Assessment of Patients with Tracheostomy: Dispelling the Myths

Transcription

1 Assessment of Patients with Tracheostomy: Dispelling the Myths Stacey A. Skoretz, M.Sc., CCC-SLP University of Toronto James L. Coyle, M.A., CCC-SLP, BRS-S University of Pittsburgh

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3 Clinician Questions Why do patient require tracheostomies? Why do we have to worry about patients with tracheostomies? What patient characteristics need to be considered beyond the tracheostomy? What am I supposed to do with these patients? Why are they dysphagic?

4 Some Answers: High incidence of disordered swallowing following intubation, tracheostomies, & prolonged mechanical ventilation (Smith et al., 1999, DeVita, 1990, Elpern, 1994, Tolep, 1996) Lack of dysphagia diagnosis and management can increase length of hospital stay and hospital costs (Harrington et. al., 1998) Mean length of cannulation time reduced when interdisciplinary approach utilised (Frank et al., 2007). Of 469 patients assessed for dysphagia in acute care, 276 aspirated silently (59%) (Smith et al., 1999) 82% of tracheostomized patients who aspirated did so silently (Leder, 2002)

5 Tracheostomy and Health Disease, Condition Prolonged mechanical ventilation Neurologic Traumatic Neoplastic Structural Iatrogenic Progressive medical decompensation Pulmonary Tracheostomy Disease, Condition Pulmonary Nutritional Community - Acquired Social Psychological Others Upper airway obstruction (acute or chronic) Laryngeal/upper airway surgery Pulmonary toilet Obstructive sleep apnea

6 Endotracheal Intubation Risk Factors for Compromised Airway Protection Translaryngeal placement Cuff position Duration of intubation Self-extubation

7 Tracheostomy Placement (Durbin, 2005) Percutaneous tracheostomy Utilisation of guide-wires, dilators, bronchoscope Guide-wire placement between 1 st & 2 nd tracheal ring Diameter of hole increased by using dilators Trach placed Surgical tracheostomy Patient under general anaesthesia Incision from 2 nd tracheal ring Hole made between 3 rd & 4 th tracheal rings with anterior portion removed Trach placed

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9 Tracheostomy Terminology Neckplate/flange Cannula Cuffed/cuffless

10 Tracheostomy Terminology Fenestration Obturator

11 Respiratory System Functions Ventilation Transfer of oxygen rich air into lungs Transfer of oxygen depleted/waste air out of lungs Respiration Transfer of oxygen to circulatory system, then to working organs Removal of some waste from working organs, via circulatory system J

12 Pulmonary Disease and Dysphagia The Respiratory System Mechanics of Ventilation Respiratory Physiology Restrictive and Obstructive Pulmonary Disease Aspiration Pneumonia and Pneumonitis J

13 Mechanics of Ventilation Ventilation: The Respiratory Pump Ventilation: air is pulled into and pushed out of the lungs 1. Muscles and frame 2. Elasticity and Surface Tension J

14 Mechanics of Ventilation Inspiration (expansion) Always Active REL Expiration ( collapse ) Passive at Rest J

15 Ventilation Mechanics Alveoli are NON- COMPLIANT, elastic Structures. Like balloons, they are less compliant When they are Collapsed. Ventilation Impeded By Alveolar tendency to collapse Surface tension, elasticity * Surface Tension * J

16 J Ventilation Mechanics Like balloons, Alveoli are More compliant When they are Expanded. * * Surface Tension Ventilation is Facilitated by: Alveoli held partially open at rest by pleural linkage, AND... Alveoli bathed in surfactant

17 Respiration and Deglutition In Normals... Exhale Swallow Exhale; Young and Old 1 Respiratory rate (young) is about 16/min. 2 (elderly) 20/min. Total Swallow Duration, Swallow Apnea Duration 3 Increase with age Decrease with lower lung volumes 1. Perlman et al., 2005; Hiss et al., 2002; Leslie et al., 2002; 2. Leslie et al., 2002; 3. Gross et al., 2003; Hiss et al., 2002; Leslie et al., 2005.; Kim, McCullough, & Asp, 2005 J

18 Aspiration Pneumonia = [Prandial Aspiration] + Source of Colonization + Poor Host Resistance Oral/Pharyngeal Colonization Medications, Oral disease** Host Risk Factors Underlying disease Mental Status (up to 70%) Obesity, neck malignancy * Medications, dementia Iatrogenic Factors Recent Extubation Tracheostomy*** * ***CDC/MMWR 46, RR-1, (1997); **Langmore et al, (1998); ***Eibling and Gross, 1996; Gross et al, (2003). J

