Thank you all for being here. I'd like to thank the CHESS conference for inviting us to give this talk. I am accompanied up here by a really fantastic group of people. We are doing a session that is titled, Whole Lot of Traching Going On. And I get to introduce some really fantastic people who have expertise in management of post-tracheostomy complications. After the introductions, I'm going to go over a little bit about the workflow of this session. I think it's a little bit different. And get your texting thumbs ready because it is going to have a decent amount of audience participation with the audience response system. So my name is Beth Molson. I am an assistant professor of medicine at the Medical College of Wisconsin in Milwaukee. I practice interventional pulmonary and critical care medicine. I am thrilled to introduce my co-chair for this session, Christina McCrosty, who is another interventional pulmonologist practicing at UNC where she also directs the Interventional Pulmonary Fellowship Program. Next up, we have Dr. Justin Fiala. Dr. Fiala is an assistant professor of medicine who focuses on pulmonary medicine in those with neuromuscular disease and those who are treated in acute care facility at a rehab hospital called the Shirley Ryan Ability Lab in downtown Chicago. Next is Dr. Ankar Kullar. He's an associate professor of surgery, practicing thoracic surgery in Emory in Georgia. Mr. Sanket Thakkar is a respiratory therapist who specializes in tracheostomy care. He practices at Northwestern Memorial Hospital down in Chicago. And Dr. Van Nordstrom, Karian Van Nordstrom is the associate professor of medicine and the director of the Interventional Pulmonary Fellowship Program at the University of California at San Diego. And last but certainly not least, we have Dr. David Young, who's a laryngologist here in Hawaii practicing at the Queens Health System. As you can see, none of us have anything to disclose. So you can read the session objectives, but the target of this session, I think there's a lot of people in this room who come across patients that have tracheostomies for various reasons in various settings. We've all been taught by various people how to care for those patients and practice in various ways. This isn't an area that has a ton of study. These aren't a group of patients that has a tendency to warrant a ton of industry-supported studies. And my main goal for this is for you guys to hear from a group of experts and add to your toolbox, right? This isn't a problem that has one fix. You might notice that some of our audience participation questions, which you can access by either this QR code or through the chest app, don't have one right answer or one particularly wrong answer. And so we're hoping to generate a discussion amongst ourselves and some thoughts for you guys. And then at the end, we'll go back and talk about questions or hear from you guys about thoughts. Okay. So our first question for you guys is that we have a gentleman that wasn't uncommon for me in the last three years, a 45-year-old guy who's had severe COVID. He's been on mechanical ventilation for over two weeks and needed prone positioning, has had problems with ventilator dyssynchrony. He is finally able to have a tracheostomy placed two days ago when he met our facility's criteria for oxygenation and pressures at a PEEP of 8 and an FiO2 of 60%. However, now two days later, there's a large cuff leak despite adding air to the tracheostomy cuff. And when you measure that, the cuff pressure is 80 centimeters of water. And so this is a great, there's no right or wrong answer. But some of your options, so would you choose to let it ride, saying this is fine? Change to a larger tube, change to a longer tube? Do you intubate them from above and direct your oral endotracheal tube past the stoma that you've created? Or do you place the patient on leak compensation? And so go ahead and select your answers. And then Dr. VanNordstrom is going to give us some input. I was going to say my answer is always right. That's correct. But Dr. Cooler said that's not true. I thought about arming them all with a weapon from CLU, candlestick, a rope, revolver. See who emerges. See who emerges the champion. All right. Let's look at some of the answers. Okay. So as we thought, maybe a mix of things. And so we do have some prepared slides, but I'm going to let Dr. VanNordstrom take it from here. Sure. So thank you. I think when we start talking about managing post-tracheostomy questions and calls, I approach this kind of by thinking about kind of the five W's, like what is in the neck? So what kind of trach is in the neck? When was it placed? So how old? In this particular situation, it's two days old. Why was it placed? So knowing why somebody had that place can be very helpful. And as you go to the bedside and actually take a look about what algorithm or what instruments you're going to need or when you're like, this is really bad, you can start making your equipment list. The other thing is who placed it, right? That can also give you some information about also why it was placed, but maybe the technique that was used and help you kind of know what you might be walking into. And also it helps you know who to call to have a friend with you there, because it's always important to not necessarily tackle these things alone. So it's great to have a friend with you. The other thing is where was it placed? So was it done in the operating room? Was it done at an LTAC? That can also give you some information. And then the last thing to know is, how is the patient doing right now, right? So when I get that phone call, when Sanket calls me, I want to get all of that information so I can start kind of coming up with my plan. And then last thing I want to know is like how is the patient doing? Are they hemodynamically stable? Is their oxygen doing well? In this situation, are we cranking up the PEEP and the FIO2? Like is that leak really causing an issue? And that would be kind of how I would start the approach. The other thing is if you know what tools you have in the hospital, what types of trachs you stock, so that if you are going to be pulling something longer, you know what's actually in central supply and how to get there. Sometimes it's the trach that's the dustiest that you need that's on the shelf. Been there getting the size 10 off the shelf and taking the dust off. But I think in this situation, the other thing are when you get to the bedside, is actually looking at that patient and then assessing the tracheostomy and the ventilator circuit. So is the ventilator pulling the trach down? Is that giving you kind of that positional cuff leak? And is that something that in a two day old trach, like you can just reposition a little duct tape and bubble gum does work from time to time. I know we don't like to say that, but sometimes it does. And then sometimes it's actually the pilot balloon, the spring in the balloon. And so you can put an IV tube cap on that and just kind of pinch that down. You've done that, right? Yeah, a time or two. Yep. More. And then if- It's usually our quick fix to- Quick fix. Yeah, to like assess the situation where exactly the issue lies. And if that's the case, then we know exactly that it's the spring valve that's the issue. Yeah. If you're lucky enough to find the unicorn of the hospital, which is the pilot balloon repair kit, find it, keep it. You don't let it go. You may never find it again, but yes, you can use it to do that. And then sometimes it's just that the cuff may have a micro tear in it from placement and things like that. I think it's important, and I'll also ask other colleagues, but something that's two days old, that stoma is not really mature. So like going in and tackling, working through the stoma is