ell me about a tracheostomy before i n eed t ell meabout a tracheostomy ... – to comply with...
TRANSCRIPT
1/10/2013
1
“TELL ME ABOUT A TRACHEOSTOMY
BEFORE I NEED ONE”
PEDIATRIC VENTILATOR APPLICATION OF PASSYPEDIATRIC VENTILATOR APPLICATION OF PASSY--MUIRMUIR® ® VALVEVALVE
Linda Dean, RRT
Clinical SpecialistPassy-Muir Inc.
[email protected](949) 833-8255
Disclosure: Financial — Employee of Passy-Muir Inc.Nonfinancial — No relevant nonfinancial relationship exists.
Is There Anything I Can Do To Postpone A Tracheostomy?
• Noninvasive Ventilation
• Airway Clearance
PEDIATRIC VENTILATOR APPLICATION OF PASSYPEDIATRIC VENTILATOR APPLICATION OF PASSY--MUIRMUIR® ® VALVEVALVE
Is There Anything I Can Do To Postpone A Tracheostomy?
There are many forms of non-invasive ventilation
Is There Anything I Can Do To Postpone A Tracheostomy?
Today’s options are much smaller
Is There Anything I Can Do To Postpone A Tracheostomy?
There are multiple mask types
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Is There Anything I Can Do To Postpone A Tracheostomy?
Sip and Puff Ventilation
Is There Anything I Can Do To Postpone A Tracheostomy?
Airway Clearance Devices
Is There Anything I Can Do To Postpone A Tracheostomy?
Airway Clearance Devices
Left: PEP Valve
Right: Bronchial Hygiene acapella® Vibratory PEP Therapy System-Portex
Is There Anything I Can Do To Postpone A Tracheostomy?
Airway Clearance Devices
The Vest-Airway Clearance System http://www.thevest.com/
Why Do Some People Need A Tracheostomy?
• Prolonged mechanical ventilation
• NIV no longer meets your needs
• Upper airway obstruction (temporary or permanent)
• Secretion management (neuromuscular disease)
• Improved patient comfort
What Are The Advantages of a Tracheostomy?
• Can save your life
• Quality of life can be great
• Frees up face/hands for eating, etc.
• May decrease need for continuous ventilation
• Provides direct access to your lungs for:
– Secretion removal
– Mechanical ventilation
– Medication delivery
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What Are The Disadvantages of a Tracheostomy?
• Increased risk of infection, bleeding, scar tissue
• Requires a surgical procedure
• Emotional and psycho-social issues – altered body image
• Communicating and swallowing may be altered
• Sense of taste and smell can be lost
• The natural warming, humidification and filtering of air that usually takes place in the upper airway is lost
• Need for home health services/skilled caregivers
• Increased equipment needs• Cost of care can be a burden
***MOST IMPORTANT: you decide
Upper Respiratory Tract
• Nasal Cavity
• Oral Cavity
• Pharynx
• Larynx
Nasal Cavity
Oral Cavity
Pharynx
Larynx
Lower Respiratory Tract
• Trachea
• Bronchi
– right and left mainstem
• Bronchioles
• Alveoli - air sacks
– lined with surfactant,
filled with air to prevent
collapse/ atelectasis
Tracheostomy or Tracheotomy?
Which One Is It?
• Tracheotomy is defined
as the surgical opening
of the trachea.
Tracheostomy or Tracheotomy?Which One Is It?
• Tracheostomy also refers
to a surgical procedure:
the creation of a stoma
at the skin surface, but
most often is referring to
the tube that is inserted
How Is A Tracheotomy Performed?
• Percutaneous – at the
bedside (usually while
the patient is in critical
care)
• Open – in an operating
room
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Open Tracheotomy
• The oldest surgical
procedure
• The patient goes to the
operating room
• Vertical incision is made
between 3-4 or 4-5
cartilage rings
• Tube is inserted and
sutured in place for
safety
What Does The Tube Look Like, And Where Does It Go?
There are many choices of tubes!!!!! Parts of a tracheostomy tube - ISO STANDARDS
Neck flange
Pilot balloon
15 mm connector-hubTube shaft
CuffInflation line
Pilot port with one way valve
Tracheostomy Tubes
• Single Lumen/Cannula • Double Lumen/Cannula
Fenestrated Tracheostomy Tube
Image used by permission from Covidien
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Extra Length Tubes
distal proximal
Increased skin-to-tracheal-wall distanceTracheal Malacia or Stenosis
Image used by permission from Nellcor Puritan Bennett LLC, Boulder, Colorado, doing business as Covidien.
