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SPCH3206 > Tracheostomy Management > Flashcards

Tracheostomy Management Flashcards

1
Q

The SLP’s role?

A

Communication
- facilitating alternate or laryngeal communication

  • Swallowing
  • preventing aspiration
  • Decannulation
  • contributing to the medical decision regarding safety/suitability for tracheostomy to be removed
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2
Q

Why does someone need an artificial airway - indications and relevant populations?

A
  • Indications?
  • To enable/improve respiratory function
    eg. In presence of impaired respiratory function or complete respiratory paralysis
  • To enable respiration to continue in the presence of any upper airway obstruction
    eg., when an obstruction, such as created by upper airway oedema, or laryngeal tumour causes reduction in airway opening and restricts capacity to breathe
  • Relevant populations?
  • MANY! Surgical pts (eg., H&N, upper spinal), Trauma pts (eg., spinal cord injury),
  • Critical care patients, Neurological conditions (eg., stroke, TBI), Degenerative disorders (eg.,MND), Respiratory disorders (eg., COPD)
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3
Q

What types of artificial airways are there?

A

Types of artificial airways

  • Short term tubes (oral and nasophgeal airways): few hours only - No SP involvement required
  • Endotracheal tubes (ETT): days up to ~2 weeks - SP involvement may be required for speech + swallow post extubation
  • Tracheostomy tubes: for long term intubation - SP involvement required for speech & swallow during and after intubation
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4
Q

The typical process of intubation that most of critical care admissions will have undergone…..

A
  • patient admitted to hospital post trauma, needing ventilatory support
  • patient is intubated via ETT either at the scene or on admission to critical care and attached to the ventilator
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5
Q

Endotracheal tubes (ETT)

A

Temporary (1-3weeks) – allow connection to mechanical ventilation

Inserted through mouth (or sometimes through the
nose) & is passed through the larynx and into the trachea

Semi rigid plastic tubes with a cuff
- Has a cuff at distal end – anchors tube in trachea and prevent air escape around tube – all inhalation and exhalation is through tube

15mm adaptor (standard fitting) at proximal end – enables tube to be connected to mechanical ventilation
Often inserted in emergency situations
risk of laryngeal/VC damage/trauma

82 pts intubated for >4 days – 94% had laryngeal oedema & mucosal ulcerations of the vocal folds

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6
Q

When an ETT Tube is in situ….

A
  • Patient cannot use speech to communicate
    Presence of tubing in oral cavity
    Tubing passes through (between) the vocal folds preventing phonation
  • Cannot eat or drink any foods/fluids orally
    (unless has nasal ETT – this is rare, Eating still difficult though due to size of tubing in pharynx)
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7
Q

Limitations to long term (>2-3 week) ETT use

A
  • Oral trauma
    Dryness, rubbing (less of an issue)
  • Tracheal / Laryngeal / VC fold trauma
    Oedema
    Pressure necrosis from cuff
    Granuloma formation (mainly inter-arytenoid)
    Haematoma/trauma to vocal fold (often left VC due to R-handed ETT insertion technique)
    Unilateral VC paresis from recurrent laryngeal nerve palsy (from over-inflation of ETT cuff)
  • Tracheal trauma
  • Tracheal stenosis (irritated tissue attempting to heal itself –
    resulting in scarring & tightening) from cuff over-inflation
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8
Q

If respiratory function improves, ventilation is no longer required ?

A

…….Then ETT will be removed

  • At this point, after ETT removal, pt may
    Present with dysphagia
    Majority of pts – duration from extubation to return to oral intake occurs <3 days (Barker et al., 2009)
  • Present with dysphonia
    often mild, transient and reflect temporary impact of intubation and lack of VC use…. …more serious? Get ENT Ax
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9
Q

Tracheotomy & Tracheostomy

A
  • A surgical procedure conducted to provide an artificial airway = tracheotomy
    Incision – 1cm above sternal notch
    stoma created between 3rd & 4th (some say 2-3!) tracheal rings (below level of larynx)
    Vertical skin incision (horizontal no longer used)
    Allows easier insertion & removal, & for more normal laryngeal excursion
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10
Q

The tracheostomy

A
  • The opening created during the tracheotomy procedure is called the tracheostomy & a tracheostomy tube is placed into the incision to create an open, artificial airway
  • The opening is then also referred to as the STOMA
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11
Q

