trach-vent dysphagia

Altered Airways

  • Tracheostomy and Mechanical Ventilation

  • COPD

  • Considerations for Dysphagia Assessment and Management

Anatomy Review

  • Trachea

    • Length: 10-14 cm in adults, consists of 15-20 C-rings of cartilage

    • Incomplete at the esophageal wall, shares a common wall with the esophagus

    • Terminates at the carina, bifurcating into right and left main stem bronchi

    • Joins with larynx at C6, bifurcates at T5

    • Mucosa: Innermost layer with cilia and mucus-producing cells (damaged by smoking)

    • Submucosa: Contains mucus-producing glands

Trachea and Lungs

  • Bronchi Structure

    • Right and left main stem bronchi extend to their respective lungs; right is shorter, wider, and more vertical

    • Bronchi branch into secondary bronchi (3 on right, 2 on left)

    • Further divides into bronchioles, terminal bronchioles, respiratory bronchioles, leading to alveoli

    • Gas Exchange occurs in alveoli

Indications and Goals for Tracheotomy

  • Prevent Injury to the larynx from prolonged endotracheal (ET) tube use

  • Long-term ventilator support, with timing for tracheotomy typically between 10-14 days

  • Ensure a patent airway, manage chronic aspiration

  • Access for secretion removal; not the primary choice for emergency access

Endotracheal Tube vs. Tracheostomy Tube

  • Endotracheal Tube: Typically used for short-term ventilation

  • Tracheostomy Tube: Suitable for long-term use

Tracheotomy Procedure

  • Typical placement is just inferior to the cricoid cartilage

  • Surgical Tracheotomy: Requires general anesthesia, with incision and tube placement

  • Percutaneous Tracheotomy: Can be performed in OR or ICU with sedation and progressive dilation; not able to replace a lost tube easily

Tracheostomy Tube Features and Types

  • Various types exist; sizing systems may differ

    • Diameter, Length, Angle

    • Standard hub is 15 mm; can get adaptors

    • Cuffed vs. cuffless options available

      • Cuffed: Promotes air seal; high-volume, low-pressure preferred

      • Foam cuffs self-inflate to fit the trachea

      • Fenestrated Tubes: Consider inner cannula and placement

Effects/Complications of Tracheostomy Tubes and Cuffs

  • Complications

    • Airflow redirection causes secretion control problems, bypassing natural filtration and hydration systems

    • Cuff over-inflation can lead to necrosis and trauma

    • Sensory impairments due to decreased chemoreceptor stimulation

    • Long-term use leads to desensitization of the larynx, unproductive cough, and granulomas/scarring

Tracheostomy and Aspiration

  • Discusses whether cuffs prevent aspiration and identifies contributing factors like intubation and underlying conditions

  • High incidence of aspiration in tracheostomized patients, with significant silent aspiration

Mechanical Ventilation Overview

  • Positive Pressure Ventilation: Includes ventilators that push gas into the lungs, raising intra-alveolar pressure

    • Types: Volume-cycled, pressure-cycled, time-cycled

  • Negative Pressure Ventilation: Creates a vacuum outside the body to assist breathing

  • Modes of Ventilation: Controlled mode, Assist Control Ventilation, Intermittent Mandatory Ventilation (IMV), and CPAP/BiPAP

Ventilator Settings

  • Tidal Volume: Air amount per breath; adjustments based on gas results

  • Inspiratory/Expiratory Ratio: The time relationship between phases

  • FIO2: The percentage of oxygen provided

  • Sigh Breath: Adds volume at intervals; mimics natural breathing

Speaking Valves

  • One-way valves to restore positive pressure; cuff must be deflated first

  • Increased coughing may occur initially; aim to increase tolerance

Tracheostomy and Swallowing

  • Importance of cuff presence and size/type for airflow

  • Poor respiratory support can affect swallowing, with issues related to laryngeal function

  • Consider the implications of ventilator settings on swallowing

COPD and Aspiration Risks

  • Higher incidence of aspiration and swallowing coordination issues linked to COPD

  • Management strategies including texture modifications and breathing exercises

Surgical Management of Aspiration

  • Tracheostomy and laryngeal stenting as potential interventions

References

  • Weiner et al. study on muscle training programs in COPD