema, especially after the procedures, .

And you know, potentially swelling of that tongue, . And that's all gonna cause obstructions to that trachea and so what the aim of these tracheostomy tubes is to unobstruct them, basically, because we're not able to pass an endokile tube through, and as well as that for long term, management of these patients, we may need to place a a long term tracheostomy tube in these patients, . Especially like while the you know, while the edoema is going down, potentially while the, you know, before the patient has the laryngeal tie back and retracheal collapse as well.

So they're ones that you really want to be watching out for when we come in when they come into the practise, you know, listening to their breathing, and listening for, stenosis and, . And, and for any obstruction looking in their mouth, I'm having a good look and also x-rays are gonna pull up things like artery collapse. So, other things, that are gonna cause blockage in our upper airways are gonna be mass, and so I've seen dogs that we had a dog that came in that crashed once and we tried to place an ET tube in it, but it had a giant mass just cordially of its own.

Of its tongue and we couldn't get the The ET tube down same again for foreign body. I've seen, dog balls and I've been through over the dog and it's got wedged in that throat. We can't get them out, and it's a critical situation because, you know, once we block those airways, those patients aren't gonna be getting oxygen.

They're gonna become hypoxemic. Leading to ischemic events, you know, cerebral events, causing, primary and secondary brain damage, because you've got that lack of oxygen, so it's an urgent situation, and we need to fix it and remedy it immediately. Other things, the tracheal tar like I mentioned, you know, might be from potential an RTA or from a dog fight.

In cats as well, it can occur, you know, if you've been in a cat fight and, the other cat's nail has got hooked into that trachea, it's only gonna cause a small hole but a hole nonetheless, edoema, and that might be because of heat stroke, it could be because of the breed, or it could be because of anaphylaxis and to get that swelling. So basically tracheostomy tubes are gonna be indicated when there's any upper airway swelling, inflammation, trauma, neoplasia or laryngeal paralysis. Some of these we know that we can manage them with sedation alone so like laryngeal paralysis but if it's so severe that the patient has severe dyspnea, they have hypoxemia on their bloods or hypercapnia so you know, increased PCO2, despite the sedation and supplemental oxygen therapy, then, if you can't place an ET tube, then a tracheostomy tube is indicated.

And then sometimes, you know, placing an ET tube, is sufficient for the upper airway to be resolved, but if it's gonna be prolonged for more than 24 hours, then tracheostomy tube placement should really be considered because those ET tubes can't stay in unless that patient is heavily sedated. Or under the general anaesthetic, so teeth, tracheostomy tube placements, are gonna allow us to have that patient conscious, and get on the road to recovery, you know, start eating, we know that nutrition is really important to, . To recovery, and also to, you know, stop, getting air passing through this, through the mouth.

So, another indication of tracheostomy would also be during intraoral procedures. This might be long, and we know potentially gonna have long dentals, that are gonna maybe cause swelling, if there's lots of teeth being removed or there's reconstructive surgery. Then we might consider a tracheostomy tube placement, for the period after, that surgery.

They should be avoided if possible in small animals just due to increased risk of complications and we'll go through that in our sort of choice of tracheostomy tubes and, you know, the care, but basically it's just because the smaller the patient. Obviously the smaller the tracheostomy tube will need to be, and that's you know, that's that's making their trachea trachea that's already kind of small, even smaller because they've got all that equipment in place, and then a smaller airway in in the middle of that. Other things we might use it for, are mechanical ventilation, so long term mechanical ventilation, and this is just we can give proper oral care, and, it's not irritant, if we're having an ET tube in, because we know that with ET tubes we doing mechanical ventilation for a long period of time.

We have to move those because otherwise we can get ischemia on the inside that you know in the trachea on the on the cells if we know we're gonna be doing tracheal suctioning, so potentially if there's lots of debris or mucus, and we know that we're gonna be doing that, then a tracheal tube is gonna be helpful because, you know, we can nebulize that and take better care of it. And not have to do it under sedation, or like I said, protection of the upper airway for prolonged periods we need that. So, Tracheostomy tubes, are much shorter than endotracheal tubes.

I'm not sure if you've seen them, but they're, probably like even a quarter of the length, and they need to be soft and pliable. You can make them out of endotracheal tubes if you chop them down, you know, if you really need, but they're really relatively easy to get hold of and not that expensive, and they come with, . They come with the ports in the top and also ribbon to wrap around the neck so it really just become a little kit and it makes life a lot easier, but, you know, sometimes if you have you're changing a tracheostomy tube multiple times and you need to clean it and you've not got enough of those the same size to change into.