Types of tracheotomy procedure

A
  • Surgical / Permanent Tracheotomy
  • Performed under surgery / anesthetic
  • Anterior portion of tracheal ring removed to form tracheal opening & stoma
  • Percutaneous Tracheotomy
  • Conduced at the bedside in ICU by the physician using bronchoscopic guidance & ETT still insitu
  • Same complications as surgical, though replacing a displaced tube may be a little more difficult
  • Local anesthetic - whole process can be done in a few minutes!
  • Perc is most common in our settings (eg., RBWH ICU data 76% perc, 24% surgical
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12
Q

Advantages of converting from ETT to tracheostomy

A
  • Reduces risk of glottic trauma (but a trach tube can still cause tracheal trauma!)
  • Reduces Pt discomfort
  • Reduces need for sedation
  • Assist weaning from ventilator
  • Oral intake & communication are possible
  • Pt can be cared for outside the ICU
  • Better secretion clearance

Tube is positioned below the level of the vocal folds

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13
Q

Why do patients that have tracheostomy considered a special group?

What does this mean for management?

A
  • “Patients undergoing chronic ventilation through a tracheostomy require special considerations for care. Outcome and patient comfort are improved with the application of a well conceived management plan applied by a skilled and well organised care team. Special emphasis is required on measures to promote patient communication, nutrition and weaning from tracheostomy”

What does this mean for mgt?

For Overall management?
* Do not proceed without medical support/referral.
* Communicate/consult regularly with the MDT

For Communication management?
* The inability to communicate is a major source of anxiety for patients and their families
* Once pt has resumed consciousness – priority is establishing some means of communication to use with medical team and family
* Important decisions and messages to loved ones

For Dysphagia management?
* More cautious management – “..maintain the delicate balance between nutrition and hydration and reduce the risk of pulmonary compromise, such as aspiration pneumonia, while trying to promote the healing process” (p. 437, Baumgartner et
al., AACN Advanced Critical Care, 19, 4, 433-443)
.
* More team discussion of decisions – not like other populations
* risk of negative impact on chest health!
* Enhanced monitoring
* O2 monitoring, resp rate,
* Importance of cautions clinical decisions based on as much OBJECTIVE available clinical evidence as possible
* instrumental swallowing assessment (FEES, MBS)

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14
Q

Why do we work in teams?

A
  • Team approach is critical !!
  • Minimum core team (in addition to SP, pt & family)
  • Medical staff / respiratory physician
    Chest health, management plan, respiratory demands
  • Nursing
    Daily care, suctioning, monitoring
  • Physiotherapist
    Chest health, airway management
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15
Q

Type of tube ? – Depends on purpose

A
  • Different factors determine the need for tubes that offer different features….Huge range….

Eg., Respiratory needs / maintaining adequate ventilation
- must have inflatable cuff to facilitate optimal gas exchange

Eg., Excessive secretions
- New types of tubes (eg., Suctionaid trach) that allow nurses to suction directly from above the cuff via tubes that are part of the trachy tube itself

Eg., Communication needs
- Must have cuffless or deflatable cuff if planning to use a speaking valve
- Fenestrated or Specialty tubes to allow phonation (“talking” trach tube)

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16
Q

Adult vs Peadiatric trach tubes

A
  • Same design – just smaller!!
  • Tubes are uncuffed due to size of tracheal lumen
  • Some cute trach holding straps available for kids
    + child friendly educational materials available
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17
Q

Explain - Obturator

A

Thin curved plastic piece which is inserted into the inner cannula – its rounded end extends beyond distal end of trach to create a rounded end to facilitate insertion of tube

Used only during the insertion process and discarded thereafter

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18
Q

Explain - Outer Cannula

A
  • Rigid outside wall of trach tube

remains insitu at all times

In some specialsed tubes the outer cannula has openings or FENESTRATIONS which can be used to assist communication

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19
Q

Explain - inner cannula

A
  • Inner cannula (optional)

sits inside the outer cannula

reduces inner diameter – impact on respiratory effort/work of breathing

come in different sizes, models:- disposable/non, fenestrated/non

can be removed for cleaning – also can be quickly removed in cases of obstruction (mucous plug)

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20
Q

Explain - Flange

A

Neck plate that allows trach tube to be secured in place by ties which tie around the patient neck

Flange also typically contains details of the size and type of tube

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21
Q

Explain - Hub/port

A
  • Front of trach tube that is used to connect things to the trach tube – such as a speaking valve, humidification device or the ventilator tubing
  • A standard 15mm size – allows attachments of ventilation tubing and all other devices
22
Q

Explain - Cuff AND Why have a cuff?

