W12 Critical Care

Intensive Care Unit (ICU)

• specialized ward providing intensive treatment & monitoring for patients with severe or life-threatening illnesses and injuries

High Dependence Unit (HDU)

• for patients who need close monitoring and specialized treatment but do not required the full resources of an ICU

• intermediary step between the ICU and the general wards

What is the critical care environment and how does it differ to other enviornments

• high-cost medical environment

• Patient turnover: high number of patients annually, avg length of stay is 3-7 days

• highly medical environment

• enhanced health & safety/infection control precautions - gloves, gown, goggles

• highly “clinical” environment - few personal belongings

• strict visiting hours and limits to number of visitors

• lights on 24/7, constant noisy equipment

different types of medical equipment needed to support critical care management at bedside environment

• ventilators + tubing

• monitors

• suctioning equipment

• temperature management devices

• infusion pumps

• arterial lines

• central venous catheters

• peripherally inserted central catheter (PICC) lines

• dialysis machines

• defibrillators

What are different types of ventilation & intubation

• endotracheal tube (ETT)

• tracheostomy tube (Trach)

different forms of hydration/nutritional supports

• intravenous line (IV)

• parenteral nutrition - nutrition delivered via the bloodstream

• enteral feeding - nutrition delivered via gastrointestinal tract: Nasogastric tube (NGT), Percutaneous Gastrostomy (PEG)

the impact of the ICU environment

• sleep deprivation

• leads to psychological issues as well as physiological dysfunction

staff of critical care units

• highly trained healthcare professionals

• nursing: 1:1 ratio nurse/bed - vital signs check every 15-60mins

• intensivists are in charge of day-to-day care: specialists in critical care medicine

• other specialists come and go

• allied health staff

allied health staff at ICU

• physiotherapists

• dietitians

• occupational therapists

• pharmacists

• social workers

• psychologists

• speech pathologists

who are the patients needing critical care

• severe illness, trauma, post-surgical

• requiring sedation and mechanical ventilation

• close medical monitoring

• high level of medical fragility

pathways of ICU admission

1. Admission → emergency → ICU and ventilated → weaned from ventilation + achieve medical stability → HDU/ward

2. admission → emergency → surgery → ICU and ventilated → weaned → HDU/ward

3. admission → surgery → ICU and ventilated → weaned → HDU/ward

Examples of critical care patient populations

• spinal cord injuries

• burns

• brain injury

• head and neck cancer

• cardiothoracic surgery & thoracic surgery

high medical fragility

• low resistance to infection

• 1 or more chronic disease, terminal illness or medical condition that might be life threatening

• can progress/deteriorate further

• fluctuations and daily variability of frailty, medications, pain levels, depression, schedules medical procedures

co-existing factors which add to the length of time in the ICU

• age

• comorbidities

• medications and other procedures: impact on alertness, other side effects

additional issues from long ICU stay

• delirium

• ICU-Acquired Weakness (ICUAW)

• Critical Illness Polyneuropathy (CIP)

what do these high medical support in ICU mean for SLP management

• do not proceed without medical support/referral

• communicate/consult regularly with MDT

• no verbal communication possible when ETT in situ

• inability to communicate is a major source of anxiety for patients and their families

• priority is establishing some means of non-verbal communication

dysphagia management in critical care

• more cautious management

• more team discussion of decisions

• monitoring safety

• base decisions on as much objective available clinical evidence as possible (instrumental swallowing assessment - bedside FEES)

SLP role in critical care in communciation

speech - impacted by ventilation/intubation

• ETT in situ - no speech possible

  • prior to extubating - communication, board, writing, mouthing

  • post ETT extubating - management of any vocal impairment

  
  

