Tracheostomy-Procedures Timing and Tubes9-27 …

1 tracheostomy : procedures , Timing and Tubes tracheostomy : procedures , Timing AND TUBES. Gail M. Sudderth RRT. clinical Specialist Passy-Muir Inc. (949) 833-8255. Objectives Indications for tracheostomy Explain how the Timing of the tracheotomy and Prolonged mechanical ventilation tube selection criteria plays a key role in successful Inability to perform trans-laryngeal intubation use of speaking valves. (trauma, max/fax deformity). Upper airway obstruction (temporary or permanent). List complications of improper cuff management. Secretion management (neuromuscular disease). List how the tracheostomy tube and inflated cuff can impact swallowing and suggest ways to reduce clinical complications. Reputed Benefits WHEN: Timing OF TRACHEOTOMY. Improved patient comfort/less need for sedation 21 Days ? Lower WOB/faster weaning from MV 7-10 Days ?

2 Improved safety 2-3 Days ? Improved oral hygiene and oral intake Less long term laryngeal damage Lower VAP rates Lower mortality Reduced ICU and overall LOS Does Timing affect outcomes ? Earlier ability to speak/ Improved participation What does the literature say ? Durbin, C. Resp Care 2010;55(8):1056 1068. Gail M. Sudderth, RRT clinical Specialist 1. tracheostomy : procedures , Timing and Tubes Endotracheal Tube Factors Cited To Contribute To Swallowing Impairment and Aspiration Laryngeal Intubation Granuloma Mucosal injury to the oral pharynx and larynx Injury to the vocal folds which hi h may beb transient t i t or permanent Tracheal edema, ulceration and stenosis Reproduced with permission from Houston Otolaryngology HOW: TRACHEOTOMY procedures Percutaneous Tracheotomy Open or Surgical Tracheotomy Tried and True Method Percutaneous Dilatation or Balloon Dilatation Tracheotomy L.

3 Less costly tl and d more convenient i t Cricothyoidotomy As seen on ER Shows Does the method of tracheotomy affect outcomes ? Permission for use granted by Cook Medical Incorporated, Bloomington, Indiana Cricothyroidotomy Parts of a tracheostomy tube - ISO STANDARDS. Neck flange Tube shaft 15 mm connector Inflation line Cuff Pilot balloon Pilot port with one way valve Permission for use granted by Smiths Medical Gail M. Sudderth, RRT clinical Specialist 2. tracheostomy : procedures , Timing and Tubes tracheostomy Tubes Routine tracheostomy Tube Changes Single Lumen/Cannula Double Lumen/Cannula After initial tracheotomy Surgeon preference To assure stoma and tract established To reduce complication p of g granulation tissue For down-sizing Difficult airways and special considerations Types of Tubes Jackson tracheostomy Tubes MATERIALS SINGLE LUMEN Improved Inner Cannula Original Style PVC, Silicone, Metal DOUBLE LUMEN.

4 Metal Reinforced FENESTRATED. SHAPE MRI COMPATIBLE. Curved, Angular, Non Non- pre formed S b l tti SSuction Subglottic ti LENGTH Trach Talk Standard CUFFS. Extra length Air, water, or foam Proximal Double cuffed Distal Un-cuffed Adjustable Flange Custom Made Jackson Metal tracheostomy Tubes PMV 2020 (clear) With Jackson Improved Original Style Improved Permanent 15mm Adapter Gail M. Sudderth, RRT clinical Specialist 3. tracheostomy : procedures , Timing and Tubes Calculating Tube Size Fenestrated tracheostomy Tube ATS Consensus: The tracheostomy tube trachea should take up no more than 2/3 the ID of the trachea trachea. (for pediatrics, no adult standard). AP Diameter of trachea Male: 18 +/- 5mm tube Female: 12 +/- 3 mm Image used by permission from Nellcor Puritan Bennett LLC, Boulder, Colorado, doing business as Covidien Not all size 6 trachs are equal !

5 ! Extra Length Tubes Size tracheostomy distal proximal ID OD L. Portex Bivona Shiley SCT 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.. Adjustable Flange Tube Cuff Choices AIR FILLED minimal leak TTS : WATER FILLED . minimal i i l occlusion l i ((can be air filled). FOME-Cuf self sealing Gail M. Sudderth, RRT clinical Specialist 4. tracheostomy : procedures , Timing and Tubes Air Filled Cuffs Water Filled Cuffs TTS. Cuff Inflated Cuff Deflated Cuff Up Cuff Deflated Cuff: Choices and Management Cuff Management Minimal Leak Cuff up or down ? Purpose of cuff Cuffs and aspiration Cuff pressures 18-22* cm H20. Minimal Leak Minimal occlusion Cuff Management Direct Measure clinical Complications - Cuff Esophageal impingement Reflux Necrosis and Trauma Laryngeal tethering Reduced airway protection Gail M.)