You can cut down and kill tubes and just being wary of the ones that are crashed, and also making sure that it's those nice silicone ones and not the red rubber ones. So basically the tubes you can have a disposable or a reusable in in a cannula, and these are really good because they allow replacement of the inner cannula, so you don't have to take out the entire tube every time you need to replace the tube. One that stays in and then you have an inner part that comes in and out, .

And this just means that you can clean that in a cannula if it's got any debris, mucus buildup and you can clean it while the other one stays in place and the patient can still breathe through that tracheostomy tube. I'm The single ones as well, and a lot of the ones that we have in our practise are just a single cannula mainly just because of the size, so they range from in a diameter of 3 millimetres to 12 millimetres so they do are quite large, but anything that's 4 millimetres or less, then they are single cannula you can't get them in a double, just because of what I talked about. Those tracheas are already small.

We're adding that tube in there that has the 4 millimetre or less in a diameter, and you don't want to be adding something else into that that's gonna make it, you know, 3 to 2 millimetres, because that's gonna create a very small airway. And those ones aren't gonna have a cough as well, and these are used for cats and small dogs. So the bigger ones, some of them do have coughs, and then if you're using a cough tube, then you just need to make sure if you've got it in the long term that you're .

Decrease in the cough every 4 hours just to allow for blood flow and prevent ischemia. So cuff tubes are indicated when positive pressure ventilation is required. So often these patients on long term mechanical ventilation, are gonna be with cuff tubes, .

In our practise we only have a few caches often we just have the single cannulas but it's really preference and what works for that patient so as I said, the ones with the disposable are reusable in a cannula, they allow replacement of that in the one, without the removal of the entire tube. I And un tracheostomy tubes are used after anaesthesia, so those patients that are awake and not sedated or under general anaesthesia, need to have uncuff tracheostomy tubes to allow for movement of that patient, and coughing, and reflexes that you wouldn't see under general anaesthesia or sedation. So, the Most appropriate tube size needs to be 6 or 7 tracheal rings and lens, so it's good to measure them or have an idea before you start doing your tracheostomy, and have a maximum diameter of 50% of the diameter of the tracheal lumen.

And so when we talked about these cuff tubes, these are good for anaesthesia because, if we're talking about these diameters, they're gonna be 50%. If you're giving, inherent anaesthesia to these patients, then, you don't want that to leak out into the environment, so coughing these is going to prevent that, . So, The other reason why we have 50% is so that these .

Once these patients are awake, they can breathe around those tracheal tubes. So often predominantly in the beginning they're gonna heavily depend on that tracheostomy tube, but as they become better, so since we've done a laryngeal tie back, since we've, you know, given a medication to help the edoema or we've just given that patient time. And they start to go down and that patient start to breathe again and this is then we'll come to, when we take tracheostomy tubes out but it basically just, it's almost like weaning them off, you know, they kind of wean themselves off if it's only a diameter of 50%, then, without us actively doing it, we're allowing them to slowly wean themselves off and be able to breathe by themselves.

So unca tubes are less dramatic and they will be less likely to accumulate secretions as well. Just a quick note as well that the size of the tracheostomy tubes doesn't correspond to the size of the ET tubes, so you still need to do, you know, if you're gonna cut it down to measure the 67, and then. Also measure, the ET tube.

So, you can't just pick a 4 and a and a 4 up to be different, so you'd need to take your your ET tube, but sorry, your tracheostomy tube out and look at it in comparison to your ET tube that you're about to cut down. So, on to tracheostomy tube placement. So patients should be ideally anaesthetized or heavily sedated or I would say that .

Anaesthetize best, but if you can't do that and it's not possible because it's not possible to place an endotracheal tube, then heavily sedated is fine, and in some situations, you know, anaesthesia or even heavy sedation isn't going to be possible, just because it's gonna compromise a patient's cardiovascular. System, so we might just do something like midazolam and pain relief, and that might be enough for that patient. They may, you know, they may lay on the back.

So basically we're gonna place them on daughter recumbency, . And then what I like to do is either roll up a towel, or you can get a foam wedge, but I think a towel or a sun sandbag actually works better, because the foam wedge, doesn't quite get that neck sort of pushed into the pushed into the air, so yeah, a rolled up towel, underneath the neck, or a sandbag. And then you basically need to secure your head again if your patient is very critical and you've not been able to anaesthetize them or like heavily sedate and you've got them like say maybe under midazolam and .

Methadone or fentanyl or something, then you might have an assistant holding the head, . And then the front legs need to be fixed cordially, so. Down towards the back leg, so there's there's nothing obstructing that tracheal view.

We want to, Prepare, as we would do with any surgery, so aseptically want to clip all the hair, and clip often from the larynx to the 8th tracheal ring and usually I go quite I just go down to the . The sternum, . And then surgically prepared so like I say with you know, with hippie scrub or iodine.