Adjustable Flange Tube
Air Filled Cuffs
• Cuff Deflated• Cuff Inflated
Water Filled Cuffs TTS
• Cuff Up • Cuff Deflated
Day to Day Needs Of A TracheostomyPatient
• Patient Information – “Neck Breather Alert”
– Reason for tracheotomy/date of initial tracheotomy
– Brand, type, size tube – spare tubes at bedside
– Local fire and rescue, police, and your electric company
should be alerted to your needs
• Assessment:
– Sputum characteristics – signs of infection
– Cough strength, mucus production
– Check security of tube holder/ties
Day to Day Needs Of A Tracheostomy Patient –Swallowing
• Presence of a tracheostomytube may:– Make swallowing more
difficult
– May increase the risk of aspiration (as high as 85%)
Assessment, evaluation, and therapy by a Speech Language Pathologist may make oral intake possible
If oral intake is not an option, alternative feeding options should be discussed
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Day to Day Needs Of A Tracheostomy Patient Humidification
HME – artificial nose Trach Collar – used with
aerosol generating device
Day to Day Needs Of A Tracheostomy Patient Humidification
• Drink plenty of fluids, eat
sensibly, and avoid
people who have colds
and flu
• Take care nothing enters
the tracheostomy(leaves, bugs, hairs, shaving cream, cotton swabs,
powders, dust, fumes, etc)
Day to Day Needs Of A Tracheostomy Patient Humidification
• NaCl Nebulizer therapy
• NaCl instillation
• Bibs that heat and filter
Day to Day Needs Of A Tracheostomy Patient Trach Care
• Bronchiol-pulmonary Hygiene
– Suctioning
– Assistive coughing and breathing techniques
– Devices
• Acapella/PEP/Therapy Vest
• Cough Assist
• Inner Cannula Change Cleaning
– Disposable inner cannula is changed daily and PRN
– Non-disposable inner cannula is cleaned 2 X day and PRN
STOMA CARESTOMA CARE
Day to Day Needs Of A Tracheostomy Patient Oral Care
• Give special care to nose and mouth
• Unable to sense mouth odor
• Good mouth care stimulates salivation and taste buds
Day to Day Needs Of A Tracheostomy Patient Stoma Care
• Trach site must be cleaned daily– After the trach stoma has healed, plain soap and water can be
used to clean the skin around the trach
• NEVER USE: powders, lotions
• Antibiotic ointment may be used for redness
• Moleskin can be wrapped around ties to prevent
rubbing
• Change/wash fabric tube ties daily – can use twill
tape, Velcro fasteners
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Day to Day Needs Of A Tracheostomy PatientRoutine Tracheostomy Tube Changes
• First tube change is done by a surgeon (preference)– To assure stoma and tract established
• Routine change of tube - physician will advise:• Change monthly if double lumen tube• Change weekly if single lumen tube
– To reduce complication of granulation tissue
– To decrease risk of infection– To comply with tube manufacturers guidelines
NOTE*** There is no current consensus/guideline for adults (local practices)
Day to Day Needs Of A Tracheostomy PatientPersonal Hygiene
When showering:
• Cover tracheostomy with HME or shower guard
• Angle spray away from stoma
How Will I Communicate?Airflow With A Tracheostomy Tube
Alternative Communication Devices
• Intercom system
• Bells on ankles/shoes to hear a child
• Tricycle horn, squeaker toy, bell• Finger occlusion
• Call system, light or bell (adapted as necessary)
• Picture, word and/or alphabet communication board• Facial expression or eye gaze board (limited mobility)
• Magic slate writing board
• Pencil and paper• Simple gesture
• Signing
• Lip reading• Speaking Valves
Leak Speech For Ventilator Patients
• Cuff is deflated to allow airflow through the mouth
• May be some loss of ventilation, adjust volumes to compensate
– to much volume can be harmful to the lungs!
• Vocalize during inspiration – why is this unnatural?
PEDIATRIC VENTILATOR APPLICATION OF PASSYPEDIATRIC VENTILATOR APPLICATION OF PASSY--MUIRMUIR® ® VALVEVALVE
The Passy-Muir® Tracheostomy & Ventilator
Swallowing and Speaking Valve
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Passy-Muir® Valve Placement
PEDIATRIC VENTILATOR APPLICATION OF PASSYPEDIATRIC VENTILATOR APPLICATION OF PASSY--MUIRMUIR® ® VALVEVALVE
Physiologic Benefits of Passy-Muir ® valve
• Restores Voice/Communication
• Improves Swallowing
• Restores Physiologic PEEP
• Improves Secretion Management
• Improves Oxygenation
• Promotes Weaning and Decannulation
• May Decrease Risk of Aspiration
• Improves Smell & Taste
Other Resources:
• www.passy-muir.com
• www.hopkinsmedicine.org/tracheostomy/living
• www.Tracheostomy.com
• http://www.ventusers.org
• http://www.upmc.com/patients-
visitors/education/documents/tracheostomycare.pdf
• http://www.kchealthcare.com/media/67088/product%
20information%20and%20tool_trach%20care_home%20
care%20guide.pdf
PEDIATRIC VENTILATOR APPLICATION OF PASSYPEDIATRIC VENTILATOR APPLICATION OF PASSY--MUIRMUIR® ® VALVEVALVE
Linda Dean, RRT
Clinical SpecialistPassy-Muir Inc.
