Tubes and Dysphagia Flashcards
Why would a pt need a tach tube (3)?
1) Upper airway obstruction at or above level of vf’s
2) Potential upper airway obstruction (edema post surgery)
3) Provision of respiratory care
How does a trach tube work?
Tube inserted into trachea via surgical incision b/n 3rd & 4th tracheal ring
3 parts of a trach tube:
1) Outer cannulaA (holds trach site open)
2) Inner cannulaB (actual breathing tube in trachea)
3) ObturatorC (smooth tip for initial insertion)
Swallowing with Tracheostomy:
Signs of Reflux or Aspiration
Food in trach
Endotracheal secretions
*Will need suctioning
3 types of trach tubes:
1) Cuffed
2) Cuffless
3) Fenesrated
CUFFED trach tube (3 things):
1) Prevents aspiration
2) Used w/ ventilators
3) Inflated for + pressure
- The cuff is blown up and there is no way they can aspirate bc bolus will sit on top of the cuff.
- longterm
- often used with a ventilator
CUFFLESS trach tube (4 things):
1) Aspiration may occur
2) May interfere w/ laryngeal
evelation during swallow
3) Assists breathing &
secretion removal
4) Long-term use
- Doesn’t allow as must laryngeal elevation
- longterm
FENESTRATED trach tube (3 things):
1) Smaller
2) Used for weaning &
decannulation
3) Short-term (3-5 days)
- smaller than others
- doesn’t interfere with laryngeal elevation like the others
- Can be use after a cuffed or cuffless to ween ppl off a trach tube
Swallowing Treatment with Trach (12)
1) Pt history (pt symptoms of dysphagia)
2) Know type of trach tube and if inflated (if it’s cuffed)
3) Determine length of time of trach
(If 6+ mos trached, scar tissue can restrict laryngeal elevation)
4) Deflate cuffed tube (w/ medical clearance)
- Inflated cuffs irritate tracheal wall during swallow, restricts laryngeal elevation, compresses on esophagus, reduces laryngeal sensitivity
5) Suction oral and trach as deflating
6) Pt occludes trach w/ gloved finger or gauze or one-way valve during & several seconds after each swallow for near-normal trach pressure and clearance of possible airway residues (exhalation)
7) Dry swallows first
8) Write down directions for swallowing
9) No more than 3cc liquid/paste/puree for swallow trials (start w/ easiest consistency for pt), 5-finger test, ready to suction
10) Cough! Cough! Cough! (especially after a trial swallow)
11) Phonate sustained vowel after swallow, head turn
Ventilator Dependent : Swallow usually worsens on vent (why) (3):
1) Respiration controlled by vent
2) Pt can’t lengthen exhalation for swallow (disrupted swallow)
3) Cuffed trach tube
Ventilator Dependent : Swallowing Treatment (3):
1) Timing of swallow at exhalation
2) Blue dye test (see if the blue dye comes out of the trach to see if they are aspirating)
3) Present a variety of consistencies
Intubated (problems that can occur):
1) May be laryngeal trauma from tube placement, TE (treacheoesophageal) fistula from tube rubbing
2) Laryngeal pathologies: granuloma, vf paresis/paralysis, edema, erythema (reddening/irritation)
Intubated Swallowing Treatment:
NONE UNTIL EXTUBATED for ~ 1 week!
Then ROM (range of motion) exercises before trial swallows
Don’t give them a bottle of water, maybe start with ice chips when you do do trial swallows.
Feeding Tubes: NG- Nasogastric: method
tube placed nasally
in through esophagus and end up in stromach
“Red Flags” (2)
Look at:
- Weight loss
- Hydration
Red Flags:
Weight Loss with Trach tubes (2):
1) 10% to 20% loss is common
(moderate)
2) > 20% of usual weight (severe)
Red Flags:
Hydration Issues with Trach tubes (7):
1) Rapid wt loss of 4+ lbs within 48 hrs
2) Pts with thin liquid dysphagia
3) Complaint of thirst
4) Reduced skin turgor
5) Decreased urination
6) Hypernatremia (increased serum sodium)
7) Elevated BUN (blood urea nitrogen)
Enteral Feeding (4)
1) NG nasogastric
2) ND nasaoduodenal
3) NJ nasojejunal
4) GT gastrostomy (PEG percutaneous endoscopic tube)
Enteral Feeding:
NG (4)
1) Selected for short duration (may be months)
2) Intact gag reflex
3) Normal emptying of stomach
4) No uncontrolled reflux
Enteral Feeding:
ND (4)
1) Short-term
2) Reflux
3) Aspiration risk
4) Decreased rate of stomach emptying
Enteral Feeding:
NJ (4)
1) Longer tube (~43” instead of 36”)
2) May need to be placed endoscopically
3) Requires radiographic confirmation of placement
4) Minimizes dislodgement back into stomach
Enteral Feeding:
GT (5)
1) If nasoenteric route unavailable
2) Long-term
3) Permanent swallowing dysfunction
4) Cosmetically more pleasing than nasal tube
5) Can intake homemade purees instead of only commercial formulas
Where is the insertion done for a trach?
above the sternal notch, below the VF so that it doesn’t damage the larynx
3-4 tracheal ring
Working with ppl with trach tubes. Make sure the facility has:
-a suctioning machine close by (know how to use it)
- don’t want any food in trach/lungs
- have suctioning machine handy with cuffed and fenestrated tachs when they are being deflated. Suction before you deflate!
We deal mostly with (2) tubes:
GT and NG tubes
first part of the small intentine
duodenum
nasojejunum
NJ tube
nose, esophagus, stomach, second part of intestine
Oralgastric and nasalgastric can be placed by:
can be placed by SLP, physicain, etc.
We could do ND or NJ if access to xray to see if in duodenal or jejunal but usually done by other professionals…
PEG tubes can be placed by:
placed by physician and are long term
jejunum
the part of the small intestine between the duodenum and ileum
NJ tube placed here
PEG =
the procedure
Weight loss significant and severe after 1 week:
1-2% after 1 week = significant
> 2% after 1 week = severe
Weight loss significant and severe after 1 month:
5% after 1 month = significant
> 5% after 1 month = severe
Weight loss significant and severe after 3 months:
7.5% after 3 months = significant
> 7.5% after 3 months = severe
Weight loss significant and severe after 6 months:
10% after 6 months = significant
> 10% after 6 months = severe
By the time the feeling of thirst hits your ____. It is too late. You are dehydrated.
hippocampus
Mild Malnutrition =
% of ideal body weight 80-90
% of usually body weight 85-95
Moderate Malnutrition =
% of ideal body weight 70-79
% of usually body weight 75-84
Severe Malnutrition =
% of ideal body weight 0-69
% of usually body weight 0-74
Where should you do a skin turgor test?
On the hand
For elderly, on the forearm bc their skin is thinner
We want the skin to pop back in place, not linger and gradually fall back in place. If the later happens, this mean you are dehydrated.
PEG method:
tube placed by percutaneous endoscopic/laparoscopic gastrostomy
RIG method:
radiologically inserted gastrostomy
Surgical method:
open or laparoscopically inserted gastrostomy