And make sure that that's asceptically prepared. I'm, I'm ready to go as if it was any surgery. So, what we want to be doing is making a midline incision and just cordal to the larynx so the 2nd and 3rd, tracheal rings, .

All down to the 6 tray ring, . And then once that's in place, . You can then use like little mini gelpies or if you've not got those you know just retracting them with hooks .

And basically what you want to do is dissect through the subcutaneous tissue, and then you want to identify the fascia between the two sid muscles. So, you want to stay completely midline, otherwise you're gonna, potentially, miss your trachea or not have a perfect view of it, . So once they dissect those muscles using Mets and bomb scissors, .

And then, to re reposition the retractors basically to pull back those muscles as well so you can expose the trachea, and then using a scalpel blade when I incise the ligament between the 2nd and 3rd tracheal rings, . And with a maximum of 50% of the tracheal circumference, so literally you can see on this picture that it's a small incision just just big enough for you to get your endotracheal tube and sorry tracheostomy tube, . So what we want to do from here is we want to place stay sutures, and these are really important.

So we only non-absorbable non-absorbable suture material around the 2nd and 3 rings, so don't make a knot, but we want to keep a large loop of suture and not at the end and then place mosquito hemostats on the end of those sutures to keep those rings. Open and that's and we'll come to that in our care of our tracheal tubes but basically there just to make sure that if a tracheal tube falls out we can hold the airway open with those stay sutures. So you can get someone to do this for you, but you want to pull those those sutures, cranially and then cordially and to open that trachea.

So if you've got your patient under anaesthesia and you've got an ET tube in, then you want to quickly insert your tracheostomy tube, and if you've not, obviously then you don't need to do that part. You just need to put your tracheostomy tube in there. Label you stay sutures so cranial and caudal so that I'm in an emergency that someone doesn't pull them the opposite way than they should be.

I'm. And then basically once your tracheal tube is in place, you can see on these pictures got these two little holes so often you use medical tape or like umbilical tape, . Around each of these lanes to tie the tracheostomy tube around the neck and you don't need to close anything up, other than the subcutaneous tissues and cranial and cordal to the stromocy, and just making sure that it's big enough and that if you were to open those sutures that you could get another tracheostomy tube in there.

This is a nice little diagram, easy one cuffs, so, they clipped from the larynx down to the inlet, . And clipped on the . They'll surgically prepare they've draped up.

You can see, once they've dissected those muscles, they've used a little mini gies to retract those. You can see the trachea there, and they've made a 50-60% incision and those sutures are in place. You can see they're pulling those cranially and cordially.

To place that in and this is just that umbilical tape that I was talking about. So the double cannulas will have this bottom picture they have this sort of like plastic piece, and then they'll have another insert there, whereas the single cannulas just have the umbilical tape tying around the portal end. So this is where it starts to get really intensive.

I'm, I, in terms of care for these patients, I'm. The stomoys for tracheostomy tubes is an open wound, and it should be treated as such. It should be kept very clean, and it needs to be visualised at least twice a day, to avoid any dehessance or necrosis from developing.

It shouldn't be dressed so, because, the tracheal ties, need to be easily accessible, so you can see from this patient actually it's quite, they, they have quite a big swelling facial swelling, but even without addressing it's very difficult to see those ties and we can see those stays put nice big stays in those, . But you need to be able to make sure that you can get a tracheostomy tube in the patients quickly should that old one obstructs, you know, with mucus or debris, or it falls out, and you need to be able to make sure that you can swap those over quickly. If you've got a dressing in place, you're going to take that off, and also the dressings can include, the end of those tracheostomy tubes.

So clean with the mic so it should, a minimum of every 12 hours, and you need to use microbial scrub solution, sorry, don't use antimicrobial scrub solution, so we usually just use saline. And we can use, cotton buds and sterile cotton buds, and we use sterile swabs as well to try and keep it as aseptic as possible. And we also use surgical gloves rather than.

Just normal gloves. I'm. You can use chlorhexine and diluted but like I say saline is fine as long as that wound looks fine, .

And then yeah, like I say we use sterile cotton swabs with sterile saline to sort of clean those and tender bits around the actual tube. Don't scrub, the site, for obvious reasons that we don't want to, disrupt that, tracheostomy tube. We don't want to cause any more swelling, .

And also we don't want to get any of that . If we are using chloroxine, we don't want to get any of it into the wound or into such care. I'm So some studies suggest that tracheostomy tube sites are more susceptible to MRSA, so it's really important to, you know, have good hand hygiene, clean their hands before and after, dealing with the tracheostomy tubes, and potentially limiting the amount of people that deal with that tracheostomy tube, and wearing surgical gloves as well.