A

Cuff - optional

  • Balloon surrounding outer cannula of trach (usually air filled, some foam cuff models)
  • Can be manually inflated or deflated depending on patient status and stage of recovery

Why have a cuff?

1/ Assists ventilation
- When inflated, forms a mechanical barrier between upper and lower respiratory tract
- Deflated: allows airflow up to upper respiratory tract
- Inflated: no airflow to upper respiratory tract…..necessary for ventilation BUT this prevents phonation!!!

Inflated…..Allows ALL airflow from ventilator to reach lungs

  1. Assists to keep trach tube insitu:
    - minimises risk of accidental dislodgement
    - When inflated, difficult to pull tube completely out of the airway
  2. To minimise aspiration – BUT does NOT prevent aspiration:
    - Food/fluids have already passed beyond vocal folds and are pooling above the cuff
    - Only MINIMISES….Cuff doesn’t stop all from passing further into airway.
    - Only traps some aspirated materials
    - The cuff creates a seal with the tracheal wall – but NOT an watertight seal – so there is some amount of aspirated material that passes down below the cuff
23
Q

How do I check cuff pressure?

A
  • When a cuff has been re-inflated – its critical to test cuff pressure using a Manometer
  • Manometer is connected to cuff pilot line to measure pressure in cuff – it’s an indicator of the pressure exerted on tracheal wall.
  • Pressures below 15mmHg provide no barrier for aspirated secretions and increase risk of nosocomial pneumonia
  • Pressures 20-25mmHg (<25cmH2O) OPTIMAL
  • Pressures 25-35mmHg exceed capillary perfusion and can cause compression, mucosal ischaemia and tracheal stenosis.
24
Q

Cuffed or uncuffed tubes, when do I use?

A
  • Although the majority of tubes used with patients are cuffed tracheostomy tubes…

Uncuffed tubes

  • Cannot be used with mechanical ventilation.
  • Most frequently used in ENT and H&N units
  • used for pts with upper airway compromise (eg., tumor) – i.e. the issue for intubation is to create a patent airway – not to ventilate due to respiratory dysfunction

Cuffed tubes

  • Air filled cuffs (most common types) are inflated and deflated using a syringe
  • Cuff is attached externally to a small pilot balloon that
    indicates inflation status
  • Balloon inflated suggests air in is the cuff
    ……….(but no guarantee!)
25
Q

What communication equipment can I use?

A
  • Speaking valves!
  • One way valve - directs airflow through the upper airways
  • you inhale in through it, then as you exhale, it closes, forcing exhaled air to go up through upper airway
  • Pt must be able to tolerate all exhaled air passing via upper airway
  • Used to assist communication for patient who can tolerate a deflated cuff
  • Attaches to hub
26
Q

Humidification and O2 equipment

A
  • “Active” heated humidifiers
  • Devices heat & humidified air which is delivered
  • via tubing attached to trach via a T-piece
  • or via tracheal mask positioned over the hub of the trach
  • “Passive” humidification devices
  • Heat and Moisture Exchangers (HMEs) (known by a number of terms eg., the Thermovent T, swedish nose, filter…)
  • Attach to hub of trach tube
27
Q

Equipment for monitoring O2 & respiratory rate

A
  • During all assessments and monitoring periods patients should be attached to a pulse oximeter for O2 saturation levels and heart rate
  • Respiratory rate can also be monitored
28
Q

Impact of a tracheotomy tube - Anatomy and physiology

A
  • The negative impact of a trach tube can be discussed in 2 categories.
  • Changes/Medical Issues that result from:-
  1. Re-direction / change of airflow
    The tube is placed below vocal folds – therefore airflow now bypasses larynx
  2. The physical presence of the tube in the airway
29
Q

What are the Consequences of re-direction of airflow?