19 Aspiration Related Infiltrates (R) Basilar infiltrates (R) Upper lobe infiltrates Aspiration produces pneumonitis or pneumonia in gravity dependent portions of lung(s). Dependence depends on posture when aspiration occurs, density & volume aspirated. J

20 Ventilation Terminology Inspiration (expansion) IRV TV ERV RV Seconds> REL Expiration ( collapse ) s. RR=20

21 J Ventilation Terminology Positive pressure ventilators Compliance Resistance Peak inspiratory pressure Pressure support ventilation (PSV) Continuous positive airway pressure (CPAP)

22 Trigger event Offset event PEEP

23 J Other stuff FiO2 (room air = 21%) Arterial blood gas (ABGs) PaCO2 (N = 45mm Hg) PA O2 (N = mm Hg) T-piece trials Plugging trials Button placement

24 J Possible Complications during Mechanical Ventilation Cardiovascular (e.g., hypotension, cardiac dysrhythmias) Respiratory (e.g., barotrauma, infections) GI (e.g., GIB, poor nutrition, decreased peristalsis) Neurovascular (e.g., increased ICP) Renal/Electrolytic complications Metabolic disturbances Psychosocial (e.g., depression)

25 J Biomechanical Alterations of Upper Aerodigestive Tract (UAT) following Tracheostomy Structural alterations Mechanical alterations Valving alterations

26 Structural Alterations Epithelial damage Fistula formation Tracheal stenosis Granulation tissue Tracheobronchomalacia J

27 J Mechanical Alterations Mechanical tethering of larynx disuse atrophy Airflow diversion Hypopharyngeal and laryngeal desensitization Decreased glottic closure and/or vocal fold paralysis Esophageal compression secondary to cuff inflation

28 Myth #1: Laryngeal Tethering? Ding & Logemann (2005) Significantly increased laryngeal elevation with cuff deflated (p < 0.001) Terk, et al., (2007) Less hyoid elevation after decannulation A large effect size favoring tracheostomy tube to increase hyoid elevation (d=0.73)??? J

29 Laryngeal Tethering Data in this study are difficult to understand Terk, Leder & Burrell, (2007) J

30 Valving Alterations Impaired laryngeal reflexes Altered timing & duration of glottic closure Decreased subglottic air pressure generation Impaired cough and secretion clearance Overall swallow discoordination (open vs. closed system) J

31 Myth #2. Pressure Generation Pharyngeal musculature functions optimally with closed system Does occlusion truly benefit swallow function? J

32 One Way Speaking Valves J

33 J One Way Speaking Valves Benefits (Hiss et al., 2002): Respiratory Good segue to plugging Assists with weaning Improved cough & secretion management Swallowing Utilising UAT Subglottic air pressure Speech/Voicing

34 J Physiologic Effects of Open and Closed Tracheostomy Tubes on the Pharyngeal Swallow Gross et al., 2003: Within subject study, 4 participants Dependent measures: Penetration/aspiration Bolus transit time (BTT) Pharyngeal activity duration (PAD) Results (with PMV removed): Increased PAD, slower BTT, more severe aspiration/penetration

35 J Occlusion Status-Valve On-Off Further benefits: Suiter, et al., 2003 (valve)-vfg Reduced PAS scores with valve ON Logemann, et al., 1998 (occlusion)-vfg Reduced aspiration from 4/4 to 2/4 Both warn of individual variability Does not benefit: Leder, et al., 2001 (occlusion)-fees Occlusion did not affect pharyngeal or UES pressures Leder, 1999-FEES Did not affect aspiration

36 Occlusion Status Effect Size for Occlusion in Aspirating Patients = 0.73 J

37 J Occlusion Status Other studies Muz et al. (1989): yes, 6/7 asp more without obturator Eibling and Gross (1996), Stachler et al., (1996), others: reduced aspiration

38 Occlusion Status/Valve On-Off Conclusions? Patient variability is high There is sufficient evidence of a potential swallow benefit caused by the closure of the upper airway circuit, in patients with tracheostomy, to justify its investigation with appropriate patients. J

39 Myth #3 Does the tracheostomy truly cause dysphagia? S

40 Causation is debatable Leder & Ross (2000): 20 subjects consecutively enrolled, variety of diagnoses Swallow Ax conducted before and after trach placement 12 subjects who aspirated before trach, also aspirated after 7/8 subjects who did not aspirate before trach, did not aspirate after trach placement