something that I definitely wouldn't do at this point. I think that five to seven day window, you're gonna have to assess that in real time if you think that stoma is developed. So knowing that you already were able to intubate, I would probably start there and then assess. With the cuff pressure being 80, I don't think I would try to ride this out, but I'll open it up. I know you guys had some thoughts about other bad things that could be going on. Yeah, I mean, I think, you know, when I get called about these things as an ENT, usually somebody's already been through that algorithm and things haven't quite worked. And so, I mean, for me with these, my answer wouldn't be up there. So for these, I would take this guy to the OR. I mean, at some point you just have to look and see what's going on exactly. It doesn't mean some of the things that I commonly see with this. I mean, again, you'll see the cuff is deflated because I think if this person was intubated before, they're easy to DL from above, put a rigid scope down there and take a look. You can see me as the cuff just deflated. Well, okay, that's easy to fix. And then the OR is much easier to change a trach out than, you know, bedside. And then also to look at other things, a common thing I saw one time, you know, this 45-year-old guy with COVID that's that sick, and we know his neck's about this big around, you know, and so if he's just got a regular eight-shiley flex, it may just be too short and half of that cuff is in the stoma. Seen that before. And so maybe he just needed, you know, a longer trach. I think it was a lot of, you know, kind of people's instinctive response there. But I mean, so that's, you know, but for me, it's just that you have to look. I'm not smart enough to figure it out otherwise. Yeah, I mean, I think thinking about all the details of how the 5Ws, like Kyrianne said, are important because a cuff leak two days after a trach is very different than a cuff leak two weeks after a trach because you start to worry about very different things, right? Like a later trach, you start to worry about things like tracheal necrosis, tracheal esophageal fistulas, those sorts of things, as opposed to an early trach, which then you start to think, well, maybe this is just an issue with positioning or the wrong kind of trach. And, you know, I would caution people about not overreacting to an early, like an early cuff leak. If you're able to ventilate the patient and everything's fine, then just let it be. But if you can't and you need to change it, I think I would just echo what David said, like it's a fresh stoma two days out. Changing that trach at the bedside without a lot of support, bad things can happen, especially if you have somebody who tries to do it in the middle of the night, right? Like we've all had that situation and I think a couple of cases are gonna start getting into this kind of stuff. So maybe I won't get into that, but like you just wanna be careful. Like I agree with David. If I got called about this and I felt that the trach needed to be changed, I would take this patient to the operating room so that I had all my tools available to me because it's a fresh tracheal stoma and I would have the patient intubated orally and then change it, as opposed to a mature stoma where I wouldn't necessarily do that, but if you feel it's necessary to change out a trach two days after it was placed, I would secure that airway before changing it. All right, I think that's all the time we have for this one. So I just need to move forward from this and then I'll bring up the responses, all right. Let's move on to our next scenario. This is an 81-year-old female that has advanced dementia with recurrent aspiration. She had a tracheostomy placed five days ago after she failed a trial of extubation. She's to be discharged to a skilled nursing facility tomorrow and has been weaned from the ventilator, but she's nonverbal, continues to have a lot of oral secretions and the cuff has remained up because of this. The hospitalist team is calling to request a tracheostomy change before she's discharged to her skilled nursing facility. So what would you do? So the first option is go ahead and change the tracheostomy tube to prove that it's an easy change before she goes out. Would you leave the tube and bring her into your office for follow-up later on? Would you leave the tube in and don't arrange any follow-up and just let her go? Or would you request a longer hospital stay, delay her discharge to nursing facility so that you can change the trach at a future date? We'll wait for just a few more votes before we look at the results. All right, let's see what everybody thinks here. All right, so it looks like most people would leave the tube and bring her back for follow-up later on in the office. Yeah, so similar to Dr. Nostrand was talking about, like we'll always look at like five Ws, go with like why the patient was trached at the first place, who placed it, when it was placed, and where it was placed. So the patient who the trach was placed because of aspiration and difficulty getting the patient extubated. So now the patient is extubated. So that goal has been achieved. Now we are trying to move on to like where. One of the questions that I wanted to ask everybody, even to our panelists, is like the cuff was left up. And so what do you guys think about that, like leaving the cuff up as an aspiration precaution? Not my favorite. The risk with leaving the cuff up indefinitely in the setting of increased aspiration risk is that you're then inviting tracheal injury long-term. Really keep in mind that the maximal pressure that you should ever have in the cuff is about 30 to 35 millimeters of mercury. That's a perfusing pressure of the trachea and the tracheal mucosa. So anything above that is going to cut off blood supply and then raise the risk for stenosis or tracheomalacia. And so from that standpoint, most patients, if you identify that cialorrhea, excessive oral secretions as an issue, the best thing you can do for them is to first start, you can start with anticholinergic medications. And this patient who has dementia, that might not be the best option. Once you've blown past the anticholinergics, if they're not effective, then things like Botox into the salivary glands as the next step to, as like a proof of concept, can we decrease that cialorrhea burden sufficiently? And then beyond that, radiation actually, to the salivary glands, if Botox was effective, because you won't have to redose with the radiation. It'll be a durable therapy. But that tends to be much more effective than trying to maintain the cuff up long-term. Yeah, I think this gets into a soapbox issue of mine, is that the cuff up does not prevent aspiration. And that's been pretty decently studied in a lot of, and especially now with the new Flex balloons that don't have much wall contact anyway, it just doesn't work. Things leak around the side anyway. And there's been a number of the studies in the sleep pathology, speech pathology literature, looking at cuff up versus down, Passy Muir versus not, in terms of post-tracheostomy dysphagia. And even there, having the cuff up, they're more likely to aspirate. So in some ways, it doesn't prevent aspiration. And there's some of the speech path literature that shows that it actually makes aspiration worse because of the altered mechanics in terms of decreased hyalurongeal elevation and just altered sensorium on the upper digestive tract. So, I mean, it's leaving a cuff up, especially for any length of time after someone's off of it for aspiration, it's just doomed to fail. Yeah, so that's essentially what we utilize in our institution as well, where as soon as the patient comes off the ventilator, we put the cuff down right away. And so, and