1 / 90

Purpose of Artificial Airways

Management of Communication and Swallowing for Adults with Tracheostomy Tubes Sally L. Gorski, M.A. CCC. Purpose of Artificial Airways. Provide adequate ventilation and oxygenation Maintain a patent airway Eliminate airway obstruction Reduce potential for aspiration

bryce
Download Presentation

Purpose of Artificial Airways

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Management of Communication and Swallowing for Adults with Tracheostomy TubesSally L. Gorski, M.A. CCC

  2. Purpose of Artificial Airways • Provide adequate ventilation and oxygenation • Maintain a patent airway • Eliminate airway obstruction • Reduce potential for aspiration • Provide access to the airway for pulmonary toilet

  3. Endotracheal Intubation Creating an alteration in the airway: • Translaryngeal -orally -nasally • Transtracheal

  4. Endotracheal Intubation • Creates an artificial airway • Insertion of a tube into the mouth or nose • Passes through the pharynx and vocal cords • Need for airway protection • Need for mechanical ventilation • Temporary

  5. Intubation Issues • Depends on the route of intubation • Size of the tube • Trauma during intubation or self-extubation • Length of intubation

  6. Complications of Oral Intubation • Trauma to teeth and gums • Abrasion of the lips, tongue, pharynx and larynx • Damage to the vocal folds • Overinflated cuff • Hypoxemia • Rare – damage to the recurrent laryngeal nerve

  7. Complications of Nasal Intubation • Trauma to nasal passages • Necrosis may result • Removal of the tube may cause epistaxis • Otitis media and conductive hearing loss due to mechanical blockage of the Eustachian tube

  8. Long Term Complications • Stenosis • Pressure necrosis • Granuloma – may develop into a polyp • Persistent hoarseness • Laryngeal web • Compromised laryngeal closure and airway protection

  9. Cricothyroidotomy • Procedure usually performed in an emergency situation • Surgical creation of an opening into the cricothyroid membrane • May be necessary due to upper airway obstruction

  10. TracheostomyTracheotomy • The surgical creation of an opening into the trachea through the neck. • The surgical placement of a plastic or metal tube into the trachea to create an airway.

  11. Indications for Tracheostomy • Facilitate weaning from the ventilator • Bypass an obstruction of the upper airway • Facilitate removal of secretions • Facilitate long-term airway management • Prevent gross aspiration from the pharynx or GI tract • Decreased risk of accidental removal

  12. Procedure – tube choice • Depends on the patient’s ventilation needs, age, size • Medical status • Physician preference • Institution preference/practice

  13. Procedure - tracheostomy • Placement of the tube above or below the 2nd and 3rd tracheal ring • Incision type and placement • Vertical skin incision is most common • Horizontal skin incision, rarely used today

  14. Risks with Trach placement • Stenosis at the stoma site: 1-8% • Massive hemorrhage: 1% • Aspiration of oral secretions • Pneumothorax • Incorrect placement of the tube can lead to cardiorespiratory arrest

  15. Long Term Complications • Tracheal granuloma • Tracheomalacia • Tracheal stenosis – assoc with longer term tracheotomy • Tracheoesophageal fistula

  16. Percutaneous Trach • Minimally invasive, “simple” technique • Eliminates a trip to the OR • Reduced blood loss • Reduced infection rates (0 to 3.3%) (As high as 36% in open trach procedure.) • Stenosis rates range from 0 – 9% • Performed in the ICU

  17. Complications of Perc Trach • Risk of bleeding • False passage of the tube • Infection and tracheal wall injury • Long Term – • Tracheal granuloma • Stenosis • Tracheomalacia

  18. Clinical Conditions – Trach • Obstructive disease; COPD, asthma • Restrictive disease; ARDS, pneumonia, scleroderma • Chest wall disorders; kyphoscoliosis, chest trauma • Neuromuscular; ALS, Guillain-Barre’, muscular dystrophy, post polio syndrome, multiple sclerosis, SCI

  19. Clinical Conditions - Trach • Upper airway; trauma, tumors, infection • Respiratory center dysfunction; sedation, narcotics, anesthesia, CVA, drug overdose • Cardiac/circulation; cardiopulmonary arrest, pulmonary edema, congestive heart failure

  20. Types of Tubes • Design: Cuffed, uncuffed, TTS cuff, fenestrated • Composition: Silicone plastic, metal, polyvinyl chloride (PVC), etc. • Manufacturers: Shiley, Portex-Bivona, Pilling-Weck

  21. Components of a Trach Tube • Neck flange • Inner & Outer cannula • Obturator • Cuff • Pilot balloon, cuff inflation line • Plug, cap or button • Standard length; extra long

  22. The Referral to Speech Path • When to intervene? -Upon consult from the physician -While pt is intubated, if awake and alert -After trach is placed, if awake and alert -As soon as the patient is communicative; yes/no head nods, mouthing, writing, gestures, etc.

