Palliative Practices to Promote Airway Clearance

1. Palliative Practices to Promote Airway Clearance Pamela V. ONeal PhD, RN Ellise D. Adams, PhD, CNM Emanuel Waddell PhD University of Alabama in Huntsville College of Nursing and College of Science

3. Purpose • Purpose is to focus on integrating palliative care practices to assist children, adults, and older adults in • Promoting airway clearance • Managing respiratory compromise • Providing supportive pulmonary care at the end of life

4. Learning Objective • Discuss functional oral mobility to effectively manipulate secretions • Describe interprofessional collaborative work to address a clinical issue • Examine involvement of healthcare providers and caregivers in assisting with simple, effective, airway clearance practices

5. Palliative Care Impact • Addresses Pain and Suffering • Across the Lifespan • National Hospice and Palliative Care Organization (NHPCO) – 1.5million patients in 2013 received hospital services • Female (55%) • Age 85+ (41%) • Less than 24years (0.4%)

6. Top Noncancer Diseases Requiring Palliative Care • Dementia (15%) • Heart Disease (13%) • Lung Disease (10%) • All diseases involve sequelae associated with airway clearance • Dysphagia • Dyspnea • Respiratory Compromise

7. Common Child Oral Concerns • Fragile mucosa (chemotherapy or radiation) • Hypersalivation – drooling is apparent • Oral mucositis – pain, inflammation, and ulceration or oral cavity • Halitosis – pathological (related to disease) or physiological (decayed food) • Stomatis – inflammation of mucus lining • Xerostomia – dry mouth (Sargeant & Chamley, 2013)

8. End of Life and Death Rattle • Noisy breathing is heard • Secretions accumulate in the back of the throat • Muscles in the back of the throat may relax • Usually unconscious, “sleeping,” not aware • Reposition, remove oral secretions, administer medications • Comfort measures are more for the Careprovider (Nunn, 2014).

9. Secretion Management • Lack of oral secretion management may cause • Excessive oropharyngeal secretions • Transit of tracheobronchial secretions • Social isolation related to • Drooling • Potentially life threatening (Elman, Dubin, Kelly, McCLuskey, 2005)

10. Swallowing, Coughing, and Secretion Production • Swallowing and coughing involves • Central and Peripheral nervous system • Skeletal muscles and Sensory function • Normal daily salivary volume produced by salivary glands is 1.5L • Daily mucus volume produced by orophayrngeal and tracheobronchial gland is 2L • Ineffective swallowing and coughing can lead to poor secretion management and airway clearance compromise

11. Oropharyngeal Anatomy

12. Anatomy of Swallowing

13. Oral Secretion Accumulation • Oral secretions accumulate • Functional ability to manipulate secretions diminishes with age and/or disease process • Secretions may change molecular structure • Increase in Viscosity (thickness) • Dehydration – volume status • Medications • Decrease in Viscosity • Not as common- overhydration

14. Orophyarngeal Secretion Accumulation • Migration of secretions to pharyngeal area • Aspiration of secretions • Outcomes – Pneumonia

15. Oral Secretion Removal • Oral secretion removal is critical • External removal when patient is unable to assist in adequate secretion management (Elman, Dubin, Kelley, & McCluskey 2005) • Lack of effective swallow • Viscosity (too thin or too thick) compromises functional manipulation by tongue • Muscular atrophy of tongue and facial muscles impacts effective swallow • Neurological impairment – can be seen in children

16. Soft-tipped Manual Aspirator

17. Interprofessional Collaboration • Nursing • Direct involvement with patient and careprovider • Chemistry • Fabrication of prototypes to improve secretion removal and assess secretion viscosity • Microbiology • Effective cleaning of device • Engineering • Suction efficiency and effectiveness

18. Interprofessional Research Team • College of Nursing, Sciences, and Engineering are collaborating on the following projects: • Pathogen identification in manual aspirators • Recommended cleaning and storage • Knowledge acquisition of patient and careprovider related to use of suction device • Retention of learned suctioning techniques • Microfluid viscometer, new design consider hydrophobic properties • Optimal compressibility location to yield maximal secretion removal based on viscosity of fluid • Practice guidelines in using a manual suction device

19. CLEAR ProjectClearance of the Airways Emanuel Waddell, PhD Ellise D. Adams, PhD, CNM

20. Healthcare Provider and Caregiver Involvement in Effective Airway Clearance Practices • Secretion management is critical in preventing pulmonary compromise • Manual aspirator has a soft tipped-end and can be used in children, adults, and older adults • Manual aspirator is easy to use and requires no wall suction

21. Outcomes of Effective Secretion Removal • Promotes effective airway clearance • Relieves deleterious effects of poor oxygenation • Provides comfort support through manual secretion removal with a soft-tipped suction device

22. Summary • Pulmonary compromise occurs regardless of primary disease • Secretion management assists with promoting pulmonary hygiene • Secretions can be removed with a soft-tipped manual aspirator • Comfort goals obtained for both the Patient and Caregiver

23. References • Elman, L, Dubin, R., Kelly, M., McCluskey, L. (2005) Management of oropharyngeal and tracheobronchial secretions in patietns with neurologic disease. Journal of Palliative Medicine, 8 (6), 1150-1159. • Nunn, C. (2014). It’s not just about pain: Symptom management in palliative care. Nurse Prescribing 12 (7), 338-344. • Sargeant, S., and Chamley, C. (2013). Oral health assessment and mouth care for children and young people receiving palliative care. Part one. Nursing Children & Young People, 25 (2), 29-34. • Towney, S., and Dowling, M. (2013). Managemetn of death rattle at end of life. British Journal of Nursing, 22(2), 81-85.

24. Questionsonealp@uah.edu