that's exactly what the rationale as well. And also, we can also move on to the next phase where we can like start trialing Passy Muir valve trials and eventually capping trials and stuff, like maybe start off with digital occlusion, see how they're doing. If they're passing digital occlusion, get them Passy Muir valve, because that also helps with the glottic pressure. It helps them with their strong cuff and clearing the secretions themselves independently. And also the patient was, so if they're passing the Passy Muir valve trial or digital occlusion, great. If not, that's when we got to think about like what's causing the failures, are they air trapping? And if that's the case, we can think about doing the trach exchange. But however, given that the patient was only trach five days ago, it brings it to the point where is this the right time? Is the stoma mature enough for the trach change now or can we wait for a few more days? And then maybe it would be a better time where the stoma is mature, it's much more safer for a trach exchange. And then we can move on to the next phase where we can like start capping and like using the Passy Muir valve, have the patient eat and talk. Because having the patient talk oftentimes is like an emotional time for the patient as well. Because these patients have been intubated for a while, they haven't heard their own voice for quite some time. So the first time we put the Passy Muir valve on, oftentimes they're just like in a shock. We're like, wow, I didn't even know I would have been talk again. So the fact that they are talking now just brings tears to their eyes. I was gonna ask everyone a question too. So we always say stoma maturity, but what markers of that do you guys use when you look at the neck? What is that? What does a mature stoma look like when you look at it? Yeah, I mean, I think in the beginning, I think it's more just a function of time. You know, so usually five days is the minimum I'll change a trach bedside. And again, and there's a lot of nuance into that, of course, why they're trach. You know, if somebody's a post-op airway reconstruction with a suprastomal stint, I mean, that's going in the OR for their first trach change, no matter when it's done. You know, but if it's somebody, you know, with a pretty decent neck, they were on event, now they're not, they're doing better. You know, I think five to seven days is a pretty reasonable time. And is that with a surgical tracheostomy? Because it's a little bit different sometimes depending on whether it's surgical or percutaneous. Even with the PERC, there's different techniques, right? You know, like the ones that sort of do it the classic way. There's a lot of institutions do this like hybrid technique now where they kind of dissect down to the trachea and then do a PERC once you can see rings. I mean, so it's, yeah, you're right. But yeah, that definitely impacts it. It kind of weighs in on your time. But once it's been in there and stinted open, as long as it's a, you know, a favorable neck, not the, you know, this neck. But yeah, kind of around that weak mark. And then, you know, when you do that first change, and so like when I think about a trach, I always, you know, think of the HELP acronym for trach changes. So H little E, you need HELP. So I always have somebody with you. The L, light, P, position, S, suction. And so it's the four things that you need, suction, light, position, and HELP, I think to safely change it. And so what I do, I take the trach out and then look with the headlight on, then just look. I mean, it's not enough time to epithelialize, but you want to look, do you see a clear track? Can I see the trachea down in there? You know, is everything just kind of going, you know, collapsing on me? Is it staying open? You know, so I think maturity is, will the track stay open long enough for me to put the next tube in, honestly. Yeah, all right. I just want to add one little piece, one little word from somebody who works at a rehab hospital, where we have great RTs, but we have a policy specifically where they have to have their first trach exchange done before they come to us. And I think that's with good reason, just to the extent that this is a demented patient who very well may pull at her trach, right? And so what does that mean then if at day six, at the sniff, right, she pulls that trach out, you know, ostensibly, we would feel better knowing that it's already been the first exchange, there wasn't a false passage that was entered. So word to the wise, you know, depending on where the patient is disposed to, it might be worth getting that first exchange done prior. And oftentimes these patients, because it's day five, they may still have the sutures in place. So, all right. I mean, the only thing I would add to this paper that was just, that's up here, is it's really kind of pretty incredible, like 42% of ENT residents surveyed in this knew of at least one loss of an airway, right? That's a really high number, right? I would have been in that, yeah. That and then 25% of them performed at night. Like I always tell our trainees, like there is no reason that a trach needs, there needs to be an elective trach change at nighttime. So, you know, for me, maturity, it's usually right around the leap mark and I look at the skin, see, make sure that things are healing well, there's no signs of, you know, an infection there. And I usually do the first trach change over an exchange catheter, just because that's my practice, isn't necessarily, probably not, but. And always have your rescue equipment available, all of your airway equipment, you know, intubation and box, all of that stuff available. Like we had this come up last week with like at our hospital, where, you know, they called us emergently because someone tried to change a trach change at the bedside and we show up there and the patient's sitting bolt upright with their head down like this and no one can get anything in their neck and everyone's screaming, yelling, trying to shove things down. And my fellow and I kick everybody out of the room, lie the patient flat and in 30 seconds, the airway's back in, you know? It's just, you gotta know how to do it. Yeah, all right. Well, let's move on to the next scenario. All right. Musical chairs. Musical chairs. All right, so another 45-year-old male, common person. Mersin pneumonia this time, no COVID. Shyliate flex placed on hospital day six due to the severity of pneumonia. However, he makes remarkable improvements. And by three days after that trach, so post day three, is on tracheostomy collar around the clock. He's mouthing words. He's that patient that Sanket really wants to get on that Passy Muir valve. He's writing, he's hungry. However, when they take his cuff down, because he's not aspirating with finger occlusion, he's not able to phonate. And the team is requesting a downsize. Recommendations would be, or possibilities, would you wait another five days? So waiting until hospital day seven or eight. Do you downsize over an exchange catheter? Leave yourself a place there. Do you take him to the OR, at the bedside into beta morally, and then downsize, making sure your trach passes into the airway properly? Or do you decannulate him? And so, watching some more votes come in. He has fast fingers. Dang. Whatever you say is right. All right, let's see what people thought. Still a mix, still a good mix. So most people thinking downsizing over an airway exchange catheter, but still a mix of things. Pass this one off to Dr. Kular. Yeah, I mean, this is a, you know, it's a young patient. He has a recoverable problem. Like, you know, he wants to be able to talk, but three days after the trach is early for me to downsize somebody for an elective reason. You know, I would wait probably