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Inner Cannula + PMV + Cough Assist

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    Inner Cannula + PMV + Cough Assist

    Hi Everyone,

    I don't know if this is the right forum topic... but here goes -- if anyone can share their experiences with any of the below, I'd really appreciate it!

    My Dad, C3-C4, has yet to be seen by a pulmonologist. It took a long time to get an approval, but now, almost a year after his injury, he'll get to see one -- but the appointment hasn't happened yet.

    A bunch of worries...

    1) Inner Cannula

    My Dad did not have an inner cannula at the long-term subacute for over 3 months. However, when he was in the ER, the RTs said that he should have one to keep his airway open. If there's any obstruction, she said that the inner cannula can easily be replaced.

    But, I noted that an RT removed it when my Dad used the Passey-Muir Valve.

    Recently, the RT (provided by the equipment vendor contracted by the HMO -- unfortunately, this RT only tends to the equipment not the patient) said that some keep the inner cannula in while using the PMV -- but then, mentioned that she can understand why it's removed. The Home Health nurse insists that my Dad use an inner cannula.

    Big question: So, does anyone know if my Dad must have an inner cannula? Should it be removed when using the PMV?

    2) Cough Assist.

    The HMO equipment vendor says that a cough assist is not FDA approved and therefore, not covered by insurance.

    The vendor also said that since my Dad is on the vent and the home-use cough assists are simple (and different from in-patient hospital ones), my Dad should not be on the cough assist.

    Has anyone encountered these problems?

    3) My Dad is currently using Portex SuctionPro72

    The HMO equipment vendor has sent Ballard Trach Care's (1) Closed Suction Sstem for Non-Ventilator Dependent Adults and (2) KimVent Turbo-Cleaning Closed Suction System for Adults.

    The Home Health nurse tried (2) but it didn't work. But, an RT at the ER said that it should.

    Does anyone know if it should work?


    By the way, the HMO equipment vendor has the reputation as the "worse" but we're stuck because of the HMO. Example: they won't tell us about "free" items -- such as complimentary drainage sponges per month. Um, they'll charge usd 93 per box otherwise... I'm not kidding.

    I'm searching online for less expensive vendors... if anyone has good ones, please let me know.
    Last edited by Joey_SF; 24 Aug 2012, 1:39 PM. Reason: edit

    #2
    Hi Joey,

    Can your Dad breathe at all on his own? Are you using the PMV inline (in the vent circuit) or offline (without the vent)?

    Typically, you want to keep the inner canula in, unless it's extremely rare for your Dad to have secretions. The advantage to an inner canula is that if a secretion "plugs" and prevents airflow through the trach, there's a chance that changing the inner canula will remove the obstruction. Otherwise, if something is obstructing the trach, and there's no inner canula, the only choice is to change the entire trach, which is not nearly as quick or easy as changing the inner canula.

    I say "the only choice" but first you would want to try other things, like saline bullets to loosen the plug, and perhaps a suction catheter could physically push it out of the way, or suction it out (I don't have much experience with suctioning as we only use the CoughAssist).

    Regarding the CoughAssist, what in the world is the vendor talking about -- in-home and hospital CoughAssist machines are different? Are there two such products? I've been blessed to stay out of hospitals, but I know that the Shepherd Center (world renown SCI rehab hospital) uses the same CoughAssist I do, which are supposed to be available through both Medicare/Medicaid and private insurance:

    http://www.healthcare.philips.com/us...st/default.wpd

    I cannot speak on suction catheter packages, however, we do buy some supplies out-of-pocket, including drainage sponges (4x4s and 2x2s) at one of these two vendors (I see who has the best total prices, including potential deals, and other products I may need):

    http://www.jrsmedical.com/CORE_WOUND...2/product.aspx

    http://www.allegromedical.com/wound-...y-p191290.html

    On a side note, you started this thread on the 15th anniversary of my injury.

    - Bill :-)
    Last edited by BillMiller823; 25 Aug 2012, 2:21 AM.
    Wheelchair users -- even high-level quads... WANNA BOWL?

