Episode 47: Tracheostomy Case

The goal is to learn , inspire and bring cardiopalm to the forefront of conversation . Thanks for joining me today and let's get after it . Hello , hello and welcome to today's episode of Talking All Things , Cardiopalm . I am your host , Dr . Rachele Burriesci . Our episode today is sponsored by Jane , an all-in-one practice management software .

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Their team would love to connect with you and see how Jane could help you and your practice . You can also use Cardiopalm 1MO . At the time of sign up for , a one-month grace period applied to your new account . Thanks again , jane . All right , welcome back . Today is Monday , february 12th .

So we are heading out to CSM tomorrow , Nicki and I , and we made it to this moment . It's been a wild week . One's good to go , but there is a Nor'easter coming up the East Coast , so I'm going to need everyone to put their good juju out in the universe .

And now you're not going to be hearing this until , I'm likely in Boston , but we're just going to manifest good travel . Okay , so we're supposed to be heading out tomorrow . We're going to get to Boston probably by early evening and we were actually planning to be there basically on time because I was supposed to present at Precon but Precon was canceled .

So we actually have a free day in Boston on Wednesday and we're hoping that's the case because we really , Nicki's never been to Boston and we wanted to explore a little bit and have a little bit of downtime before the hustle and bustle of CSM . So I'm not going to go too much into CSM this week . We'll probably chat about it next week .

I think CSM is a wonderful experience , just brings a lot of energy . So I'm excited to come back with new information , new ideas and just that energy , and that energy is something real . So super excited for that .

If you are listening this week because it will be Wednesday right at the start of CSM and you are at CSM and you see me and we've never had a conversation , but you know who I am please stop me and say hello . It's nice to meet people who listen to the podcast , who follow on Instagram and if we've chatted in the DMs , please tell me who you are .

I think the internet is the wildest thing . I grew up in the timeframe where I can remember not having internet . I can remember the start of what internet was . Internet to us was AOL , and this is funny because this is how my mother still thinks the internet is .

My mother thinks AOL is the internet , and fair to her , because when we first started out with Dial-up , we would get access to the internet via AOL CD . So the CDs would come in the mail and it would be like this free . It would be basically like free access from an app , but instead of an app it would be a CD .

So you would plug the CD into your hard drive of your computer and then it would basically bring up the AOL software and then you would dial it and I don't know if there was like expirations on these things , but like you would get them every few months , like I don't even remember the details of them at this point . So , like I watched the internet happen .

I didn't even have Google like a true internet experience when I was in grad school . So I was in grad school . I graduated from grad school in 2013 . Googling was like just starting and it wasn't very robust . When I was in grad school , I didn't even have text messaging on my phone . I still had a flip phone and texting was like really brand new .

And I remember it was probably the first month of the PT program . Like you know , you started to make friends and like people want to meet up for lunch and people were texting and I was like you sit across the room for me . You need to stop texting me . I pay by the character . So it wasn't long after that .

I think it was probably maybe the year I graduated from grad school . That texting was more of a thing and that year was like the first year I got a smartphone and that was a Blackberry , so again , not super functional . Like , you had email , you had some search capabilities and that was about it .

I don't remember why I'm talking about the internet , but I was in oh , the internet's a wild place . That's why . So I really didn't have much of a social media presence . Like people had , like made me get a Facebook , and that was right around when I graduated from PT school , so like 2013 .

And then , in general , I just didn't have a big presence online because of my personal life . So meeting people on Instagram wasn't really ever in my foresight of things that would happen . So creating all things Cardio Palm Instagram was a big deal and it's been wonderful , and I have met so many people across the country .

I have a wonderful business community of people who I've had conversations with like about life and goals and all the things for months , and then , for instance , I had a business conference and met these people in person for the first time and there was like the scary feeling behind it .

But also I knew these people and that , I guess , is just a weird thing that , like , you can have these genuine relationships with people that you've met through Instagram , through Facebook , whatever platform you're using and then meet them in person .