And as well as that when we come to our suctioning and general care, so everything, try and keep everything sterile, so sterile swabs, sterile cotton buds, if you're able to use new . Suction and equipment so you can use like urinary catheters or the special tubings and we can get those sterile or you know, try and keep them as clean as possible if you start to see debris on them and then we want to be replacing them and also making sure that they're not, just on the floor by the kennel. What I like to do is have .

Oh A bag, a sterilisation bag and put everything in that and hang it on the kennel door so that it's not on the floor and it's away from the patient as well . So as well as that, the, the tube ties, if you notice that they're getting a bit, manky, they're getting a bit dirty, then we need to change those as well because obviously, anything that's there can track infection into that open wound. So patient care is really important for these patients, because we've got these tracheostomy tubes, it creates a foreign body response, so it can create this cascade of inflammatory responses, causing inflammation and potential swelling to that tracheal lining, and as a result you get these protective secretions.

So, actually this dog on the left, this happened to you and it's quite a severe, reaction, this dog, . Was producing a lot of secretions and we had suction a lot more often we had to change tracheostomy tube quite a lot, and it would get blocked with these very thick and hardened, mu mucoid secretions, so it's really important that we follow our patient care to try and prevent this as much as possible, . So because we've got a tracheostomy tube, when we think about the airway in general, you know, from the mouth down, the trachea, it's been warmed up, and it's humidified, because, because that patient's breathing through its mouth, and we put a tracheostomy tube and it's gonna introduce cold dry air.

And that's gonna dry it out and it's gonna cause more, you know, inflammatory responses, more of these secretions because it's, it's reacting to having that, dry, dried out, trachea. It's gonna as a result, kind of be like, right, let's get this, . Let's get this tricky and nice and moist, so as a result, we need to basically imitate that, because, if we have a lot of .

So if we have a lot of cold dry air, it can desiccate the tracheal mu mucosa, . And we don't want that and we obviously don't want these to muoid secretion it's gonna cause obstructions to our tubes. I'm so.

We'll come to that in a second, but basically we want to create an environment that's going to imitate that warm humidified air and to. Make sure that that doesn't happen. Vagal stimulation is reported in 10% of our patients following tracheal stimulation during tube maintenance.

So, when we're replacing tubes, some section in tubes, it's something to be really, careful of, picking like our brachy so the breeds, because our vagal responses are often quite dramatic, . So I'm just being careful, being mindful when we're suctioning when we're replacing tubes, that we're not doing it too roughly, that we're not, you know, shoving those tubes in, . Because of airway secretions and 90% water, airway clearance becomes difficult for patients systemically dehydrated.

So we think about these trauma patients, . You know, these sicker patients if they're already dehydrated, if they've had some element of shock, we need to replace that shock deficit as well as that dehydration. And that's just to make sure that the mucosa that's there has the chance to be as moist as it can be, before we start introducing that cold dry air in there.

Other things that we're gonna be thinking about with our patients as well are occlusion, so patient interference, they might be lying down on it. You saw on the last slide that dog had extreme swelling, so skin folds again brackbres like bulldogs and things like that. They've got a lot of skin folds, .

They're gonna obstruct that entryway to that tracheostomy tube, build up of mucal secretions are obviously gonna cause obstruction, and so therefore these patients need round round the clock nurse care, and whether that be place in ICU or whether you have a dedicated nurse, they do need someone constantly watching them because. Even if they just block their airway for 30 seconds, that could cause, you know, a lot of hypoxemia and potentially brain damage. So be looking for respiratory distress, dyspnea, or respiratory arrest, and then providing oxygen to our patient when necessary, we might want to measure our graph on there, .

You know, there's a lot of things we can do from place and pulse oximetry, potentially, rectally if you've got the rectal probes, and just making sure that we're keeping up to date with our patients and seeing whether they've got any ventilation perfusion mismatches, whether they're hypo they have any hypoxemia or hypoxia, . So other things that we might have on these patients as well is a continuous ECG so we can see if there's any arrest or if there's any changes to that ECG as a result of . Of any obstructions.

Other things that might cause obstructions as well that we need to consider is hair. So, on the last slide that patient was a a collie and had quite a lot of hair, so we had to, we ended up clipping, and then cutting down the hair that surrounded the neck and the the jaw as well because that was like kind of dangling down into it. Cats, cat litter, is another culprit for obstruction.

And then other things that we can do for these patients is to administer mild, analgesics or anxiolytics to help provide the comfort, you know, making sure that we have appropriate bedding, so that bed's probably best, rather than lots of blankets and towels, this patient in this picture was kind of being propped up by that towel, but once that patient was moving around, she just had a bed bed. Other things that we want to consider is that we should be putting them in an easily accessible and relatively quiet central area. So like I say ICU if that's not possible.