• tracheostomy in situ - no speech possible when cuff inflated

  • role in managing cuff deflation, re-establishing speech with speaking valves

speech + language - impacted by ICU management

speech + language - impacted by the medical condition that caused admission

The SLP’s role with swallowing in critical care

swallowing - impacted by ventilation/intubation

• ETT in situ - no oral intake possible

  • post ETT extubation - management of any swallowing impairment

• tracheostomy in situ

  • role in managing swallowing safety for cuff deflation, re-establishing upper airway flow, cough with speaking valve

swallowing - impacted by ICU management

swallowing - impacted by medical condition that caused admission

the SLP’s role in weaning from the tracheostomy (decannulation)

• contribute to medical decision regarding safety/suitability for trach to be removed

• MDT input

• manage secretions, saliva, swallowing without aspiration if tracheostomy is removed

when is speech pathology involved in critical care

• patient admitted & ventilated via ETT (if >48hrs, swallow and voice Ax & Mgt post ETT extubation)

• changed to trach, ventilated via trach; commenced weaning from ventilation: communication & swallowing for ventilator depending on patients

• weaned from ventilation → commence trach cuff deflation trials → decannulated (tracheostomy removed)

  • SLP mgt of pt weaned from ventilation & able to tolerate partial cuff deflation

  • commence cuff deflation trials, manage swallowing conduct speaking valve trials, advise on decannulation readiness

evolution of SLP role in ICU

• continuing to expand and be recognised

• role in post ETT extubation management

• SLP role in dysphagia management

• evidence for efficacy of dysphagia treatment increasing

• equipment advances

• impact of covid

4 key recommendations for ICU management

• review of current caseload service delivery to identify capacity for increased service provisions

• identify staff with ICU-specific clinical skills in relation to communication, swallow and trach pt management

• clinical education for ICU specific clinical skills

• consider staff training needs for provision of rehabilitation service post ICU discharge

Endotracheal tube (ETT)

• temporary (1-3 weeks): allows connection to mechanical ventilation

• inserted through mouth, through the larynx and into the trachea

• semi rigid plastic tubes with a cuff

types of artificial airways

• short term tubes (oral and nasophgeal airways): few hrs only, during surgery

• endotracheal tubes (ETT): days up to 2 weeks

• tracheostomy tubes: for long term intubation

2 reasons why would someone need an artificial airway

1. impaired respiratory function or complete respiratory paralysis e.g. high spinal cord injury, post severe stroke, degenerative conditions, COPD disorders

2. any upper airway obstruction e.g. oedema, laryngeal tumor, surgery involving upper airways, oral/dental infections causing extreme swelling of tongue

what is restricted when an ETT tube is in situ

• cannot use speech to communicate

• cannot eat or drink orally

• SLP role is once the ETT tube is removed

impacts of an ETT which can lead to issues with voice and swallowing

• impacts from insertion of ETT: often inserted in emergency situations when airway access is difficult

  • risk of trauma once removed

• impacts from duration of intubation

  • oral trauma

  • tracheal/laryngeal/VC fold trauma: laryngeal oedema, mucosal ulcerations of the VF etc.

  • tracheal trauma

when is there increased risk of oropharyngeal dysphagia + voice change

• >48 hours before the ETT is removed associated with increased risk

who are the ETT patients SLPs see in the ICU

• ETT extubation after 48 hours

• wait 4 hours after extubation

• SLP Voice & Swallow Assessment

potential causes of dysphagia and dysphonia after ETT removal

• trauma

• critical illness induced weakness

• respiratory weakness

• sensory changes

• underlying medical condition/cause of critical illness

process for rehabilitation if presenting with dysphagia

• typically difficulty with thin fluids + residual illness/weakness: compensatory Mgt (food/fluid modifications, alertness), rehabilitation Mgt (controlled swallow, supraglottic swallow, effortful swallow etc. )

• majority will recover and return to full oral intake in <3days

process for rehabilitation if presenting with dysphonia (mild dysphonia or dysphonia persisting more than 5 days)

• typically mild dysphonia, breathiness reflecting temporary impact of intubation, residual oedema and lack of VC use

  • encourage voicing to build up strength + monitor

  • often recovers spontaneously

• if persisting more than 5 days: Seek ENT Ax to confirm VCs and arytenoid function

