TRANSTRACHEAL OXYGEN
THERAPY: PHASE II
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PURPOSE:
To establish guidelines for Phase II of the Trantracheal Oxygen Program: Transtracheal Procedure and Stent Week.
SUPPLIES NEEDED:
SCOOP Transtracheal Procedure Tray, sterile surgical gloves, Lidocaine 2% with epinephrine 1:100,000 (5 cc),
Chlorhexidine 4% surgical scrub (10 ml), sterile saline irrigation (500 cc), plastic adhesive tape 1: wide (1 roll), facial tissue (1 box), oximeter, x-ray viewing box, thermometer, blood pressure cuff, stethoscope, nasal prongs, oxygen source, mayo stand and ENT examination chair with headrest, if available.
GENERAL COMMENTS:
The goal of performing the trantracheal procedure is to create a quality tract at the proper level for stability, in the midline of the trachea while avoiding placing the catheter through the cricothyroid membrane or exposing the cartilage. It is best to do the procedure early in the day and early in the week. This allows the patient to be monitored at home or in the hospital through the remainder of the work day and for the remainder of the work week.
PRE-PROCEDURE ROUTINE:
PERSON: ACTION:
Respiratory Therapist/RN 1.
Have patient arrive approximately 1 hour before the procedure
(RT).
Obtain a brief interim history and physical to identify any new symptoms (increased cough, purulent sputum, or wheezing). Note: If patient is unstable due to an acute exacerbation, the procedure is postponed by the physician (RT).
3. Check patient’s oxygen saturation via oximetry (RT).
4. Administer pre-procedure medications as ordered by the physician one hour before the procedure: (RN) a. One Tylox or Percocet capsule for patients with PaCO
2
< 50 Torr
Benadryl 25-50 mg for patients with PaCO
2
> 50 Torr. b. Cephalexin 500 mg for infection prophylaxis. Note: Any antibiotic effective against staphyloccoccus aureus may be given. c. Optional: Tessalon Perle 100 mg may be given for cough suppression.
5. Thirty minutes before the procedure, administer a nebulized bronchodilator in patients at risk for bronchospasm (RT).
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TRANSTRACHEAL OXYGEN
THERAPY: PHASE II
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6. Have patient change into hospital gown Note: Females do not need to remove their bra (RT)..
7. Place the patient supine on a stretcher with head of bed elevated 80 degrees and place a pillow or other support to slightly extend the patient’s neck. If available, seat patient in an ENT examination chair with a headrest. Angle the back of the chair backward about
10 degrees, and adjust the headrest to slightly extend the patient’s neck (RT).
8. Reposition nasal prongs to arrive from behind. Note: If the patient is using a non-rebreather face mask, invert the device and tape to the forehead (RT).
9. Display the most recent PA and Lateral check x-rays on a vie box in the procedure room (RT).
10. Open the patient’s chart to the trantracheal procedure worksheet
(RT).
11. Place the SCOOP transtracheal procedure tray on a small Mayo stand in front of the chair (RT/RN).
12. Place the following supplies on the counter in the procedure room
(RT/RN). a. Two pair sterile gloves in the required sizes. b. Lidocaine 2% with epinephrine 1:100,000 (5 cc). c. Chlorhexidine 4% surgical scrub (10 ml). d. Sterile saline irrigation (500 cc). e. Plastic adhesive tape 1” wide (1 roll). f. Facial tissue (1 box).
13. Make patient comfortable. Encourage patient to sit erect and straight on the stretcher or in the chair, with his/her head square on his/her shoulders (RT/RN).
14. Orient the tray on the May stand with the label readable by the physician (RT/RN).
15.
Remove the tray from the plastic bag and open the paper drape taking care not to touch the inside of the drape (RT/RN).
Note: The upper tier is used clean while the lower tier is used sterile.
16. Prepare the upper tray. a. Remove all packing tapes. b. Open the alcohol swabs. c. Draw up 5 ccs of 2% Lidocaine with epinephrine 1:100, 000 into the syringe with the 20 gauge needle, then change the
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PROCEDURE ROUTINE
PERSON:
Physician
(Respiratory Therapist)
(Respiratory Therapist)
TRANSTRACHEAL OXYGEN
THERAPY: PHASE II
Page 3 of 8 needle to the 27 gauge x 1 ¼” needle. d. Add 5 cc of 4% chlorhexidne soap to the prep well and dilute with 10 ccs of sterile saline.
17. Locate the patient’s storage envelope and label with the patient’s name and set aside (RT).
18. Assist the physician with the steps outlined below:
ACTION:
1. Palpate the superficial anatomy of the anterior neck with the neck slightly elevated and square on the shoulders. Pay special attention to the anterior neck veins and the position of the trachea.
2. Using the surgical marking pen, mark the notch of the thyroid cartilage with a “V”, the cricothyroid membrane with a horizontal
“__” and the notch of the manubrium with a gentle “U”.
