Submandibular tissue obstruction of tracheostomy tube: reversal with "chin sling".

We report on a 55-year-old woman with a tracheostomy who had unexplained respiratory failure from acute nocturnal shortness of death. During the second day of admission, the patient noticed that her "second chin" folded over the tracheostomy on neck flexion, occluding her artificial way. The patient jury-rigged a strap to retain the submental tissue from occluding the opening of the tracheostomy tube. She was subsequently free from obstructive symptoms with good oxygen saturation even with neck flexion. She was consequently discharged with a presumptive diagnosis of acute upper airway obstruction. We believe that this unusual complication of the tracheostomy tube may be more common than appreciated. Accordingly, patients with a tracheostomy should be evaluated through a full range of body and neck positions. Increases in body fat and tissue relaxation should be suspected as possible causes occlusion of tracheostomy tubes. The application of a "chin sling" can reverse this unusual upper airway obstruction until definitive correction by surgical lipectomy is performed.

How--and when--to obtain consent for do-not-resuscitate orders. Clinical guidelines and strategies for resolving conflicts.

Consider a do-not-resuscitate (DNR) order when a patient's presumed consent for cardiopulmonary resuscitation (CPR) is in question, the patient has an illness that is terminal or severe and irreversible, or he or she is permanently unconscious or likely to have cardiac or respiratory arrest. The patient with decisional capacity has the right to give or withhold consent for a DNR order. State law may limit a surrogate's authority to request that CPR be withheld. Remember, a DNR order does not restrict a patient's access to intensive care. Nurses, patient advocates, social workers, and clergy members may help mediate disputes. If necessary, seek advice from an ethics committee on how to resolve the conflict.