[email protected](949) 833-8255
Disclosure: Financial — Employee of Passy-Muir Inc.Nonfinancial — No relevant nonfinancial relationship exists.
Definitions:• Airway: The passage that allows air (oxygen) to get to the lungs
• Ashen: A word that describes a pale, gray color to the skin
• Bactroban: An antibiotic ointment used for redness or irritation around the
tracheostomy
• Breathing: The process of taking air through the airway and into the lungs,
supplying the body with oxygen vital for survival
• Canister: A collection device for secretions and saline, attached to the
suction machine
• Cannula: The part of the trach tube that is inside the airway
• Catheter: A thin tube used to suction secretions out of the tracheostomy.
Catheters come in different sizes (example, 6 French)
• Circulation: The process of blood being pumped by the heart and traveling
through the body via blood vessels, arteries and veins
• Dusky: A blue color to the skin, lips or nail beds that signifies a decrease of
oxygen in the body
Definitions:• Flanges: Flat plastic/silicone front of the tube with holes on each side. These
holes are where the trach ties are inserted and secured.
• Humidification: The process of putting moisture in the air, done by a
humidifier. Humidification keeps secretions in the tracheostomy from becoming dried out and plugging the tracheostomy tube
• Humidifier: A device that puts water in the air via a machine
• Moleskin: A soft material with a sticky backing that can be applied to the
trach ties to prevent or decrease irritation from rubbing trach ties
• Mucus: Thick secretions from the tracheostomy. These need to be suctioned
from the trach in order to keep the airway clear and patent
• Mummy Restraint: A sheet or blanket, wrapped securely around the child to
hold his arms down and prevent excessive movement during a procedure
• Obturator: The stiff piece of plastic shaped like the trach tube with a
rounded end that guides the flexible trach tube into place during a trach
tube insertion. The obturator must be removed immediately after the trach is
in place because it obstructs the airway.
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Definitions:
• Resusitation Bag: A device that allows you to push oxygen into the lungs via the airway. The resusitation bag may be connected to an oxygen tank.
• Rescue Breathing: The process of delivering one breath every 5-10 seconds into the tracheostomy because he/she is unable to breathe independently
• Respiratory Distress : A condition demonstrated by difficulty breathing, retractions, dusky or ashen color, fast breathing
• Retractions: Sucking in of the neck and/or chest between the ribs (a sign of respiratory distress)
• Shiley, Bivona, Portex, Tracoe: Brands of tracheostomy tubes • Sterile Water : Tap water that is boiled and stored in sterile container. It
may also be purchased.• Stoma : The opening in the neck where the trach tube is inserted• Suctioning : The process of removing secretions from the tracheostomy
by applying suction through a catheter
Definitions:• Ties: Twill tape, Velcro® fasteners, or shoelaces that are
threaded through the flanges on each side of the tracheostomy to keep the trach in place
• Trach: Short for tracheostomy• Trach Nose: (HME) A special piece of equipment with a filter
to collect heated/humidified air on exhalation, to heat/humidify inspiration on the next breath into the tracheostomy
• Trach Size: The particular diameter and length of the trachtube (varies with the age and size of the patient)
• Trach Tube : The piece of the tracheostomy providing the artificial airway that goes into the patient’s body
• Tracheotomy : A procedure that creates an opening for an artificial airway to maintain your patient’s ability to breathe
• Twill Tape: Cotton strings used to tie the tracheostomy in place
• Velcro Ties: Trach ties commercially available that use velcroto secure around the neck
Trach Safety:
• Use caution around water – shower guards
• Foreign objects small enough to inhale• Avoid turtle necks shirts and plastic bibs
• Use care with gauze padding – can become an obstruction• Environmental Control: dust, lint, mold , pet hair, and smoke in
the home• Systemic hydration – drink plenty of water• Avoid aerosol sprays
• Transport with care on windy, cold days• Practice infection control: vaccines, hand washing, crowds,
screen visitors• Watch for change in secretions – signs of infection
• Disinfect toys – dishwasher• Disinfect respiratory equipment – white vinegar
Equipment Recommended For Home:
• Spare Trach Tubes (same size and smaller sizes)• Suction Catheters
• Suction Machines (-80 to -100mmHg)• Sterile Water• Resusitation Bag and face mask – proper sized• Bulb Syringes• HME’s (artificial noses)• Compressor for Humidification• Trach Collar and Tubing• Q-Tips• Hydrogen Peroxide
• Gloves• Oxygen• Apnea Monitor• Pulse Oximeter