Note: The cervical trachea rests between the “____” and the “U”, and creates a vertical axis. The most stable position for the catheter is at the crossing of the security necklace and the trachea.
3. Prep the skin over the procedure site with an alcohol wipe.
4. Insert the 27 gauge needle at the anterior margin of the sternocleidomastoid muscle and create a wheal by injecting 2 ccs of the local anesthetic across the midline to the contralateral sternocleidomastoid muscle.
Note: Intradermal injection causes blanching and is too superficial while failure to create a wheal indicates injection is too deep.
5. Transfix the trachea with the thumb and forefinger of the nondominant hand. Proper transfixion of the trachea is important because it is critical for the identification of the midline of the trachea. Flex the wrist and keep the elbow down at the side to avoid touching the patient’s face. Keep the fingers about 1 ½” apart and inside the anterior margins of the sternocleidomastoid muscles.
Respiratory Therapist looking over physician’s should confirm midline positioning of needle prior to skin puncture.
6. With the trachea transfixed, inject 1cc of local anesthetic from the skin down to the trachea but not into the trachea.
7. Remove the 27 gauge needle from the syringe and attach the 20 gauge needle.
8. Tell the patient to expect an incipient cough, bad taste and globus sensation which is caused by the transtracheal injection of the local anesthetic.*
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Respiratory Therapist
(Respiratory Therapist)
TRANSTRACHEAL OXYGEN
THERAPY: PHASE II
Page 4 of 8
* Tell the patient they might have the “illusion” that their breathing is different. Tell them it is normal and it will pass.
9. Encourage the patient to resist the urge to cough for a few seconds and give the patient a facial tissue.
Respiratory Therapist looking over the physician’s shoulder confirm midline positioning of needle prior to skin puncture.
10. With the trachea transfixed and an alcohol swab in the palm of the same hand, insert the needle into the trachea at the puncture site, aspirate air into the syringe, and quickly inject the remaining 2 ccs of the local anesthetic.
11. Immediately remove the needle to avoid lacerating the mucosa with coughing, place the alcohol swab over the puncture site permit the patient to cough.
12. Prep the anterior neck with the chlorhexidine scrub. The prepping takes five to ten minutes and should extend from the jaw superiorly to the upper chest inferiorly and beyond the sternocleidomastoid muscles laterally. Systematic scrubbing begins at the puncture site and extends radially outward without coming back to the center. Use the second sponge in a similar way.
Note: Scrubbing should remove most of the orientation marks, but the selected puncture site will remain visible due to the central
20 gauge needle puncture mark and blanching of the skin from epinephrine in the local anesthetic.
13. Wipe the chest with 4” x4” gauze sponges at the level of the clavicles to permit the Steri Drape to stick to the skin.
1. Remove the upper tier from the Mayo stand by inserting fingers into the wells.
2. Place the necklaces and wire cutters in the patient storage envelope.
3. Pour sterile saline into the fluid well at the top of the tray.
4. Put on sterile gloves and follow sterile technique hereafter.
5. Apply the Steri Drape straight across the chest at the level of the clavicles.
6. Prepare the lower procedure tier: a.
Remove the scabbard from the No. 15 scalpel and set aside in a gutter on the perimeter of the tray. b. Fill the syringe with about 2 ccs of saline from the fluid well and attach the 7 cm 18 gauge thin wall needle. Remove the guard from the 7 cm needle and syringe to the original location. c. Inspect the wire guide and palpate the atraumatic end.
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Physician
TRANSTRACHEAL OXYGEN
THERAPY: PHASE II
Page 5 of 8 d. Open the packet of water soluble jelly and apply a small dab to the tip of the pre-SCOOP stent. e. Open the suture packet, grasp the needle with the needle holder, and return the needle holder to its original location with the needle tip pointed down. f. Discard the plastic bag from around the 4” x 4” gauze sponges.
1. Hold a 4” x 4” gauze sponge in the palm and transfix the trachea with the nondominant hand.
Respiratory Therapist looking over physician’s shoulder confirm midline position before skin incision is made.
2. Using the belly of the No. 15 scalpel make a vertical 1 cm incision at the selected puncture site.
Note: Try to place the incision to the side of any visible anterior neck veins to avoid bleeding and bruising. Two passes of the blade are usually required and sequentially expose dermis, which is white, then fat which is yellow. Often a pea size amount of fat herniates through the incision.
3. Grasp the syringe and 7 cm needle like a dart and pass the needle through the small incision down to the trachea.
4. Gently palpate the cartilages with the needle which is then popped through an inter cartilaginous ligament.
5. Pass the needle horizontal to the floor. This will usually cause the needle to enter the trachea perpendicularly.
Note: A common misconception is that the trachea is parallel to the anterior neck and chest. In most patients the trachea falls away from the anterior chest wall at about a 45 degree angle. With the patient sitting 10 degrees back, the trachea is usually vertical.
