Educational Webinar: Tracheostomy Care

Good afternoon and welcome everyone to the mckesson Clinical Connection webinar series. I am Patricia Howell on the mckesson Clinical Resource team. Our program today is sponsored by the mckesson Clinical Resource team. And this series has been created to provide an opportunity for education and discussion related to clinical topics affecting the postacute care market. Following the call, attendees will receive a copy of the presentation of recording via email to ask a question, locate the chat box at the bottom of your screen. Today's feature speaker is Patricia Rennie, who is currently the respiratory clinical manager for the mckesson Medical Surgical extended Care Division. Prior to joining the mckesson clinical resource team, Patricia was an account manager for the mckesson home medical equipment segment. Patricia has been in the healthcare industry as a registered respiratory therapist and home care advocate for more than 35 years. Her experience includes national and independent HME and H and IV. Pardon me, IV companies, Patricia has developed training programs focused on staff development, marketing and customer satisfaction to allow clients the opportunity to expand and increase productivity in this highly competitive industry. Patricia. I will now turn the program over to you. Thank you, Patricia. Let you know that we are P square together everyone. So uh thank you everyone for attending today's uh Tracheoscopy care. Uh There's questions as Pat said that if you have questions, please put them in the chat box and we will get them either answered during or at the end of our presentation. Uh But I'm gonna begin since your time is very valuable and we only have one hour. So as we continue, uh you'll see this, this is our disclaimer uh uh that min that we put out. So again, know that it's there. I don't think I have to read it. So we'll move on and we'll go to trios to care slide. So the, the objectives for today, we wanna understand the basic tracheostomy care as well as the equipment used in home health, hospice, skilled nursing, uh as well as you know, other facilities that may utilize um respiratory products. So, any of your H and V providers may have it your home infusion. So hopefully you'll all get a little something that you can take away from this. So as we begin here, sometimes it's just nice to understand what is a tracheostomy. Uh You know, we, we see the patient, we ha it's already been inserted because it usually gets inserted in the hospital. Um But we never get to really understand sometimes the actual anatomy. So, as you can see here in this, this graphics, you're seeing that the tr tube is placed below the cryo iro membrane and the cricoid cartilage. And that we try to make sure that it gets it in this view. You're seeing that the esophagus is to the back of it. And again, that's to make sure that there's no asphyxiation, um as well as any type of, you know, food, um aspiration. So it just protects them. So that's just your basic of where that's gonna be going. Uh You can understand based on the pharynx and the larynx, why they have a hard time talking because as we talk, right, the air passes from our nose or mouth and goes over our vocal cords. Well, because the trachea below the vocal cords, it doesn't get the air. So that's why our patients have a hard time talking. So who is our typical patient? So you're gonna have patients that have maybe a throat or mouth obstruction. Uh Maybe they have edema, uh pulmonary lung conditions, airway reconstruction. Sometimes you'll see somebody that may have had laryngeal, uh C A. And so you'll see that because of where the surgery was, the tr might even be off center because they have to really do some reconstruction, um airway protection from secretions or, or food because of swallowing problems right through dysphagic. Uh maybe they've had a stroke, um or again, airway protection after head or neck surgery. So interesting though, over 100,000 Americans have tricks performed annually. That's like a crazy amount. Uh It's showing you that it's, it is extremely prevalent. It is something that is out there more than I think people are aware of and I'm seeing and hearing more and more or even in health facilities, they, they are creating more respiratory units where they have tr patients or vent patients. So again, I think it's, we're gonna be seeing more of this as um people become uh more compromised depending on their, their health issues. So, what are the complications? We all know that hemorrhage, right? It could be a complication, hypoxia, which is a drop in your saturation, usually, usually below 90% trauma to the laryngeal nerve. Uh I think some of us if we, if clinicians you've seen some people get uh intubated in the emergency room. Um Some of those were pretty scary, especially if they were uh you know, first year attendings or residents that have never done it. We all got a little nervous at that uh damage to the esophagus, pneumothorax. Uh Obviously there's infection uh or subcutaneous emphysema if it's not placed right, you get the crackling all around the tr site and it's just like popcorn, it just sort of crackles underneath your, your, your fingertips. So it gets very um uncomfortable for that patient. So those are some of those possible complications. The thing to think about though. What are the tubes? So those of us that have been around for a while, uh, we started by using the metal tubes, right? We had the Jackson's, uh, stainless steel silver, which is