Tell Me About A Trach Before I Need One
Transcription
Tell Me About A Trach Before I Need One
1/10/2013 PEDIATRIC VENTILATOR APPLICATION OF PASSYPASSY-MUIR® VALVE “TELL ME ABOUT A TRACHEOSTOMY BEFORE I NEED ONE” Linda Dean, RRT Clinical Specialist Passy-Muir Inc. [email protected] (949) 833-8255 Disclosure: Financial — Employee of Passy-Muir Inc. Nonfinancial — No relevant nonfinancial relationship exists. PEDIATRIC VENTILATOR APPLICATION OF PASSYPASSY-MUIR® VALVE Is There Anything I Can Do To Postpone A Tracheostomy? Is There Anything I Can Do To Postpone A Tracheostomy? There are many forms of non-invasive ventilation • Noninvasive Ventilation • Airway Clearance 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 1 1/10/2013 Is There Anything I Can Do To Postpone A Tracheostomy? Is There Anything I Can Do To Postpone A Tracheostomy? Airway Clearance Devices 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 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 2 1/10/2013 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 Upper Respiratory Tract • • • • Nasal Cavity Oral Cavity Pharynx Larynx Nasal Cavity Oral Cavity Pharynx Larynx ***MOST IMPORTANT: you decide Lower Respiratory Tract Tracheostomy or Tracheotomy? Which One Is It? • Trachea • Bronchi – right and left mainstem • Bronchioles • Alveoli - air sacks • Tracheotomy is defined as the surgical opening of the trachea. – lined with surfactant, filled with air to prevent collapse/ atelectasis 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 3 1/10/2013 Open Tracheotomy What Does The Tube Look Like, And Where Does It Go? • 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 There are many choices of tubes!!!!! Parts of a tracheostomy tube - ISO STANDARDS Neck flange Tube shaft Cuff 15 mm connector-hub Inflation line Pilot balloon Pilot port with one way valve Tracheostomy Tubes • Single Lumen/Cannula Fenestrated Tracheostomy Tube • Double Lumen/Cannula Image used by permission from Covidien 4 1/10/2013 Extra Length Tubes distal Adjustable Flange Tube proximal Tracheal Malacia or Stenosis Increased skin-to-tracheal-wall distance Image used by permission from Nellcor Puritan Bennett LLC, Boulder, Colorado, doing business as Covidien. Air Filled Cuffs • Cuff Inflated • Cuff Deflated Day to Day Needs Of A Tracheostomy Patient • 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 Water Filled Cuffs TTS • Cuff Up • Cuff Deflated Day to Day Needs Of A Tracheostomy Patient – Swallowing • Presence of a tracheostomy tube 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 5 1/10/2013 Day to Day Needs Of A Tracheostomy Patient Humidification Trach Collar – used with aerosol generating device HME – artificial nose 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) STOMA CARE Day to Day Needs Of A Tracheostomy Patient Day to Day Needs Of A Tracheostomy Patient Humidification Trach Care • NaCl Nebulizer therapy • NaCl instillation • Bibs that heat and filter • 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 Day to Day Needs Of A Tracheostomy Patient Oral Care Day to Day Needs Of A Tracheostomy Patient Stoma Care • Trach site must be cleaned daily • Give special care to nose and mouth • Unable to sense mouth odor • Good mouth care stimulates salivation and taste buds – 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 6 1/10/2013 Day to Day Needs Of A Tracheostomy Patient Personal Hygiene Day to Day Needs Of A Tracheostomy Patient Routine Tracheostomy Tube Changes When showering: • First tube change is done by a surgeon (preference) • Cover tracheostomy with HME or shower guard • Angle spray away from stoma – 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) 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 PEDIATRIC VENTILATOR APPLICATION OF PASSYPASSY-MUIR® VALVE Leak Speech For Ventilator Patients The Passy-Muir® Tracheostomy & Ventilator Swallowing and Speaking Valve • 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? 7 1/10/2013 PEDIATRIC VENTILATOR APPLICATION OF PASSYPASSY-MUIR® VALVE Physiologic Benefits of Passy-Muir ® valve Passy-Muir® Valve Placement • 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 PEDIATRIC VENTILATOR APPLICATION OF PASSYPASSY-MUIR® VALVE Other Resources: www.passy-muir.com www.hopkinsmedicine.org/tracheostomy/living www.Tracheostomy.com http://www.ventusers.org http://www.upmc.com/patientsvisitors/education/documents/tracheostomycare.pdf • http://www.kchealthcare.com/media/67088/product% 20information%20and%20tool_trach%20care_home%20 care%20guide.pdf • • • • • Linda Dean, RRT Clinical Specialist Passy-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. 8 1/10/2013 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: • • • • • • • • Equipment Recommended For Home: 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 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 trach tube (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 velcro to secure around the neck • • • • • • • • • • • • • • • 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 9