I mentored to two people from 2022 to 2023 ish , like timeframe about a year and a half one of which set for the CCS and one was new to Cardio Palm and faculty , and so I mentored through like a year and a half on zoom and we met twice a month , actually four times a month .

You know chit , chat about life and things and get to know these people , and I wasn't actually until this Christmas that I realized that I haven't met these people in person . So one of the two people is actually within driving distance , and so I did a drop off for cookies instead of shipping them through the mail , and I just asked him .

I was like , hey , are you home ? Because if you are , like I just realized that we haven't actually officially met in person and he's like I had the same thought and so it was so it was so funny because it wasn't strange . It was like I have known this guy for a year and a half , right ?

So the point of all this is relationships that are built in this new space is very real and can be very genuine . Genuine , and I hope I come across that way because I am . I am who I am . I'm a very transparent person . What you see is what you get .

And you know , if we've chatted through DMs , please say hi , because it's nice to put a face to the name . It just kind of makes that connection even more . Whatever , I don't want to say real because it's real . Anyway , if you're at CSM , reach out to me , say hi , let's take a selfie and I know I might have some , like you know , swag on me .

I don't know . Just saying things . Things might happen , all right . So let's talk about today's topic . I wanted to talk about my patient with a tracheostomy . Just go through his case a little bit .

We're not going to go too in depth in his pathophys because I actually his history was so long that I don't have all the nitty gritty details and actually the start of his diagnosis wasn't really cardiopulmonary based but it ends up in a cardiopulmonary issue . So here we go . We have a 76 year old male .

He had a large thyroid , goter , goiter , goiter and he had removal of said goiter and that was a few years back , which kind of led him to getting a tracheostomy . That's like the opening to his his case . He was recently readmitted to have a revision of his tracheostomy and he , at the time of eval was on room air .

He was on FIO to 21% via tracheolor with humidified air heated humidified air . I should say he was having some dysphagia . So he was already evaluated by speech and they had put him on a minced , moist , mildly thick diet .

He was just starting on a passi-mirro valve and if you're not familiar with the passi-mirro valve , it's a speaking valve so essentially it covers the trache . It's a one way valve and the purpose of it is when we cover the trache it actually allows air to be able to move up past the vocal folds so that we can make sound , so he can pull air in on inhale .

But on exhale it won't leak out the trache , it's going to pass up through the valve and he was having some issues

with that . He felt short of breath . He really had some anxiety . That was like a big handoff that I was given about this patient that he was very anxious . He was a little bit particular . He had declined therapies in general based on like timing if it wasn't good timing for him . But all of this was related to this goiter that he had on his thyroid .

When actually getting his history , this had been very long standing . He had multiple surgeries .

He actually went home on a vent at one point instead of going to long term care and he basically had 24 seven support from his family and they all traded in and out and they were all trache and vent trained , which I think is phenomenal , and they were very knowledgeable and they were very capable and they were . They were truly wonderful .

I met two of them during our visits . So this was a really fun case for me because as a PRN I don't always get a lot of carryover , but I was able to see him three days in a row . I actually treated him twice .

On the first day that I met him he did decline , but I really made it a point to build rapport with him and we talked about timing and we talked about benefits and all of the things . And when I came in the second day , he was very willing to work with me .

He was very excited to work with me and he got more interested as we were doing more , more like chest exam stuff and that he hadn't had that before . So as I was evaluating him , he did not have his Passee mirror on . His daughter was in the room which was helping with some of the in depth conversation . But I'm pretty good at reading lips .

It just gets a little bit dicey when they start speaking at like normal cadence and don't take a break for you to confirm the statements . If you work on ICU you start to get better at that and if you're not , I would recommend trying to pay attention to lip reading and it can help the patient feel more comfortable . He was capable .