You know, having a dedicate nurse, but basically making sure that that area is quiet, a lot of noise or stress that patients can cause respiratory problems, you know, and we, we want to basically treat these patients as if they were, you know, like the same as we would with cardiorespiratory patients. So we want to try and keep them as stress-free as possible. Making sure that you have an oxygen source nearby as well.

Because, you know, if that patient all of a sudden needs oxygenating, you don't want to be running around the practise trying to get any oxygen to them, so you might be using, you might have, you know, a small canister with them, you might have them there, you know, one of your anaesthetic machines, but just as long as you know where the nearest oxygen port is and it's near to them. So we make sure that it's visible but also audible. So that last patient was actually in a buster cage in like an oxygen cage, but because of where it was, it was in, we have this inpatient monitoring room where that was in the, we had it in there.

We had the door open most of the time because it was it had angiolytics and it was pretty flat, but you just need to bear in mind that oxygen cages and busted cages and things like that can get hot and also they can . Don't soundproof, so you don't want to miss anything if they're coughing, if they're going into respiratory arrest, you know, if they're chain soaking, you, you can't always hear that. So I was a dedicated team member to the patient, whether that's a nurse, whether that's a vet, even a nursing assistant, you might have a nursing assistant just watching, you know, so I'm happy taking respiratory rates and.

You know, assessing effort, and you might keep a dedicated staff staff member as well as having a nurse pop in and out as well. So said continuous pulse oximetry and ECGs. I'm Ideal.

Obviously pulse oximetry isn't always achievable in our conscious patients. We want to alert other staff members, and this is even though we have this dedicated team member, you know, team members for a second to the toilet or they need help, urgently, and then we just want to make sure that other staff members are in no that that that patient needs, help. So anxious and stressed patients become hypothermic and increase the likelihood of any airway obstructions, that's what I said about those.

Mild analgesics, or anxiolytics and help provide comfort and reduce that stress and treating these patients like cardiorespiratory patients, is often the way that I look at it and we want to try and keep them as stress-free, you know, we don't want them to be overheated, and we want them to be comfortable, relaxed, and in the best position that they can be so they can breathe for themselves. As I said about the sleep position, those patients with chronically obstructured airways, they may sleep, in a certain way to try and, you know, you think about bulldogs that you get in that they, they lie, like flat on the floor with their, you know, elbows out and try and just expand the chest as much as they can, but that's gonna obstruct the airway, so, . Whether you create, you know, towels under the chin to try and create a bit of airway, or you give them.

Axiolytics or sedation and mild sedation. To try and and have them sleep in a different position. So skin incision can be uncomfortable, and then tracheostomy tube ties can rub as well, so it can often cause irritation and discomfort.

So this is why we check our patients, the wound twice a day. We want to be making sure those ties aren't too tight. You know, there's no skin irritation.

I'm placing it. I'm. Best co these patients isn't gonna be possible because that's gonna potentially block our airway or cause, you know, changes to the air that's surrounding that tracheostomy tube, so.

You know, using anxiolytics, using the light sedation if you need to, you know, we use Microderm, or, sometimes we'll put them on a very, you know, microderm, CRI, and so as patients are a bit more amenable to the treatment that we're giving them. So we just basically want to rehabilitate them for new areas. We want to get them to use to, breathing out of that tube, and not slipping into the old ways, particularly in those ones that are chronically obstructed.

So teach them how to comfortably lie down, arranging the bedding to accommodate in this new ceiling composition and like I say, using, analgesics or anzootics to provide comfort. So tracheostomy tuca, we talked about that, cold, dry air that we want to try and mimic that warm humidified air. A humidified air in practise is very difficult to imitate, .

And it's just because it's quite expensive, you know, the machines to provide them are expensive, whereas nebulizer, is a lot cheaper and a lot more accessible skill wise, so previously it was thought that putting sterile phone. Via these tracheostomy tubes trying to help prevent this buildup of, this thick, these thick viscous secretions is more beneficial, as, as it was thought that saline broke up or dissolved these secretions, but because this mu mucus is 99% bound by disulfide bonds, and the introduction of the saline isn't gonna make this any less viscous, and also. The huge thing that I think about when you know when when I think back to when we were first doing it was that we're we're putting down 1 to 2 mLs of saline into an airway essentially we're potentially introducing the risk of fluid into the lungs and contributing towards an aspiration pneumonia, which we don't need the patients to have any more problems with the ventilation .

So humidifier or nebulizing in the air is gonna prevent the mucus build up hopefully sometimes it doesn't like to say that dog that I showed the little French bulldog. I'm sorry it was a Boston Tarry, not a French bulldog. I'm I'm.