A
  • Impact on smell & taste
  • Inhale through tube – therefore no nasal airflow
  • Olfaction (smell) major component of taste perception - so negative impact on taste & appetite
  • Reduced humidification of inhaled air
  • No upper airway humidification
  • Inspiring air directly via tube which has a humidity deficit can lead to mucosal changes, thick secretions, deep airway changes – increasing risk of infection & blocking of tube
  • So…….Gases inspired through tracheostomy need to be heated & humidified
  • humidified air via mask or head-and-moisture exchangers
  • Aphonia
  • When cuff inflated, pt exhales through tube - inhibits voicing as no air passing up to VC’s – so aphonic when cuffed tube insitu
  • Long term absence of voicing..…can lead to dysphonia once cuff can be deflated / tube removed due to long term inactivity – need to restrengthen and re-train voice
  • Inability to cough
  • Absence of expiratory air passing up to larynx – inability to cough
  • post swallow – unable to cough/clear or assist in clearing residual material from airway
  • Once something is aspirated (when cuff is inflated) – it can only be removed by suction OR by coughing when cuff gets deflated
  • Reduced laryngeal sensation
  • Absence of airflow through larynx….. Gets desensitised
  • Lack of laryngeal sensation less aware of pooling, the need to cough/clear.
  • Long term diversion of air can lead to poorly coordinated laryngeal closure response during swallowing – allowing material to enter airway
  • Causes blunting of cough reflex. Over time this can result in a decrease in glottic closure response – eventually cough ineffective.
  • Increased secretions
  • Increase in secretions due to disruption in normal airflow
  • No oral airflow – evaporation of oral secretions is reduced therefore they build up
  • Natural humidification/warming of air bypassed – irritation to airway - increased secretions produced
  • Loss of effective sensation/awareness + inability for cough / throat clearance
  • Oral & tracheal suctioning becomes necessary
30
Q

What are the consequences of having a physical tube in?

A
  • Tracheal necrosis
  • High cuff pressure pressing on tracheal wall – impacts negatively on tissue capillary perfusion pressure = tissue breakdown / death.
  • Tracheal granuloma (short term, more common)
  • from abrasion at the stoma site by trach. Can impact airway
  • On tracheal wall from rubbing

Scarring & stenosis (longer term)
- Narrowing (stenosis) created by scarring of by healing tissue after trauma eg. frequent tracheal infections, multiple tube changes, continuous movement of TTube

  • Tracheoesophageal fistulae (long term)
  • Caused by combination of overinflated cuff + large feeding tube – pressure causes necrosis and opening forms in party wall.

Tracheomalacia (longer term)
- Softening of the tracheal cartilage

***Causes dysphagia?????
- It was strongly believed for years that the presence of the tube itself “anchors” the larynx, minimising laryngeal elevation.
- Theory was weight of tube, anchoring created by stoma surgery + “anchoring” created by inflated cuff
- Recent research (2008-2010) evidence supports that this is not 100% the case – i.e. NOT a direct causal effect * Some trach pts have normal laryngeal elevation
- It was strongly believed for years that it was too hard to swallow with an inflated cuff – theory was that the inflated cuff exerts pressure on the tracheo-esophageal wall – impacting on swallowing
* Not the case – unless perhaps if the cuff is over inflated – which is quickly rectified

31
Q

So what causes dysphagia in a pt with a tracheostomy?

A

The clinical condition of the patient!!!!!
* Existing neurological damage
* General ill health - Impact on awareness, alertness, medical
stability, neurological functioning, muscle strength / fatigue
* Impact of Medications
* Antihistamines, decongestants, sedatives, & antidepressants commonly given to trach & vent pts – all can cause xerostomia (excessively dry mouth)

Working with the dysphagic trach patient is just like any other dysphagic patient – determine what’s:
- CAUSING the aspiration (medical condition, neurological involvement)
- NATURE of the aspiration (physiology of the swallow that’s disrupted and causing aspiration pre, during or post swallow)
- commence management accordingly!
- So…old thinking of delaying intervention - because “just need to get trach out and all will be better with the swallow” – is WRONG

32
Q

Explain why we would suction

A

Secretions need regular removal
* When pt is unable to effectively clear secretions – must be manually removed
* Secretions build up in
The mouth / pharynx
Above the cuff
Below the cuff in trachea

Indications suction is needed?
“noisy” (gurgly) breathing, respiratory distress, oxygen desaturation, pt request

