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)