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It’s that time of year, with hot and dry weather, forest fires, and low atmospheric humidity for most of us. For patients who depend on tracheostomies and ventilators, routine humidification is critical, but it might not be enough because hot weather can cause airway irritation and plugging.

A thermometer on a very hot day might cause airway plugging for patients with tracheostomies and ventilator systems.
Hot weather can cause airway plugging for those who are dependent on tracheostomies and ventilators.

Most people are born with a functional nose and an intact upper airway that warms, filters, and humidifies the air we breathe. When you’re not sick, it’s a perfect system that minimizes infections and helps us breathe with ease and comfort. However, some people were born with abnormalities in the upper airway—or they acquired illnesses or abnormalities at some point in their life—that led to the placement of a tracheostomy tube to breathe. But here’s the thing...when you breathe through a trach tube, you lose the humidification, warmth, and filtering provided by the upper airway. So, we must add routine maintenance systems and devices to provide filtered, warmed, and humidified air to the upper and lower airways in the lungs, which is vital to the health of the tissues and the ease of breathing.


Our lungs function best when the airway temperature is 98.6 degrees and saturated with humidity. Otherwise, tissues dry out, the protective beating function of airway cilia to mobilize secretions slows, and the risk of airway plugging rises. If a person is on a ventilator through a tracheostomy tube, sterile water is added to the system to provide a source of humidification through the humidifier, where it’s warmed, and the ventilator filters the air. It’s not perfect—because there are potential sources of infection or device failures—but it does a pretty good job of mimicking what the upper airway would normally accomplish to achieve a 98.6 temperature and 100% humidity.


If you have a trach and you’re not on a ventilator, an HME—or heat-moisture exchanger—is a plastic device with specialized paper/foam that attracts and holds water. It fits over the end of the trach tube and they’re a universal fit for all trach tubes in the market. They provide filtering, warmth, and add humidity so that the patient’s airway tissues are moist, and their airway cilia can function towards peak performance. Mucous plugging—a potential airway emergency—is minimized, but it’s not necessarily eliminated; it’s always a risk.


Again, HME’S are not a perfect system, partly due to people opting not to use them, children tossing them across the room throughout the day, or poor insurance reimbursement that limits the availability of HME’s. And while they don’t filter out all the germs or particles in the air, it's the only device available to replace what the upper airway would have normally accomplished.


But what if routine maintenance with an HME is not enough and your patient is showing signs of thicker secretions?


Saline drops or nebulized saline is an effective way to add extra moisture during the hot summer months, when an illness thickens secretions, or when the patient is away from home and a humidifier cannot be used for those on a ventilator. The provider can order a specific number and frequency of saline drops for the trach tube, or a specific amount/frequency of nebulized saline to add moisture back into the respiratory system. It’s certainly a thoughtful discussion to have with your doctor or nurse practitioner on how to achieve optimal airway moisture.


In any case, to take the best care of these people, we must add moisture, warmth, and filtering via the trach tube in some way. It’s vital for tissue health, respiratory function, and—most importantly—it serves to minimize airway obstruction, either in the tube itself or in the lower airways of the lungs.


When it’s hot outside, the risk of airway plugging increases. Therefore, watch for thicker secretions and, if necessary, go beyond the routine humidification methods to provide optimal airway health and minimize the risk of plugging.

 

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A screenshot of The Trach Safe Initiative report.

Being a nurse is an honor that comes with the intersection of many emotions over the span of your career. This happened to me about 15 years ago—when there were too many preventable deaths at home within our trach/vent population.

 

During the years prior, any preventable death at home was always a tragedy, but not extraordinary. These are sick children, but that year was different—so different and sad that I connected with a colleague and we both felt the need to do something to stop the tragedies. 


We weren’t sure what we’d do, but we ended up collecting ten of our best ideas on how to make home-based trach and vent dependence as safe as possible. That led to a series of targeted meetings over the course of three days with several wonderful colleagues, other nurses, RT’s, parents, and doctors.  A short time later, The Trach Safe Initiative was written and the Seattle Children’s Trach Safe Program was launched, which targeted three interventions to make care safer at home:

 

  1. Trach Safe Emergency Airway Diagram:

    1. An airway diagram developed for every tracheostomy patient prior to the first discharge home, then repeated over the years when the doctors felt they needed more information on the airway or the emergency/ reconstruction plan.