He was able to like write his needs if needed and he was actually strong enough that he was starting to make sound with the trach open . So we actually had pretty pretty good conversation . But he was very Mucoussey . He had a lot of secretions . He was still being suctioned to remove said secretions .

On Oscultation he had pretty coarse ronkai or coarse wheezes the other terminology but pretty apparent . This was one of those guys that I wish I had my stethoscope that records because it was like perfect ronkai . It's got that like snoring , gurgling sound on . He was actually both inhale and exhale and it was throughout .

But he had some diminished breath sounds and actually while we were I was oscultating and doing chest exam on him I noticed some like contour differences on his ribs and he actually had a fall at some point with multiple fractures .

It sounded like he had a flail rib cage and so a flail rib cage is when you have a fracture in two places that basically displace a middle section of your rib cage and that middle section is basically free floating .

So when you inhale on your chest is supposed to be coming up and out , that section is just getting sucked in because it's not really attached to anything . A flail chest is a medical emergency so I don't know the details behind that . He told me most of it so I only got so much of the depth and I didn't have enough time to like get the whole history .

But he actually had removal of portions of his ribs in certain spaces and so it was interesting . He had some removed on the back end posteriorly as well as anteriorly and I really wish I was able to kind of dig in a little bit more because I would have been some interesting information .

What was even more interesting was that the left side of his rib cage is where he had those fractures . On chest wall assessment the left side of his rib cage actually had better excursion than his right , but he also had increased mucus throughout his right side Anteriorly , posteriorly upper , middle and lower lobes . He had positive fremitus .

So just placing your hands on his chest wall you could feel that increased vibration when he was either breathing or speaking . I tried to get him to utilize his passy muir during our session but he had declined .

He was wearing it earlier in the day and felt that it wore him out and because we were just starting to make a little bit of rapport , I was only going to push so much .

So one of the prior notes , he had done some marching in place , he had done some seated exercises and he , I think , ambulated for the first time 10 feet times two but needed a seated rest break . So I was given handoff that I should take a chair follow , not because he couldn't make the distance but because he had high anxiety about making the distance .

So I was only one person , so I did not have a chair follow . So I did the second best thing and I set up basically three chairs at 10 foot intervals from his room into the hallway and then back . He maintained on room air without any oxygen . But he was the gentleman that had that really cool adapter piece , the hydro trach .

So we tried to utilize the hydro trach to help with some of that humidification piece and it worked okay . But he was having a little bit more resistance as well because it's kind of like a cap . It has a little bit of an opening but he kept coughing and when he coughed he would kind of shoot it off . So it was kind of null and void at that point .

He was setting well on room air without humidification and we just made sure that when we came back we got him right back on that humidified , heated air . So performing the chest exam A was fun because he was just like one of those guys where you're doing these things and like you're excited too because like you want to see what you're going to get .

So he had positive Ronchai throughout . He had some diminished segments on the posterior left upper lobe and lower lobe . He had increased left lateral costal motion compared to right , even though that was aside with his prior fractures and rip removals .

He had some ability to activate his diaphragm but , as we talked about in the last episode on tracheosomies , he had his trach open and we tried to utilize the sniff technique to engage that diaphragm and he was able to . But you could tell that he lost the force due to the opening in the airway .

When he was breathing in through his mouth he was able to activate his diaphragm with queuing , but he was primarily an apical breather , so upper chest was had increased movement compared to his diaphragm . I didn't do from it . I didn't do mediate percussion on him , but he would have been a fun one because I would expect to get a dull sound .

This is one of those ones . If I had a student with me I would have done it , just so that they could hear it , but media percussion wouldn't give me any additional information that I already had . His cough was relatively weak and congested .

He lacked inspiration , he lacked a good inhale before his ability to attempt a cough and then , of course , because he's a trach , he doesn't have glottal closure , so he's not able to increase that pressure on the hold , which kind of loses that effectiveness . So he was really having some issues with his mucus .