about a week. I would tell them that, you know, he just needs to wait longer before he can downsize. I mean, there's no reason the patient can't be off the vent with the cuff down and, you know, communicate other ways. And I know he wants to speak, and I think we'll get into some of that in the next case. But for safety reasons, you know, that stoma needs to mature before you downsize that. And I wouldn't decannulate somebody from a size eight. Some of the ENTs I've worked with have different opinions on this. I would take them down to a six and then decannulate from there. I've known some surgeons that will go from a six and go all the way down to a four before they'll decannulate. I think that's probably a bit excessive. You probably don't need to go all the way down to a four, but I wouldn't decannulate someone this soon. I think the paper they put up here is the role for a tracheostomy service, people who are trained in how to take care of trachs. And, you know, you can clearly see a lot of value in that. I think we've all had bad experiences with trachs from people who kind of tried to manage them but didn't really know what they were doing. I think in this paper they found that when they had a tracheostomy service, I think this was actually done mostly with RTs in this paper, the rates of getting patients decannulated before the left ICU was higher, rates of loss of airway were much lower, rates of death in trach patients was much lower. It was kind of provocative paper, I thought. But, yeah, I think bottom line is that three days is too fast for me. I don't have a lot of hard and fast science or data to support that, but it's too soon for me. Yeah, I think my question to some of the pulmonologists and people that take care of trachs on the floor, right, is this guy's gonna also leave the ICU? And so most likely he's going to a new environment and how does that reflect in how he gets care? Yeah, I mean, I think once the patients leave the ICU, it is helpful to have kind of these trach services or the team that put it in to continue to follow so that there is some continuity and that there are a point person who can kind of handle those things as they come up. And I think each institution kind of does that differently, but having someone take ownership of that and those decisions really does help the patients. And I'll just give a plug for how our institution does this, and that actually is through a role that is specific within RT, a subset of RT self-identify and then get extra training to become trach specialists. And so Sunket is one of our trach specialists who will go and then follow these patients who have tracheostomies wherever they are in the hospital. Yeah, that's exactly what I was gonna mention as well. So like in our institution, we actually do have this specific team that follows this patient no matter where they are in the institution. And we try to see each and every patient in a 24 to 48 hour period every day to every other day. And we keep track of them and we see how they are progressing and we try to push those limits as like, is this the right time for a trach exchange or starting the capping trial or passing Miraval trial? And if so, like are the sutures are still in with day seven or eight, it's fine. Like the sutures may still be in, but like sometimes the sutures may get left for like day 10 or day 14. And we try to keep track of like those things and get them moving along and get them to the next phase. Yeah, I have a question for you guys. Does this specialty service continue into the outpatients or after they get discharged with a tracheostomy? How do you sort of follow that? Yeah, so unfortunately we only cover the inpatient side. We don't necessarily have like an outpatient. So depending on, and that's the other, other like huge challenge too. Like, so when they do get discharged, depending on where they're getting discharged, right? Like, so if they're getting discharged at a skilled nursing facility, oftentimes our LTAC and things like that, like where they do have like similar roles and response, like people with like similar capacity that they can take over. But where the challenge comes in is like when they getting discharged to home. So now we are like trying to teach trach care and like trach management to the family member who like oftentimes are not in the healthcare field and they don't even know what a trach is and they get like really like apprehensive of like learning and they really want that support from the outside institution, whether it may be healthcare company, home care company and such. I was gonna ask how often are you able to get home health support for these patients? We struggle with that at UNC and just getting supplies for, you know, intercannula changes even can be tricky. So do you guys have that same problem? A lot of problems. So I think our biggest issue is that it is very difficult to follow patients up if we haven't been the group that decided or was in on placing the trach in the first place. So it's this idea of who decided to go ahead with tracheostomy. So the issue comes more from the neuro ICU and the surgical ICU where we have less of a presence. Whereas if we knew the patients of our colleagues or other pulmonologists looped us in, in that decision making, then we feel like yes, that we will get the patient into our clinic and follow them up and then we're able to, you know, go through all the red tape to get everything for them. But there are definitely patients who fall through the cracks because there hasn't been that unified consensus about who was going to manage the trach once it's in. Yeah, I mean, I think it's a great point. Like, you know, our personal, my personal practice is like the short, like when I get asked to do a trach, if it's going to be somebody who I think is going to get decannulated pretty quickly, I will do it. But if I think it's someone who's going to need a long-term trach and long-term management, I actually won't do that, not because I can't, but because I'm not going to be the one following that patient. And I will defer it to either the interventional pulmonary service or the ENT service because that patient's going to need long-term trach management. They're going to need supplies. They're going to need cannulas. They're going to need trach exchanges and things that, you know, I personally just don't do at our institution. It's not that I can't. I just, you know, I'm doing other things. And there are other services that do that. And I think it's a very important point. And at your institution, it's one that kind of needs to be thought about when you're requesting a trach from a service. It's not just like, call the person who gave it. You don't just call the person just because they can do it. You've got to think about the long-term implications of this. And I think that's going to come up in our next question, as well. It will. That was a great segue. I'm very impressed. Very impressed. So our next case is a 32-year-old male with a spinal cord injury from a motor vehicle accident who's been intubated for respiratory failure. The patient and his family hope that he'll be able to utilize leaked speech once a tracheostomy is placed, although it's unlikely that he'll be weaned from the ventilator. Initially, a Shiley-7 was placed 10 days ago, and he's unable to have sufficient leak. What are your next steps? Would you replace the Shiley, sorry, replace with a Shiley-5 at the first trache change and attempt leaked speech at that time? Would you place a low-volume, high-pressure cuffed tracheostomy tube on the first exchange? Would you place an uncuffed tracheostomy tube on the first exchange? Or would you place a fenestrated tracheostomy tube on the first exchange? Votes are coming in a little slower on this