Outline 11/13/2009. Yikes! This Kid has a Trach: Intervention. Community Settings

Transcription

1 Yikes! This Kid has a Trach: Intervention In Community Settings Outline Pediatric Tracheostomy Anatomy and Physiology of Airway Timing and Indication Physiologic Complications Communication Options Low & High Tech Passy Muir Speaking Valve Evaluation Treatment Strategies Case Studies Identifying Resources Pediatric Airway Anatomy Softer, larger palate Lumen size is smaller Larynx is higher Close approximationof of larynx and tongue More cartilage (softer) 1

2 Timing of Pediatric Tracheostomy 85% are under 1 year of age (Albamonte et al. 1993) Average age 2 3 years old Critical time for development Practice and hear their own vocalizations Indications for Pediatric Tracheostomy Ventilation/pulmonary disorders Pulmonary toilet Neuromuscular disorders Airway obstruction Normal Trachea Image from Airway Atlas by John Sherry II, M.D. 2

3 Grade 3 Subglottic Stenosis Source: Laryngoscope 101: December 1991 Grade 4 complete obstruction Source: Laryngoscope 101: December 1991 Laryngomalacia Image from Airway Atlas by John Sherry II, M.D. 3

4 Tracheal Web Image from the Virtual Children s Hospital Vocal Cord Paralysis Source: American Academy of Otolaryngology Head and Neck Surgery Clinical Complications of Tracheostomy AIRFLOW 4

5 Effects of Tracheostomy on Communication Development Caregiver interaction(aradine, 1983) Voice quality Speech (Kaslon & Stein, 1989, Singer et al., 1989) 61% have articulation error Consonant and vowel errors Excessive use of phonological processes (stridency and liquid deviation, cluster reduction, fronting) Language Tracheostomy and Aspiration Laryngeal Tethering (Butcher 1982; Logeman, 1995) Decreased Sensation in the Oropharynx 2 (Feldman et al., 1966, Nash 1988) Reduced Airway Closure (Sasalo & Isaccson, 1988; Nash, 1988; Logeman, 1995) Reduced Subglottic Air Pressure (Sasaki & Isaacson, 1988, Gross et al, 1994 and 2004) Pediatric Studies Swallow Physiology 91% of 36 trach infants had swallowing disorders; 1/2 attributed to underlying neuro or anatomic deficits (Rosingh and Peek 1999) Higher incidence id of enteral lfeeding (Wilging 2000) Trach effect (Abraham 2000) Toddlers with trach Reduced laryngeal elevation Delayed swallow response penetration 5

6 Decreased Secretion Control and PEEP Removal of filtration & humidification Decreased cough Abraham (2009) All 50 children in study had secretion management issues 98% level of trachea 40% level of larynx 56% oral Communication Options Low Tech Thumbs up/down Eye blink system Squeeze Hand Kick or move leg/foot Any reliable body part movement Dry erase/magic slate Notepad/pen Sign Language Advantages: Readily available Inexpensive Easy to use/access Easy to use/access Disadvantages: limited Low Tech 6

7 Switches Communication Options High Tech Big Mac Switch/Voice Output Switches (toys, computer interface) Vi Voice output devices Computer based devices Dedicated Communication Devices Environmental Controls High Tech Advantages: Greater capability for higher and lower level patients Disadvantages: Expensive Reimbursement issues More complicated Requires greater skill of clinician Evaluation and attainment can be difficult and time consuming 7

8 Passy Muir Valve Restores Airflow to Upper Airway Clinical Benefits Improved swallow Improved voice Improved Secretion Management Abraham (2009) 24/49 children wearing PMV full time secretion management within normal limits in average of 2 weeks. 8

9 Cotreatment Expedites Decannulation and Weaning Restoration of normal physiology Utilization of expiratory muscles Accustomed to more normal breathing pattern Increased PEEP and oxygenation Able to communicate Less WOB, easier to tolerate Pediatric Studies PMV in children Cho Lieu study (1999) Retrospective evaluation 3 days 18 years old (50% under 1 year) Variety of airway pathologies and diverse medical problems 52 of 55 tolerated PMV Youngest children in study average 27 m. to decannulation Greatest period of speech development Every effort should be made to place a speaking valve when feasible 9

10 Passy Muir Valves Team Approach Multi disciplinary Patient Centered Policies and Procedures Psychological aspects General Differences Habilitation Behavioral considerations 10

11 Patient Selection Cognitive status Awake, responsive, attempting to communicate Medically stable Able to tolerate cuff deflation Able to manage secretions Factors Effecting Upper Airway Patency Size of Tracheostomy Tube Presence and Degree of Obstruction Edema Secretions To Assess for Upper Airway Patency Deflate cuff Finger occlude and voice or cough on exhalation Use mirrors, cotton, feathers, whistles or bubbles to assist with the oral exhalation process. 11