    I'm a C1-2 with a legit 255 high bowling game.

    Comment


      #3
      Ok, I just did a quick Google search, and the only "cough assist machines" I found were the Emerson/Respironics CoughAssist machines that I linked in the previous post.

      Either the vendor doesn't know what he/she is talking about, or perhaps he/she is referring to the automatic and manual CoughAssist models. But they are not wholly different. They are basically identical, except one has the ability to cycle automatically to settings you choose (automatic controls). Both models can be operated "manually" i.e. the operator controls the switching from inhale to exhale, etc, and the duration. Shepherd Center has the automatic models, however they operate the automatic models in manual mode (at least that was true in late 1997* and I see no reason why they would change; I think manual operation is likely more effective than automatic operation).

      As such, when ordering a CoughAssist, we chose the manual model because it functions the same as operating the automatic model in manual mode, but the manual model is lighter (and perhaps slightly smaller?) because it doesn't have the automatic controls. It's also a bit less expensive than the automatic model.

      *For the record, in 1997, Shepherd was using Emerson's mechanical in-exsufflator machines, the predecessor to the CoughAssist, which is now a Respironics product. I actually have one in-exsufflator and one CoughAssist -- and no suctioning equipment whatsoever. That said, some people prefer suctioning to the CoughAssist. To each their own. No worries.

      I hope I explained that well enough. It's not my most "clear" writing.
      Wheelchair users -- even high-level quads... WANNA BOWL?

      I'm a C1-2 with a legit 255 high bowling game.

      Comment


        #4
        The cough assist devices are very complicated and I know few patients who use them at home. If he has a trach then suctioning- and we usually go pretty deep is what we do . You can be taught to do an assisted quad cough for your father.
        Inner cannula-s the most common thing that gets plugged are by mucous plugs due to to dry or too thick secretions and not enough suctioning- if you have to remove the inner cannual because it is clogged then something else has to be done- mor emist, more meds, more frequent suctioning.
        I personally like trachs with no inner cannula.
        For chronic patients-The trach keeps the airway open and all that inner/outer cannula stuff is phooey.
        Frequent suctioning, keeping the secretions thin enugh to cough or suction up and respiratory treatments are most important. And you should know how to do the heimlich to just in case also for a quad--- and basically the assisted quad cough is very similar to that!
        But they should train you and caregivers in hospital before sending home!
        Things you and caregivers should know- any issues with respiratory problems-and ventilator and it looks he is not oxygenation- disconnect, ambu bag him with 100% oxygen, suction, bag and keep bagging 10-12 breaths a minute- not too fast, count to 8or 10 slowly! Always have a spare trach in ase it pops out and know how to put it back in!
        CWO
        The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

        Comment


          #5
          CWO, I don't wish to argue, but must respectfully disagree about the CoughAssist being very complicated. My caregivers, who were trained to suction at Shepherd, all would much rather use the CoughAssist on me. It requires a bit of coordination, but my grandparents (in their 80s) can do it. It's non-invasive, and my caregivers know that their chances of "hurting me" are much less with the CoughAssist vs. sticking a suction catheter into my trach (and beyond) and not really knowing what they should do. You may say that's a training issue, but we've trained quite a few family members and friends on how to CoughAssist, and from my observation of being suctioned at Shepherd, suctioning is a more difficult skill to master. Even Shepherd nurses had difficulty getting my lungs "clear" via suctioning, whereas I have friends with little CoughAssist experience (none except with me) who can get me clear without much difficulty.

          That said, I acknowledge that I know some vent users who prefer to be suctioned. But, in terms of the skills, a person only needs to know how to CoughAssist sufficiently in order to effectively remove my secretions and not cause harm (advanced skill is not required). Whereas I believe significant training and proficiency are required for a person to effectively suction and not cause harm.

          Just my opinions. Peace.
          Wheelchair users -- even high-level quads... WANNA BOWL?

          I'm a C1-2 with a legit 255 high bowling game.