Can SLPs do suctioning?
- SLP Scope of practice
- Oral suctioning only
- Nasopharyngeal, pharyngeal and tracheal suctioning BEYOND SCOPE OF PRACTICE (SPA Tracheostomy position paper, 2005) - UNLESS YOUR CLINICIAL SETTING ALLOWS TRAINING & CREDENTIALLING FOR YOU

Suctioning equipment:
- Rigid suction catheter (Yankuer sucker) for oral suctioning
- Flexible tubing for tracheal suctioning
- Suction generated by wall unit – though portable suction units also available
- Gloves, saline solution, (mask)

33
Q

Explain the steps of suctioning

A

Step 1: Oral, Oral/pharyngeal:

  • Typical process involves suctioning from mouth & pharynx first.
  • Gag reflex may trigger when suctioning the back of the oral / pharyngeal region
  • Uses a rigid oral suction adaptor (Yankuer sucker)

Step 2: Tracheal Suctioning – getting secretions below the cuff:

  • After oral suction, then tracheal suctions from below the cuff are removed. Accessed via tracheostomy tube
  • Cough reflex will often trigger when suctioning tracheal substances
  • Important:- the negative suction pressure necessary to remove the secretions also “sucks” air from the lung. Impact on the patients respiratory state
    - Time from insertion to removal
    of suction catheter should be <5-
    10sec
    - Suctioning desaturates the
    patient (it sucks out air as well as
    secretions from lower airway!)
    and is unpleasant for patients
    - No more than 3 suctions per Ax
    session recommended

Step 3: Tracheal Suctioning – getting secretions pooled above the cuff:

  • After you have suctioned out secretions below the cuff, THEN need to suction out secretions pooled above the cuff
  • This is achieved by suctioning simultaneously while the cuff is being deflated
  • As cuff deflates, secretions drop past the cuff and get suctioned out
34
Q

Cuff deflation and re-inflation procedure

A

Cuff deflation and re-inflation are important steps SLPs perform in most swallowing and communication sessions

Important to FULLY understand the changes in physiology you are creating by deflating and inflating the cuff

Particularly in relation to:
- Secretions above the cuff
- Changes created by re-establishing airflow through the larynx and upper airways

35
Q

Process for Cuff deflation

A

Cuff deflation procedure:-
* Pt must be suitable for cuff deflation (medical direction)
* Staff needed: SLP and nursing staff
* Provide any supplemental / pre-oxygentation if required
* Suction oral and tracheal (nursing)
* Insert syringe into cuff valve & deflate cuff by drawing out the air, while nursing staff SIMULTANEOUSLY suction as needed during deflation
* Once full deflated, allow patient to rest and adjust to airflow now going to upper airway

36
Q

Re-inflation of the cuff

A

Once you have finished the period of cuff deflation, the cuff
must be re-inflated
* Appropriate inflation is critically important!!! Why????
* Over inflation - can cause trauma to tracheal tissues from compression
* Insufficient inflation – issues of both Respiratory compromise, AND enhanced aspiration risk if the patient cannot manage their own secretions

Involves attaching a syringe to the pilot balloon and inserting air
- Pilot balloon will inflate too as an indicator that the cuff is inflated
- But how do you know how much to put in?????
- There are a number of ways you can return air to the cuff and make sure its sufficiently inflated

LEAST ACCURATE METHOD (but is used clinically when you become familiar with a patient and their cuff) you just replacing same volume of air as removed when you deflated cuff
- i.e. Withdraw 8ml on deflation, put 8ml back when reinflating
- Problem? – are you sure the right amount was in there before?

Main method used by SLPs……..Minimal leak technique (main SLP technique)

  • Pt voices as the cuff is gradually inflated via air filled syringe until the point at which voicing ceases.
  • Can also be done by returning some air to cuff, checking if they can voice, then alternating with little bits and voice checking, until voicing ceases
  • Then - check with the manometer to ensure it is not over inflated!!!
37
Q

why DO SLPs take regular note the volume of air that is removed and returned to the tube?

A

If you remove 8ml of air from the cuff regularly, then one day
remove only 4ml……what’s happened – has their been a cuff leak?

Is the cuff faulty and tube needs changing? Has there been an
incorrect inflation?