12 Placement Guidelines Patient education Patient position Suctioning Achieve complete cuff deflation Use the warning label provided with packaging Oxygenation Vital Signs Breath Sounds Color WOB Patient Responsiveness Baseline Measurements Distress Signs and Symptoms Increased RR, HR Anxiety and fear Restlessness Increased irritability Stridor Grunting (infants) Retractions Nasal flaring Head bobbing Sniffing position Decreased BS during auscultation Decreased chest movement Decreased LOC Decreased PaO2 (SaO2) Increased PaCo2 Paleness or cyanosis Decreased perfusion/mottling Bradycardia/hypotension (this is a late sign) 12

13 Guidelines Approach to Education Higher incidence of airway obstruction Normal baselines Reaction time Transitions may be gradual Children 0 6 months old Evaluation: Infant communication developmental scale Oral motor function and feeding skills Treatment: Parent education Early developmental milestones Non nutritive oral stimulation/ sucking Bottle feeding Double-click to edit Double-click to edit Double-click to edit 13

14 Children 6 24 months old Evaluation: Receptive and expressive language Play and cognition Oral feeding Skills Treatment: Parent education Facilitate oral exhalation Facilitate vocalization Augment with alternative communication systems as necessary Oral feeding PLAY,, PLAYP LAY,, PLAY! Goal 1# Increase Oral Exhalation Techniques Imitation Blowing Bubbles Whistles Horns, Kazoos Pinwheels Straws Cotton balls 14

15 Goal #2 Increase Voicing Activities Planes, trains and automobiles Play dough Rice and beans Animals Books Songs Toby Tracheasuarus Case Study: Rudy History: 28 week preemie H i li d6 h Hospitalized 6 months Rehospitalized 2 3x first year: Pneumonia/trached Tracheomalacia/subglottic stenosis D/C home 12 mo. with PMV and home nursing Referred for speech eval 15

16 Case Study: Rudy Evaluation: Babbling intermittently Does not tolerate PMV Developmental delay LT Goals: Utilize PMV waking hours Age appropriate speech skills Age appropriate language skills Caregiver education for feeding and s/l development Case Study: Rudy ST Goals: Utilize PMV 1 minute during play or eating 4/5 trials Produce /p,b,m/ in syllables during play or babbling 5x session Attempt animal/vehicle sounds 3 5x session Imitate oral movements/mouth play 5 x session Wave or vocalize to greet with 80% freq with min cues Laugh 2 x session Caregiver will verbalize understanding of PMV use Apply PMV before all meds and meals Demonstrate proper care and cleaning Mom s Perspective When he first got the trach, my aunt who is an RN, commented that he would be severely speech delayed once it came out. I was determined that such would not be the case, so we required him to wear a PMV as soon as we got it. He didn't like it, he would fuss when we put it on. But the doctors had said we could use it, and that he could work up to it. So we would put it on for so many minutes at a time & distract the heck out of him while he fussed. I held him at the window, would swing him, etc. It wasn't too long before he wore it all day. He had a home nurse until he was in his 3rd year, but attended church, took family trips out of state, and had a normal life except for water restrictions. His trach came out when he was 4. He wore a bandana for about 6 months while the hole closed, but we still let him play outside and do everything he could. 16

17 Rudy: A Great Outcome! Case Study: Deke History 2 years old 3p deletion syndrome Craniofacial deformities Trach: alternate airway/pulmonary toilet Chronic/long term Severe developmental delay Severe motor impairment G tube Respiratory treatments PM Ventilator Life expectancy: 5 7 years Case Study: Deke Evaluation: Severe/profound motor, cognitive, speech, language impairment Dysphagiadue to severely impaired oral motor skills Non Verbal Tracheostomized/does not tolerate PMV Ventilated at night 17

18 Case Study: Deke Long Term Goals: Tolerate PMV waking hours Oral motor skills adequate for words Use words or augmentative communication devices to express basic wants, needs, feelings and/or ideas Demonstrate understanding of cause/effect to control/interact with environment and play Case Study: Deke Short Term Goals: Utilize PMV for 30 seconds during play 3x per session (increase incrementally as possible) Participate in intensive oral motor program for increased strength, range of motion, and function of lips, cheeks, tongue and jaw 2 3x daily Vocalize while wearing PMV 3x per session Demonstrate reliable body movement to activate switch or AC device 3/5 trials Use AC device or toy to demonstrate cause/effect 5x per session (fan, talking picture frame, Big Mack, etc) Produce /p, b, m/in isolation/syllables during play 5x per session Case Study: Deke Outcome: Move mouth for kisses Laugh/giggle at fan, bubbles, grandma singing on Big Mack or in person Wears PMV waking hours Reduced need for suction/clearer upper airway Vocalizes with PMV: ma for mom and cooing and some babbling during play Activating switches with fist and foot Participating in some outdoor activities (swing, trick or treat in wagon with device) 18