the first one at the top, right. Uh, those are usually permanent traits. I used to see those more for, um, laryngectomy patients. Um, they're clean, they're reused, they just keep processing them. Then they became the plastic or the Polyvinyl, uh, which are the most common today. Uh, the picture here is you're seeing the Metronic, uh shyly their new flex tube. Uh So that's a little bit more pliable than the old, older ones which you will see in some, um, of the pictures that are were much heavier, not as flexible for that patient. Uh And then on the bottom, you get those silicone tubes which are the softest, they need to be cleaned, they're reused, they're with or without a cuff. Um, a lot of times that might be the bone does. Uh So you'll get cuffed or uncuffed depending on what's going on with the patient if they're ventilated or if they're not ventilated. Um And that's that balloon. So again, looking at this picture in the middle here on the right, you see that cuff, it's a balloon that gets inflated and it fits in the air in the airway. So that again, air does not go around it, secretions don't go around it, everything is passing up and back through the tubing. So if they're in an, you know, in the home, whether it's a facility or they're in their own private home. Things that we not need to always be aware of is, you know, had the patient or the caregiver been taught skin and stoma care, you know, do they have a comfort in changing the tracheostomy ties? You know, we do have those new ties now. Right. The, the more the padded ones with the Velcro, which are so much easier than the twill tape that we've had from years gone by which are still around and usually in your trade care kits. But it, it's, it's nervous right when you try to go to untie that cause you're like, oh my gosh, what happens if they're gonna cough is the drake gun come flying out at me. So those are some of the, the things that we want to make sure everybody is comfortable with um humidification. We're bypassing the nose and the mouth. So now that air is very dry and when it's dry it gets desiccated, which does cause them to cough more. Uh, it, it's just very uncomfortable. So they may have trick humidification. So they might be wearing a tr mask which would go around and you'll see that in future slides or maybe they're on the ventilator and they have a humidification or they're using a HME, a heat moisture exchanger which adds that little bit of moisture to that air and warms it so that it's a little bit more comfortable and then we have the just the overall considerations for the home health patient, you know, who's taking care of them, what do they need? How do we help keep them healthy to and prevent readmissions? So I think that's the key that we all strive for as we continue, you know, in our own goals here in, in home health. So in this picture, you're seeing some Permal care, I am not the queen of this stuff. M my uh wound care nurses are so I always relay it back to them. But as you can see on this picture here and you know, they say a picture tells 1000 words and this one definitely does. You can see the tr hasn't been really cleaned well, you see the the skin around, it is very edematous looking, it's red, uh it's, you know, cracking. So what do, what do we have to do? Unfortunately, there's no international guidelines for the care of the the Permal skin around it. So, you know, we have some general guidelines, you know, clean with saline, do not put a avoid, you know, avoid hydrogen peroxide. People will want to go there first. Not a good idea. Best practices is recommended to select an absorbent prepackage trait dressing. Sometimes the gauze which would be like your your basic, you know, eight ply four by four, the split or two by two if your pediatric still gets stuck to that wound area. So you need something that's, that's not gonna be too adherent but is gonna be able to be absorbent. Um You never wanna take those two by twos or four by fours and cut them. So if all of a sudden you just have the plain gauze and it's not already presplit, please don't cut them. Those fibers are gonna come right out and they're gonna get um inhaled by that patient. So we really wanna make sure that you're using the things that are are precut. As in the pictures here, you wanna assess the area for, you know, any type of uh contact dermatitis inflammation. Uh What's happening with the secretions? Do they have a staph infection? Do they have pseudomonas infection? You know what is going on and how do we help mitigate some of that infection? So this site can heal and the patient will feel more comfortable tr ties again. I talked about it a little just a bit ago. Their cotton or velcro change it when they get wet or dirty. Um Today, I personally say stay away from the twill tape. It's very uncomfortable for the patients because it has a tendency to dig into their neck and then you're creating another area of where you can have breakdown. So that padded, it's nice, it gives a nice padded into the back of their neck and it's you can adjust it so it's not too tight and it's also not too loose. So it has a very good comfort level for that patient. You want to assess it daily. Uh Actually, if they're in a facility, I would say you, you're gonna, you should have it, you know, Q shift where you're checking that and making sure that the back of the neck is, you know, free of any type of contact dermatitis, no pressure injuries. We need to teach the patient and the family how to do this. It's a two person procedure. You