Tracheostomy Care

1. CRC 432 Subacute Care Problem-Based LearningModule I Tracheostomy Care/Amyotrophic Lateral Sclerosis

2. TracheostomyCare • Tracheotomy: procedure of establishing opening in trachea via incision. • Tracheostomy: opening created by tracheostomy procedure (stoma = opening).

3. Tracheostomy Care PURPOSES FOR TRACHEOSTOMY • Primary route for overcoming upper airway obstruction (foreign bodies, vocal cord paralysis, surgical edema, tumors, burns) • Patent airway overcoming trauma • Facilitation of secretion removal (severe bronchitis in debilitated patient, paralysis of chest muscles & diaphragm)

4. Tracheostomy Care PURPOSES FOR TRACHEOSTOMY • Prevention of aspiration of gastric contents (prolonged unconsciousness) • Prolonged mechanical ventilation • Airway for long-term care in patients with NMD • Myasthenia gravis • Guillain-Barré syndrome • Amyotrophic lateral sclerosis

5. Tracheostomy Care PURPOSES FOR TRACHEOSTOMY • Decrease WOB & increase VT by reducing VD anat

6. IMMEDIATE Hemorrhage Pneumothorax SubQ/mediastinal emphysema Resp/cardio collapse Dislodged tube LATE ♠ Airwayobstruction ♠ Infection ♠ Aspiration ♠ Tracheal damage ♠ Dislodged tube ♠ Hemorrhage Tracheostomy Care

7. Tracheostomy Care SUCTIONING • Purpose • Airway patency crucial for survival • Facilitate patient comfort • Increase ventilatory efficiency • Decrease risk of airway obstruction • Decrease risk of infection

8. Tracheostomy Care SUCTIONING • Indications • Inability to cough • Mucus bubbling/gurgling in trach tube • Crackles/gurgling heard on auscultation • Audible (naked ear) gurgling • Difficulty breathing • Patient restlessness

9. Tracheostomy Care SUCTIONING • Indications • Low SaO2 • Cyanosis • Increased PIP-Pplateau difference • Patient request • Stridor/changes in breath sounds

10. Tracheostomy Care CLEANING INNER CANNULA • Clean usually in AM and PM • Clean inner cannula PRN • Rid inner cannula of bacteria • Remove accumulated secretions & decrease risk of infection

11. Tracheostomy Care EQUIPMENT TO CLEAN INNER CANNULA • Manual resuscitator • Spare tracheostomy tubes: same size & one size smaller • Suction equipment • Tracheal dilators • Tracheostomy mask & O2 if in use

12. Tracheostomy Care INNER CANNULA CLEANING PROCEDURE • Wash hands • Explain procedure to patient • Assemble equipment • Don gloves • Prepare separate basins for H2O2 and NS • Suction through trach tube • Dispose of gloves, & re-glove • Unlock, & remove inner cannula

13. Tracheostomy Care INNER CANNULA CLEANING PROCEDURE 9. Immerse inner cannula in H2O2 basin 10. Dispose of gloves, & re-glove 11. Insert temporary inner cannula, & lock in place 12. Using H2O2, clean inner cannula with bottle brush/pipe cleaner 13. Transfer, & immerse inner cannula to NS basin

14. Tracheostomy Care INNER CANNULA CLEANING PROCEDURE 14. Shake clean inner cannula to remove excess NS 15. Remove temporary inner cannula 16. Reinsert clean inner cannula 17. Lock clean inner cannula to outer cannula

15. Tracheostomy Care CHANGING TRACHEOSTOMY TUBE • PURPOSES • accidental displacement of existing tube • mucous plug in existing tube causing distress • ruptured cuff • planned tracheostomy tube change • decannulation process • change type or size of tube

16. Tracheostomy Care EQUIPMENT FOR CHAGING TRACHEOSTOMY TUBE • Manual resuscitator • Spare tracheostomy tubes: same size & one size smaller • Suction equipment • Tracheal dilators • Tracheostomy mask & O2 if in use

17. Tracheostomy Care CHANGING TRACHEOSTOMY TUBE • Check MD orders (size, type) • Wash hands • Assemble equipment • Explain procedure to patient • Suction airway & pharynx above cuff • Remove inner cannula from new trach

18. Tracheostomy Care CHANGING TRACHEOSTOMY TUBE 7. Insert obturator, & lubricate tip 8. Assess cuff of new trach for leaks 9. Attach, & secure tie to one flange 10. Deflate cuff on indwelling trach tube 11. Cut trach ties, and remove trach tube 12. Don gloves

19. Tracheostomy Care CHANGING TRACHEOSTOMY TUBE 13. Insert trach tube into trachea 14. Remove obturator 15. While holding tied flange, secure other flange 16. Inflate cuff 17. Check intracuff pressure 18. Insert inner cannula, & lock in place

20. Tracheostomy Care UNABLE TO RECANNULATE STOMA • Assess patient for adequate ventilation • Provide O2 at stoma site • Manually ventilate stoma with 100% O2 • Prepare to recannulate, or to perform endotracheal intubation

