🫁 RESPIRATORY & TRACH SAFETY MANIFESTO
🛑 ACTION REQUIRED: OXYGEN CEILING & DRIVE WARNING
- Action Required: Do not titrate or force oxygen to reach 100%. Excessive oxygen suppresses his respiratory drive and risks absorption atelectasis. [1, 2]
- Oxygen Ceiling: Supplemental oxygen must be titrated conservatively to maintain an active target saturation of 95% or higher (95%–98% ideal). [1]
- Home Baseline: Daniel uses no oxygen at home and does not require it at baseline. Forcing a 100% reading via excessive oxygen is toxic.
🚫 Absolute Refusal of Erroneous Labels
- No Lung Failure: Daniel does not have and has never had chronic respiratory failure or recent pneumonia.
- Charting Errors: This label was a "copy-paste" charting error perpetuated across systems without clinical justification.
- Trach Purpose: His current tracheostomy (Shiley Size 4) is used strictly for pulmonary secretion management and airway clearance due to quadriparesis—not due to mechanical lung or airway failure.
🚨 Hospital Trach Sizing & Mandatory Discharge Rule
- Inpatient Upsizing: Because his trach routinely risks accidental dislodgement during hospital manipulation, the clinical team may upsize him to an XL trach during this inpatient admission for his immediate safety, as needed.
- Mandatory Discharge Rule: However, he must be transitioned back to his normal Shiley Size 4 prior to discharge. The trach does not dislodge in his home environment, and his quality of life, comfort, and food tasting require the smaller tube. His trach does not become dislodged at home.
🛏️ Bedside Tips to Prevent Dislodgement
- Tie Placement: Put the small part of the trach tie on the right side of his neck. The left is harder to access — he leans that way.
- Tie Tightness: Tighten well. Exactly one finger should fit easily beneath the band; more fingers means it may dislodge.
- Drain Pads: Use plain white split drain pads, not thick pink foam ones — keep the trach flat against his neck skin. It is also completely okay to not use drain pads at all if it helps safety and visual tracking. The skin around the trach is well conditioned to handle this. The trach is over 8 years old.
- Patient Turning: Before turning him to change sheets, check that the trach is secure.
- Humidified Air Mask: The humidified air mask can dislodge the trach — a heat moisture exchanger is a fine alternative, or please monitor the mask or ask for a towel to put under his arm to keep him from pressing his arm against the mask.
- Equipment Restrictions: Please do not use the Airbow or Highflo if it can be avoided.
- Suction Restriction: Please do not use the inline suction attachment, as it protrudes out too far and causes the trach to dislodge.
If in doubt, discuss with Cat in RT. She knows Daniel very well and can help.