It was super thick , his trach tubing , his inner tube was getting gunked up , so he had just had his inner tube cleaned and that can happen right . So he has this really thick , sticky mucus . We talked about hydration and so he was hydrating .

Well , but the other thing that could be done and again this is something that I can't necessarily do here but could be a conversation with the RTS , is actually using saline drops into the trach to help thin that mucus a little bit .

And then the one thing that we hadn't tried yet because we were just building some rapport was covering the trach on the actual cough . So we really concentrated on HuffCoff technique and he actually said that the night before an RT taught him how to HuffCoff and it was the first time anyone had done that .

So he was really surprised that I came in and did the same thing . He's like I've had this trach for three years and no one's ever taught me this and he was really good .

So we , you know , tried to I try to get him to actually take a little bit of an inhale before he made the Huff to give him a little bit more power , and with practice he actually did really good .

So we were able to get up to or three productive mucuses into the trach and then we were actually able to use just the yanker around the edge to pull up the rest . And then I had the nurse come in and suction him .

We also did percussion and vibration and so he said that was the first time that had ever been done as well , and he really liked how it felt he sat in pretty decent , like 93 to 96 , for the most part on his own like 96 was the best . But when I came in and he was super junky , he was in the lower 90s .

After we were actually during percussion his oxygen hit 100% . He his eyes lit up , he's like I haven't seen that number . So he was really like excited about what we were doing . And then so we did percussion anterior bilateral upper lobes with him sitting in the chair and I had him slouch down to try to get some angling .

They're all modified positions so I don't have them in a true postural drainage position , but you can do a decent job with the upper lobes in the chair , the lower lobes not so much . You'd have to be in a trendelin birth position to actually get that and then you'd have to make sure that he's not an aspiration risk .

So on the posterior upper lobes I had him lean elbows onto his knees and we did percussion as well and I did do some percussion towards the lower lobes even though he was in that position , just to kind of help break up some of that .

When he sat back up we did vibration vibrations like just a cool technique to give a little extra and some people really love it and some people don't , because it's a little bit more forceful in the sense that you're applying pressure to the rib cage and like a down and in force .

So percussion you perform throughout inhalation and exhalation at a pretty rapid pace and you should be using a cupping hand and if the person is more frail it's recommended to use some padding to basically give a little bit of cushion for them .

Vibration is hands to the chest and a technique I learned from a colleague of mine at U of M actually uses an anterior-post-ear hand position and so it's only performed during exhalation . So you kind of follow them through their breathing pattern . A few goes .

You follow them through that inhale and then , as they're exhaling , you're applying a pressure down and in as your hands are oscillating , vibrating against that chest wall . And some people love it . They're like wow , that's the coolest thing I've ever felt , and some people they don't . They don't love it so much .

So if they like percussion more than vibration , use percussion . If they like vibration more than percussion , use vibration . So really just dependent . But you want to be making sure that you're monitoring sats while you're doing any of these techniques . A drop in 4% in your spO2 is a negative sign or an abnormal sign .

So you definitely want to pay attention to your spO2 during this . We then , after doing breathing exercises and airway clearance techniques , we moved to paired breathing and we started with bilateral upper tremini movement .

We did shoulder flexion with paired breathing , so inhaling on the way up , exhaling on the way down , horizontal ABA deduction , inhaling on the way out , exhaling on the way in and then shoulder shrugging . And he did great . He was really able to pair .

We really talked about only going as far as your breath allows and because he loses some of that breath once he inhales , like it's kind of just falls out that exhale time is a little bit less . So he did a really good job .

And then we moved to lower extremity and we just did all active range on the first day Just to see what his vital sign response would be and to see what his fatigue level was and all that good stuff .

So we did active long arc quads , hip flexion , heel raises , toe raises and sitting position , and then we did sit to stands as well and we did standing marching , all of which we worked on pairing our breath with . And then , after we took a rest break . We did ambulation with those chair setup .