41 Causation is debatable Donzelli et al. (2005): 37 consecutive patients w/ tracheostomy, variety of diagnoses, variety of trach types Instrumental Ax w/ FEES Pureed boluses Assessed with trach in situ and directly after decannulation 35/37 aspirated before and after decannulation 2/37 aspirated after decannulation Decannulation did not alter the incidence of aspiration/penetration Medical diagnoses had more bearing on swallow impairment rather than the tracheostomy itself

42 The Clinical Assessment Types of Patients Decannulat Goal of cuf Evenutal de Cuff Norma Not in decan Long term Ventilator d Inflated c Long term

43 The Clinical Assessment Part I Attending referral Medical history Chart review Discussion with attending Discussion with RT, OT, PT, RN, family Patient observation

44 Medical History Attend to medical diagnoses and complications,?stability e.g., sepsis, LOC, Current and past respiratory details Trach details: size, type, cuff deflation, plugging trials Anatomic abnormalties Weaning parameters, number and length of intubations,rr, O2 requirements, suctioning frequency Hx of po attempts? Results? Physical abilities e.g., ambulation, sitting tolerance, self care

45 Patient Observation SECRETION TOLERANCE suctioning frequency, spontaneous phonations, spontaneous coughs, spontaneous swallows LOC General bed/chair mobility Respiratory measures: RR, tracings, O 2 sats

46 The Clinical Ax Part II Oral Facial Sensory-Motor Exam Assess oral mucosa (hydrate if necessary) Assess oral hygeine, dentition Oral/tongue function/strength Cuff Deflation (if not already deflated) Attending approval necessary, done in conjuction with RT

47 Why Cuff Deflation? Is decannulation the goal? Tracheotomy site is inferior to vocal folds NO Aspiration can be reliably detected while cuff inflated Only oral stage can be observed while cuff inflated If cuff deflation is NOT approved, patient may NOT be a good candidate for significant oral intake at this time. Again, what is the overall goal?

48 Myth #4 Does the tracheostomy cuff affect swallowing function? Does it eliminate aspiration?

49 Cuff Inflation Status Prevention of Aspiration? No! The cuff lies below the vocal folds!!! Tracheostomy cuffs may not completely seal upper from lower airway Winklmaier, et al., (2006) Pig tracheas; water and artificial saliva, vent and no-vent conditions

50 Cuff Inflation Status Winklmaier, et al., (2006) 6mL methylene blue infused over cuff Inspection at 5, 10, 15 minutes Portex: Water with vent: 2.68, 13.46, ml leakage Water no vent: 5.53, 60.45, 75.0 ml leakage Saliva no vent: 0, 0, 0.93 ml leakage Significantly more leakage with water/saliva

51 Cuff Inflation Status Ding & Logemann, patients with tracheostomy Cuff inflated or deflated during the VFG study Significantly greater frequency of silent aspiration in cuff inflated condition (p < 0.001) Significantly less hyolaryngeal elevation during swallow (p < 0.001)

52 Cuff Inflation Status Excessive inflation pressure

53 Cuff Deflation Process Medical clearance, pretrial suctioning Cuff is deflated, suction repeated Note additional matter suctioned (from above cuff) Note volume of air removed from cuff Note tolerance of deflation Patient remains stable Occlusion on expiration ONLY Airway back pressure, absent voicing or glottic voicing on cough ENT referral

54 Cuff Deflation Process (con t) Saliva swallow during occlusion?spontaneous Often the next step is the swallow trials!!

55 The Clinical Ax Part III Feeding trials Observations to make: Vocal (wet) quality change Cough/clear airway with or without cue Laryngeal elevation & timing Changes in RR, anxiety, O 2 sats Oral residue Variable responses according to consistency Referral for instrumental Assessment

56 Myth #5 To Dye or Not to Dye. J

57 Clinical Assessment Myths The Blue Dye Plague of 2003 Cameron JL, Reynolds J, Zuidema GD., (1973). Aspiration in patients with tracheotomies. Surg Gynecol Obstet 136: Evans Blue Dye Tracheostomy aspiration Test Thompson-Henry S, Braddock B (1995). The modified Evan s blue dye procedure fails to detect aspiration in the tracheotomized patient: five case reports. Dysphagia 10: Stained boluses administered J

58 The Blue Dye Plague of 2003 FD&C Blue #1 has resulted in a few publicized patient adverse events...and has been pulled from the healthcare market

