Respiratory Disease during Rehabilitation

1. Respiratory Disease during Rehabilitation Dr. Michelle Caldecott Respiratory & Sleep Disorders Physician Epworth HealthCare Austin Health Victorian Respiratory Support Service

2. Respiratory Disease • Tracheostomy management • Tracheostomy misadventures- vignettes • Internal fixation of multiple rib fractures • Fitness to fly post chest trauma

3. Tracheostomy

4. Tracheostomy

5. Reasons for tracheostomy • Recently weaned from long period of mechanical ventilation • Unable to clear copious or thick secretions - bronchitis/pneumonia - background respiratory disease - ineffective cough • Aspiration risk - bulbar dysfunction - reduced consciousness • Upper airway obstruction

6. Reasons for tracheostomy • Recently weaned from long period of mechanical ventilation • Unable to clear copious or thick secretions - bronchitis/pneumonia - background respiratory disease - ineffective cough • Aspiration risk - bulbar dysfunction - reduced consciousness • Upper airway obstruction

7. Reasons for tracheostomy • Recently weaned from long period of mechanical ventilation • Unable to clear copious or thick secretions - bronchitis/pneumonia - background respiratory disease - ineffective cough • Aspiration risk - bulbar dysfunction - reduced consciousness • Upper airway obstruction

8. Reasons for tracheostomy • Recently weaned from long period of mechanical ventilation • Unable to clear copious or thick secretions - bronchitis/pneumonia - background respiratory disease - ineffective cough • Aspiration risk - bulbar dysfunction - reduced consciousness • Upper airway obstruction

9. Types of tracheostomy tubes • Cuffed versus cuffless • Adjustable flange • Suction aid tracheostomy

10. Types of tracheostomy tubes • Suctionaid tracheostomy

11. Types of tracheostomy tubes • Suctionaid tracheostomy - allows suction above cuff prior to cuff deflation

12. Types of tracheostomy tubes • Suctionaid tracheostomy • allows vocalisation if cuff cannot be deflated • Achieved by flow of 02/air via suction line

13. Steps towards decannulation in rehabilitating patient • Initial assessment • Acute lung disease – CXR, sputum culture • Chronic lung disease – usually COPD • Gas exchange – Sp02, ABG • Sputum quantity, viscosity (humidification impt) • Cough strength • Neurologic assessment • Speech pathology assessment • Physiotherapy assessment • Tracheostomy size & type

14. Steps towards decannulation in rehabilitating patientCuff deflation

15. Cuff deflation & use of 1 way valve • Returns air movement to the upper airway • Allows optimal cough, using glottic closure • Allows assessment of vocal cord function • (importantly phonation) • Confirms upper airway patency • Blue dye tests

16. Tracheostomy

17. Tracheostomy

18. Steps towards decannulation in rehabilitating patient • Use of 1 way valve - Passy Muir Speaking Valve

19. Tracheostomy

20. Steps towards decannulation in rehabilitating patientCuff deflation X

21. Decannulation • Requirements Ensure the patient can tolerate cuff deflation Ensure the patient can tolerate use of the Passy-Muir valve (or finger occlusion) N.G feeds should have been stopped 6 hrs prior Patient must be medically stable Have same size trachy, 1 size below and emergency trachy kit (including bougie/introducer) Prefer decannulation prior to midday Notify speech pathology and physiotherapy of successful decannulation

22. Steps towards decannulation in rehabilitating patient Benefits of Timely and Safe Decannulation • Vocalisation • Commencement oral intake • Visually appealing • Psychological benefits • No need for humidification equipment • Easier to attend gym

23. Tracheostomy Misadventure Case 1: 40 y.o male C2 complete quad post MVA Ventilator dependent 6 weeks post MVA 3 weeks post tracheostomy Type II DM Fatty liver

24. Presenting illness 3/7 blood during suctioning via tracheostomy Training new staff ? trauma >200 ml in last 24 hrs Central chest pain Nil infective symptoms

25. Initial management Laryngoscopy/bronchoscopy No supraglottic lesions Tracheostomy tip at 3 cm from carina, abutting anterior tracheal wall Small volume blood at carina No mucosal lesions visible in trachea CT angio-chest

28. Angiography ? False aneurysm in innominate artery versus tracheo-innominate artery fistula 9 x 38 mm covered stent deployed covering most of the length of the innominate artery

30. Progress Admitted to ICU Repeat bronchoscopy and tracheostomy change - Size 9 Bivona adjustable flange tube inserted - Tip sitting below level of origin of (previously stented) innominate artery

