Swallowing Disorders: Tracheostomy Tubes Flashcards
What are types of respiratory problems?
COPD (Can’t get air out)
Restrictive Airway disease (can’t get air in)
What are the types of COPD?
emphysema
asthma
cystic fibrosis
chronic bronchitis
What are the types of restrictive airway disease?
pneumonia
neuromuscular problems
What is the function of artificial airways?
maintain airway patency
facilitate removal of secretions
facilitate mechanical ventilation
What are the types of endotracheal tubes?
- orotracheal intubation
- nasotracheal intubation
- tracheostomy tubes
What are the Pros to orotracheal tubes?
more common
less traumatic
larger diameter tube which facilities secretion removal and decreases airway resistance
placement is temporary (10-15 days) if you need it longer it’s likely they’ll consider something like a tracheostomy
What are the cons to orotracheal intubation?
discomfort and gagging
accidental extubation
oral hygiene is difficult
PO nutrition is impossible
What are the pros to nasotracheal intubation (not as common)?
more comfortable
oral hygiene can be facilitated
smaller diameter tube necessary
better tube stability
better toleration of tube
used in cases of oral trauma/surgery
Super rare
What are the cons to nasotracheal intubation?
less common
more complications
increased airway resistance (tube has to be smaller so you can’t get more air in)
sinusitis (breeding ground for bacteria)
Otitis Media (Middle ear infections)
suctioning is difficult
frequent tube changes are required
What are subclinical problems of intubation for orotracheal and nasotracheal intubation?
vocal fold damage:
- granulomas
- contact ulcers
- laryngeal webs
What are granulomas
basically scar tissue
caused from anytime there’s been trauma to the vocal folds
What are contact ulcers?
kind of the same thing as granulomas–tubes are just sitting on the vocal folds and this creates a contact ulcer
What are laryngeal webs?
scar tissue connecting the anterior portion of the vocal folds
What is anoxia?
Complete/total lack of oxygen
What is hypoxia?
Reduction in oxygen
What is respiratory failure?
Exchange of O2 &/or CO2 between the alveoli & pulmonary capillaries is inadequate.
What is intubation?
Placement of endotracheal tube (trach tube)
What is extubation?
Removal of endotracheal tube
What is tracheostomy/tracheotomy?
Creation of a hole in the trachea; usually to insert an endotracheal tube
What is a tracheotomee?
Actual patient with a trach tube (typically just call them trach patients)
Why are tracheostomy tubes placed?
If there is Upper airway obstruction at or above the level of the true vocal folds (you want to get below where the obstruction is)
Potential upper airway obstruction (ie., edema following oral, pharyngeal, or laryngeal surgery)—think someone with anaphylactic shock, you are bypassing the swelling
Provision of respiratory care—it’s the easiest way to provide respiratory care.
How do they place a tracheostomy tube?
Generally inserted into the trachea through a surgical incision through the 3rd and 4th tracheal ring
Placed well below VF to avoid damage to the larynx
If emergency, may be placed at the 2nd tracheal ring and can cause laryngeal scarring
Left in place until airway obstruction is past & respiratory care is completed
Occasionally, may remain permanently—there are patients who will never get rid of their trach.
What are the pros to tracheostomies?
Decreased resistance (larger tube than oral or nasal tube) Efficient secretion removal/cleaning
Minimizes damage to larynx, vocal cords
Oral nutrition is possible
More comfortable
Verbal communication possible
Bypasses upper airway
What are the cons/complications to tracheostomies?
Hemorrhage
Thyroid injury
Injury to laryngeal nerves
Air leaks (e.g. neumothorax)
Tracheoesophageal fistula-the trachea and the esophagus share a wall…
Cardiac arrest—can happen because of a trach tube
Tracheostomy too high or low
ON EXAM
What are the physiological changes that occur when someone has a trach?
phonation (phonation is different because when they talk the sound will come back through the tube no their mouth)
humidification/filtration/warming (if we take that away, all the dust and pollen go straight into our lungs)
Secretions (when you go to cough, it comes out of the tube)
decreased ciliary activity
increased airflow resistance
decreased back pressure within lungs
bathing/showering (you could drown)
swallowing (the trach anchors the larynx & reduces laryngeal elevation; decreases supraglottic pressure)
psychological changes (just the fact that you have a tube in your throat, it can be very psychologically impacting)
What are the trach tube parts?
outer cannula
inner cannula
obturator
describe the outer cannula
always stays in place to hold the trach site open until it can be allowed to close
describe the inner cannula
remains in the tube except for cleaning
describe the obturator
inserted only to provide a smooth, rounded tip for the initial insertion of the trach tube. This helps to prevent a fistula.