          Comment


            #6
            I have had great success with the Cough Assist in my patients also. It can be used with the trach on a vent. Suctioning is good, but the Cough Assist can help where a suction cannot. It does take getting used to the Cough Assist. It is actually a pretty easy device to learn it is all about education and figuring out the pressures that are right for the patient. I hand out the educational CDs with the cough assist all the time. It has adaptive parts for trach, mouth and mask.

            An ENT can help you straighten out the trach issues where the RT cannot. Most pulmonologists don't address the trach.

            pbr
            The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

            Comment


              #7
              Thanks for the advice...

              1. My Dad can't breathe without the vent. Early in July while he was in the ICU, it was discovered that he could "trigger his own breaths" for about 15 min and the RT said that it "looked good" and showed me the little graphs -- they tried the next day and my Dad could "trigger his own breaths" for 20 min but couldn't sustain -- so, I'm not sure if this means that he could breathe on his own if we unplugged the vent for 1/10 or 1/2 * 20 min...

              He is using the PMV in the vent circuit.

              2. Thanks for letting me know that the cough assist is covered.

              Our insurance company is contracted with a home health equipment vendor who informed me that the cough assist isn't covered and they also said that since my Dad can't breathe without the vent, he can't use the cough assist which requires that he's taken off the vent -- but I kinda remember that tho my Dad was taken off the vent to "cough," he could get oxygen "in-between" the cough... thus, the vendor rep said that the hospital models may be more sophisticated or have more functions, but the home models are simpler and don't allow this.

              3. I regret that my Dad did not participate in a good rehab program which provides good family training. Gosh, we should learn how to do the assisted quad cough.

              We did get some training for trach care such as how to suction (and how to ambu-bag) but not how to change the trach. When I asked about changing the trach -- the reply was to go to the ER. Sigh.

              I should be able to take my Dad to a pulmonologist in Sept. -- but
              I'm stressed since it's now been over 2 months and since he has pseudomonas, I logically think that the trach should be changed as soon as possible.

              The home health agency wants the home health equipment vendor to help with changing the trach, but the vendor claims that their RTs are only responsible for the equipment, machine, and training but not patient care.

              The home health agency requested my Dad's primary care doc to help find an RT for home, while my Dad's primary care doctor doesn't know how to find an RT for home visits.

              4) Sorry, dumb question: what is an ENT?


              I'd appreciate any shared experiences and solutions.

              Comment


                #8
                My Dad finally saw a pulmonologist.

                1) The P says that he's never seen any patient on the vent + trach use a cough assist. He actually has a lot of years experience working with SCI patients, and works at a major SCI rehab program in the city -- but it's obviously not as advanced as Shepherd's or Craig's.

                I mentioned that my Dad used a cough assist at two facilities.

                Good news: the P says that he's open to getting info.

                Are there any publications or any documents so that he can learn about it? Would anyone be kind enough to let him contact you or to contact him?


                2) My Dad had the trach replaced - it's been over two months since the previous change. The pulmonologist said that if he doesn't use the inner cannula, he should change it once a month. If he uses an inner cannula, he could wait every two months since the inner cannula makes it "cleaner."

                I never saw my Dad bleed so much -- would the change be easier if it were once a month (the doc mentioned the skin growing around the trach)?

                Also - has the contention that the inner cannula helps to prevent infection been disproven? For example, my Dad has pseudomonas -- logically, the inner cannula wouldn't help.

                3) The hospital didn't help to clean the blood -- I used saline to clean the stoma area. Is this correct?

                I'd appreciate anyone's advice and sharing -- esp on how to clean the stoma area
                Last edited by Joey_SF; 9 Sep 2012, 2:01 PM.

                Comment


                  #9
                  I am agreeing with you but the key words are- trained caregivers!!!
                  As mentioned, this particular person needs to see a pulmonologist(soon) for the first time-I don't feel we have enough information and don't want to mislead them until that time.
                  Definitely needs some type of cough assist .I am not going to say he is a candidate or not. And see what is appropriate for him or not. Not sure why they were given misinformation except that the home care company doesn't know how to use- but they could be trained when/if doctor says appropriate.