21. Amyotrophic Lateral Sclerosis • Referred to as Lou Gehrig’s disease • Neurodegenerative disease of upper (brain) & lower (spinal cord) motor neurons • Motor neurons are brain & spinal cord cells that control voluntary muscle movement • Motor neurons carry impulses from brain to brainstem & spinal cord, then to vol. muscles • Gradual degeneration and death of motor neurons. • Muscles unable to contract • Causes muscular atrophy & fasciculations

25. Amyotrophic Lateral Sclerosis At the age of 32, Lou Gehrig had already made his name as one of the greatest baseball players of all time. He was a two-time MVP, had become the league leader in BA, HRs, & RBIs, and had not missed a game in over 12 yrs with the NY Yankees. Yet, by ’38, his teammates and fans noticed that something was wrong. He was dragging his feet during practice, and his batting average was slipping drastically. Day by day, he grew weaker.

26. Amyotrophic Lateral Sclerosis By 1939, Gehrig was too frail to play any longer. At last, a doctor delivered the bad news: he had ALS. Gehrig died just two years later – one of the finest athletes the world had ever seen, unable to move a single muscle, or to draw another breath. Lou Gehrig died in 1941.

30. Amyotrophic Lateral Sclerosis • Stephen Hawking said, "ALS has not prevented me from having a very attractive family, and being successful in my work . . . I have been lucky that my condition has progressed more slowly than is often the case. But it shows that one need not lose hope."

32. Amyotrophic Lateral Sclerosis • Eventually, all muscles under voluntary control are affected • Motor neurons die, and muscles waste away • Patients lose their strength and the ability to move their arms, legs, and body. • Patients lose ability to breathe when diaphragm and chest wall muscles fail • Ventilatory support then needed

33. Amyotrophic Lateral Sclerosis • Aspiration pneumonia and medical complications of immobility contribute to morbidity. • ALS occurs in about 5 of 100,000 people • Onset usually occurs in patients aged 40-60 years • Progressive fatal illness • Death 1 to 3 years after diagnosis

34. Amyotrophic Lateral Sclerosis • Bulbar symptoms: first notices slurring of words or choking during meals; aspiration events or acute respiratory symptoms of air hunger occur. • Somatic symptoms: wrist drop interfering with work performance; may find reduced finger dexterity, cramping, stiffness, weakness or wasting of intrinsic hand muscles; develop foot drop resulting in a fall or sprain; sensory neurons unaffected.

35. Amyotrophic Lateral Sclerosis LOWER MOTOR NEURON SYMPTOMS • Weakness & muscle wasting • Fasciculations & muscle twitching • Signs of increased muscle irritability • Fasciculations: benign when no muscle weakness or atrophy occur • Fasciculations: pathologic with ALS symptoms

36. Amyotrophic Lateral Sclerosis UPPER MOTOR NEURON SYMPTOMS • Spasticity, stiffness in lower limb, jaw, face • Walking difficulties • heaviness • fatigue • stiffness • lack of coordination • Laughter/crying outbursts with minimum provocation (emotional lability)

37. Amyotrophic Lateral Sclerosis

38. Amyotrophic Lateral Sclerosis • Bulbar involvement causes speech and swallowing difficulties • May be only manifestation of ALS • Some ALS patients have bulbar involvement, but normal strength in arms, legs, & respiratory muscles • Difficulty controlling saliva

39. Amyotrophic Lateral Sclerosis • Not abnormal amount of saliva produced • Mouth & tongue cannot cope with handling normal amount of saliva • Drooling (sialorrhea) occurs • Medications used to decrease saliva production: • glycopyrrolate • tricyclic antidepressants • amitriptyline • nortriptyline • atropine • scopolamine patch

40. Amyotrophic Lateral Sclerosis • Extreme, uncontrollable laughter or crying; called emotional lability

41. Amyotrophic Lateral Sclerosis DIAGNOSIS • Clinical diagnosis (No specific tests) • Worsening of symptoms • Symptoms of both brain & spinal cord • Stiffness in legs, face, jaw • Decreased coordination • Fatigue • Exaggerated reflexes • Uncontrolled laughter and crying

42. Amyotrophic Lateral Sclerosis DIAGNOSIS • Electromyography (EMG): detects electrical activity in muscles • Magnetic resonance imaging (MRI): creates images of brain & spinal cord • Nerve conduction velocity (NCV): how fast nerves transmit impulses

43. Amyotrophic Lateral Sclerosis • No loss of anal sphincter tone occurs • Cardiac and smooth muscle are not involved. • Course is progressive, and initial symptoms primarily are those of weakness. • Ocular musculature is not involved. • Quick definitive diagnosis is rare. • Neurologists need many months to exclude other diagnoses in patient presenting with upper and lower motor neuron signs.

44. Amyotrophic Lateral Sclerosis • ALS does not affect • the senses • personality • thought • memory

45. Amyotrophic Lateral Sclerosis • 10% familial/genetic • Familial/genetic = 2+ cases in same bloodline • No family history = sporadic ALS • Gene defect superoxide dismutase 1 (SOD1) accounts for 10% ALS

46. Amyotrophic Lateral Sclerosis TREATMENT • No cure • Rilutek (brand name); riluzole (generic name)