What surrounds the lower portion of the trach tube like a balloon?
a cuff
When is a cuffed trach used?
when there is need for respiratory treatment or potential for patient to aspirate material
If you deflate the cuff, what is it the same as?
the same as an uncuffed trach allowing air to pass upward. If you deflate the cuff–you can hear some voicing.
What happens if you keep the cuff inflated all the time?
it’s going to anchor the larynx even more, so you will have decreased laryngeal elevation/hyoid excursion
NO MATTER WHAT, WHEN WORKING WITH A TRACH PATIENT WHAT MUST YOU DO?!?!?!?
DEFLATE THE CUFF!!!!!
Once you deflate the cuff, what should you do? and what is the rule of thumb?
If you deflate the cuff, and you do a finger occlusion to check voicing—rule of thumb means that if they can’t voice they aren’t ready to swallow. If they’re not voicing at all with a finger occlusion, this probably means the trach diameter is too big, and should be changed.
if the patient is able to voice, what should we do?
If they are able to voice, GREAT! Then you can consider a Passy-Muir Valve. It’s a one-way speaking valve that allows for voicing. You gotta be careful cause the valve can cause resistance. The patient should ONLY BE ALLOWED TO WEAR THE VALVE WHEN SOMEONE ELSE IS IN THE ROOM.
What do you think needs to be done immediately after you deflate the cuff?
need to suction immediately
Why are fully inflated cuffs not usually left in place for long periods of time?
due to the pressure of the cuff contacting the tracheal wall, which can cause irritation. May cause ischemia and lead to stenosis.
To prevent ischemia & stenosis, what might you do?
may fully inflate the cuff then take 1-2 cc of air out of the cuff so some leak and decreased pressure on tracheal wall
T/F
Sometimes, fully inflated cuffs will still allow air leakage and aspiration due to ill-fitting tubes &/or tracheal wall deviations.
True
Describe fenestrated tubes
Fenestrated tubes have a window cut into the tube to allow for greater airflow.
Usually made only to the outer cannula. So, need to remove the inner cannula if you want them to talk.
Used for patients having difficulty producing voice with a normal trach tube or close to being weaned from the trach tube.
Rare for cuffed trachs to be fenestrated (negates what a cuff does).
How do pt.’s eventually get weaned off a trach?
Usually done by decreasing the size of the trach tube (decrease the diameter)
May use a plug or cap to see how functioning with normal respiration.
Wearing a Passy-Muir Valve oftentimes helps with weaning people off the trach.
What are caps/plugs?
inserted onto/into trach tube to force normal respiration and voicing
What is the most common one-way speaking valve?
passy muir valve
What does a Passy Muir valve do?
Allows air to come in through the trach tube but not out…forcing it up through the VFs allowing a voice to be produced.
How are Passy Muir valves when used appropriately?
CUFF MUST BE DEFLATED!!
As part of the weaning process
To create closed pressure system—this is fantastic for swallowing! Remember: If they can’t provide voicing, they’re not ready for swallowing.
As tolerated by patient
Describe the Blue Dye Test
Deflate cuff. If not able to deflate due to medical stability, then question if swallowing is appropriate yet.
Check voicing and speech using finger occlusion.—again, if they can’t voice they’re not ready for swallowing!!!!
Use finger occlusion or valve during swallowing.
Creates closed pressure system which may help the swallow
Ideally, should have RT and RN present
CA has given SLPs the okay to do deep suctioning. But most facilities require training from RN or RT
Only about 40-50% accurate
No false positives…may have false negatives though
Do your bedside swallowing evaluation as usual but add blue food coloring to all consistencies. Some people do grape juice instead of blue dye b/c some say the blue dye doesn’t go away if they aspirate it.
YOU MUST DEFLATE THE CUFF!!!!!!!!!
Provide a closed pressure system if possible. (either finger occlude, put on a Passy Muir Valve)
You’ll want to suction immediately, 10 minutes later, 20-30 minutes later. Nursing or RT will continue to monitor throughout the day.
Trach patients are often silent aspirators
IF MEDICALLY/PHYSICALLY ABLE, DO AN MBS OR FEES!!!!!!!!!!!!!!
Question for final: walk me through a swallow eval on a trach patient
…
What is ventilator dependence also known as?
mechanical ventilation
What is the goal for mechanical ventilation?
To maintain alveolar ventilation appropriate to patient’s metabolic requirements
To correct hypoxemia (decreased 02 in arterial blood causing hypoxia)
What are problems with speech and swallowing if someone is on mechanical ventilation?
- Difficulties coordinating speech or swallowing with breathing cycle for ventilator.
- Difficulty with short exhalation cycle of ventilator.
- Cuff is usually inflated. They typically have fenestrated tubes instead.
What is the assessment process for someone with mechanical ventilation?
- Best to focus on speech before swallowing.
2. Present food at beginning of exhalation.