know, one person should hold the tube in place, the second person should apply the care, you know, that will make everyone feel very comfortable. Some things that I'm seeing and hearing our patients are being discharged and nobody's really been taught and then they get home and now it's, you know, home health is coming in and they're saying, oh, I, you know, we have a lot to do now, you know, it's, it's already stressful getting that patient home now. It's even more so because people don't have a comfort level with how to take care of that. So it's really making sure that the hospital communicates well to the home health or the HME provider. Uh, let's make sure we're communicating and having everybody involved in that patient's care so that everyone is comfortable and if they're comfortable, we're gonna have a good distance church and hopefully they're gonna be able to stay home and not be readmitted. Um You wanna take, make sure when you're looking at it too, that the tube is loose enough, but it's not too tight. Right. You wanna make sure that there's gapping between the skin and the tr two. The nice thing about the new tracks that are out between cortex um by Smith um Medical IC U Medical as well as the Metronic is that they sit up a little bit higher. So it's not sitting flush against the skin. So I'm hoping with the new types of trachea, ostomy tubes that we have, that there's gonna be less irritation and less collection of secretions um underneath that, that Tr Lange and again, we'll go through that. Um When in doubt, always go to the, the ifu the information from uh usage that the manufacturer has. It's in every trick two box in every language imaginable. Um uh Metronic also has that online. So you could just go and, and key it in and it can pop up. So uh know that that's always available for you. So uh medical device injuries, you know, it's that as you're looking at this picture at the top, right, you can see that this is a Bivona trays, I can see it on the side there, but it's sitting really close. So because it's right there on the skin, it's getting an irritation because it does move it, you know, just like our trachea moves as we talk or we swallow, same thing is happening for them. So they've got this constant pushing back and forth on their trachea. So you're gonna get that irritation, that redness, especially if it's a new tr if it's, you know, only a couple of weeks old, even a couple of months old, depending on the patients. Uh um, you know, uh condition, uh sorry, having a little flash here, um their own condition and it may take a little longer to heal. So you always want to be careful of that. So a good idea is take some pressure off, use a foam or Hydrocoyle dressing and put that under the pressure points. And when doing that, that'll help, you know, increase that healing um for any full thickness of the pressure injury in the bottom, right? You also see that because of sitting up, it rests against the top of the phalange that can also cause. So we just wanna make sure that this whole area of the neck and I'm pointing to my neck. Hopefully you can see me um that that's the part that is staying, you know, protected. Um If somebody has a really thick neck, you really want to make sure that there's a little extra um gauze around it so that it just, it just cushions above the tr as well as below the tr. So that's the trig tube. We we all know that there's been issues with trigs, right? Everybody's, we've had, you know, recalls, we've had back orders because of supply issues. Um So it's, it's been very frustrating. Um I think for the industry and for health care because it's not something that we can just change automatically. So with that, you know, it's good to understand who are the manufacturers out there. So you have Metronic, which is the shyly, the flex is their new style. And again, it's very flexible. Uh It's an opaque, it's clear, I shouldn't say it's opaque, it's transparent. So you can see in the pictures here on the right, you can see through it. They did that. So that as a caregiver, you can see the skin below it. So again, help to identify before there is a pressure injury, you'll be able to see maybe a little bit of reddening or a little bit of secretion, you know, starting to collect there. It also doesn't lay flat. Um So again, you get that air and air is good for helping the skin heal. You have Smith Medical, which is now IC U medical, which is the cortex and the bi bona and again, the cortex has been put to bed and they're now calling it the blue. Select. The thing is it is not a 1 to 1 transition. So they have a cross, but it's not always dimensionally the same. So it's very best when it's talking about the, the the the cortex that you really might need to get a position involved to make sure that the new trait that they're recommending is going to fit. Um there's also Teleflex who has the Jackson Silver Silver and Athos just bought Bryant Medical, who has the Racco. So these are the typical ones that you're seeing out there. There are some others. But to me, these are the ones that you see the most in acute care coming into the home or into a facility you have cuffed, which has the balloon again, the picture to the top, right, you're seeing the balloon, which is the clear one. That's right at the end of the tube, the blue piece that you see off to the left of it, that's the pilot balloon. And that's where we take a lur lock syringe. And usually it should need to be more than a five CC and you slow play air to start that occlusion