Principles of Neuroplasticity and Tracheostomy and Ventilator Dependency CC12

CC12 Dysphagia

Principal 1

• Use it or use it!

• “Neural circuits not actively engaged in task performance for an extended period of time begin to degrade.”

• Example = PEG - dependent patient

Principle 2

• Use it and improve it!

• “Training that drives a specific brain function can lead to enhancement of that function.”

• Patient can be taught using constraint-induced movement therapy (CIMT) to restrain a functional arm to make the patient use the hemiparetic arm as much as possible

Principle 3

• Specificity

• “The nature of the training experience dictates the nature of the plasticity.”

• Tailor the activity or exercise to produce a result in the neural circuitry

Principle 4

• Repetition matters!

• “Induction of plasticity requires sufficient repetition.”

• How much time will it take? 

• Research has indicated that it requires as much practice as possible

• Plan for as many repetitions as possible

  • 20 or 30 is not enough. 100 reps is more reasonable.

Principle 5

• Intensity matters!

• “Induction of plasticity requires sufficient intensity.”

• What is the proper dosage of therapy? How many sessions are needed?

• For example, once a week for someone with apraxia of speech is not enough

• More intense therapy is more likely to generate results and more likely for those to be maintained over time.

Principle 6

• Time matters!

• “Different forms of plasticity occur at different times during recovery.”

• Earlier is better!

• This is especially important to prevent maladaptive behaviors from forming

Principle 7

• Salience matters!

• “The training experience must be sufficiently salient to induce plasticity.”

• What the training means to the patient can affect his/her recovery

• Important for the SLP to know what is important to the patient as emotion can affect the therapy

• Helps the patient to remember the skills or what is important to him/her since the brain is already overwhelmed

Principle 8

• Age matters!

• “Training-induce plasticity occurs more readily in younger brains.”

• The younger the patient is the better!

• Younger brains are more adaptable and more plastic

• This is important to think about when working with older versus younger patients.

Principle 9

• Transference or Generalization!

• “Plasticity in response to one training experience can enhance acquisition of similar behaviors.”

• The SLP needs to understand how the behavior will transfer to the real world environment to be independent in the home.

Principle 10

• Interference!

• “Plasticity in response to one training experience can impede acquisition of similar behaviors.”

• When patients can come for therapy but it is delayed for some reason, the patient comes to the therapeutic environment with compensatory behaviors for deficits which he/she has learned but these may not be the best way to compensate

• Must teach the patient to “unlearn” these compensatory behaviors 

Inner Cannula

• Removable portion for cleaning and sanitizing

• Fits inside the outer cannula 

• May be disposable or permanent

• Patient to be suctioned when inner cannula is removed

Cuff

• Portion surrounding outside of the tube, which works like a balloon

• Can be inflated to block air from escaping or to prevent aspiration from excessive secretions (does not prevent microaspiration)

Pilot

Small balloon like piece on the outside of the neck

Parts of Tracheostomy Tube

• Inner cannula

• Cuff

• Pilot

Pilot

• Used to inflate or deflate the cuff

• Overly inflated = potentially put pressure on the esophagus and cause an obstruction

WHO CARES?

• These patients CANNOT SPEAK and will not be able to SWALLOW as trach tube tethers larynx = preventing laryngeal elevation 

• Ability to speak is highly dependent on cannula size and type

• Can be done in three ways:

  • Fenestrated cannula = has an opening which allows air to flow up through the vocal folds

  • Narrow outer cannula diameter = allows air to flow around tube and up through vocal folds

  • OR…

Speaking Values

• One way valves allow patient inhalation, but not exhalation

• Air will enter during inhalation, and will either go through fenestration or around tube during exhalation

• Do NOT place speaking valve on patient with cuffed tube unless cuff is deflated or patient has a fenestrated tube 

  • Patient will not be able to exhale = breath stacking

Speaking valve can assist patient in three ways

• Establishes a functional voice

• Aids in development of a cough

• Facilitate swallowing process = re-establishes more normal pharyngeal pressures