32. Tracheo innominate artery fistulaAllan JS, Wright CD. Chest SurgClin N Am 2003; 13: 331–41Grant CA et al. BJA 2006; 96(1): 127-31 • True incidence difficult to assess 0.1% - 1% of surgical tracheostomies (Allan) 0.3% of percutaneous tracheostomies (Grant) • 69% site of erosion at cannula tip • Risk Factors Diagnosis associated with abnormal neck posturing in 48% Low placed tubes (below 4th tracheal ring) Pressure necrosis from high-pressure cuffs Radiotherapy

33. Tracheo innominate artery fistula • Peak incidence in first 1-2/52 - 75% within 3/52 • Minor tracheal self-limited warning bleed (“sentinel bleed”) present in ~50% • Pulsations of tracheal cannula in 5% • 50% of those with tracheostomy bleeding >10mls found to have TOIF • No correlation with tracheostomy tube type

34. Tracheo innominate artery fistula • Death likely from asphyxiation (cf. hypovolaemia) • Mortality ~100% in absence of appropriate management plan • Acute Mx of massive bleed • overinflate cuff • oxygenation • consider endotracheal intubation • digital pressure on innominate via jugular notch • prompt surgery with either resection of innominate vessel or covered stent.

35. Tracheo innominate artery fistula • KEY POINTS - Any bleeding between 3 days and 6 weeks post tracheostomy insertion should be considered to be a TOIF until proven otherwise - Prompt management or referral are mandatory. Lengthy attempts at diagnosis via imaging etc. are likely to be a waste of time, and could cause a fatal delay.

36. Tracheostomy Misadventure Case 2: 26 yo male, 4 weeks post MVA Diffuse axonal injury Multiple rib fractures Ventilator associated pneumonia Transferred to ward 2 days ago , from ICU Turning ‘blue’ with SpO2 70% What do you do?

37. The ‘Blue’ patient with a tracheostomy • ASSESS AIRWAY • • Look for breathing movements of the chest. • • Listen for breathing sounds from the tracheostomy tube. • • Feel for air coming from the tracheostomy tube or nose or mouth • If airway OBSTRUCTED • • Deflate cuff (Check the PMV is not on with cuff up) • Suction the tracheostomy tube. • • Change the patient’s inner cannula tube if one is present. • • Extend the patient’s neck slightly with a small towel rolled • under the shoulders. • If the tracheostomy tube is still blocked or dislodged: remove and re-insert a new tube • If unable to recannulate, try again using a smaller size tube or bougie • If still not breathing • If patent tracheostomy, resuscitate via this • If no patent tracheostomy, resuscitate via nose and mouth, • manually covering the stoma to minimise leak

38. Management of Multiple rib fractures

39. Management of Multiple rib fractures Flail segment

40. Management of Multiple rib fractures Flail segment

41. What is the rationale for operative intervention? • Shorten mechanical ventilation times • Earlier discharge from ICU • Less ventilation associated complications • Avoid long term disability, deformity, restrictive lung defects • Avoid chronic pain syndromes • Earlier return to physical activity and work Courtesy: S. Marasco

42. Absorbable prostheses Inion Resorbables Courtesy: S. Marasco

45. Prospective Randomised Trial The Alfred, A/Prof S. Marasco Commenced Jan 2007 – completed enrolment Dec 2011 • 46 patients enrolled • Patients referred within 48 hours of arrival in hospital • Proceed with surgery within 72 hours of enrolment Inclusion Criteria: • patients with multiple (>3) segmentally fractured ribs between the level of ribs 3 to 10 resulting in a paradoxical movement of the chest wall. • Fractured ribs confirmed on CXR and CT chest. Exclusion Criteria: • Age over 80, sepsis, severe head or spinal injury, coagulopathy, sepsis

46. Endpoints Primary endpoints: Mechanical ventilatory time (hours) Secondary endpoints • ICU stay (hours) (time to ready-for ICU discharge) • respiratory complications • Pneumonia • pneumothorax (barotrauma) • tracheostomy insertion • intercostal catheter usage and duration • hospital stay (days) • readmission to ICU • spirometry at discharge and on follow up at 3 months • CT chest 3D reconstruction at 3 months • Short Form 36-item Health Status Questionnaire (SF-36) at 6 months • return to work and type of work activity • cosmetic result and any residual chest wall deformity

47. Results - demographics

48. Injury description

49. Outcomes

50. Conclusions • Operative fixation of flail chest reduces ICU stay and requirement for non invasive ventilation • Cost savings significant  Surgical group – 124 hours less in ICU (=5.17 days)  Cost of ICU bed per day = $4109  Cost saving per patient of $13,643 • No difference in lung function (spirometry) at 3 months • No difference in QOL at 6 months