19 Care, Cleaning Passy Muir Valves Allow to air dry Double-click to edit Double-click to edit 19

20 Children 3 years old School Age Evaluation: Receptive and expressive language Oral feeding Skills Treatment: Parent education Coordinate services with school, IEP Elimination of negative behaviors Intensive voice and speech therapy Additional Voice and Speech Goals Improve voice quality Weak Harsh, hyperfunctional Pitch Improve coordination of respiration and speech Improve articulation and phonology Swallowing and Feeding Goals PMV for assessment (clinical & instrumental) PMV for oral feeding Decrease sensitivity (facial/oral stimulation) Tastes Textures Feeding Equipment Positioning 20

21 Double-click to edit Resources Agencies/Individuals: Physician Hospital Based SLP, Nurse, Education Program DME, Home Care Agency Resources Web based Position Statements html html nts/pages/respiratory disease pediatric/childtrach1 12.html 21

22 Resources Web based Tracheostomy/Respiratory General Speaking Valve muir.com/ Trach Care %20Feb% pdf Resources Web based: Children s Hospital of Los Angeles 8D8F/Ventilation_Videos English.htm Cleveland Clinic Children s Hospital tion_guidelines.aspx /tracheostomy_care.aspx Phoenix Children s Hospital center/child healthtopics/tracheostomy.html Cincinnati Children s Hospital cpr.htm Resources Books: Kertoy, M. (2002). Children with Tracheostomies Resource Guide. Ontario, Canada: Singular Publishing Group, Inc. Bleile, K. editor(1993). The Care of Children with Long Term Tracheostomies. San Diego, CA: Singular Publishing Group, Inc. Bissel, C. (2000). Pediatric Tracheostomy Home Care Guide. Grafton, MA: Twin Enterprises, Inc. Dikeman, K.J., and Kazandjian, M. Communication and Swallowing Management of Tracheostomized and Ventilator Dependent Adults. Singular Publishing Group. 22

23 Educational Opportunities WEBINARS or SELF STUDY COURSES Basic Application Ventilator Application Advanced Pediatric Application Swallow and PMV Building a Trach Team Ventilator Basics for the Non RT Pediatric Ventilator Application muir.com ASHA, AARC and California Board of Nursing Credit References: Respiratory Care, April 2005, Vol 50, No 4 Respiratory Care, Sept 2006, Vol 51, No 9 Carron, J. et al. Pediatric tracheostomies: changing indications and outcomes. The Laryngoscope. 2000; 110(7): Lewis, C et al. Tracheostomy in pediatric patients. Archives of Otolaryngoloy yhead and Neck Surgery. 2003; 129: Care of the Child with a Chronic Tracheostomy; The official statement of the American Thoracic Society adopted July Can be located on website. Simon, B. et al. Communication development in young children with long term tracheostomies: preliminary report. International Journal of Pediatric Otorhinolaryngology. 1984; 6: Kertoy, M. et al. Speech and phonological characteristics of individual children with history of tracheostomy. Journal of Speech, Language, and Hearing Research. 1999; 42:

24 References: Abraham, S & Wolf, E. Swallowing physiology of toddlers with longterm tracheostomies: a preliminary study. Dysphagia. 2000; 15: Cho Lieu, J. et al. Passy Muir valve in children with tracheotomy. International Journal of Pediatric Otorhinolaryngology. 1999; 50: Abraham, S. Babies Bbi with ihtracheostomies: The challenge hll of providing specialized clinical care. The ASHA Leader Online. Waldowski, K. Baby Trachs. Advance for SLPs. Volume 12, Issue 26, page 6. Cordle, K. Speaking Valves for Infants. Advance for SLPs... Volume 16, Issue 11, page 9. Hofmann, L. et al. Passy Muir Speaking Valve use in a children hospital: An interdisciplinary approach. Perspectives on Voice and Voice Disorders. 2008; 18: References: Abraham, S. Clinical and Fluoroscopic Issues in the Management of Swallowing Disorders in Infants and Young Children with Tracheostomies. In Dysphagia in the Trach/Vent Population. ASHA Professional Development and Special Interest Division Harvey, G. Treatment of voice disorders in medically complex children. Language, Speech, and Hearing Services in Schools. 1996; 27: Woodnorth, G. Assessing and Managing Medically Fragile Children: Tracheostomy and Ventilatory Support. Language, Speech, and Hearing Services in Schools. 2004; 35: Kaslon WK, Stein RE: Chronic pediatric tracheostomy: Assessment and implications for habilitation of voice, speech and language on young children. Int J Pediatr Otorhinolaryngol 9: , 1985 Hill BP, Singer LT: Speech and language development after infant tracheostomy. J Speech Hearing Dis 55:15 20,