so that the patient can be on a ventilator as you notice on this um balloon. That's here. The, the cuff, I should say it's tapered, the tapered decreases some of the pressure. So again, the, if you have too much pressure, too much air in there, you could get esophageal erosion. So we wanna make sure that we don't have any of that tracheal to esophageal um issues happening. Uncuffed. That's pretty much what we see the most at home, right? Is that a patient, once they get discharged, they'll end up with an uncuff. They don't need to be ventilated. Um It's more for, you know, just having a good passage way, then it's there's gonna be like the one in the middle, there's no cuff on it. Everything else is pretty much the same. It's just a very easy tube that goes in. You don't have, you know, much to be concerned about but know that there's no balloon in there. So if they do cough, we have to make sure that you have your tr um, ties on properly and then you have a fenestrated, fenestrated, allows air to pass over. So it goes from the vocal cords and allows it to speak. So that gives them a little way of talking. So if they're not using a speaking valve, they, they might be using a frate tracheostomy tube. Your tras go pretty much for gels from a size six to a nine and peds are usually somewhere between a 2.5 to a 5.5. Um, those are your typical. Again, it's really looking out what's the size, what's the outer diameter and what's the length? So when you're looking at a tube, you know, I've had many people with, with the supply chain issues saying, well, can, is there an alternative? Unfortunately, if the doctor has already put in a size, you know, four, I'm gonna say an old four shyly that has an, a diameter of a 6.5. Well, I can't do something that's a 7.5 or I can't do something that's, you know, if it's only 42 centimeters or millimeters I'm sorry, uh, put something that's longer because it might end up hitting the Corina that we have to really make sure, you know, what size, what's the length that the doctor put in? There was a reason they did that, that we should always go back to the physician. Um, I always say, you know, show them both catalogs and say which one should we go with Doc and have him write the new order her, the new order I gave you some HP codes here. So that just so you see if you're an HME or, or an hit provider home infusion and you're doing tricks, you know. So the 752, you're allowed one every three months of Medicare. I know it's odd because manufacturers just change them every 24 or 28 days every three months. So you're gonna have to make sure there's a cleaning process that you have uncuff the same, but it's a 7521. And you have the options of either having an, a cuffed or an uncuffed with a reusable inter cannula or with a disposable inter cannula. If you have a disposable inter cannula, you can um, you are allowed to change them and you're allowed to a day. So that would be 62 a month. So I'm just giving you what the, the national ranges are just. So you have a good idea. It's also important to note that all of these items have expiration date codes on them. So, it's imperative that you, you know, where you're keeping that storage or you're using some type of, you know, uh fulfillment for, you know, distribution to that patient's home. So you don't have to store them because I have found in the past and, you know, having gone through many accreditation surveys, that's always the first thing the surveyor looks for. Right, is what's sitting on these shelves that are decoded that, that should have been moved or, you know, sent back or whatever the case may be. So, just make sure that you have a way of tracking that trade care kits, there are many trade care kits out there. I can't believe when I started researching this prior to me coming to mckesson, how many there were? And I'm like, why do we need so many? Um, you know, I think you need to look at what does the patient need? What's the basic to keep the patient protected and to keep the caregiver or, or whoever is gonna be performing that trade care protected as well, especially if there's an infection. So in this one that I'm showing you doesn't matter what's in the tr care kit, they're all reimbursed the same. So you need to be cognizant of that as well saying, OK, if this is what I'm using, what's, you know, how's, how's that cost related to what you're being reimbursed? So, in this one that I'm showing you it has a pair of powder free gloves, tr brush, some pipe cleaners, some cotton chip applicators. They will always come with the twill tape tr tie. So they don't come with that, um, cushion tie, the, the pattered one. Um, they'll have the four by four gauze and they'll also have usually a four by 46 ply drain gauze. They'll have a, a basin so that you can clean it and not, um, and usually at least a Drake that you can put over it. So again, to keep it as clean as possible, but note that hydrogen peroxide for when you're cleaning the tr in that basin, not in the patient. Um that isn't covered us. Oh, but this is a typical one. And here on the bottom you're seeing the picture of the tr tie with, with Velcro and that does have a AHP code as well as an A 7526. So and, and you're allowed one a day. So these are just things to know, you know, again, these are Medicare, these are not Medicaid and then not private insurance, but most of them do follow the Medicare C MS standards. So just, you know, helps to get a guide on where you stand with that. So our accessories, so we talked about the, the