We were nebulizing that every 2 hours and that still has a huge amount of mucus buildup, and we think potentially it was something to do with the actual dog, not with the treatment that we were doing, so anyway, the, nebulizing this area is gonna mimic the tracheal environment, and I think there's a picture from the next slide, of these little nebulizers. They're handheld, portable. You just need to put in the little cups, and then it basically puffs out nice nebulized like wet air, and it's gonna mimic this environment.

I'm If there's a lot of new card build ups, and then we basically wanna be changing it in a cannule or the whole tube if we've got a single tube for a new sterile one, because we can do suctioning, we'll talk a little bit about suctioning, but there are a lot of risks, and disadvantages to suctioning, so if we're getting a lot of new buildups and it's finding that we need to suction all the patients, you know, pulse oximetry or . Capnograph isn't looking so great then we probably want to change our cannula. We can use techniques such as coupage, so cupping the hand, and rhythmically bashing the chest, to loosen the secretions and then cause a cough, so often we do this after nebulization we cause that nice warm and then.

That warm like humidified environment and then clapping on the chest wall and breaking up that debris and provoking a cough reflex, but just being wary of that that, you know, then we might get a mucus buildup in the actual tube if it's not able to get past that tracheostomy tube. We can also, inadvertently remove the tracheostomy tube if the patient starts coughing too much as well, so just be wary of that. Other things that you can do as well is walking a patient at short distance, so often we do this rather than coupon, and just it's better tolerated, and it increases the tidal volume, stretches these airways, and promotes the coughing.

Yeah, this is a nebulizer. There are actually human nebulizers, . But they're really easy to use.

You can use a mask. You don't have to, I've got a picture on the next slide of us with that collie, just sort of washing it underneath rather than trying to put that mask near it, so we don't occlude that tracheostomy tube. So you can get oxygen bubblers, they're easy to use and cost efficient, and they saturate inhale the oxygen with water vapour.

We talked about heat humidifiers, so they're most commonly associated with mechanical ventage you might see these in. The hospitals that have long term mechanical ventilators, and they are very effective, but they're also very costly, so I'm gonna just touch on those quickly, but basically the warm air carries more water vapour and then it increases the number of water molecules delivered to the airways so it's still creating that, like moist environment. And then nebulizers, which like I said, cheap, easy to get hold of and the most effective way to miten the airway to delivering large volumes of liquid to the airways.

So, we often do nebulization for about 20 minutes of our patients as long as it's well tolerated, and often it is because, other than the noise, there's nothing, you know, you're not touching a patient, . And you can give him a bit of TLC while you're there as well, so it just creates liquid droplets of mist, as opposed to humidifiers which will deliver water vapour, . And so what we're gonna be observing for is airway irritation, bronchospasm.

Systemic overhydration, hypothermia androgenic infections, so, this is why we use sterile saline to try and minimise arogenic infections. Hypothermia is often going to be more, with our heated humidifiers. But systemic overhydration could happen from too much nebulization, but often again it's gonna be another heated humidifier problem and bronchospasm because it may cause that transient cough and airway irritation as well.

So just watching out for signs of that, you know, changing our respiratory rate, respiratory effort, any coughing, any swelling, you know, any occlusion to those tracheostomy tubes. So this is a collie and I had lots of neck swelling. And we've got a nebulizer here.

You can see, obviously you can't see on the picture, but it was missed, and that travels up there through the tracheostomy tube. It was relatively well tolerated by this patient. And we would sit there for 20 minutes doing that.

So I think it's really, I've put it in the notes, but I'm, I think with these patients we talked about those round the clock care. I think it's really useful to have laminated instructions on how to care for the tracheostomy tube. How to care for the patient, you know, what to be watching out for the patient and what equipment needs to be kept for that patient at all times.

So I put all lists in In the notes as well, . But the tracheostomy tube car, so the double cannula car. Basically what we're looking for is the inner cannula, we need to be examined every 2 to 4 hours, .

I think we have to examine it every 2 hours once that patient is, you know, settled and I've got not got a lot of secretions, but if you find that a patient has a lot of muoid secretions and you do need to look at that, we do ours every 1 to 4 hours just depending on the amount of secretions produced. So again if they producing excessive mucus, it may require care every 30 minutes or more, depending. So as I said, using sterile gloves, you would remove the inner cannula, and, leave that outer cannula in place.

So you want to soak it in a sterile bowl con containing sterile salines, you know, just like the little kitten dish or the sterile bowl that you use for scrubbing up in surgery. Soak it in that and then you can use soft pipe cleaners if you're able to get hold of them, and they're sterile or just use sterile cotton buds, and often the cotton buds will be enough, depending on your size, obviously the bigger sizes you might need to find, you might need to, sterilise soft pipe cleaners to get rid of those. And then rinse thoroughly in another, sterile bowl with sterile saline, and remove anything that could irritate the, mucosa, so making sure that the outer bit's clean, the inner bits clean, and then shape dry or dry with a gauze.

