Challenges in Changing Tracheostomy Tubes: A Case Study - Pulmonology

Issues with Changing Tracheostomy Tubes

---

Hello Dr.
Zhou,
Background of the issue: My 65-year-old mother has a tracheostomy tube that needs to be replaced in about a month.
After a consultation with the ENT department at Hospital C, an endoscopy revealed that there is dry secretions in the trachea, making it difficult to replace the tube.
Initially, Hospital C suggested that the patient return to Hospital A for the procedure.
If performed at Hospital C, it would require going to the operating room and anesthesia.
The doctor mentioned that the surgery carries life-threatening risks, including the risk of a second stroke and significant bleeding.
Question (1): In April and May, the tracheostomy tube was replaced at Hospitals A and B, which was a simple and direct replacement without any surgical intervention.
Is the issue of dry secretions in the trachea severe enough to necessitate a high-risk surgery, or are there alternative management options?
Question (2): The doctors at Hospital C speculate that the dry secretions are due to the caregivers not properly cleaning the tracheostomy tube.
Is maintaining the cleanliness of the tracheostomy tube the responsibility of the caregivers? (We have also consulted with a pulmonologist at Hospital A, who indicated that the hospital where the patient is located would generally handle such matters unless the hospital lacks the necessary equipment.)
Hospitalization background: On March 8, 2023, my mother was hospitalized at Hospital A due to a hemorrhagic stroke.
After the first extubation, she experienced respiratory failure and required re-intubation.
In late March, the attending physician recommended a tracheostomy, which was performed by a pulmonologist on March 27.
On April 12, the tracheostomy tube was replaced at Hospital A with a model that allows for speech practice.
Due to health insurance regulations, she was transferred to Hospital B at the end of April, where the tube was replaced again on May 10.
According to the doctor, the tracheostomy tube needs to be replaced every month.
She was transferred to Hospital C on May 22, with the next replacement scheduled for June 8 based on Hospital B's recommendation.
At the end of May, the rehabilitation physician at Hospital C consulted with an ENT specialist, who indicated that the inner tube was difficult to insert and that the brand of the tracheostomy tube was different from what is typically used at Hospital C, leading to uncertainty about a successful procedure.
An endoscopic examination revealed dry secretions in the trachea, and the doctor advised against direct replacement due to the risk of significant bleeding, explaining to the family that surgery would be necessary, which carries substantial risks.
The anesthesiologist also warned that the situation could become severe enough to require ECMO support.
Management from March to June at various hospitals:
- Hospital A: The tracheostomy tube was cleaned daily by nurses, and mucolytic medication was administered via the tracheostomy tube.
- Hospital B: The tracheostomy tube was cleaned three times daily by nurses, and mucolytic medication was administered via the tracheostomy tube.
Oxygen was gradually removed to practice spontaneous breathing.
- Hospital C: The tracheostomy tube is cleaned daily by nurses, and mucolytic medication is administered via a nebulizer.
They have now discovered dry secretions and have started administering pure oxygen in hopes of softening the dry secretions.
Patient status: She has suffered a brain injury and stroke, is partially paralyzed, has a nasogastric tube, a tracheostomy tube, and just had her urinary catheter removed.
She can breathe independently (without supplemental oxygen).
In April, during suctioning, it was noted that the secretions were more viscous, so mucolytic treatment has been continuously administered.

---

Jiaoji de jiashu, 30~39 year old female. Ask Date: 2023/06/06