one, which is totally fine. That's tricky. Yeah. Right. Yeah. I guess while people are voting, I do want to amend what I said the last day when I made it a little bit. Because I guess the exception to what I said earlier is if it's someone who needs a surgical trach, right? Who has difficult anatomy and needs a surgical trach. And what I would encourage, and this is a group of pulmonologists, what I encourage you to do, what I do in my practice is if I think that it's going to be one of those patients that needs me to put the trach in, but needs long-term management of the trach, I will, before I even do it, I will coordinate with either the ENT or the pulmonary service and say, hey, I'm going to do this trach, but I need someone to do the long-term care of it. And so if you're in an ICU and you have a patient who might be in that situation, I would, again, multidisciplinary collaboration only helps. Isn't that usually the answer? Yeah. Multidisciplinary discussion. That makes great sense. All right, let's see what everybody thinks about this patient. So we have a decent mix, but most people were replaced with a Shiley-5 at the first exchange. So let's hear from Dr. Fiala about what you think. Yeah, so I actually agree with the consensus here. And the reason is, I think the first question to ask with these patients is, and actually, let me back up and say, for those who are uninitiated and haven't heard of leak speech before, this is a phenomenal way to give patients their voice back when they are still ventilator dependent. So what we do is we intentionally deflate the cuff. It does not have to be completely deflated. It's kind of patient by patient. And what you're basing it on is the actual ability to phonate. So sometimes it's halfway down. Sometimes it's four CCs out. You can determine that and then put that in your notes. And that becomes kind of the standard for that patient. The goal is that with the deflated cuff, you're going to get some auxiliary flow around the trach that goes past the vocal cords to allow for phonation. During ventilation, though, be aware that your maximal flow is going to be during inspiration, not during expiration. So this will create a weird speech pattern for the patient where it'll actually take some education. Oftentimes, we lean on our colleagues in speech and language pathology to train the patients to kind of speak in reverse. And my trick here is that instead of some of the, so this paper that's cited here mentions increasing the PEEP as a way to augment the flow to give a better voice. My argument is that the PEEP, if you go up on it, yes, it will increase flow that is continuous. However, what you're going to run into is patient intolerance because of excessive airway drying and kind of dry mouth, dry throat sensation. So oftentimes what we will do is instead of increasing the PEEP, we will elongate the inspiratory time. And what that does is it kind of gives them this inverse kind of respiratory pattern where they actually have a decently long time to speak on inspiration. So now going back to kind of the specifics of the question, this is a patient who you fear has a high C-spine injury that is unweanable, so like a complete C1 injury. And so they're probably not going to be able to come off the ventilator, which means that they are going to need ventilation for the duration, right? For as long as you can kind of foresee. That means that you probably should not be using a low volume, high pressure cuff, like a Bovona TTS in these patients because that's going, when you inflate that low volume, high pressure cuff, it is going to create a higher pressure, increase the risk for a tracheal injury. So in this case, I would go with a Shiley because you think that this patient is going to need ventilation more durably. Then the reason to not go with a fenestrated trach is because there's decent data that suggests that the fenestration increases the risk of granulation tissue formation and then tracheal injury. So it's either that you get granulation tissue or, and or, because it can actually occur in a combination, tracheomalacia or stenosis. And so from that standpoint, to try to preserve the caliber of the trachea as much as possible, our practice is to never use fenestrated trachs. Instead, we will start leak speech. And what we'll do is get a blood gas before we start the session and then do a blood gas after to see. So we're aiming for optimal phonation. What we have found, Linda Morris is one of our trachea experts at Shirley Ryan, and she found that the optimal vocalization occurs at 10 liters per minute of flow. Generally speaking, if you were gonna do leak speech, and if they're on volume control, please be aware that you need to have a special circuit set up where the machine will be able to kind of feed back some of this exhale tidal volume to give you a better sense of what the actual tidal volume is and you're gonna probably have to put on leak compensation. What we often do for leak speech, instead of increasing the tidal volume is to actually go into a pressure control mode and to go up by about four centimeters of water pressure. If you're in a volume control mode, about 100 to 150 extra cc's of air is generally about right to maintain ventilation and provide phonation. And so I think from this standpoint, a patient who is not gonna be able to come off of the vent long-term, who is now past the point where they can safely have their trach exchanged, I would downsize them to try to increase the space around the trach, but I would use a Shiley because that Shiley allows for longer term ventilation. I'll just put a little soapbox moment here for the fenestrated trach. Please don't ever, ever, ever, ever, ever, ever put a fenestrated trach in someone, I'll tell you why. Because the hole in the trach is never in the middle of the airway. It's either on the back wall of the airway or it's in the stoma and in either case, it gets occluded with granulation tissue and then I get called at one in the morning to come take care of this person with a trach that can't breathe and everyone's scared and they're coughing blood out of it and everything. So it's just, I mean, if you need a fenestrated trach for some reason, you can actually, there's some nice trach that you can do custom in the OR and you basically put a marker on an alligator and you put the dot in the middle of the airway and then you get a derm biopsy punch and you can customize and put a fenestration in. But unless you can really ensure that that little hole is where you want it to be, it's just a, it's a time bomb. Yeah. Well, to that point, I was gonna say like, even when the trach, it's placed, like after it's placed, it never stays in the same place, right? The patient's moving, the ventilator's attached, the ventilator tubing might be pulling the trach itself. So there's a lot of moving components where the trach can be malpositioned if it's not tightened down properly and then the fenestration hole, even though it may be placed in the correct placement, but now it doesn't stay in the correct place because of all these moving parts. But you can get excellent phonation. And so I welcome you to try it on your patients because again, like Sanket was alluding to earlier, this is an emotional thing for patients. It's actually my favorite part of the job is giving people their voice back. And I think leak speech is one of those tools that we have to allow that, even in patients who are not weanable. You know, it's something I see in a lot of patients that I think we forget about is that they have no concept of what a tracheostomy is. And I think for, I do a lot of trachs, I'm kind of an airway person. And so if I had a nickel for every patient that when they realize that they're not going to have a, hi, my name