Last week, my daughter had her second significant run-in with one of the biggest dangers for people with a tracheostomy: a trach plug. We’ll discuss what it is and what to do about it as part of the Tracheostomy 101 series. (For previous medical posts see the first Tracheostomy 101, NICU Family and Friends Guide, and Intro to RSV.)
What is a trach plug?
A trach plug is anything that unexpectedly blocks the tracheostomy tube. A trach can be partially plugged, which often causes gurgling, wheezing, or whistling sounds as air moves around the plug, or it can be fully plugged in which case air cannot pass in or out of the tube at all. Typically plugs are mucus or wet “secretions” coughed up from the lungs. It is normal for the lungs to secrete mucus- those of us without a trach actually cough or politely “ahem” this mucus to the top of our trachea and then swallow it down our esophagus without thinking (we’re gross like that!) For people with a trach though, it has to come out the trach, and when a hefty glob like this is dislodged from the lungs, it can unexpectedly seal off the entire trach tube.
Why are trach plugs dangerous?
Plugs must be cleared from the trach because they limit- or completely stop- normal breathing through the tube.
To use an illustration, imagine you are underwater in the ocean with no way to surface, and you are using a snorkel to breathe.
A trach plug is like stuff getting lodged in that snorkel tube, ranging from something small like a bug partially blocking the tube, to something large like a glob of seaweed completely sealing off your source of air.
What should be done when a trach plug occurs?
Generally, trach plugs can be cleared either by:
- Coughing In this case the person with the trach must be aware of the need to cough, be physically able to cough, and be able to cough with enough force to dislodge the plug. There are many reasons that these conditions may not be met, and the person with a trach cannot cough out the plug.
- Suctioning The suction machine is a vital piece of equipment that must be near the person with the trach at all times, for this exact situation. Even a healthy person with strong lungs may not be able to cough out a plug if it is preventing them from inhaling the air necessary to do so.
- Changing the trach Sometimes coughing and suctioning both fail, such as when the plug is too large or dry to be moved. In this case, an emergency trach change is needed in which the trach tube is removed and replaced with a new one. For this reason, a spare trach is always kept nearby (actually two- more on that later). We keep spares everywhere- the suction bag, the changing table, the stroller, the emergency bag, and the car console.
After the plug is cleared, the person may need extra oxygen administered or other medical help to recover from the event.
What is involved in an ’emergency’ trach change and how can you prepare for it?
A trach change is supposed to be a planned, sterile procedure in order to limit the germs the new trach and airway are exposed to, and to reduce the chances of harming the airway, which is often the only usable airway the person has. An emergency trach change is not planned and may not be sterile if fast action is needed, such as when the trach is fully plugged. We have found these tips to be helpful, but it is not necessarily applicable to all people with trachs; as always, rely on the orders and advice of the medical professionals familiar with your health situation.
- Keep emergency equipment nearby including suction machine, spare trach, smaller or “step down” trach, ambu bag, and emergency oxygen.
- Equipment must be quickly accessible. It is easy to become a little complacent about detailed emergency procedures and supplies when they are not needed for long periods of time. When my daughter had her first total trach plug, I had gotten in the habit of storing our ambu bag in the front seat of the car under two other bags when we traveled because I had never used it in the six months she’d been home. But when I suddenly needed it when my daughter couldn’t breathe, the seconds that it took to dig it out from the front seat seemed to stretch on forever. Now I keep spare ambu bags everywhere, including right below my daughter’s car seat.
- Equipment must be in working order. Follow the maintenance instructions for equipment and supplies that aren’t used often; many should be run, cleaned, or replaced regularly to remain functional. A more widely applicable example, though still relevant to trach families, is a home fire extinguisher that has been expired for years (or is wedged behind storage in the pantry for that matter, revisiting #2).
- Account for supplies daily using a check list. Create a supply check list for separate areas or situations so that if you use a supply, you won’t forget the replenish it. For example, separate lists for checking what should be in the total supply stash, the bedroom area, the car, the emergency bag, and what should be brought when away from home or staying at the hospital. When the trach plug occurred last week, we had recently moved our daughter’s room around, and I hadn’t unpacked that month’s supply shipment yet. So I discovered in a bit of a frenzy that the four brand new trachs sitting on top of her dresser were all step-down (smaller size) trachs. (In my panic I forgot that I have a dozen used-and-sanitized trachs stored in her room and suction bag, I was only looking for new trachs in the box like we used in my emergency training at the hospital.) I used a smaller size and then retrieved the proper size and switched it out.
- Trust your judgement when fast action is needed. An emergency trach change will not be like how you practiced in the hospital because it is not a slow-paced, controlled situation like the training. You may not have the exact supplies or equipment you want or the ideal sanitation conditions. You will have to adapt to the situation and make decisions about how to accomplish your goal, which for the moment, is solely and completely to enable to person with the trach to breathe.
- Ongoing care. As mentioned, the person with the trach may need ongoing care after the event. Oxygen deprivation during the event may be evidenced by blue skin and lips (cyanosis) or loss of consciousness; extra oxygen, a medical examination, or other care may be needed. Other people involved in the emergency, such as family members who assisted with the event, may need help processing the stressful experience afterwards as well.