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Purpose of Artificial Airways

Purpose of Artificial Airways

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Purpose of Artificial Airways

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  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