59 SUMMARY OF REPORTS... the FDA is aware of 20 cases... associating the use of blue dye in tube feedings with blue discoloration of body fluids and skin, as well as more serious complications. There have been 12 reported deaths... In more than 75% of all reported cases, patients had a reported history of sepsis (and therefore likely altered gut permeability) before or during systemic absorption of Blue 1... J

60 ...patients at risk for increased intestinal permeability, which includes those with sepsis, burns, trauma, shock, surgical interventions, renal failure, celiac sprue, or inflammatory bowel disease, appear to be at increased risk of absorbing Blue 1 from tinted enteral feedings. David W. K. Acheson, MD Chief Medical Officer Center for Food Safety and Applied Nutrition Food and Drug Administration J

61 The Blue Dye Plague of 2003 Volumes used in enteral formula: cc per 1000 cc. Safe human consumption: Data from life-exposure animal studies supports an ADI (acceptable daily intake) of Blue 1 of 12.0 milligrams/kilogram body weight/day. (HEALTHY individual) 110 lb. patient mg/day. J

62 The Blue Dye Plague of % solution is most common dilution (99.5% water) 12.0 mg to 2388 mg water (2.4 liters) = 0.5% sln. 50mg Blue (minimum safe) 12 liters water 600mg Blue (max safe) 144 liters water 25 to 293 lbs. FD&C Blue 2 solution 75% adverse event cases included sepsis (septicemia) as a diagnosis J

63 The Blue Dye Plague Reported Contamination of Multiple Use Container File, et al., (1995) Gastric colonization with pseudomonas aeruginosa from common use blue food color bottle used for enteral feeding dye, caused ventilator associated respiratory infection outbreak in ICU Knoll, 1993 Gram negative and gram positive rods found in opened and unopened bottles of blue dye in hospital nursing station. J

64 J Conclusion There is no credible evidence suggesting that the use of small amounts of FD&C blue #1 is harmful Avoid use in patients with abnormal gut permeability

65 Precision of Clue Dye Testing Overwhelmingly, the sensitivity is found to be moderate to poor. Sensitivity: % aspirators detected Specificity: % non-aspirators detected O Neil-Pirozzi et al, (2003) Simultaneous, masked VFG/MEBDT Donzelli, et al., 2001 Visualization of subglottic larynx J

66 Precision of Clue Dye Testing Diagnostic Variable Formula Calculation Result and its Meaning Sensitivity a/(a+c) 13/21= % of actual aspirators were correctly identified as aspirators with BDT. Specificity d/(b+d) 23/29= % of actual non aspirators were correctly identified as non-aspirators with BDT Positive Predictive Value Negative Predictive Value a/(a+b) 13/19= % of patients thought to aspirate with BDT actually aspirated d/(c+d) 23/31= % of patients thought to NOT aspirate with BDT did NOT aspirate Moderate Sensitivity and Specificity O Neil-Pirozzi et al. 2001, J

67 MEBDT Donzelli et al. (2001) Microaspiration not detected with MEBDT (0%) Overall (50%) 50% false-negative Larger volume aspiration detected (67%) Sp=inadequate data Poor Sensitivity and Specificity for Microaspiration

68 Case Review 63 y.o. male MVA, C7# - functioning as a C4# PMHx: sleep apnea,?chf, HTN Post-op course: POD# 8: trach POD# 12: PEG Patient already on DAT at time of referral S

69 Case Review CSA: Voicing with partial cuff deflation Trached & vented RN report of suctioning food particles from trach post meal Typically eating with cuff inflated Weak volitional cough OME

70 Case Review 49 year old male admitted for CABGx2 PMHx: MI, failed angioplasty/stent, hyperlipidemia, smoker OR: uncomplicated Post-op course: multiple intubations difficulty weaning from vent tracheostomy placement/decannulation

71 Case Review VFSS #1, POD #28: Frank silent aspiration across consistencies tested, airway penetrations during/after swallow, vallecular/pyriform sinus residue Swallow maneuvers, postural changes and consistency modifications ineffective Alternative to oral feeding, ice chips sparingly (1/4 c. bid with supervision)

72 Case Review VFSS #2, POD #34 Effortful swallow (ES) appeared to reduce residue and no aspiration/penetration events observed with same ½ cup level 3 or pureed tid w/ ES, alternative to oral feeding for nutrition/meds VFSS #3, POD #38 Discharge imminent, patient refusing feeding tube (removed), MD ordered repeat VFSS, respiratory status stable (room air, chest clear, afebrile) semg & VFSS

73 Case Review semg training POD #34-40 with po (modified diet) Discharged POD #40 Outpatient dysphagia follow-up and repeat VFSS