Day2 1040-1130 Boesch TrachVent - Amazon Web Services€¦ · Microsoft PowerPoint -...
Transcript of Day2 1040-1130 Boesch TrachVent - Amazon Web Services€¦ · Microsoft PowerPoint -...
Day 2 – 1040‐1130Tracheostomies and the Aerodigestive Management
of Mechanically Ventilated Patients
R. Paul Boesch, DO, MSAssistant Professor, Pulmonary Medicine
Mayo Clinic Children’s Center
The tracheostomy, the ventilator, and the child
• “Appropriate” tracheostomy considerations:– At the current time the trach:
• Sits well on the skin• Tip does not impact airway wall• Big enough to decrease plugging risk• Big enough to allow adequate ventilation
– Balance between breathing through and around tube
• Small enough to allow PMV if/when possible• Length considerations
– Need to support tracheomalacia or want to stop supporting malacia– Need to have tip beyond or above vascular compression or TEF pouch
“Appropriate” tracheostomy considerations
• How it looks in airway not good enough• Need to understand where child is in terms of:
– Weaning or windowing from vent support– Secretion control– Tolerance of infections– Respiratory physiology
• Pulmonologist potentially best suited to tracheostomy‐related decision‐making for ventilated patients– Or at very least should be closely partnered with ENT– OR presence is best as findings can result in on‐the‐spot decisions
• ie: how will removal of granuloma affect ventilation
Extended‐style tracheostomy tubes
Days with PU
Days w/o PU
Extended 5 1118
Standard 385 6354
Patients with PU
Patients w/o PU
Extended 0 72
Standard 27 484
P< 0.0001 P= 0.038
Boesch RP et al. Prevention of tracheostomy-related pressure ulcers in children. Pediatrics 2012 March; 129 (3)
1. Skin and device assessments2. Mepilex3. Extended trach tubes
Cuff considerations
• In general prefer uncuffed tubes• Cuffed tubes can allow child to live in 2 worlds
– Cuff up when need vent more– Cuff down when need more leak for PMV, etc
• Differences between air‐filled and water‐filled cuffs
Air‐filled cuffs allow direct measurement of cuff pressureWhen deflated resistance around cuff remains
Measuring cuff pressure in an air cuff‐
Pressure here
Equals pressure here
Pressure here is elastic recoil pressure of cuff bladder
Make pressure here 20 cm H2O
Pressure here becomes 20 cm H2O
If pressure here <20 cm H2O…
Water‐filled cuffs deflate fully Cuff pressure not directly measured
One way valves
• Benefits:– Restore PEEP– Improved secretion management– Improved cough clearance– Improved swallow– Improved smell
• Risks:– Dryness/plugging– Inadvertent PEEP build‐up
It’s all a simple mechanical issue
Vocal cords
INHALE EXHALE
Speaking Valve Pressure Test = Expiratory pressure <10 cm H20 pressure during quiet breathing
Exhaled pressure with quiet breathing essentially PEEP
1/16 in. holes
Exhaled pressure at rest is PEEP…
This child wore a PMV all day for a year with a pressure > 30!
In‐line PMV
• May hold PEEP above PEEP set on ventilator but ventilator will be unaware
• Will prevent ventilator from measuring Vte– Will have to disable low minute ventilation alarm
• Requires a patent enough airway and a leak that simultaneously is enough to allow PMV but not too much as to affect ventilation– Not generally achievable in young kids
Chronic Vent Management
• Goals:1. Minimize work of breathing to foster growth and
development2. Prevent/minimize other pulmonary insults3. Minimize ventilator‐induced lung injury 4. Prevent trach/vent accidents5. Identification of readiness to wean6. Weaning protocol and timeline based on
underlying cause for respiratory failure
Longitudinal AssessmentRespironics NM3
• Continuously measures:– SpO2, Pulse, Mvexp, Mvalv. Vti, Vte, PIF. PEF, freq– PIP, MAP, PEEP, Raw‐i, Raw‐e, Cdyn, ETCO2, VCO2, PeCO2 Vd/Vt
• Measures Vte more accurately than vent• All can be trended and downloaded into Excel• Leak% and Vte/kg can be easily calculated/trended
– Vti‐Vte/Vti = % Leak– Goal: <20% (but >zero)
• Relationships can be evaluated• Means, correlations, etc can be calculated
‐0.40
‐0.20
0.00
0.20
0.40
0.60
0.80
1.00
1.20
0
10
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701 32 63 94 125
156
187
218
249
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311
342
373
404
435
466
497
528
559
590
621
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683
714
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776
807
838
869
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931
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1024
1055
1086
1117
1148
1179
1210
1241
1272
1303
1334
1365
1396
1427
ETCO2
Vte/kg
Leak%
24 weeker, CPAP/PS, cuffed trach
Variable leak associated with variable tidal volume
• Leak% and ETCO2, sorted by Leak% and graphed
0.00
0.20
0.40
0.60
0.80
1.00
1.20
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1 9 17 25 33 41 49 57 65 73 81 89 97 105
113
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ETCO2
Leak %
Rate increased to 30: 4am CBG: 7.36/37/+3Increased rate to 40
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
<30 30-34 35-40 41-45 46-50 >50
Liberation from chronic vent
Edwards JD, J Pediatr 2010
Lung/Airway diseases
Neuromuscular diseasesCentral hypoventilation
Decannulation of the un‐weanable child
• Transition from invasive to non‐invasive ventilation– Most often: Isolated central apnea with sleep
• Usually school‐aged child or older• Prove mask acceptance first• Prove ability to ventilate non‐invasively… if possible• Secretion handling will differ between pressure applied above vs below glottis