trade care kits having the IV um splits. They may need more than one a day or two a day if they have a lot of secretions if they have a very perent um infection, then we're gonna need to have that, you know, dry and remove those frequently. So you wanna make sure that you have extra in that in their home uh And they can be changed. Um and reimbursed usually three a day. Speaking bells another way. So passe mirrors is probably the, I don't wanna say gold standard, but it's, it is really probably the, the first one that was out there. That's the purple one that you're seeing pictured here. Uh Metronic also has one as well as she effect has one for the Jackson tr. So that's gonna really help your patient in talking and warm in the air so that they can have a little bit more of a conversation. Um It gives them a better feeling that they're moving forward in their, in their health, right. And that they're, that they at least get their voice back and, and feel like they're getting a little bit more control over who they are uh below that is your heat moisture exchanger. Um This is a typical basic one for the most part. That's all you need if somebody is not on a ventilator, um it, it just can sit right there uh right on top of the tr they don't have any other humid fire. It is usually not a bacteria filter. It's more of just a straight up heat moisture exchanger and Ken Smith Medical. Um Although I have by air here since I did this by air, um, sold this off to uh Sun Meed. So that would really be an air life product. And the trai they come, there's many companies out there that have them. Um mckesson is one and Dale is probably the one that was first out in the market with it. So that's what some people really know. So I was talking about humidification with the um heat, moisture exchangers, the HMES. So tr humidification in this picture you're seeing right? This picture to the left, this person is on a and you can tell that pretty much by just the, the tr adapter they're on and the type of tubing that is and then over here to the right, they have a Tr mask. So, and you can see where the tape where, you know, they have twill tape, how it's tied in. You can see even in this picture that it's pretty tight just based on the way the neck is situated. So, you know, people have a little bit thinner skin, uh looser skin. So you really want to make sure that that's protected. So as you're doing that and they need humidification if they're not gonna use an HME, because they need maybe more, maybe they have very thick viscous secretions. Um You might need to get a little bit larger humidifier. You know, you have your room humidifiers you could always use, which can, you know, really help in the air, but it doesn't always manage with some of these patients. So they might need to have something that's using with a, a bun compressor or a 50 P si compressor. You could see, I just slipped into that bun because that's what we used to always call it. Uh So this is a 50 P si you're seeing this one I think is drive. Um It helps in generating that pressure. Uh Next to it, you have a large volume empty nebulizer. So this is gonna give that higher concentrated mist that the patient's gonna get and they're gonna be able to breathe. You can have it with oxygen or just plain, you know, air with water. Uh and that a lot of times is, is really all the patient needs to keep those secretions moving so that they can cough and expectorate on their own without having to be suctioned. We do also have prebuilt nebulizers right in the industry. So this works more for, I think facilities it lasts a little bit longer. Um It's, it's a little bit more expensive uh from, from a home care perspective. Uh and doesn't always need to be used in the home. But I think when you're looking at facilities, it definitely bodes well as especially from a uh infection contro control, then you always have corrugated tubing. It can come in 6 ft, two bean lengths can come in 100 ft. Uh But usually I see patients usually get the 100 ft and then the, usually the therapist or the nurse will cut it to the length they need. Usually don't want to be too much more over really 12 ft, I would say because that water will start condensing in there and then you're gonna start hearing the bubbling. Well, when you start hearing that bubbling, that affects the air, getting to the patient as well. And if the patient gets rolled over to their one side or another, that water could also come back and they could aspirate it. So you really want to make sure that you don't put it too low, too low and that you have it so that it's looped appropriately, you might have a tubing connector to hook two pieces together uh as well as the tray mask, trick mask come in pediatric as well as adults. So just uh you know, understanding that these could be the products that would be again in a facility or at the patient's home. So as they're getting ready to discharge, these are some of the questions that really should be asked so that we can be proactive on getting things to that patient's home prior to them being discharged. Suctioning. Um No one wants to be suctioned, no one wants to suction. It's not a comfortable situation. But if we can't get that patient to have thin secretions where they can cough on their own, we unfortunately have to do an invasive procedure. And that's putting this tubing down. As you can see in this picture over on the right, we're gonna insert the tubing through that tracheostomy tube. You always clean above the balloon first because they're