Nursing staff report that they are suctioning nasogastric feeds from the tracheostomy of a patient with cuffed tube in situ. How will you manage this problem?
A practical problem. It may be addressed thus:
(a) Sit the patient up if possible.
(b) Determine if the patient is actually aspirating NG feed by mixing food dye or methylene blue with feeds and repeat ETI suctioning intermittently.
(c) Check tracheal cuff pressures and absence of air leak. presence of seal. Ensure appropriate size tracheostomy in situ. Check tracheostomy tube position above carina and that cuff is at least 2 em below the cords.
(d) Check position of NG tube in stomach.
(e) If all the above conditions are satisfactory and the patient still appears to be aspirating, the feeds will have to be ceased and investigations for a trachco-oesophageal fistula may need to be instigated.
The causes of aspiration may numerous. One must identify which of the follwoing problems is present:
A practical approach would resemble the following sequence:
Elpern, Ellen H., et al. "Pulmonary aspiration in mechanically ventilated patients with tracheostomies." CHEST Journal 105.2 (1994): 563-566.
Bone, David K., et al. "Aspiration pneumonia: prevention of aspiration in patients with tracheostomies." The Annals of thoracic surgery 18.1 (1974): 30-37.
Thompson-Henry, Sheri, and Barbara Braddock. "The modified Evan's blue dye procedure fails to detect aspiration in the tracheostomized patient: five case reports." Dysphagia 10.3 (1995): 172-174.