  23. The Initial Consult • Review the chart • Discuss pt’s status with the RN, physician and the respiratory care practitioner • Can pt tolerate cuff deflation? • Level of ventilatory support • Secretion status

  24. Passy-Muir Speaking Valve • If the patient can tolerate cuff deflation, on or off the ventilator, proceed with the initial trial of the PMV.

  25. Open Tracheostomy Tube • Inflated Cuff • Breathing in and out through the tube only • No airflow through the upper airway • Lack of vocal production

  26. Open Tracheostomy Tube • Inflated Cuff • Decreased sense of smell/taste • Risk of tissue necrosis • Cuff impingement on esophagus may cause reflux

  27. Lack of Airway Pressure • Decreases effectiveness • Patient is unable to mobilize secretions effectively • Patient requires more frequent suctioning

  28. Lack of Airway Pressure • Decreased physiologic PEEP • Decreased gas exchange due to reduced surface area of alveoli • Decreased oxygenation • Possible atelectasis

  29. Open Position Valves • All other valves are open position valves • Patient must exhale to close the diaphragm of the valve • Secretions travel up the tube and may occlude the valve • For communication only

  30. Passy-Muir Valve Design • Closed position, “no leak” design • Open only during inspiration with minimal effort • Closes automatically before the end of the inspiratory cycle/beginning of the expiratory cycle

  31. Passy-Muir Valve Design • No air leakage occurs through the PMV during exhalation • A column of air is trapped in the PMV and in the trach tube that inhibits secretions from entering the tube • Restores more normal “closed respiratory system”

  32. Closed Position Design Animations courtesy of Passy-Muir Inc. Irvine, CA.

  33. Physiologic Benefits of the PMV • Improved voice production • Improved sense of smell/taste • Restoration of normal physiology may prevent aspiration • Deflated cuff allows for increased laryngeal elevation

  34. Physiologic Benefits of the PMV • Restoration of subglottic pressure facilitates a better swallow and decreases the risk or aspiration • Swallow is not only mechanical, but a pneumatic system as well • The patient has a more efficient and effective cough

  35. Physiologic Benefits of the PMV • Improved secretion management • Improved cough • Decreased suctioning needs • Decreased risk of tracheal damage

  36. Patient Selection • Where is the patient? • What type of trach tube? • What type of vent? • Who are your allies? • Where do you begin?

  37. Team Members • Varies depending on the setting • Speech-Language Pathologist • Respiratory Care Practitioner • Nurse • Physician

  38. Indications for Use of the PMV - review • Traumatic Brain Injury • Spinal Cord Injury • Chronic Obstructive Pulmonary Disease • Chest or laryngeal trauma • Acute Respiratory Distress Syndrome • Neuromuscular diseases; ALS, MS, Guillain-Barre’

  39. Contraindications for Use of the PMV • Unconscious and/or comatose patients • Inflated cuff on the trach tube • Foam-filled cuffed trach tube • Severe airway obstruction • Severe risk for aspiration • Severely reduced lung elasticity

  40. Patient Assessment • Medically stable • Adequate level of alertness • Ability to handle secretions • Swallowing status/risk for aspiration • Viscosity and abundance of secretions

  41. Patient Assessment • Monitor baseline parameters • Oxygen saturation • Heart rate • Respiratory rate • Blood pressure • Breath sounds

  42. Normal Values • Oxygen Saturation: 90-100% • Respiratory Rate: <28 bpm • Heart Rate: <120 bpm • Acid-Base Balance (pH): 7.35-7.45 • Albumin: 3.5-5.5

  43. Ventilator Adjustments • Alarms -Volume -Pressure • Compensate for loss of airflow through vocal cords if necessary

More Related