still having saliva. That saliva is gonna collect above the balloon. If you drop that balloon, they're gonna aspirate all that saliva. So you really wanna make sure you're always cleaning out the mouth, cleaning above the tube first and then you go inside the tracheostomy tube. So what are our reasons for suctioning to maintain a pain airway is the primary, we wanna improve gas exchange, primarily oxygenation. Uh As well as we might have to do a tracheal aspirate. Find out what bacteria do they have. Uh We also want to prevent effects of retained secretions. You know, we wanna make sure that their lungs are a rating that they don't get these, um, nice little, you know, mucus plugs that end up plugging off part of their airway can affect how they oxygenate later as well. Uh One thing I don't see enough of and that's pre oxygenation. So if you're gonna be suctioning somebody, it really, you should have this resuscitation bag with that patient. So if they're coming home or if they're going into a home, you should always give them a couple of breaths with oxygen. So it helps inflate their lungs, it will also help loosen. So if they've been on humidification and you give them a couple of nice breaths that's gonna loosen up. Also. What, what might be um, clogging for lack of a better clinical word, uh their, their lungs and it will help make the suctioning process less obtrusive to them where they don't feel like they're being robbed of everything cause you're suffering air out of their lungs when you do that. So you wanna make sure you oxygenate before and you oxygenate afterwards. And again, we talked about the cuff tube. If it's cuff, you wanna make sure you do an oral first and then you let the air out afterwards. So your suction machines, you're gonna, there's a couple of different types. The one on the left, that's the heavy duty. That's pretty much the one that you would see in a home where the person's not very ambulatory, very portable bedside. It's, it, it's a workhorse. It very, I, I don't think I ever see him, you know, break down. So you're gonna see in the, in here you have a small tubing that goes to that regulator. There's always a bacteria filter going into this container and the containers usually will, will snapshot. So that again, you don't get secretions other way, you know, they won't tip over and such like that over here over on the right. That's your A CDC model. So lightweight, easy to port, you know, portability. If you have somebody that might be, has a power wheelchair, very easy to sit in the bottom of that power wheelchair. So they could still be suctioned as they're on, you know, on the move. So know that there's still a couple of different kinds out there of, um, that can benefit to that patient. There are also smaller ones out there. So it depends on, again, the size of the patient and the severity of that patient. So your supplies, you get your canisters, you're allowed two a month. Ok. So this again, Medicare standard C MS two a month. So you're gonna have to rotate it. So you're gonna end up jumping it out into the toilet, please. And then rinse it and then put it back out and that should be done. I would say, you know, depending on what's going on with that, that patient at least every eight hours. If not more, your connective tubing, you're gonna be rinsing that in between. It comes in a variety of lengths anywhere from 1.5 ft to 20 ft 20 ft might be a little bit excessive for uh home care. But I think it a 10 ft is usually pretty suffice for most of those patients. Um, that are, even if they're in bed, it still gives you enough room that the machine's not on top of them. You might need a yank our tip again, could be non vented, which means it doesn't have, um, uh thumb control or it's one that has, that's vented that you have to put your finger on it. So they get three a week for those and then your filters. So nobody reimburses for those, unfortunately, but it's always good to have those different types of catheters. Um, uh, we, we saw, you know, a lot of changes happen with COVID. So, you know, we still are using though the open catheters that, that are not, that don't have a sleeve over them. Um, in this picture you're seeing a kit comes with usually, you know, two powder freak gloves, a little basin that can pop up so you can put saline in it to rinse your catheter off. Um, and the tubing, uh, as well as that suction catheter uh in the bottom you're seeing, it's got the thumb control. That's still probably the, the method of using it because it gives you that full control. You don't want anything that's, that doesn't have that because again, when you're suctioning, you're doing intermittent and bringing it back up and you want to be able to lift your thumb off of that vent. If that's on all the time, you're gonna hurt the, the lung tissue. So you really wanna make sure that you're taking that and you're bringing it back just nice and slowly manufacturers. There's only a few out there now. Um, there's been a lot of mergers uh with the, with the suction, um Catheters. So again, y you're gonna see some that are with um Avios or Valle those are, the two primary cardinal has some out there MEDLINE. Uh, you know, there's a few that are definitely out there. So size 5 to 18 are your typical five are usually 568, maybe even 10, go to pediatrics to young adults. Uh, 18 French, that's like a garden hose. So we don't have a lot of people like that, but you might have somebody that is extra large and they may have a very large, um, you