Then you want to just replace the outer cannula, . Or store in, replace it in the outer cannula or store in a sterile manner if you're not using that one. If you're finding that there's mucoretions in that outer cannula as well, when using a stay in the same manner that we talk about or single cannula, so.

Ways we can look at our single cannula without having to actually take it out, because obviously with the double cannula we've got that advantage that we have a cannula still in that patient still has an airway so it's much easier to inspect that every couple of hours, but we can change listen to change in pitch and you can sort of listen near the actual tracheostomy tube opening, . To hand often I prefer to do a glass slide. You can do tough to cut them, but I think, cut them or potentially that's gonna introduce foreign bodies, I'll get stuck to the side if you know if there's mal secretions on the outside, on that wound.

So a glass slide is my favourite. I put it in front of the tube, and you can look at the air flow. So if it doesn't look like it's very much, then it's probably, time to, to take it out and look at it.

Again, you can look at capnography as well. You can place a mainstream capnography on the end of that and just see what I'm I'm. Topnography is reading.

What your ATCO2 is saying, so if you've got a change in that, then, it's probably best to take your camera out. So again, same, same way you would do with your inner cannula, take it out, put it in your sterile bowl. And then, you know, introducing more sterile cotton swab, on pipe cleaner and to remove any debris.

I You can do it in place, but you just need to be really careful. You're not going to push anything into the airway. So I would say if you're, if you're trying to clean it, I would take it out and either replace it with a brand new one and clean the other one in your own time or have someone hold the safe features open while quickly clean it and put it back in, .

Because I think otherwise, you're on the risk of pushing muco secretions in there or including in the airway, which we don't want to be doing. So as you can see, in this instance there was just moussecretions just in the in a bit here rather than like in the actual cannula as you can see on the right hand side, . You can just use that to clean that in a bit, but I wouldn't be shoving pipe cleaners or swabs.

Yeah, cotton buds down that pipe, and in this instance this was very hardened, so we struggled to clean, we struggled to clean it, and we just placed a new one instead. You can post these dressings, . This patient I'm even with mild sedation.

And anxiolytics and all the rest of it did keep trying to scratch it there so we put this on, but we just made sure that the safe features were able to be got and that we had access to these tube ties. So tracheostomy sectioning is quite a contentious subject, I think now I think previously it was done quite often . But I would say that if you're having to do this quite frequently with your patients that you should consider changing your tube rather than keeping suction in so for conscious that spontaneously breathing patient, I basically just want to hold the patient and hold the neck up.

Again, pulse oximetry and ECG are gonna be preferable, and then we want to oxygenate prior. And in between and after every suction pass and to avoid iatrogenic hypoxia or hypoxemia. So you can just hold, the oxygen up to the tracheostomy tube.

I am wearing sterile gloves and advance the catheter into the lumin of the tracheal tube, so no more than a few centimetres past the end of the tracheal tube, because we don't want to be started suctioning the actual tracheal mucosa, so, potentially when you put your tracheostomy tube in measuring it so that when you're using your cat, you know, these urinary catheters or suction tubes that you can mark off your . The area that you need to stop at basically. Do you want to twist the suction catheter so you can sort of like twiddle it between your forefinger and your and your thumb, .

And withdraw it while tapping the proximal port and to produce intermittent suction. You don't want constant suction, again, otherwise you might cause rogenic damage to that trachea. We're gonna performance really quickly so that you twiddle down back out less than 5 seconds and oxygenate this patient because while while we've got this suction in there, it's gonna be depriving that patient of oxygen and obviously causing an inclusion as well so .

We want to make sure that the amount of time without oxygen is as short as possible. So once suction catheter is removed, we oxygenate and allow for a brief, so 2 minutes or more recovery period, and you can do that again, but we shouldn't be doing it more than 2 or 3 times. If you're doing it more than 2 or 3 times in one period, you want to change the tube, have a look at what's going on in there, .

You can auscultate the chest or the throat and listen to the patient's breathing as well and use that glass glass slide. If we're gonna be suctioning aggressively, so we'll not tap in the end, create that intermittent suction, or advancing that catch too far, then we're gonna cause severe coughing, bronchospasm, vomiting, all those vagal episodes that we talked about, and potentially causing collapse. The removal of the stomy tube, it can vary from days to week depending on the primary condition.

It just depends on the patient's ability to breathe adequately when we either partially or completely occlude that tracheostomy tube. So we talked about it's only taking up 50% diameter. If we occlude that and they've got, you know, they're fine to breathe around it, they've got 50% to be able to breathe adequately through their mouth, so.

