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

Tracheostomy Care

Tracheotomy: procedure of establishing opening in trachea via incision.

Tracheostomy: opening created by tracheostomy procedure (stoma = opening).

Tracheostomy Care

PURPOSES FOR TRACHEOSTOMYPrimary route for overcoming upper airway obstruction (foreign bodies, vocal cord paralysis, surgical edema, tumors, burns)Patent airway overcoming traumaFacilitation of secretion removal (severe bronchitis in debilitated patient, paralysis of chest muscles & diaphragm)

Tracheostomy CarePURPOSES FOR TRACHEOSTOMY

Prevention of aspiration of gastric contents (prolonged unconsciousness)Prolonged mechanical ventilationAirway for long-term care in patients with NMD

myasthenia gravis Guillain-Barré syndrome amyotrophic lateral sclerosis

Tracheostomy Care

PURPOSES FOR TRACHEOSTOMY

Decrease WOB & increase VT by reducing VD anat

Tracheostomy Care

Complications

IMMEDIATE

♣Hemorrhage

♣Pneumothorax

♣SubQ/mediastinal emphysema

♣Resp/cardio collapse

♣Dislodged tube

LATE

♠ Airway obstruction

♠ Infection

♠ Aspiration

♠ Tracheal damage

♠ Dislodged tube

♠ Hemorrhage

Tracheostomy Care

SUCTIONING

Purpose Airway patency crucial for survival

Facilitate patient comfort

Increase ventilatory efficiency

Decrease risk of airway obstruction

Decrease risk of infection

Tracheostomy Care

SUCTIONINGIndications

Inability to cough Mucus bubbling/gurgling in trach tube Crackles/gurgling heard on auscultation Audible (naked ear) gurgling Difficulty breathing Patient restlessness

Tracheostomy Care

SUCTIONING

Indications Low SaO2

Cyanosis

Increased PIP-Pplateau difference

Patient request

Stridor/changes in breath sounds

Tracheostomy Care

CLEANING INNER CANNULA

Clean usually in AM and PM

Clean inner cannula PRN

Rid inner cannula of bacteria (biofilm)

Remove accumulated secretions & decrease risk of infection

Tracheostomy Care

EQUIPMENT TO CLEAN INNER CANNULA

Manual resuscitatorSpare tracheostomy tubes: same size & one size smallerSuction equipmentTracheal dilatorsTracheostomy mask & O2 if in use

Tracheostomy CareINNER CANNULA CLEANING PROCEDURE

1. Wash hands2. Explain procedure to patient3. Assemble equipment4. Don gloves

5. Prepare separate basins for H2O2 and NS6. Suction through trach tube7. Dispose of gloves, & re-glove8. Unlock, & remove inner cannula

Tracheostomy CareINNER CANNULA CLEANING PROCEDURE

(CONT.)

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

Tracheostomy Care

INNER CANNULA CLEANING PROCEDURE

(CONT.)

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

Tracheostomy CareCHANGING 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

Tracheostomy Care

EQUIPMENT FOR CHAGING

TRACHEOSTOMY TUBEManual resuscitatorSpare tracheostomy tubes: same size & one size smallerSuction equipmentTracheal dilatorsTracheostomy mask & O2 if in use

Tracheostomy Care

CHANGING TRACHEOSTOMY TUBE

1. Check MD orders (size, type)

2. Wash hands

3. Assemble equipment

4. Explain procedure to patient

5. Suction airway FIRST, then oropharynx & above cuff

6. Remove inner cannula from new trach

Tracheostomy CareCHANGING TRACHEOSTOMY TUBE

(CONT.)

7. Insert obturator, & lubricate tip

8. Assess cuff of new trach tube for leaks

9. Attach, & secure tie to one flange

10. Deflate cuff on indwelling trach tube

11. Cut trach ties, and remove “old” trach tube

12. Don gloves

Tracheostomy Care

CHANGING TRACHEOSTOMY TUBE

(CONT.)

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

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

Amyotrophic Lateral SclerosisReferred to as Lou Gehrig’s diseaseNeurodegenerative disease of upper (brain) & lower (spinal cord) motor neuronsMotor neurons are brain & spinal cord cells that control voluntary muscle movementMotor neurons carry impulses from brain to brainstem & spinal cord, then to vol. musclesGradual degeneration and death of motor neuronsMuscles unable to contractCauses muscle atrophy & fasciculations

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.

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.

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."

Amyotrophic Lateral Sclerosis

Eventually, all muscles under voluntary control are affected Motor neurons die, and muscles waste awayPatients 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

Amyotrophic Lateral Sclerosis

Aspiration pneumonia and medical complications of immobility contribute to morbidity. ALS occurs in about 5 of 100,000 peopleOnset usually occurs in patients aged 40-60 yearsProgressive fatal illnessDeath 1 to 3 years after diagnosis

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.

Amyotrophic Lateral Sclerosis

LOWER MOTOR NEURON SYMPTOMSWeakness & muscle wastingFasciculations & muscle twitchingSigns of increased muscle irritabilityFasciculations: benign when no muscle weakness or atrophy occursFasciculations: pathologic with ALS symptoms

Amyotrophic Lateral SclerosisUPPER MOTOR NEURON SYMPTOMS

Spasticity, stiffness in lower limb, jaw, faceWalking difficulties

heaviness fatigue stiffness lack of coordination

Laughter/crying outbursts with minimum provocation (emotional lability)

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

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

Amyotrophic Lateral Sclerosis

Extreme, uncontrollable laughter or crying; called emotional lability

Amyotrophic Lateral SclerosisDIAGNOSIS

Clinical diagnosis (No specific tests)Worsening of symptomsSymptoms of both brain & spinal cordStiffness in legs, face, jawDecreased coordinationFatigueExaggerated reflexesUncontrolled laughter and crying

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

Amyotrophic Lateral SclerosisNo 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.

Amyotrophic Lateral Sclerosis

ALS does not affect the senses

personality

thought

memory

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

Amyotrophic Lateral Sclerosis

TREATMENT

No cure

Rilutek (brand name); riluzole (generic name)