    2. This diagram lists the medical diagnoses, but also the explanation of the diagnoses without using medical jargon.

    3. We discovered in our workgroup that parents and home nurses did not reliably know why their child had a trach tube and we wanted to try and fix this. You have to know this in order to save their lives.

    4. Most important, every child went home with a personalized emergency airway plan showing how that child would be resuscitated in the event the trach was either in or out of the stoma.

    5. EVERY trach patient prior to going home for the first time had the diagram sent to the paramedics at the fire station near the home and the home nursing agency.  Everyone could know the patient-specific emergency airway management plan.

  2. Trach Safe Emergency Airway Management Class:

    1. Since 2014, over 250 nurses have attended this class that focuses on how to respond to an airway emergency at home.

    2. It was very well received by the home care and school nursing community and a great place to practice through simulation without the fear of causing patient harm.

  3. Trach Safe Near Miss Data Collection:

    1. Each vent clinic visit includes a questionnaire to the family on the events at home requiring the use of emergency airway care, such as airway plugging, equipment failures, which also then provides an avenue for review and congratulations for a job well done.   

 

Trach Safe has made a positive impact on the homecare community and patient/family safety at home. It significantly dropped the number of preventable deaths at home and I can’t say enough about how parents shaped this program for success. Anything we do to promote home safety must include the voices of those doing the care at home. ‘Nothing about us without us’ is a powerful statement that should guide all homecare safety improvement ideas.

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The logo for BreatheWell Inspiration, the best simulation lab classroom for tracheostomy and medically complex education.

The spark to create BreatheWell Inspiration ignited in 2008—with no name, no office, and no classes in mind. All I had was an intriguing idea—an idea that caught the attention of every colleague I spoke with.


At that time, I was working as a nurse in Pulmonary at Seattle Children’s Hospital and taking care of both the outpatient and inpatient children and families served by the department. It was the best job ever, no doubt. I was able to connect with the families and the home care community in wonderful ways, and I had the opportunity to work with legislators on how the State of Washington could do better by these families.  I had wonderful colleagues and mentors—people I still treasure and admire.


Despite being the best job ever, I was distracted by conversations with the caregivers I interacted with in the hospital and over the phone…they needed more information on medically complex caregiving. They needed more information on tracheostomy/ventilator care.  The rolling education I received needed to reach these caregivers—so they had access to the same information. This was my guiding light to create what has now become BreatheWell Inspiration. I want to share my education with others.


Fast forward to Spring of 2023. I still carried the dream of being a nurse educator, but I was nervous and a little hesitant to take the big leap from a comfortable nurse case manager job at the hospital to being a new business owner. What did I know about starting and owning a business? Nothing at all, but I needed to either take the leap or forget about it. Ultimately, I needed to try because I would have always wondered what could have been—if I decided to not act.  So, I took the leap and gave my notice in August 2023 and I’ve remained confident in this decision.


I really hope BreatheWell Inspiration becomes successful and I’m giving it my all. I’ve been rewarded, challenged, disappointed, happy, worried, irritated, and nervous—sometimes all of these in the same hour, but I always keep pushing forward. I want BreatheWell to operate in all 50 states and three other countries, that’s all, but not as a get rich quick scheme—more as a community service, while still paying the rent. For now, I’ll focus on the Federal Way office and give every student the best information on how to keep technology-dependent patients comfortable at home and cared for with minimal to no distress—to help them become more confident in their skills with providing the best routine and emergent care all day, every day.


For those who’ve already attended classes, thank you for your time, commitment, and energy to invest in how to be a great caregiver for the medically complex community. I’m learning from you too and it’s an honor to be able to educate and get to know all of you. We are people helping people and they deserve the best care that we can give them—the kind to help everyone breathe easier. This is the beginning of BreatheWell Inspiration.

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