Dysphagia Exam 2: Tracheostomy and Swallowing
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What is endotracheal intubation?
What does it provide?
What are 2 indications?
Is it long-term or temporary? How long?
- Insertion of tube into mouth or nose passing through pharynx and vocal folds into trachea
- Artificial airway to connect to mechanical vent
- Airway protection & mechanical vent.
- Temp.; 14-21 days
What are some complications of ORAL endotracheal intubation? (7)
- Trauma to lips, gums, lips, tongue, pharynx, larynx
- Vocal fold damage: direct, cuff overinflation
- Hypoxemia: Lack of oxygen to tissues
- Left lung collapse
- Esophageal intubation (putting in wrong way, distension)
- Rupture of esophagus
- Cardiac complications
What are some complications of NASAL endotracheal intubation? (2)
Long-term complications? (7)
- Otitis media and conductive hearing loss
- Pressure necrosis (skin breakdown)
- Granulomas (lumps forming into polyp)
- Stenosis (narrowing)
- Laryngeal web (membranous formation)
- Glottic incompetence (protection)
- Endotracheal tube cuffs
- Tracheal stenosis (narrowing of trachea)
What is a tracheotomy?
What are indications (needs for trach)? (6)
- Surgical placement of plastic or metal tube into trachea to create an airway
- Decannulation risk
- Secretion removal
- Reduced risk of laryngeal complications
- Improved weaning from mech. vent.
- Increased options for oral communication and feeding
Indications for tracheotomy cont. (9)--more serious
- Paralysis of muscles affecting swallow causing danger of aspiration
- Prolonged intubation
- Subglottic stenosis from prior trauma
- Obstruction from obesity for sleep apnea
- Congenital abnormality of larynx or trachea
- Severe neck/mouth injuries
- Inhalation of corrosive material smoke or steam
- Presence of large foreign body that occludes airway
- long term unconsciousness or coma
Procedure of trach
- General anesthesia
- Incision at 2nd or 3rd tracheal ring
- Tube size based on age, weight, height
Complications of ETT--Explain why
- Related to abrasion at stoma site (58%)
- Softening of cartilage of trachea due to erosion of tracheal rings
- Narrowing that occurs with healing (infection, tube changes, tugging on tube, large stoma)
- Necrosis of tracheal and esophageal wall which forms passageway between GI tract & airway
Materials of trach tubes?
- PVC- single use
- Silicone- sterilized and reused
- PVC mixed with silicone
- Metal (nondisposable)
Parts of trach tube
- outer and inner cannula
- Flange (neck plate, holds tube in place)
- Obturator (eases insertion)
- Button (occludes tube used for weaning)
- Cuff (prevent air escape)
Types of trach tubes--Explain them
- Cuffed or cuffless, single or multiple fenestrations, allows air to pass from trachea through fenestrations to vf, improves phoantion, not used for those high risk of aspiration, use in decannulation
- Attached to inflation line leading to pilot balloon, used during mech. vent., reduces risk of aspirated secretions entering trachea, fenestratrated/nonfenestrated, high volume, low pressure
- Single-outer cannula only, provides least airway resistance
- Double- Used with outer and inner--standard tube
- Extra long- Single, special needs patients (stenosis, malacia, anatomy changes, burns)
Trach tube variations
Other trach tubes?
- Size, tube angle, cuffs (high volume low pressure, shape, fit to tube), Flange (swivel, shape, material), inner cannula (texture, connection)
- Talking trach tube--vent dependent, can't tolerate cuff deflation; external air tube connected to compressed air, provides continuous airflow for speech
- Tracheal buttons- maintain open stoma after trach removal; maintains opening in trach wall
1-way valve allows air to enter trachea on inspiration, valve closes on expiration directing air upward through vf; phonation or cough/clear throat
Impact of trach on swallowing?
- Complications inherent in population who may need trach
- Reduced laryngeal excursion (horizontal incision, decreased BOT--pressure and disuse, weight of equipment, cuff inflation (drags tracheal wall over, partial esophageal obstruction, disruption of esophageal pressures due to changes in timely CP relaxation and opening)
Saliva and secretion management with trach/swallowing?
- Medications specific to trach and ventilator dependent patients may lead to xerostomia
- Increased secretions (upper airway filtering and humidification bypassed), chronic lung disease, lack of fluid intake (dehydration)
Physiologic impact on swallowing
- Disruption of airway pressures resulting in pharyngeal residue (1-way valves normalized pressures for less impact)
- Reduction of airflow through glottis (elimination of expiratory airflow to clear residue from airway, loss of laryngeal sensation, disco ordination of glottic closure response--w/in 3 months)
Effects of mech. vent. on swallowing
- Disruption of normal apneic interval (vent may force air in when vf closure is occurring, disruptions swallow sequence)
- Tube feedings/intubation (premorbid dysphagia patients more at risk, difficulty tolerating extubation due to decreased airway protection; feeding tubes increase aspiration risk; NPO increases potential for bacteria (ORAL CARE)
- GI bleeding from stress ulcers (physical and emotional stress)
Oral feeding and cuff inflation
Aspiration: Cuff inflation does NOT prevent aspiration--incomplete seal, accumulation of aspirated material at top of cuff, destruction of cilia (remove mucus and aspirated contents, destroyed at cuff inflation site)
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