  • if VC palsy - VC adduction exercises

  • for long-term persistent issues or arytenoid dislocation = surgery

tracheotomy

• surgical procedure conducted to provide an artificial airway

• after around 3rd & 4th ring

• vertical skin incision

• tracheostomy: insertion of a tube

stoma

the hole created when making an incision for a tracheostomy

where is a tracheostomy inserted

• tube is positioned below the level of the vocal folds

• tube is inserted into the stoma and directly into the trachea

types of tracheotomy procedure

• surgical/permanent tracheotomy: performed under surgery/anesthetic

• percutaneous tracheotomy: most common, conducted at bedside, local anesthetic

Advantages of converted from ETT to tracheostomy

• reduces risk of glottic trauma

• reduces Pt discomfort

• reduces need for sedation

• assist weaning from ventilator

• oral intake & communication possible

• Pt can be cared for outside the ICU

• better secretion clearance and ability to monitor

main components of a standard tracheostomy tube

• obturator: used only during the insertion process

• outer cannula: rigid outside wall of trach tube, some specialised tubes/fenestrations in the outer cannula to assist communication

• suction line: important to remove secretion

• inner cannula: sits inside the outer cannula, reduces inner diameter, can be removed for cleaning as well as cases of obstruction (mucous plug)

• flange: neck plate that allows trach tube to be secured in place, contains inner and outer diameter of the tube and presence of a cuff

• hub/port: standard 15mm size, used to connect things to trach tube

• cuff: balloon surrounding outer cannula of trach, most common is air-filled cuffs

where is the cuff attached

• attached externally via the inflation line to a small pilot balloon + spring valve for inflation

• balloon indicates inflation status

• if the balloon is inflated, the cuff is inflated

how are air-filled cuffs inflated or deflated

• using a syringe at the end of pilot balloon

why have a cuff?

• assists ventilation

  • when inflated, forms a mechanical barrier between upper and lower respiratory tract

  • creating a close system is essential for efficient gas exchange

• helps tracheostomy tube in situ

  • minimises risk of accidental dislodgement

  • when inflated, difficult to pull tube completely out of airway

• to minimise aspiration (does not prevent)

what happens when the cuff is inflated vs deflated

• deflated: allows airflow up to upper respiratory tract

• inflated: no airflow to upper respiratory tract; necessary for ventilation but prevents phonation

uncuffed tracheostomy tubes

• not meant to be used with mechanical ventilation

• only used to create a patent open airway

• for patients with upper airway compromise, not to ventilate due to respiratory dysfunction

why does the cuff only minimise aspiration not prevent

• cuff is located below the vocal folds so material has already aspirated

• the cuff creates a seal with the tracheal wall but not a watertight seal

• traps some aspirated materials from passing further into the trachea

• some amount of aspirated material passes below the cuff eventually

where do secretions build up

• the mouth/pharynx

• above the cuff

• below the cuff in trachea

when is suction needed and some indications

• when pt is unable to effectively clear secretions - must be manually removed

• “noisy” (gurgly) breathing, respiratory distress, oxygen desaturation, pt request

• when the tube first comes in, suction might occur every 15-30 mins

process/location of suctioning (Step 1: oral suction)

• can be performed by SLP or nurse

• typical process involves suctioning from mouth first

• be aware of gag reflex

• use rigid oral suction adaptor (Yankuer sucker)

process/location of suctioning (Step 2: Tracheal Suctioning - below the cuff)

• getting secretions from below the cuff

• conducted by nurse, physio, SLPs need site specific training

• inserting a small suction catheter into the tube and down into the trachea

• triggers cough reflex

• sucks air from the lungs, ensure the catheter is there for less than 5 secs

• unpleasant, desaturating

process/location of suctioning (Step 3: Tracheal Suctioning - above the cuff)

• suction out secretions pooled above the cuff

• suctioning simultaneously while the cuff is being deflated - secretion catheter at the end of the tube ready to catch any dropped secretions