Because it does, occupy like 50%, it, it is gonna skew our patient's normal respiration, so we just have to be mindful of that, but. Basically, we just want to make sure these patients can Breathe adequately and the other tests that we can do is we can take it out as long as we keep those safes in place, we take it out, see how they get on if they struggle, put the tracheosomy tube straight back in. So complications that can arise post, tube removal, or infection, obviously we have that wound, tra tracheal stenosis because we've had that tracheostomy tube in place and an inefficient respiration because of, .

That patient's been unable to respond properly through its trachea and potentially. Because I've, I'm, I rogen stomach as well. So they should be monitored closely for several hours, and then still require regular monitoring until discharge.

So often we keep a nurse with them to sit in the kennel for the first few hours after they have that done, and then we have regular respiratory checks on that patient, often, every hour, to make sure that they're fine, . As I discussed that emergency tray, so with all the equipment that you need for for your tracheostomy tube, new tracheostomy tubes, you know, suction equipment, any sterile gloves and whatnot should still be available on that on that dogs or cat's kennel, and then we need to leave those state suits in place for 24 hours post tube removal just because of . If that patient struggles at all, we've got immediate access that that tricky rather than having to go back into surgery.

The stoic is unless to heal by second intention, which usually takes 7 to 10 days, and, you know, we don't need to su this, we just leave it to heal, and we might dress it, but often we're not going to be dressing it either. We're just gonna be keeping it clean. Complications arising from tracheostomy tubes, aspiration pneumonia we talked about.

So, introduction, . Potentially it's gonna cause aspiration pneumonia, so watching for respiratory distress, and increased respiratory effort, . You know, any change to lung sounds, and then X-ray if we need to, dislodging the tubes so either the patient or us, .

That's gonna cause cyanosis, hypoxy to those tissues and hypoxemia, if they're deprived of oxygen for a while. And so again occlusion of the tube from the patient, or if we're doing an aggressive suction and and we're gonna be cluing that tube and causing cyanosis, hypoxia and hypoxemia. Tracheal stenosis, as well as necrosis and fistulas, they're quite rare.

I think necrosis is probably the most common out of those three, and so we just need to be careful with our suctioning. And then gagging and vomiting with the presence of the tube, so again that's gonna be causing increased risk for aspiration pneumonia. I'm suing in, we mentioned that vagal response, so they get coughing or stimulation of the gag reflex.

I'm I'm having a vagal response. I'm, if we're suctioning, I'm too hard, we're gonna be causing hypoxia to those tri mucosa. Again, dislodging the tube, cyanosis, hypoxia, hypoxemia, as well as tracheal stenosis and necrosis.

Patients are contraindicated, so we talked about tracheal collapse is one of our patients that have that are a candidate, but just considering when we look at our X-rays where that tracheal collapse is, so if it's tracheal collapsed distal to the tracheal tube site, or any previous tracheal stents, then this patient isn't a candidate for a tracheostomy tube, . You know, you can move the tracheostomy tube slightly and to accommodate it, but you know it's only so far we can move it without . You know, going too far down.

Again, a mass surgical obstruction distal to the site of the tracheostomy tube placement, that needs to be addressed, and potentially those patients, might go on a tracheostomy tube once that placement, that obstruction has been cleared, for recovery, but you know, it's unlikely unless there's a an an obstruction further up. And patients with coagulopathy and thrombocytopenia for obvious reasons ever replacing tracheostomy tubes, we've got that open when we're doing lots of . Well, you know, cutting into the muscles and cutting into the trachea, and we're gonna be causing bleeding unnecessarily, and these patients on a can, and then increased intracranial pressure or an unstable cervical spine, so I'm thinking about this patients in an RTA and if they've had spinal damage or they've got any form of head trauma.

You know, postal tube, is gonna potentially cause increase to your intracranial pressure, and we don't want that it's gonna, disturb your cerebral perfusion pressure which we know is very important in traumatic brain injury. Thank you very much for listening. I'm like saying in the notes, there's a kit list, but if you, I need anything else, and then I'm like what our protocols are, then I'll have to send those to, but yeah, any questions?

Thank you, Chloe. That was an amazing amount of information and fantastically good information as well. When you first start using tracheostomy tubes, they really are scary things.

But once you've listened to great presentations and and information like this, it does make it seem less daunting and easier to deal with. So thank you for your time and thank you for the information. You're welcome.

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And, we do that by getting feedback from you. So do us a favour and just take those couple of minutes and fill in the survey monkey. Chloe, there are no questions.

You've obviously answered everything for everybody. So it is just up to me once again to thank you for your time tonight. And thank you to all of those that attended.

We really do appreciate your attendance. Those that are listening to the recording afterwards, I hope you enjoyed it and got as much information out of it as I did. So, thank you, Amy.

Chloe and thanks to Amy for her work in the background as well. From myself, good night.