Tracheostomy Ven/la/on

Transcription

1 Tracheostomy Ven/la/on Dr Hélène Prigent Service de physiologie et d explora4ons fonc4onnelles GHU Paris- Ouest site Raymond Poincaré - Garches UVAD GHU Paris- Ouest site Raymond Poincaré - Garches UMR1179 «End- i- Cap» - Inserm - UVSQ

2 Tracheostomy ven/la/on : Indica/ons Decreased indica<ons of invasive long term ven<la<on Make Chest 2008 Windisch Pneumologie 2010 HAS 2006

3 Tracheostomy ven/la/on: who? Divo et al., Respiratory Care 2010

4 Tracheostomy in Europe (Eurovent survey)! Nasal Mask! Facial Mask o Tracheostomy Lloyd- Owen et al, Eur Respir J 2005

5 Which ven/la/on modes? HAS 2006 Make Chest 1998

6 Which ven/la/on modes? What is prescribed? Volume- controlled Swiss prescrip/on over the 90 s Pressure- controlled Janssens et al, Chest 2003

7 Which ven/la/on modes? Control of day<me hypoven<la<on kpa Pressure- controlled Volume- controlled Annane et al, Chochrane 2014

8 Which ven/la/on mode? Residual AHI Pressure- controlled Volume- controlled Annane et al, Chochrane 2014

9 Which ven/la/on mode? Nocturnal SaO 2 minutes below 90% Pressure- controlled Volume- controlled Annane et al, Chochrane 2014

10 - Comfort - Leak Compensa/on - WOB Reduc/on - Volume garanteed - Air stacking Pressure- controlled Volume-controlled

11 Which ven/la/on mode? Impact of pa/ent s dependancy Percent of pa<ents Barometric mode Volumetric mode Hybrid mode Nocturnal NIMV N + D NIMV IMV Lofaso et al, Respiratory Care 2014

12 Ven/la/on modes Are the pa<ents ven<lated with a cuffed tube? = No leaks The sewngs should be adjusted: To the characteris/cs to the underlying disease To efficiency on hematosis HAS 2006 Make Chest 1998

13 Ven/la/on mode The real ques/on Can the tracheostomy tube be deflated?

14 Why deflate the cuff To reduce tracheal local complica/ons: o Haemorrhage Rare : 0,7 % Scalise Chest 2005 Iodice Respiratory Medicine 2005 ± o Reduces tracheal mechanical complica/ons Stenosis 3-12 % Fistula < 1% Epstein, Respiratory Care 2005 Soudon Chronic respir disease 2008

15 Why deflate the cuff To improve swallowing: Amathieu et al BJA 2012

16 Why deflate the cuff To improve swallowing: Swallowing improves in tracheostomized NMD pa/ents when ven<lated with a cuffless tube 12 Duration of wallowing (sec) Terzi et al, AJRCCM 2007 SB MV Terzi et al Neuromusc Dis 2010 Number of swallows Before Tracheostomy MV After Tracheostomy

17 Why deflate the cuff To improve olfac/on and taste By restoring airflow through the upper airways Bach et Alba, Chest 1990 Lichtman et al. J Speech Hear Res 1995 Tippef et al Dysphagia 1991 Adler et al ERJ 2009 Dystrophie Musculaire Canada hfp://muscle.ca/tag/tracheostomy/

18 Why deflate the cuff To allow the pa/ent to speak By restoring airflow through the upper airways I speak! Vocal cords Expiratory Valve Ventilator INSPIRATION

19 Why deflate the cuff To allow the pa/ent to speak By restoring airflow through the upper airways I can t speak! Ventilator EXPIRATION Prigent et al AJRCCM 2003

20 When we deflate the cuff: leak ven<la<on Defla/ng the cuff creates uninten/onal leaks - Loss of 15% of VT during speech - Risk of hypoven/la/on Shea et al Biol Psychol 1998 Bach et al, Chest Air leaks during ven/la/on is a cause of persistent hypercapnia Gonzalez J et al ICM 2003

21 When we deflate the cuff: leak ven<la<on Requires ven/la/on adjustments Increasing the /dal volume Bach et al, Chest 1990 Tippef et al Dysphagia 1991 Shea et al Biological Psychology 1998 => But is it enough?

22 Efficiency of leak ven/la/on Uninten<onnal leaks SaO 2 P tc CO 2 90% 45 mmhg Nardi, J. et al Sleep Med 2013

23 Which solu/ons? Decanulate? ERJ, 2006

24 Which solu/ons? Infla/ng the cuff during night- /me? Nardi, J. et al Sleep Med 2013 Impact and risks of long term cuffed tracheostomy tubes

25 Which solu/ons? Infla/ng the cuff during night- /me? Nardi, J. et al Sleep Med 2013 Using «mechanical» preven/on of UAw leaks: - increasing tracheostomy tube size? - using chin straps? Gonzalez J et al ICM 2003 Using new ven/la/on modes liable to compensate the leaks? => Interest of volume- targeted pressure controlled modes?

26 Leak compensa/on Bench evalua/on=> only 3 ven/lators avoided hypoven/la/on during the leak Fauroux et al. ICM 2010

27 Leak compensa/on Single- limb configura<on Double- limb or expiratory valve Bench study => Limits of volume targeted pressure support ven/la/on Compensa/on befer insured in vented mode (but no volume guaranteed) Khirani et al. Respir Med 2013

28 Leak compensa/on Bench study => Compensa/on befer insured in vented mode Carlucci et al. ICM 2013 Further evalua<on and improvement are needed for this specific situa<on

29 Is PEEP needed? Usually not required for ven/la/on purpose But PEEP can improve speech during leak ven/la/on Potential speaking time Potential speaking time Speech threshold PRESSURE FLOW inspiration inspiration expiration

30 Is PEEP needed? Usually PEEP levels of 4-6 cmh 2 O Hoit et al Chest 2003 Garguilo et al, 2014 Chest

31 Humidifica/on Complete «bypass» of the upper airways => Risk of dryness +++ Mandatory Windisch Pneumologie 2010 Water - Heated humifica<on Heat & moisture exchangers

32 Humidifica/on Comparison of 49 passive humidifers Lellouche et al CCM 2009 «dry» air flow with leak compensa<on Filter inefficient with phona<on valves

33 Tracheostomy ven/la/on and security Alarms What do you expect from my alarms? HAS 2006 Deconnec<on? => Low pressure, Vt, MV Occlusion? => High pressure

34 Tracheostomy ven/la/on and security Dependency Ven/lator free- /me < 4 to 8h Life support ven/lator Addi/onal ven/lator Extra baferies InformaGon of Electricity providers Make Chest 1998 HAS 2006 Windisch Pneumologie 2010

35 Tracheostomy ven/la/on and autonomy Adapta/on of the ven/la/on to the daily life of the pa/ent => Ven/la/on «on the move»

36 The Check list Make Chest 2008

37 Conclusion Concerns severe and fragile pa/ents with a high level of dependency Not so simple if you want to op/mize QoL Progress in leak compensa/on may help to improve ven/la/on