• nurse will insert the suction catheter

• SLP deflates tracheostomy cuff

what is a Suctionaid tube

• used to remove secretions pooled above the cuff

• in this equipment, there is a small opening in the outer cannula connected to a suction line

• secretions can be suctioned out using this suction line

• cuff remains inflated

what is the importance of cuff deflation for speech pathology

• important for communication (voicing) and swallowing

process of cuff deflation

• syringe is attached to the spring valve (on pilot balloon) and air from the cuff is withdrawn

• pilot balloon will be flat indicating cuff has been deflated

• note the volume of air (ccs/ml on syringe) removed from the cuff

• airflow re-established to upper airways

• need to allow pt a few mins to adjust to the changed airway conditions once deflated

importance of correct cuff re-inflation

• once you’ve finished the period of cuff deflation, the cuff must be re-inflated

• over-inflation - can cause trauma to tracheal tissues from compression

• insufficient inflation (under-inflation) - respiratory compromise and enhanced aspiration risk

process of re-inflation

• attaching a syringe to the spring valve on pilot balloon and inserting air into the cuff

• pilot ballon will inflate as indicator cuff is inflated

how do you know how much air to put in

• Option 1: replace what was withdrawn (least accurate method) - once familiar with a patient

• Option 2: Minimal leak technique - get the patient to voice while air is inserted into cuff until voice ceases

• checking cuff pressure: important to check cuff pressure using a manometer

  • manometer is connected to cuff pilot line to measure pressure in cuff (indicator of the pressure exerted on tracheal wall) - want to be in the green zone

2 categories that a negative impact of a tracheostomy tube can result from

medical issues that result from

1. re-direction/change of airflow

2. the physical presence of the tube in the airway

consequences of re-direction of airflow

• impact on smell & taste

  • no nasal airflow

  • olfaction is a major component of taste perception so negative impact on taste and appetite

• reduced humidification of inhaled air

  • no upper airway humidification: air is dryer and colder

• aphonia: inability to phonate

• inability to cough: absence of expiratory air passing up to larynx

• reduced laryngeal sensation: can cause blunting of cough reflex

• increased secretions: due to disruption in normal airflow, evaporation of secretions is reduced, need for oral and tracheal suctioning

consequences of the impact of the tube on trachea

• tracheal trauma

  • tracheal necrosis: high cuff pressure pressing on tracheal wall

• tracheal granuloma (short term, more common): irritation from abrasion at the stoma by the trach tube

• scarring & stenosis (longer term)

  • tissues of the trachea can become harder and narrowed

• tracheoesophageal fistulae (long term): opening in the wall between the trachea and oesophagus

• tracheomalacia (longer term): softening of the tracheal cartilage

managing nonverbal communication for tracheostomy patients

• establish a form of communication

• non-verbal communication: call bell, mouthing, gesture, writing, iPads, AAC

• make sure all people are aware of communication method & can facilitate this

managing verbal communication for those who are non-ventilated & cuff deflated

1. voicing by allowing airflow around the cuff/tube

• finger occlusion

• speaking valve/one-way valve

• used once pts can tolerate cuff deflation

2. finger occlusion

• suction, then deflate the cuff

• finger occlusion forces exhaled air out for phonation

swallow assessment for tracheostomy patients

• begin slowly, short trial durations: occlusion during expiration only, then occlusion for both inhalation and exhalation

• monitor patient tolerance of the voicing trial - this will dictate when to stop

• once a patient can successfully produce phonation using digital occlusion, a speaking valve trial can be considered

One way valves/Speaking valves

• attach to hub of trach tube only when cuff is deflated

• directs airflow to the upper airways

• inhales through the tube but is not exhaled through the tube → air goes through upper airways