                  Also age, other issues- comorbidities, the whole picture has to be looked at.
                  And a pulmonologist or sci expert should order the specific regimen.
                  I love the cough assists and the good old manual "quad cough" ( like the heimlich") and all caregivers should learn this.. but he needs to be evaluated and then see what recommendations are. But when appropriate it does take training- as all things do!
                  Glad to hear postive remarks about it !!!!

                  CWO
                  The SCI-Nurses are advanced practice nurses specializing in SCI/D care. They are available to answer questions, provide education, and make suggestions which you should always discuss with your physician/primary health care provider before implementing. Medical diagnosis is not provided, nor do the SCI-Nurses provide nursing or medical care through their responses on the CareCure forums.

                  Comment


                    #10
                    Originally posted by SCI-Nurse View Post
                    I am agreeing with you but the key words are- trained caregivers!!!
                    As mentioned, this particular person needs to see a pulmonologist(soon) for the first time-I don't feel we have enough information and don't want to mislead them until that time.
                    Definitely needs some type of cough assist .I am not going to say he is a candidate or not. And see what is appropriate for him or not. Not sure why they were given misinformation except that the home care company doesn't know how to use- but they could be trained when/if doctor says appropriate.

                    Also age, other issues- comorbidities, the whole picture has to be looked at.
                    And a pulmonologist or sci expert should order the specific regimen.
                    I love the cough assists and the good old manual "quad cough" ( like the heimlich") and all caregivers should learn this.. but he needs to be evaluated and then see what recommendations are. But when appropriate it does take training- as all things do!
                    Glad to hear postive remarks about it !!!!

                    CWO

                    I think you misread his post. The poster does the care. He did just arrange to see the Pulmonologist (although an abbreviated visit) for the first time, and the Pulmonologist does not sound experienced with using Cough Assist with SCI patients.

                    I'll wait for the nurses to answer your questions #1 and #2 and #3, but cleaning with saline should be fine. It is very scary looking with a lot of bleeding at the site (I remember my Dad's trache...).

                    Can I ask where you took your Dad? There actually isn't a major SCI center in SF, so that's why I'm wondering...

                    Maybe you need to try to set up appointments very early in the day, so that if the ambulance is late, the doctor will still be there to squeeze you in. I would also speak to a supervisor at the ambulance company to make sure you understand what went wrong and let them know damaging the outcome was for your father to miss most of the appointment. I would also insist on them not charging you for the appointment, since their late arrival made you miss your appointment. But I am a hard ass and this is the kind of thing that makes me crazy...

                    Comment


                      #11
                      IMO, two months is way too long between trach changes (because of encrustation, colonization, and stoma adhesion). We do mine every two weeks, and we use Vetericyn gel for twice daily stoma care. The idea that using an inner canula reduces infection seems like nonsense.

                      Can't speak to cough assist as I use a pacer and my abdomen is hyper sensitive.

                      Comment


                        #12
                        I'm glad multiple CareCure folks are replying, and I'll share what I can.

                        Regarding the bleeding from the trach change, does your Dad still have a cuffed trach? If so, can he tolerate having the cuff down (deflated) 24/7?

                        Trach changes were a bloody mess (literally) when I still had a cuff, because somehow my granulation tissue would adhere itself to the cuff and my pulmonologist would literally have to rip my trach out. Not fun. But with the cuffless trach, my trach changes became much easier -- enough so that my family and PCAs can do them.

                        If your Dad can go with the cuff down for at least a few weeks (perhaps months) you could demonstrate that he could use a cuffless trach.

                        Regarding pseudomonas, candidly, I do not know how bad it is for someone to have, but my nurse once told me that most people (I think) carry trace amounts of it. Also, I think it's easily identifiable by odor (kinda smells like Limburger cheese, I'm told) and I get it occasionally. I could be wrong, but I personally haven't noticed any significant problem besides the odor (which typically cannot be smelled by someone merely standing near me; I think it's primarily noticeable when removing the secretions).