So I had planned on doing interval walking with him and sitting every 10 feet and he was super confident , his sats were great , His shortness of breath was none and he ended up walking . I believe it was where are my notes ? I think it was 30 or 40 feet straight and then we turned around and came back .

So he walked about 60 feet with me on the first day and we did that two times . So that would still be considered interval training , right , 60 feet take a rest break , 60 feet take a rest break . So that basically doubled what he did the day before actually tripled what he did the day before and he was way more confident . He was just very appreciative .

So he was just awesome to work with . I wish I could have kept seeing him . I was lucky enough and I got him one more day

. So the second day we did very similar startup . We started with our warm up , which included breathing exercises , paired breathing with bilateral upper extremity and lower extremity movement , and then we worked on airway clearance between the two . We did a five times set to stand for time on that second day and he was at 27.65 seconds .

So clearly has a lot to work on with potentially stamina and strength , but also there is a balance component in there too . So he is not . He's like halfway from age match control . He should have been less than 12 seconds and so he's indicative of falls and that is of no surprise . On the second day we actually doubled his distance and he went 60 feet .

No , I lied , he went 100 feet straight and we did that twice so he had an appropriate blood pressure response . He actually increased by about 20 beats , 20 , 20 millimeters of mercury systolic Lee . His diastolic was pretty steady , his heart rate increased about 12 . And he sat it actually his stats actually improved by 1% post ambulation .

So he was just I love this , I love this case . Right , I was .

I was like a kid in a candy store got to do all my chest exam stuff , did all breathing exercises , taught him some new things that he had never done before , had some tricks to help him be a little bit more effective with this cough technique , and I think the biggest part of it all was creating that rapport and giving him some of that control .

You can tell that he was in a situation where he's been in this hospital setting for a long period of time and sometimes , when that's the case , you try to take control by controlling the things you can , and sometimes that means declining your therapies because you're going to eat your meal or you're going to you know . Fill in the blank .

So building that rapport was key and it also helped increase his own confidence and what he was capable of doing and just less anxious overall .

So really just goes to show that having those conversations and , you know , letting people voice their concerns and learning about their journey and what they've been doing because him and his family had a lot of knowledge on trachs and vents and , like I said , I learned from him as well and I think when you are open to that , patients can kind of feel in the

lead there . So he was a fun one , saw him over a three-day period of time in theory and in that three days he made significant improvement and that actually included talking about inpatient rehab . He was kind of wishy-washy , maybe going to go home and then go to IPR when he felt ready .

He was ready , he was the perfect candidate and we really just discussed like what that would look like if he went home versus IPR now and education is what we do , and then education can look different , based on the patient that you have .

So don't be afraid to you know , give advice or give knowledge and help your patients understand what their choices are , because it allows them to have ownership and it gives them the control back which is , at the end of the day . You know , autonomy is everything .

When you're in the hospital setting and you don't have control over the basic things in your life , it could feel very out of control . And when you have patients who are in and out of the health care system for long periods of time , you can see some of that come out in different ways .

Some people might be aggressive or standoffish or decline or whatever it might be , and some people can be very particular and seem to want to be in control of the situation . And it's probably because they do . They want to be in control of their own life in some way , shape or form .

So I always encourage my students to understand that the position that they're in right now is not the best place that they've been right Like . They're in a very vulnerable place and sometimes we have to kind of put down some barriers to allow them to get the most out of their time there and give them the control and independence that they need .

All right , I think that is all I have for you today . If you have any questions , please reach out to me on the Instagrams . At all things . Cardio Palm , you can shoot me a text message . I will have my number in the show notes . And again , if you're at CSM and you see me , please give a shout out , say hi , take a selfie . I would love to meet you .

I'm very thankful for the people who are here , who are listening , who are engaging . It means the world to me , so I hope you all have a wonderful day . If you are traveling to CSM , safe travels and hope to see you there . Whatever you have to do , I get after .