What are the post-discharge management and care instructions for a patient with complex medical conditions, including mechanical ventilation, tracheostomy, and multiple chronic conditions?

Post-Discharge Management for Chronic Ventilator-Dependent Patient with Tracheostomy

This patient requires continuous 24-hour skilled nursing care with at least two trained caregivers capable of managing all aspects of ventilator support, tracheostomy care, and emergency interventions, as ventilator-dependent patients face high risk of life-threatening complications including tracheostomy obstruction, accidental decannulation, and cardiorespiratory arrest. 1

Caregiver Requirements and Training

Mandatory caregiver qualifications:

• Minimum of two adults must be trained in all aspects of care before discharge 1
• Training must demonstrate proficiency in both technical skills AND decision-making, not just task completion 1
• All caregivers must be capable of tracheostomy tube replacement and emergency management 1
• If no trained caregiver is available at any time, immediate hospital readmission is required 1

Essential competencies each caregiver must demonstrate:

• Tracheostomy suctioning technique and frequency assessment 1
• Recognition of tube obstruction or displacement 1
• Emergency tracheostomy tube removal and replacement 1
• Ventilator troubleshooting and alarm response 1
• CPR specific to tracheostomy patients 1
• Management of accidental decannulation 1

Monitoring and Equipment Requirements

Continuous monitoring (24/7) is mandatory due to high mortality risk: 1

Required bedside equipment:

• Waveform capnography for immediate airway assessment 1
• Pulse oximetry with alarm settings 1
• Two oxygen sources (wall and portable cylinder) 1
• Suction equipment with sterile catheters 1
• Self-inflating bag-valve device 1
• Two spare tracheostomy tubes (same size and one size smaller) immediately available 1
• Tracheal dilators (institutional preference varies) 1
• Emergency airway equipment including oral/nasal airways and laryngoscopes 1

Emergency Response Protocol

For respiratory distress or desaturation <95%:

1. Immediate assessment of tracheostomy patency 1

   • Remove any caps, speaking valves, or humidification devices 1
   • Remove inner cannula if present 1
   • Attempt gentle suction catheter passage 1

2. If suction catheter passes easily: Continue ABCDE assessment with ventilator support 1

3. If suction catheter does NOT pass: 1

   • Deflate cuff immediately 1
   • If no improvement, remove tracheostomy tube completely 1
   • Apply oxygen to both face and stoma 1
   • Attempt ventilation via oral route while occluding stoma 1

Critical warning: Attempting vigorous ventilation through a displaced tube causes fatal surgical emphysema—remove the tube if obstruction suspected 1

Ventilator Management

Current settings to maintain: 2

• Mode: SIMV-VC
• Tidal volume: 450 mL (appropriate for lung-protective strategy)
• Rate: 12 breaths/min
• PEEP: 5 cm H₂O
• FiO₂: 22%

Monitoring parameters requiring immediate medical evaluation:

• Oxygen saturation <95% (check for hypercapnia before administering supplemental oxygen) 1
• Increased work of breathing or respiratory rate elevation 1
• Ventilator alarm persistence despite troubleshooting 1
• Signs of ventilator-associated pneumonia (fever, increased secretions, infiltrates) 1

Infection Control

Strict contact isolation must continue indefinitely: 1

• Patient carries CRAB (Carbapenem-resistant Acinetobacter baumannii) and MRSA
• Dedicated equipment required
• All caregivers must use personal protective equipment (gloves, gowns, eye protection) 1
• Hand hygiene before and after all patient contact 1

Airway Clearance and Secretion Management

Routine interventions:

• Regular chest physiotherapy (frequency based on secretion burden) 1
• Scheduled suctioning with sterile technique 1
• Consider mechanical insufflator-exsufflator if secretion clearance inadequate 1
• Maintain adequate humidification to prevent mucus plugging 1

Nutrition and Medication Administration

PEG tube management:

• Continue Jevity Plus per dietitian protocol 1
• Maintain hydration schedule (350 mL saline q8h as prescribed)
• Flush tube before and after each medication 1
• Monitor for aspiration risk despite PEG feeding 1

Medication administration via tracheostomy:

• Nebulized medications (Ipratropium) should continue as prescribed 1
• Emergency medications (epinephrine, naloxone, atropine, lidocaine) can be given via tracheostomy at 2-3× IV dose if IV access unavailable 1

Pressure Injury Prevention

Given existing decubitus ulcer and total immobility:

• Repositioning every 2 hours minimum 1
• Specialized pressure-relieving mattress required 1
• Daily skin inspection, particularly sacrum, heels, occiput 1
• Tracheostomy site care with dressing changes per protocol 1

Seizure Management

Due to chronic seizure disorder:

• Continue Keppra 500 mg BID via PEG 1
• Caregivers must recognize seizure activity and know emergency protocol 1
• Maintain rescue medications as prescribed 1
• Prolonged seizures may precipitate respiratory decompensation requiring ventilator adjustment 1

Coordination of Care

Essential care coordination structure: 1

• Primary pulmonologist oversees ventilator and tracheostomy management 1
• Neurology for seizure management and altered consciousness 1
• Gastroenterology for PEG management and nutrition 1
• Infectious disease for resistant organism management 1
• Ideally, shared electronic medical record access for all providers 1
• If shared EMR unavailable, written communication plan mandatory 1

Scheduled follow-up:

• Pulmonology within 1-2 weeks of discharge 1
• Neurology for seizure monitoring 1
• Primary care for routine health maintenance 1

Indications for Immediate Hospital Transfer

Call emergency services immediately for: 1

• Inability to pass suction catheter through tracheostomy 1
• Accidental decannulation that cannot be immediately corrected 1
• Oxygen saturation <88% despite interventions 1
• Seizure lasting >5 minutes 1
• Fever with hemodynamic instability (given sepsis history) 1
• Ventilator malfunction that cannot be resolved with backup equipment 1
• Significant bleeding from tracheostomy site 1

Critical Pitfalls to Avoid

• Never attempt forceful ventilation through potentially displaced tracheostomy tube—this causes fatal surgical emphysema 1
• Never administer supplemental oxygen without checking for hypercapnia—oxygen alone without ventilation support is dangerous in ventilator-dependent patients 1
• Never leave patient without trained caregiver present—even brief periods unattended risk fatal complications 1
• Never delay tracheostomy tube removal if obstructed and not passing suction catheter—continued obstruction is immediately life-threatening 1