know, tracheostomy tube, you'll do some sterile saline. Pretty much. You're gonna see the, the 10 ML bullets. So you can use those five ML, they have the three ML. Um or you might also use the 500 ML um Saline in the bottles. But again, if you're doing that in the patient's home, the patient needs to understand that it's not gonna be good forever. They can't just keep using it or reusing that container, which is a lot of times what they'll do. So you have to just make sure there's a process in place. Um sterile water the same. It's um 500 MLS. You can also find it in, in 1000 ML or um 2000. But the sterile water, you wanna just make sure that if you're using infra suction, you want the irrigation. Um and you're not putting it in there, you'd only put the saline in there um in their tr but if you're using it for inhalation, that would be what you would be filling the container with. So you wanna make sure that when you do fill a container it's, it's inhalation water for inhalation only again, you can use distilled water and that's probably the most cost effective way. Um, distilled water has zero chemicals in it. It's actually, to me, I think it's still the best, um, from a cost effectiveness, I mean, from, we've been doing home care for many years now. We always did distilled water. We always taught our patients how to boil water and, and, and do that stuff. So that could be a way that is more economical for your patient. So again, you need to understand your patient and what's gonna work for them. No touch, suction catheters or if you wanna say closed suction catheters. Um Medicare will cover 30 a month, which means one a day. Uh which means you're reusing that through the day. So I'm gonna just flip to the next slide. Uh No, I won't flip to the next slide. Um So I thought I had one for the, for the drink. Oh, I do. It's actually here. Ok. Sorry about that. I'm getting, I'm seeing too many slides all of a sudden on my, my screen and that's mine. Um So anyway, so this the sleeve part as you can see over on the right hand side, it's like a plastic sheath that goes over it and it's the tubing slidess down away from it. So you're never touching the suction catheter and it stays very clean. Um, you'll see this a lot more with ventilators, um, COVID. When we, you know that all happened, you started seeing a rise in the closed suction catheters in the home. We didn't see that as much previously, but since probably 2019 that has really picked up and is becoming more of a standard that if they are ventilated, we'll use the, the closed section at home. And this way you don't break the circuit. Um and it is actually more cost effective um for the care of that patient. So just some process right before doing any of your care. Um If it's tracheostomy care, you wanna make sure that, you know, good hand washing, you want to describe the function of each part of that tracheostomy tube to the patient so that they understand um explain how to remove it, how to change the inter cannula, how to clean the inter cannula two or three times a day. That's one of the most important aspects. Um how to check for the, the tracheostoma site, how to monitor tracheal secretions. You know, they need to understand when to contact their physician if they see a change in color. Um you know, are they having a temperature all of a sudden, there's like a, a very odd smell from the the uh secretions. All this information is very important to get back to that position. So, it just makes it a very, if they know what they're looking for, they're much more relaxed and less apt to call EMT in a panic before trying some of these methods. So the more we can get them better educated and better armed for themselves, I think it makes everybody, um, I don't know, maybe a little bit more responsible for their own care too, but it just helps in, in keeping the, the patient in a control setting where they have control over their destiny. And to me, that is one of the most important things. So make sure you have a plan. How do they communicate, medical alert, bracelets, um backup tracheostomy tube that should always be taped to the head of the bed or to the wall above the, the bed. And I always say this to, to those that are coming out of the hospital, they have one already taped to the head of their bed at the hospital that's already been built to them. If they're being transported home, that should be coming with them. So you wanna make sure that, you know, when the discharge coming and you're giving us the one at the head of the bed, right? So, so make sure all that, you know, comes with them, but make sure you're also keeping that at, you know, within the home as well. Make sure it's sterile, make sure the package Tracheostomy kit is available at the bedside for emergency So it's always good just to have one, just talk right nearby. So that if all of a sudden something happens when, you know, nursing is in there, nobody has to go, you know, looking for something. It's right there at the fingertips and you can take care of the situation before it becomes traumatic. The trick tube comes out, replace it immediately. Don't panic. Usually their airway is still pretty patent. You know, usually when it's first put in, it's sutured in. So you don't have to worry, you know, after a couple of weeks, there's usually some tracking that's beginning so it should be fine. Um, but you wanna make sure it's replaced immediately, make sure they're not swimming, make sure they understand the brand of the tr tube that they have, understand how to