Talking Tracheostomy Tubes

• Patient may benefit from a “talking tracheostomy tube”

  • Allows for phonation 

  • Re-establishes ability to speak when cuff is inflated

• Method works well for patients who cannot tolerate cuff deflation and remain ventilator dependent

• Consists of typical cuffed tracheostomy tube, but it has an outside source of air

  • Injects air into laryngeal cavity when air control port is occluded 

  • Air can then be directed upward through vocal folds allowing phonation to take place

Tracheostomy Team

• Team includes attending physician, pulmonologist, nurses, respiratory therapists, physical therapists, occupational therapists, nutritionist, and speech therapist

• SLP should learn how to suction from nurses and respiratory therapist

• Working with tracheostomy and ventilator patients = SLPs must have intense training in altered anatomy and physiology, along with how process works

• SLP’s are allowed to suction patients, but should never change settings on ventilator

• SLP’s should be familiar with patient’s normal ventilator settings and report any problems to physician 

Trach

Refers to the trachea

stomy

Refers to surgical creation of an opening in a structure

tomy

refers to cutting into part of the body

Gastrotomy

Refers to cutting into the stomach

Intubation

Insertion of a tube into an organ, usually breathing tube into the trachea

Extubation

Removeal of the tube from the trachea; follows a period of warning

Decannulation

Gradually lowering the width (French) of the cannula to allow for the stoma to close

Stoma

Hole in the neck by which breathing occurs

Weaning

Gradual process of reducing the patient’s dependency on the tracheostomy tube

Button/Plug

Usually a red piece of plastic which is inserted into the end of the trach tube to direct air through the nose and mouth so that the patient is able to breathe normall

Normal Respiratory Rate

12 - 20 breaths per minute

In tracheostomy patients respiratory rate….

may be a bit higher due to respiratory compromise around 16 to 20 breaths per minute breaths per minute

Important!

To monitor O2 in the bloodstream

O2 monitoring is done by

A pulse oximeter - measured on the tip of the finger to obtain the O2 saturation rate (normal is 96%-100%)

Patients likely to have a trach

• COPD - chronic obstructive pulmonary disease 

• Cancer - especially head and neck cancer 

• Asthma

• Trauma - GSW or MVA

• Medical Debility - severe overall weakness

• CVA/TIA/AMS

• Degenerative neurological diseases - MS, MG, ALS

Endotracheal Intubation

• Tube is inserted through mouth, passes through cords and into the trachea 

• Patients are on a mechanical ventilator to control breathing

• Performed for surgical procedures where general anesthesia is being used

• Patients are not swallow candidates 

• This form of intubation is easily performed and removed, 

• If long term (14 or more days) = tracheal intubation is performed 

  • Longer endotracheal tube is in place = weaker vocal folds become, which results in poor protection during swallow

Tracheal Intubation

• Performed via tracheostomy 

• Tracheal tube surgically inserted into trachea through lower neck below level of vocal folds

• Used for chronic illness or acute airway blockage (i.e., patient choked on food)

• Width or diameter of tube comes in a variety of sizes and is measured in French (abbreviated Fr or F)

• Standard size for women is usually 10 mm in outer diameter while for men, it is 11 mm 

• Tube should be 2/3 to 3/4 the diameter of trachea

So what?

• Many trach patients will be referred to the SLP

• Obviously, there will be communication deficits 

• May also need a swallowing evaluation 

• Presence of trach tube anchors the larynx and reduces amount of laryngeal elevation, which interferes with protection during swallow

• Can also cause neurophysiological changes within laryngeal mechanism, which contributes to high rate of aspiration

• Long-term intubation is associated with high rate of pneumonia

Parts of the Tracheostomy Tube

• Depends on whether it is single or a dual cannula system 

• Single cannula systems = cases of trauma

• Dual cannulas are more common

• Outer cannula: 

  • Main portion of the tube

  • Extends from the neck 

  • Fixed in place usually with elastic tie or is sutured in place

Outer Cannula:

• Main portion of the tube

• Extends from the neck 

• Fixed in place usually with elastic tie or is sutured in place