is David, good to see you, after the tracheostomy, because they confuse laryngectomy and tracheotomy, I'd be a rich man. I could almost afford to buy a house here. And so it's, you know, it's, yeah. But no, but so I think that that's a big part of it. I think part of why they're so emotional because I think they may think, oh, I'm going to have to use one of the, like they just have no clue that they can actually do it. All right, we're going to cut you off there. Next, we have an 80-year-old guy who got a trach for COVID, shyly eight, for, who's had good recovery. So he was trached eight days ago. He's now tolerating trach collar, but has again, respiratory distress with prolonged finger capping and a speaking valve. And so for this guy, do you downsize him? Smaller trach. Do you downsize him? He's on trach collar. Is this a gentleman that you could consider a low volume, high pressure trach, such as a bovona? Do you give steroids for upper airway issues? Do you do a tracheoscopy just via the tube itself with a pullback? Do you do a tracheoscopy? Do you look from above? Or is this somebody that you can just decannulate? He's doing so well after his COVID. All right. Is that moving? All right, just about everybody. Oh, one more. I'm sorry, go ahead. Oh, nice. Yeah, so this is mine to talk about. Tie ball game. Yeah, so cool. All right, so I get this consult at least once a week. And so, yeah, this is kind of, yeah, I think these are kind of the two things that I would come down to here as well. And so, I mean, certainly in somebody like this, he's eight days out, I mean, downsizing first and would actually, you know, probably not even you put in a cuffed trach. If he's on trach collar and he's this far out, I'd probably put in a six cuffless and just see, you know, how he was doing. But at some point, you're going to probably have to take a look. And again, like I would say, I'm not smart enough to just kind of guess it. I just have to look in there and see. And so I think, you know, a thing that we don't necessarily think about all the time in terms of intubation and critical illness is the rates of injury above the stoma that can happen. So there's a great paper out of Vanderbilt about four years ago that one of my co-residents wrote at the time. We did it as a prospective trial, a hundred patients in the MICU. All of them scoped immediately after extubation. The rate of severe laryngeal injury was 57%. And then tracked all of those people and all of them had worse breathing outcomes, worse voice outcomes and more issues afterwards. So, I mean, that's, you know, more than half had severe injuries and that's not even getting into the literature on subglottic stenosis after intubation or, you know, superstomal collapse after, you know, PERC trach and you fracture in that upper cartilage ring and block off half the lumens. And there's a bunch of ways that you can get obstructions. And so it's just, it's so easy to look and just know. It's such an answerable question to kind of guess at it. You know, it's just not worth it. But certainly the beginning, you know, they've got such a big trach in and there's a cuff. I mean, an eight cuff is a pretty big thing to overcome, you know, with a standard kind of, you know, 14 millimeter diameter trachea. So I downsize it to a cuffless and see how he did, you know, from there. Roll for steroids. I mean, at this far out, I don't think so. I mean, what are we treating? I mean, he's been, you can't, you've been trached for eight days. There's no been no tube in there. I mean, unless there's some other reason for swelling, I don't know if that's really, you know, doable. But yeah, when, where and how to scope. I think in this particular case, if he fails with the cuffless, then he's definitely getting a scope. And I'm kind of a nerd. I buy by scope in any way, so. Yeah, and I think the important thing about how to scope is tracheostomy through the tracheostomy tube. Unless you're able to pull it back far enough that you can flip that scope around and look up, which is hard to do, you're gonna potentially miss the subglottic stenosis. I think, you know, an important part of this, and you alluded to this, is how is the trach done, right? And talking to the person who did the trach, like, did that ring fracture, right? Are you sure you were low enough and you were both, you didn't do a crike, right, accidentally? Because we've seen that. All these things kind of go into it. And that's why I think looking from above is really kind of important. I mean, I agree. I think I would probably downsize to a six. And I am, you know, you guys can tell me what you think, but I've actually kind of moved away from doing eights at all. I pretty much standard, my standard trach at this point is a six. I very rarely will place an eight because I worry about fracturing that. And this is something I think I learned during COVID. Fracturing that ring is just, it's hard. Once they get that A-frame deformity, it's really hard to fix it once you've fractured that cartilage ring. So I go with a six and I, you know, I do perc trachs. I do sort of a hybrid perc trach technique, but I tell my residents, when you're passing that blue rhino dilator, you gotta be quick because you're not ventilating, but you have to be really gentle with that because you don't want to fracture a ring. So I would take a look in this case. And I would look from above, not through the trach. Yeah, I think you bring up a good point. So looking from below and flexing up, and I do that every time in the office with any trach patient. But one of the problems is, is that typically if there's a suprastomal stenosis, when you, the degree of curvature on any of these little flexible scopes, you're gonna go right around the stenosis and you're gonna look up and you're gonna see the soft palate up there through the cords and think, wow, this is so wide open. What about the subglottic airways like this? Cause you just, that's what you got through and you just didn't realize it cause it's next to your scope and you can't see it. So yeah, definitely from above. These folks are a little tricky. You know, I typically, you know, I do a lot of awake bronchoscopy in the office. And so you just have to topicalize the vocal folds and the trachea itself. These can be tricky to do. So typically for these, a working channel scope, and then especially if they've got a trachea, you put a Passy Muir on it or finger occlude them if they can, or if they can just get some, you know, either two or 4% lidocaine and just drip it directly on there. If you can get them to phonate while they're doing it or hold their breath so the cords close and it sits there longer, that's even better. But yeah, you numb them up and then you can just drive right through and see exactly what's going on and move on with your day. I agree with both of you guys, but I think the other thing as pulmonologists too is you may not know what to expect, but always have your colleagues on speed dial so that you can call them in to potentially see what you're seeing or take a really good video because, you know, we may be seeing it, but we may not necessarily be the ones to fix it. And so it's good to have a phone a friend and just make sure that you take, you know, good videos or if they can come in and actually see what you're seeing, I think that's equal or better. Yeah. I think this is the last one. This is a 47 year old male with a complex course after motor vehicle accident requiring tracheostomy, recovered successfully, decannulated, presents with dyspnea on exertion as he increases his activities. He slowly and recovers from his injury. His expiratory strider on forced exhalation and CT neck chest shows possible narrowing at the tracheostomy site. So would you do an inspection bronchoscopy