6. Aspirate air back and detach the syringe from the needle.
7. Rotate the needle to bring the notch on the hub to the inferior rim, this directs the bevel of the needle downward.
8. Elevate the hub to angle needle downward toward the carina.
9.
Insert the atraumtic end of the wire guide through the needle into air.
Note: Insertion should feel like passing the wire guide through the needle into air. If any resistance is met, it may be because the needle is in the mediastinum rather than the trachea. If there is any doubt, remove the wire guide and repeat the procedure.
10. After proper positioning of the wire guide, remove the needle.
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Respiratory Therapist
Physician
Respiratory Therapist
Physician
POST PROCEDURE ROUTINE/STENT
WEEK
PERSON:
Respiratory Therapist
TRANSTRACHEAL OXYGEN
THERAPY: PHASE II
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1. Hold the black reference mark on the wire guide at the level of the skin to free the physician for the dilation step.
1. Pass the dilator over the wire guide with a firm and steady push. It is not necessary to twirl the dilator.
2. Angle the dilator downward toward the carina to avoid traumatizing the posterior tracheal wall.
Note: When the dilation of the intercartilaginous ligament reaches the full diameter of the dilator, less resistance is encountered.
3. Insert the dilator an additional 2 cm into the trachea. DO NOT go beyond the black reference mark at 8 cm.
4. Leave the dilator in place for one minute to fatigue the elastin fibers of the ligament. Tell the patient the procedure is almost over.
5. Remove the dilator. Take special care to leave the wire guide in place.
1. Hold the black reference mark on the wire guide at the level of the skin.
1. Immediately insert the previously lubricated stent over the wire guide.
Note: As the tip passes through the neck tissues, it is twirled a full 360 degrees until the flanges comes to rest against the skin. The exchange form the dilator to the stent is made quickly because venous oozing is most likely to occur at this point and the stent tamponades the bleeding.
2. Ask the patient to cough gently before the stent is sutured in place.
Note: This should result in air regurgitating out the lumen of the stent. If not, a syringe is used to aspirate air out and confirm that the tip of the stent is in the airway.
3. Stabilize the stent with 1 cm sutures passed vertically through full thickness of the skin.
4. Leave the 1 cm vertical incision open to permit the stent to function as a surgical drain.
5. Tape a non-occlusive dressing lightly over the flange of the stent.
6.
Fill out procedure sheet and order chest x-ray.
ACTION:
1. Take patient to x-ray for PA and lateral film. Measure distance of catheter tip from carina and document on the transtracheal procedure worksheet.
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TRANSTRACHEAL OXYGEN
THERAPY: PHASE II
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2. Inspect tip of dilator for splitting or etching which would suggest exposure of tracheal cartilage.
3. Wash suture scissors and wire guide with chlorhexidine solution, place in patient’s storage envelope, and set aside for use the following week.
4a. Observe patient for a minimum of one hour following the procedure.
Note: Patients with a single MOC score of 2 or combined score of 3 should be admitted to an observation unit overnight at the discretion of the physician.
4b. Perform pulse oximetry and titrate on nasal prongs to acceptable
SaO
2
.
5. Insure that patient has all post procedure prescriptions filled. a. Cephalexin 250 mg TID is prescribed for 2 weeks post procedure. b. Tessalon Perles 100 mg every 4 hours for cough suppression. c. Topical Lidocaine may be dispensed at the discretion of the respiratory therapist or physician for additional cough suppression and is mixed by the therapist as follows: 1 cc of 1%
Lidocaine to 3 cc saline for instillation as often as once per hour.
6. If the patient requires anything for pain relief, plain Tylenol is recommended.
7. Show patient post procedure segment of the SCOOP Patient
Education and Training Video.
8. Review all post procedure instructions with the patient: a. Instruct patient to not connect oxygen to the stent, but to continue wearing nasal prongs at the prescribed flow rates. b. Frequency of prescribed medications. c. Tract care: Clean tract twice daily (BID) with cotton tipped applicator and 3% hydrogen peroxide. Change dressing as needed. Fold 4” x 4” gauze sponge in half and tape. Patient may remove the dressing after the first day desired. d. Confirm that patient has printed instruction in the Patient
Workbook and Guide. e. Instruct the patient to call the physician with any questions or concerns, including significant bleeding, subcutaneous air, increased cough, or significant hoarseness. Confirm that the patient has the phone number, including answering service for after hours.
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References:
JC-HAS:
OTHER:
TRANSTRACHEAL OXYGEN
THERAPY: PHASE II
Page 8 of 8 f. Tell patient that it is normal for regurgitation of air through the stent to stop after two or three days once the lumen becomes blocked by inspissated secretions. g. Discharge patient home and follow up with a phone call that afternoon to confirm that the patient is not experiencing problems.
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Original Date 01/02/01
Review/Revision Date 04/28/03
 Supersedes all Previous
Approved: _____________________ Date 05/28/03