• NEVER attach a speaking valve when a cuff is still inflated

process of putting on a speaking valve

• must suction, then deflate the cuff

• safety step - check patient able to voice with finger occlusion

• carefully attach speaking valve to hub of trach tube

• commence with short trials of speaking valve

what do you investigate once you re-establish speech after a tracheostomy

• bedside screening

• cognitive-communication + receptive/expressive language: potential for language impairments associated with critical injury

• assessment of language function while in ICU

• identification of any issues - referral for further screening and further assessment once progress to general ward

what could be the cause of dysphagia in a pt with a tracheostomy

• the clinical condition that lead to need for tracheostomy

  • neurological damage, impacted respiratory function

• impacts of critical care management

  • critical illness - impacts to awareness & alertness, delirium, fluctuating medical stability

  • ICU Acquired Weakness impacts proximal muscle function

  • impact of medications and side effects e.g. xerostomia

• impacts of the re-directed airway

  • inability to cough and clear airway

  • lack of airflow to the upper airway causing blunting of laryngeal and pharyngeal sensitivity

• impacts of the tube: if cuff is over inflated

what does this mean for dysphagia management: what must be determined

• whats causing the aspiration (medical condition, neurological involvement)

• nature of the aspiration (physiology of the swallow that’s disrupted and when aspiration occurs)

what tools do you use to assess swallowing in ICU

• clinical swallow assessment

• instrumental assessment: FEES

differences of a clinical swallow assessment in ICU

• need to deflate cuff & use finger occlusion or a speaking valve to allow cough + voicing

• use coloured food/fluids (blue)

• suction to check for aspiration

CSE process for a patient with a tracheostomy

• observations

• oromotor exam

• suction

• deflate cuff, suctioning after deflation

• occlude tube/attach speaking valve - check phonation & cough

• dry swallow trial

• conduct bolus trials with coloured foods/fluids (blue)

  • observe spontaneous cough

  • occlude tube post swallow - check phonation

  • suction if you believe pt has aspirated - see if any aspirated material are suctioned through the trach tube

• suction & re-inflate cuff

• monitor and consult with other professionals

how to test for penetration/aspiration

• note any spontaneous coughing or clinical signs of aspiration

• wet ‘gurgly’ voice

• suction - see any blue in secretions

• ask nursing staff to monitor secretions

what does it mean if no blue was observed from suction

• no aspiration

• very little aspiration which was not picked up by suction

how many suctions per clinical swallow exam for tracheostomy patient

• don’t exceed 2-3 suctions each session

what food/fluids to trial for people with a tracheostomy?

• same as in a usual CSE

how many consistencies to trial

• due to fatigue, 1-2 consistencies at a time

• use different colours so they can be distinguished

how much to trial

• small trials initially and build up

what should you consider regarding the pt’s alerteness and food and fluid

• cautious decision making - delay until they confirm status

• typically commence on small amount of oral trials

management & rehabilitiation of swallowing for people with a tracheostomy

• compensatory techniques

• direct interventions: strength-based rehabilitation approach

  • oromotor exercises

  • EMST (strengthen respiratory and hyolaryngeal complex) - strengthen respiratory and hyolaryngeal complex

  • Effortful swallow - efficiency/residue

  • supraglottic swallow - safety, airway protection

decannulation

• process of removing the tracheostomy tube

• tube is removed when indicators for the tracheostomy are no longer present

• once the sole decision is made of the medical team

stages to removing the tracheostomy

• Pt weaned from ventilation → decannulation

• manage full cuff deflation for 24-48 hours

criteria for determining suitability for decannulation

• based for success when managing cuff deflation trials speaking valve for 24-48 hours

how long can the process take from initial cuff deflation trial to decannulation

• usually within a week

what happens once trach is removed?

• emergency re-cannulation kit is kept close by - re-insertion available within 48 hrs post decannulation

• stoma edges are approximated and occlusive dressing are applied

  • stoma heals/closes within 10 days

  • recommend holding hand on dressing during phonation/coughing in initial period post decannulation

• pt is monitored very closely

• recommend not to change diet in the 24 hours pre and post decannulation