If you remove 8ml of air from the cuff regularly, then one day
remove 12ml……what’s happened – over-inflation risk, Need to
discuss with team

38
Q

Why DO SLPs take regular note the volume of air that is removed and returned to the tube

A

If you remove 8ml of air from the cuff regularly, then one day
remove only 4ml……what’s happened – has their been a cuff leak?

Is the cuff faulty and tube needs changing? Has there been an
incorrect inflation?

If you remove 8ml of air from the cuff regularly, then one day
remove 12ml……what’s happened – over-inflation risk, Need to
discuss with team

39
Q

What are some non-verbal communication strategies a tracheostomy patient could use?

A
  • call bell (for emergency)
  • mouthing
  • gesture
  • writing
  • iPads/texting
  • basic AAC
  • electronic AAC
40
Q

What are the methods of verbal communication with tracheostomy tuebs?

A
  1. airflow through the tube
  2. airflow around the tube

!check with finger occlusion trials!

41
Q

Explain verbal communication with a tracheostomy tube by allowing airflow around the tube

A
  • most common, used when patients can tolerate cuff deflation

Can be achieved via finger occlusion:
- if cuffed tube: deflate first
- finger occlusion forces exhaled air up through vocal folds to allow phonation
- BEGIN: digital occlusion during expiration only: breathe in through trach and exhale through upper airway
- THEN: digital occlusion for both inhalation and exhalation - breathe in and out through upper airway

42
Q

What are some things to do when using the finger occlusion trials?

A
  • begin slowly, short trial durations
  • monitor patient tolerance of the voicing trial - this will dictate when to stop trial
  • watch for changes in respiratory rate, O2, pulse rate, discomfort coughing, sounds of breathing
  • once a patient can successfully produce phonation using digital occlusion, a speaking valve trial can be considered
43
Q

How is the speaking valve used to allow trach patients to verbally communicate?

A

(if cuffed tube - must first deflate)

  • attach speaking valve to hub of trach tube
  • this allows patient to inhale through speaking valve and then exhale through upper airways
  • one way - air can go in but can’t come out

Trials:
- patient should be sitting
- ensure cuff is deflated and suction patient
- check voice using finger occlusion
- select appropriate valve model/type and attach
- monitor O2 stats, vital signs, patient’s colour, distress, work of breathing, etc.
- begin with short trials only and build up
- complete voicing trials
- remove valve and monitor patient

44
Q

Explain why you never occlude the tube when the cuff is still inflate

A
  • prevents inhalation and exhalation!
45
Q

Explain why you never attach a speaking valve when the cuff is still inflated

A
  • prevents exhalation!

Inhaling = okay - breathe through speaking valve
Exhaling = can’t! because air cannot get past cuff to release to upper airway and can’t release through tube

46
Q

Explain the steps of the CSE (slightly modified) for the assessment of swallowing in trach patients

A
  1. Patient’s condition
  2. Oromotor
  3. Deflate cuff to evaluate
    - extent of pooling above cuff
    - laryngeal function
  4. assess dry swallow - observe laryngeal elevation, frequency of spontaneous swallow
  5. trial coloured foods and fluids
  6. re-inflate cuff
47
Q

Summarise the process of the third- final steps of the CSE

A
  • suction
  • deflate cuff, suctioning after
  • occlude tube/attach speaking valve - check phonation and dry cough
  • dry swallow trial
  • conduct bolus trials
  • observe spontaneous cough
  • occlude tube post swallow - check phonation
  • suction = patient likely aspirated
  • suction and reinflate cuff
  • monitor. . . consult. . . then make decisions
48
Q

What are some positive signs for swallow safety?

A
  • no evidence of material pooling above cuff
  • strong reflexive cough
  • clear phonation post swallow
  • adequate laryngeal elevation
  • prompt swallow trigger
  • no evidence of aspirated materials in tracheal suctioning
  • improving medical condition
49
Q

What are some indicators for aspiration/aspiration risk?

A
  • evidence of pooling above cough
  • weak/absent cough
  • limited pharyngeal elevation
  • delayed swallow
  • evidence of aspirated materials in tracheal suctioning
  • reduced O2 stats during trials - declining chest health
50
Q

What is decannulation?

A
  • removal of trach tube
  • tube is removed when the indicators for the tracheostomy are no longer present

SPCH3206 (12 decks)

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