6 Sudderth, RRT clinical Specialist 5. tracheostomy : procedures , Timing and Tubes Cuff Over-Inflation clinical Complications Reduced Airflow Taste, Smell, Sensation Voice Reduced Positive Airway Pressure Physiologic Peep Cough Valsalva Swallow Airflow Late Complications Granuloma-Stenosis Tracheal Malacia Fistulae Benefits of Passy-Muir Valve Airway Assessment Improved Voice/Speech How does tube size and Improved Smell & Taste type affect airway Improved Swallow assessment ? May Reduce Aspiration Tube must be small Improved Secretion enough for adequate Management airflow. i fl Restored PEEP Cuff takes up space in Improved Oxygenation the airway Improved Quality of Life Tube length may cause Expedites Weaning and resistance to airflow Decannulation Foam cuff is absolute Cost Savings contraindication Shorter Lengths of Stay Routine and Emergency procedures Decannulation Plan Suctioning Begins at Intubation-What is the Plan ?

7 Broncho-pulmonary Hygiene Evaluation for Decannulation Oxygen and Humidity Therapy Reason for tracheotomy has resolved Medically stable Trach Care/Stoma Care Patent upper airway Inner Cannula Change Cleaning Tolerates speaking valve Oral Care Can manage oral and tracheal secretions Unplanned Decannulation Tolerates capping/plugging Blocked Tube or Inner Cannula Risk of aspiration assessed Gail M. Sudderth, RRT clinical Specialist 6. tracheostomy : procedures , Timing and Tubes Airway Management Team Resources tracheostomy expertise must follow the patient Hess DR. tracheostomy tubes and related wherever they go in the hospital. Heffner, John E. appliances. Respir Care. Apr 2005;50(4):497-510. Team Approach Timing and tube selection Yaremchuk K. Regular tracheostomy tube When to downsize changes to prevent formation of granulation Plan of care tissue.

8 Laryngoscope. Jan 2003;113(1):1-10. Communication Epstein, S. Late Complications of tracheostomy . Swallowing Decannulation Respir Care. Apr2005;50(4); 542-549. Impacts continuity of care Johnson, et al. tracheostomy Tube Changes. Impacts safety, length of stay clinical procedures Jan 2010 ( ). and costs Resources Resources Cameron, T et al. Outcomes of patients with spinal LeBlanc, et al. (2009) Outcome in Tracheostomized cord injury before and after introduction of an Patients with Severe TBI following Implementation interdisciplinary tracheostomy team. Crit Care of a Specialized Multidisciplinary tracheostomy Resus Mar 2009;11(1);14-19. Team. Published in: Journal of Head and Trauma Kamel KS et al. al In vivo and In vitro morphology of R h b Rehab. the human trachea. Clin Anat, 22:571-79, 2009. Tobin A and Santamaria J (2008) An Intensivist-Led Durbin, CG.

9 tracheostomy : Why, When and How? Respir Care Aug 2010; 55(8);1056-6 tracheostomy Review Team is Associated with Shorter Decannulation Time and Length of Stay: A. Heffner, JH. Toward Leaner tracheostomy Care: First Observe, Then Improve. Respir Care, prospective cohort study. Critical Care on-line at: 2009:50(12) Resources Additional Educational Opportunities Self-study webinars available on demand Getting Started Ventilator Application Cook Medical Inc., Bloomington, Indiana Swallowing www Premusa com Pediatric Premier Medical, Inc. Special Populations Shiley tracheostomy Pocket Guide Live group webinars x?fileticket=AF0%2b2G%2bTVaU%3d&tabid=18 4 Passy-Muir Inc. is an approved provider of continuing education through ASHA , AARC, CMSA. and California Board of Nursing Credit Gail M. Sudderth, RRT clinical Specialist 7. tracheostomy : procedures , Timing and Tubes Receiving CEU's for this Course You will have 72 hours from the time this courses ends to complete the evaluation, which is required Gail M.

10 Sudderth RRT. to receive credit. clinical Specialist Look in your email for a reminder link, or type this into your Passy-Muir Inc. I t Internet t browser's b ' address dd bar: b (949) 833-8255. Gail M. Sudderth, RRT clinical Specialist 8.