                        That said, that's one of the main reasons I'm so in favor of the CoughAssist -- because with it, secretions don't stay in me long enough to become big problems. I use the CoughAssist as needed (7-10 times per day is probably normal for me, currently) and I am almost certain that I trace aspirate occasionally, if not fairly often. But the resulting secretions get removed efficiently and effectively by the CoughAssist.

                        My trach care routine is on the respiratory care overview here:

                        http://www.lookmomnohands.net/overview_of_my_care.htm

                        I wrote that a few years ago, but that's essentially what we still do.

                        God bless all.
                        Wheelchair users -- even high-level quads... WANNA BOWL?

                        I'm a C1-2 with a legit 255 high bowling game.

                        Comment


                          #13
                          To answer one of your questions above, an ENT is an ear, nose, and throat doctor (otorhinolaryngologist, technically, which is why everyone calls them ENTs!). ENTs are who should be seen for bronchoscopies and any trach stoma cauterization. I learned that the hard way, first going to a pulmonologist for a bronchoscopy (which was actually performed as an outpatient procedure in our local hospital, including sedation) and even if the pulmonologist found something that needed to be removed, he would've referred me to an ENT for the removal.

                          During my first trip to an ENT, I wanted to ask if he'd be comfortable doing a bronchoscopy on me. He asked me if I could breathe some with my trach out, I said yes, and two minutes later, he had my trach out and a scope in my airway looking for problems! ENTs get stuff done. That's been my experience anyway.

                          On a related note...

                          I wanted to clarify about what I said in post #5 about the CoughAssist being safe... it's basically just a medical version of a Shop-vac machine, i.e. it pushes air in, and with the flip of a switch, pulls air out -- along with secretions. To assist the expulsion of the secretions, we do a modified "quad cough" or "assist cough" (more on that below).

                          SCI Nurse PBR mentioned getting the pressures set correctly for the patient, which is a key to both safety and effectiveness. My pressures are relatively high (I think) but one reason I can do so is because I have no cuff, and when the CoughAssist is on inhale (filling me with a big breath of air) I actively let some air go out my mouth/nose while it's giving me the breath. This keeps me from over inflating my lungs, which could be a problem for someone using a CoughAssist with the cuff inflated (it could force air and secretions out the trach stoma if the pressure builds up too much). Yet another reason that I think a cuffless trach is the way to go, if a vent user can tolerate not having an inflated cuff.

                          Joey, you mentioned wanting to know about how to do a quad cough or assist cough, and SCI Nurse CWO said it's like doing the heimlich maneuver. I think technically that is correct, that basically you are thrusting upward on the person's abdomen to force air and (hopefully) secretions out, or up to the person's mouth where they can be removed. I think someone once described putting their wrists together, spreading their fingers, and pushing just above the quad's belly button in an upward thrusting motion. That seems like it would be effective to me. Someone please correct me if I'm wrong in that description.

                          That said, we do a modified "assist cough" which is more like doing a CPR compression (except we use a "flat hand" to disperse the pressure). My caregivers, when we switch from inhale to exhale with the CoughAssist, they push anywhere from 3-7 times on my chest to help knock the secretions loose and expel them. The number of times they push depends on the pushing technique; some do short, quick pushes, some do longer, "rhythmic" pushes where I somewhat rock with my chair or bounce with my mattress. Some observers have wondered how we haven't broken any ribs (knock on wood and thank you God) and I think it's largely because the chair and mattress both have "some give" and the pushing isn't with me on the ground (like CPR, where ribs are broken occasionally I'm told).

                          I mentioned "flat hand" above. Basically, my caregivers are instructed to use their whole hand with their fingers spread as much as possible to disperse the pressure they are applying. And, in bed, often several blankets cover my chest where they push, which can also reduce the pressure I absorb from the pushing. Plus, the pushing does NOT need to be particularly hard. I described exactly how we use the CoughAssist on the below page of my website, and I'd like to do a demo video at some point. Here's my written description:

                          http://www.lookmomnohands.net/How_We...xsufflate).htm

                          God bless all.
                          Wheelchair users -- even high-level quads... WANNA BOWL?

                          I'm a C1-2 with a legit 255 high bowling game.

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