as a general pulmonologist, say with like moderate sedation in a bronchoscopy suite, would you refer to an interventional pulmonologist for possible dilation? Would you refer to an ENT doc for laryngoscopy, tracheoscopy and dilation? Would you refer to your thoracic surgery colleagues? Would you just monitor based on symptoms, repeat scans and PFTs? Or would you have a multidisciplinary discussion about this patient? Shortest and least. Some quick answers coming in this time. All right. Let's see what we got. All right, a fair mix. So it looks like most people would have a multidisciplinary discussion. A close second is referral to ENT. And then third is referral to interventional pulmonologists. So this is sort of one for our entire panel. Who would like to step up first? I think people wanted to call you, so. Okay, well, all right. That makes sense. Everyone's paged you. Yeah, oh yeah, definitely. This is definitely a 4.30 Friday call. And especially when you're the only laryngologist for 2,000 miles in all directions. This is definitely your Friday afternoon call. Yeah, so I mean, so I get this a lot and it's sad, I think for these folks, how long it takes them to get into care. If I see a lot of these folks that are treated for asthma or new onset COPD or something without any kind of imaging, without a scope, without a pulmonary function test, anything that would have given you some objective data, they just hear wheezing that's actually strider. And it just takes a lot of time sometimes for these folks to get into care. And so, yeah, so I mean, with this kind of thing, I mean, you're obviously worrying about some kind of a stenosis. And after tracheostomy, I tend to see two different kinds of stenosis. There's either, well, maybe three. You know, probably the more classic one is your typical A-frame deformity where the stoma itself after the trach is removed, you know, kind of does like this. And it looks like an extra set of vocal cords when you're going down through the trach from above. I see that one, you see subglottic stenosis, or posterior glottic stenosis, typically from the endotracheal tube injury that was there for however long he was sitting there with his MBA before the trach. And then the other one, and this is where my colleague in my left when he definitely comes in, is sometimes they develop a more distal stenosis from the cuff from the tracheostomy tube. You know, and those tend to be a lot more distal and a lot more challenging for me to deal with. But yeah, I mean, I think this is, you know, someone that's certainly gonna require, you know, some additional interventions. And it can get in this, you know, it gets kind of tricky, you know, depending on where exactly the stenosis is, what kind it is. Most of these kinds of stenoses don't tend to respond that well to endoscopic approaches, at least not in my hands. And I think in general, I mean, sometimes I think you get lucky if you get a patient that is not particularly active and they don't need that much airway. So maybe you can get by with a little small eight to 10 millimeter lumen, but certainly anybody that wants to be more active is gonna be very limited. And I feel like a lot of these, I don't know what your experience has been, but for me, I think a lot of these, like I counseled them early, we can try endoscopic things, we can try stinting, we can, you know, T-tubes or suprastomal stints with a trach or whatever. I think a lot of these ultimately end up going to some kind of resection. Yeah, so I'm not a huge fan of T-tubes in general. We don't do a lot of it. I don't think anybody does a lot of T-tubes much anymore, but, you know, the way this consult is handled at our institution is it, you know, whoever it comes to first, whether that's me as the thoracic surgeon, the ENT or the interventional pulmonologist, it starts with some sort of endoscopic evaluation. Which of the three services doesn't really matter, we can all kind of do it. But it starts with an endoscopic evaluation and usually we will make some attempts at endoscopic therapy, whether that be with, you know, laser dilation, rigid dilation, balloon dilation, some form of endoscopic therapy. And we'll usually do, make two or three attempts before we will move towards surgical resection. Some of that depends on, is it an A-frame deformity, is it circumferential deformity, is it a web? You know, all that kind of plays into it. Like if it's a classic A-frame, we may not spend a lot of time doing endoscopic therapies. We might be more quick to pull that trigger. But if it's a long segment stenosis that's extending down into, pretty down into the chest, we may give it more of an attempt to try endoscopic therapies if we think the surgical intervention is gonna be more complex. So I think all of that kind of plays into it. There's really not a lot of data comparing. Obviously, this is not the kind of thing that you study with a randomized control trial, right? There is no such trial. And the other point I'll make is that I think CT scans frequently underestimate the severity of the stenosis. A direct visualization is really, I think, important. If they've had a trach or a prolonged intubation and they have these sorts of symptoms, it warrants somebody looking endoscopically. Yeah, I think looking at the patient or the imaging in the context of the symptoms is really key in this situation, yeah. And I think looking at these folks endoscopically too, I mean, this is where I do a lot of awake bronchoscopy because this is where you can get yourself into a lot of trouble. You know, these are the cases that I don't sleep a whole lot the night before. If I'm doing somebody with some kind of multilevel laryngotracheal stenosis that I've never really done much with before because they can go haywire and you can end up in a not intubatable, not maskable situation very quickly. And so, yeah, I just think, you know, doing this, I love to do these awake when I can while they're spontaneous and just take a look, at least get some initial sense of what, you know, what's laying in wait for you when you get in there. You know, so I think you have to be really careful. I've definitely heard of some stories of, you know, people that go to take a look, you know, in the endoscopy suite with a flex bronch and then suddenly realize, you know, they, I've seen a lot of, you know, that emergent crike or something because they suddenly were for emergent slash trach because the crike's even too high for the stenosis and they, you know, they run into some trouble. Yeah. And then what, were you going to say something? No, I was just saying, you know, if you are taking a look and you want to get a lot of information and you want to make sure that the patient stays stable throughout your inspection. And then, you know, often our measurements, we want to make sure that we're getting, you know, the distance from the carina to the distal end, the length of the stenotic and the length from the proximal to the vocal cords. And often I think we tend to, what we see endoluminally is not necessarily what you guys would see in resection. Yeah, I mean, what we see at the time of the operating room is essentially what you guys see endoscopically and then you add a centimeter, like probably at least half a centimeter on either side at minimum. But I think as Dr. Van Nostrand pointed out, like if you, when you do scope them, the measurements that your surgeons are going to want to, the measurements that are important of the distance from the core is the distance from the carina, the length of the stenosis and the lumen of the airway. Those are the four measurements that you really want to take before you start, you know, dilating and intervening. I mean, I think that this is a, like, not all these patients are