read the flange on the flange. There's gonna be the actual number, the size, the inner diameter, the outer diameter. If it's color coded, the color code on it, if it's blue, well, then the tr um inter Cannula for disposable is gonna be blue as well. So those numbers will start matching. So them everything. So they understand what are some of the keys. So if they're getting things brought into their home and they know that their inner cannula was always blue and they get one now that's red, that should make them say, wait a minute, what's going on here. Should I have a red one? And they can start asking questions to make sure that they didn't get a wrong order phone at the bedside. Pretty much everybody has cell phones today. So again, it's kind of hard if there's a phone at the bedside in their tr right, the patient's not gonna do it, but you wanna make sure that if there's a, a traumatic incident that happens and maybe there's they obstruct and there they need to be resuscitated. You wanna have a phone right there so that whoever is doing the resuscitation, if they have to be able to talk on the phone and put it on speakerphone, it's handy. It's not, you know, three rooms away from them. So we always wanna make sure what's the process so that everybody understands no smoking, no fumes, no dust, no mold. I think that that's pretty standard. So if there's others that smoke in the house, they really need to go outside, they really need to stop that. We won't go there, but they really need to go outside. Um, and just make sure they, they do good hand washing before they come back in because their hands will have that oil, that smell, um, which could trigger again. Uh, any type of an issue with this patient people should be trained in CPR. Um, know where they, again, em, emergency management is and always make sure you have your, you know, phone numbers on the refrigerator as well as any type of advanced directives that should always be um at a prominent spot. So that again, when EMTS, if they do get called, they know exactly. That's always the first place they're gonna look is usually in the refrigerator to say what's what are the advanced directives for this patient. So with that, that is my life slide doing pretty good with time too. I want to introduce to you all though. This is our mckesson Clinical team. We have a very diverse team of wound care specialist of nutritional specialist, uh infusion myself. I do respiratory. We have an incontinence um specialist as well. So we have a group of clinical team here that can help you in helping your patients have the quality of life that you want them to have. So please never hesitate to contact us or talk to your mckesson uh rep and they can definitely get us connected with you. Is looking at questions right now. Um I see one right now in there saying are the allowable for Medicare guidelines. Yes, it is Medicare guidelines um under their local um coverage determination, their L CD. And that that's exactly where I've, I received that in uh information. Thank you so much Patricia. As a reminder to our attendees, you can submit your questions in the Q and A box that should be on the lower left um of your window. So I'll just give another minute here if anyone has any other questions for Patricia and I have here on this side, you'll see there's plenty of resources. Um uh You'll have a copy of this other live link so that you can, you know, get more information as you desire and go into our last slide. Well, we don't have any more questions right now. Um But feel free to reach out. Um If any questions come up after today's webinar, today's webinar was recorded and will be available um on our website. Oh, we do have one question. Um Is it necessary to preoxygenated prior to administering a nebulizer treatment via trait collar? You know, that's a great question. Um It really isn't, they're getting the whole idea of the, the nebulizer treatment right? Is to get that albuterol in um whether you oxygenate them or not oxygenate them, it's not gonna change that. Um But what's gonna change is after right after they take that treatment, they're gonna have hopefully better oxygenation. So at that point, you may be doing a little suctioning afterwards if all of a sudden it started to mobilize secretions. But I think, you know, you'll be fine just giving him there that oxygen uh that nebulizer uh depending on where you are, you could always give that nebulizer treatment with oxygen. So instead of hooking it up to the compressor, you could always hook it up to uh you know, uh the oxygen flow meter, e cylinder, maybe wall, wall, um oxygen, whatever you have. Um concentrator doesn't have enough liter flow maybe if there's a 10 L, but it usually just doesn't have enough to power it. Um But I would say, you know, either regular cylinder if you needed to, if it was an emergency, you know, if their sats were really low at that time and you needed to give a treatment. I would rather see you give it with oxygen um than even have to hyper oxygenate before. Great. Thank you. Um So I'll move forward here with our um disclaimers if you could, would please take a moment um and just know that these are here um for you to review. And then we'd also invite you to view our upcoming webinars by visiting our website M MS dot McKesson dot com slash educational dash webinars. And in closing, I'd once again like to thank Patricia for sharing her expertise with us today and all of you for attending. Have a great rest of your day. Thank you, everyone. Have a good day.