Compliance with proper self-cleaning protocols may
enable trach patients to live independently and prolong their
lives
Seven days post placement of a SCOOP transtracheal oxygen
catheter via the FastTrackTM method, a 77-year-old man called
the special procedures respiratory therapist complaining of
shortness of breath and stated he was unsure of whether he was
getting his oxygen. The therapist instructed him to leave the
SCOOP catheter in place, but to switch to an oxygen cannula
and come in for evaluation. The patient presented on an oxygen
cannula at 8 lpm. Pulse oximetry revealed a Spo2 of 91%.
Mucous plug
The respiratory therapist inserted a wire guide to switch
out the SCOOP catheter and could not move it in or out. She
cleaned the catheter in place, instilling normal saline and
advancing the cleaning rod alternatively. The patient became
increasingly short of breath and was placed on a
non-rebreathing mask with a Spo2 of 90% noted. The patient
received a nebulized breathing treatment with albuterol, and
the respiratory therapist continued to clean the catheter in
place. After 1 hour of care, the patient bent forward and
coughed, gagged, and expectorated a massive sputum plug, fully
5.5 cm in length, which was placed in a specimen container and
sent to the laboratory for examination. The catheter could
then be removed and replaced. Although the patient was
physically exhausted from the ordeal, he quickly recovered and
was placed on 5 lpm SCOOP with a Spo2 of 91%.
The respiratory therapist reviewed cleaning in place
instructions. The patient was discharged to his home with
instructions to increase his cleaning in place regime from
twice daily to at least three times per day until the tract
matured.
Following lengthy and intensive reinstruction, the patient
learned to manage his SCOOP catheter care independently, and
continues to benefit from SCOOP TTOT at 5 lpm, with acceptable
Spo2 levels and no subsequent problems. SCOOP catheters are
approved by the US Food and Drug Administration for flow rates
up to 12 lpm, literally allowing the patient additional room
to breathe as his oxygen demands increase.
Discussion
Both the chronic and acute
management of this patient was very challenging for several
reasons. He had reached or surpassed the limits of an oxygen
cannula to effectively maintain acceptable oxygen saturations
regardless of flow rate. His desire to live independently was
compromised by his advancing age and deteriorating health. His
diminished ability to learn and demonstrate new skills
presented a challenge to the clinical care team.
When confronted with a SCOOP catheter that could not
readily be removed, the respiratory therapist correctly
avoided the temptation to forcibly extract it. Instead, she
patiently and persistently followed the cleaning in place
protocol. The massive plug was eventually dislodged and
expectorated, much to the patient’s relief. Had the therapist
been unsuccessful in dislodging the plug, an intervention with
fiber-optic bronchoscopy would have been necessary.
The etiology of the massive plug is suspicious. Small
mucous balls on the SCOOP catheter are not uncommon, but
massive gelatinous plugs are virtually unheard of. It is
possible that the plug resulted from a combination of factors
including the placement of the SCOOP, arid climate, and the
patient’s poor compliance with the cleaning in place protocol.
The clinicians involved in the patient’s care did not think it
was likely that such a massive plug would form in so short a
time post-SCOOP placement, however. The fact that the patient
had been very recently hospitalized with an acute exacerbation
of chronic obstructive pulmonary disease and had a history of
hemoptysis suggests that the plug may have already been
residing in an airway and merely became lodged on the end of
the SCOOP catheter.
Although the patient was slow and reluctant to learn the
SCOOP self-care routine, and managing the SCOOP catheter
challenged his limited manual dexterity, the special
procedures respiratory therapists were gradually and
eventually able to assist him in achieving complete
success.
The combined skills of the surgeon, pulmonologist,
respiratory therapists, and pulmonary rehabilitation team
worked in concert to achieve the best possible outcome for an
extremely challenging end-stage COPD patient with limited
options in life. Studies have shown that patients receiving
oxygen through a SCOOP transtracheal catheter live an average
of 2 years longer than patients who are clinically similar but
using a nasal cannula.
For this patient, successful implementation of SCOOP TTOT,
combined with pulmonary rehabilitation, may have been the key
factors in fulfilling his wish not only to live independently,
but to continue living at all. He continues to live
independently, has had no recurrent hospitalizations, and
continues to participate in a pulmonary rehab program.
John A. Wolfe, RRT, CPFT, is a clinical specialist at
North Colorado Medical Center, Greeley, Colo, and is a member
of RT’s editorial board.