the same, right? This is a very heterogeneous group of, this could be either somebody who has a really long segment, narrow stenosis that's corkscrew and really complex, or it could be a relatively straightforward web that is a few millimeters in length that is easily dilated, right? There's a wide variety here that is captured in this scenario. And I would add too that when, as an interventional pulmonologist, if somebody is requiring sort of multiple, you know, dilations, at what point would you think about stenting? I would have a discussion with my surgery team about the appropriateness of stenting, how any inflammation related to a stent would affect surgical resection if that's in the patient's future. So again, having that multidisciplinary discussion is important, but I'd love to get your input on that too. Yeah, I mean, we have an airway conference where we kind of, the three surgeons meet once a month and go over these cases and discuss everybody because stenting makes my job a lot harder. And so we tend to, for this indication, we reserve the stents for the ones that can't be resected just because it takes a, you know, what was a one centimeter stenosis and can turn it into like a five centimeter stenosis, which is not resectable. So I think that collaborative discussion is really important. All right, do we have any questions from the people that have joined us today sitting in the audience? So diligently answering our ARS questions. I actually have a quick question just for the pulmonologist. Do stents actually do anything for these kind of rigid scar fix things? I mean, it just seems like, does it ever help? That's a good question. I do like a trial of stenting. Sometimes it's helpful and sometimes it's not, but stents introduce a whole other set of complications depending on what type you put in, you know, mucus plugging, granulation tissue, you have to do repeat bronchoscopies. You can't just put one in and let a patient go. So it's kind of exchanging one chronic problem for another and it's just kind of how the patient feels afterwards. But you know, there is some value, there's some information to be gained from it, right? Like if you're not sure if the stenosis is flow limiting and causing symptoms, like you have a patient with COPD or pulmonary fibrosis and they've got a million and a half reasons to be short of breath and you're not sure if it's the stenosis. Like in some ways it's a diagnostic maneuver. If you have a short term stent, you can place it and see if it feels better and then take it out pretty quickly thereafter. Usually those are decisions that we make with kind of everybody. All together, yeah. Thanks for the great discussion. One question I had, this is something that Brendan McGrath has described in the UK and something that we've had preliminarily from good experiences over the last year is above cuff vocalization using the subglottic suction port of a trach. Kind of going back to the discussion of achieving speech, leaked speech, trouble with the outer lumen of the trach being too big. We switched to this at our hospital as a default trach place. So there's always potential option to give people speech. Wonder if you guys have had any experiences with this type of device and this kind of technique. Yeah, I fear that it's coming into vogue because I just met someone else today who said that their hospital system was switching from Shiley to Portex specifically for that added capacity. My sense is I've seen enough tracheal injuries due to fenestrated trachs where it's not my favorite thing to do. And I have a lot of faith in leaked speech and the fact that luckily I work at an institution where the RTs are on board with it to know how to manage it. I think that's the hard part, right? It's like, what's your culture? Because it's not a thing that can happen overnight. If you're gonna institute something like a leaked speech policy, you really have to have everybody on board. You have to have in-services for the nurses and SLPs and RTs. So I think time will tell, right? I wonder if we'll see an echo of this with tracheal injuries to come as more centers maybe are going in that direction. But that's what I would fear. Thank you. Time for maybe one more question, anyone? No, all right. Well, thanks for... I think Dr. Gillespie had a question. I was gonna tell if you were leaving or not. Sorry. With the new Shiley, we've had a tremendous amount of difficulty with that tapered cuff and that we've had to the point that we're switching towards Portex because Shiley's response to leaks is put a bigger appliance in. And for me, that's anathema to what I wanna do. I want the small supplies to achieve the goal that I need to provide a seal. Has there been anyone who's had difficulties with that tapered cuff? I can kind of... We're smiling because we anticipated this question. Yeah, we were just talking about it. And even in our institution, we were facing that similar issues. So we are kind of going through that phase right now, ourselves, where we are... Basically, our value analysis people want to do a quote-unquote trial before we fully commit to it, just in case. But that's kind of like where we are at as well. I think we had a mix among people that... We have some fans of the new design. Yeah. I mean, I think, yeah. There's some good things about the trade, but I can tell you where I am now. We've already switched products. Yeah, I think it works well in the rehab setting, actually. We're not using high pressures if we're ventilating. And I think that's probably where you run into the higher leak issue. But everybody's basically on a peep of eight or less if they come to the rehab hospital. So it probably has to do. Yeah, I mean, I like some of the design features of the newer one. I think that the outer diameter is smaller. I also think they're a little more dummy-proof, right? Because if you don't have an inner cannula, you can still ventilate the patient. But again, I'm not traking the patients who need a lot of extra vent support. That's not the group that I... I'm not traking the people who have the chronic respiratory failure and all those other sorts of issues. And so I've certainly heard that concern a lot, and I don't know if I have a great answer for it. Yeah, and there are many trachs out there, and there's not one trach fits all. Every trach kind of offers different pros and cons in different situations. So just really assessing what the patient really needs and then kind of selecting the trach for that particular moment. And as the patient condition changes, while the plan may change, they may need a different type of a trach itself. So I think. Yeah, I think maybe the issue is, because there's pros and cons to everything, I think it's probably what got a lot of us is that we all kind of stocked Shiley as the default, and then that's the only one that they had. It kind of speaks to me, the underlying issue is you really need a nice assortment. Like when I came here as the first laryngologist, they kind of have what they had, and so that was kind of one of my initial battles. And now I've got the range of Portex, I've got the Shilies, I've got all the different kinds of XLTs, I've got Moors, we've got some Trachos, Jacksons. I mean, there's a lot of, and they're all different. They're all just, it just depends on the patient and just having a nice selection and picking the right thing for the job in front of you. All right, well, I think we're out of time. Thank everyone for coming and for participating, and have a good rest of your day. Thank you.

post-tracheostomy complications

cuff leak

cuff management

oral secretions

respiratory distress

endoscopic evaluation

multidisciplinary approach

individualized patient care

interventional pulmonary medicine

ENT surgery