Tracheostomy prevention

Different auxiliary methods of administration can be used in conjunction with nebulizers to deliver aerosol to the patient [144]. A mouthpiece may be inserted in the mouth or a face mask may be attached tightly to the face. A large-bore inlet adapter attaches tubing from the nebulizer outlet to the mouthpiece or mask. It is possible to compensate for exhaled aerosol without increasing resistance to prevent condensation. A face tent fits more loosely around the patient s mouth, allowing speech. The latter arrangement is frequently used with ultrasonic nebulizers. A tracheostomy mask may be fitted to the patient s tracheostomy tube directly and requires a T-shaped adapter. Environmental chambers are used to enhance therapy and include incubators, pediatric croup tents, and hoods. 

Fig. 23-9. This patient is recovering from bubonic plague that disseminated to the blood (septicemic form) and the lungs (pneumonic form). Note the dressing over the tracheostomy site. At one point, the patient s entire body was purpuric. Note the acral necrosis of (a) the patient s nose and fingers and (b) the toes. Photographs Courtesy Ken Gage, Ph.D., Centers of Disease Control and Prevention, Fort Collins, Colo.

Bulbar muscle dysfunction should he evaluated in all patients with ALS. Apart from rating scales like the ALSFRS (101), one of the best ways to measure muscle dysfunction objectively is by comparing the MIC with the VC and the PEF with the PCF. The wider the gradient, the better the hulhar function (33,35). Bach has shown that in ALS, the ahdity to generate assisted PCF > 180 L/min and to have a high MIC to VC difference is associated with the capacity to use continuous NIV (36). However, when strictly tailored NIV and mechanically assisted cough do not prevent oxygen desaturation below 95%, aspiration is likely and tracheostomy should be offered (10). 

Preventive actions and assessment are related to systematic follow-up, especially just after discharge, including physical, psychosocial, social, and cognitive dimensions. In patients on HMV, it is mandatory to try to solve specific needs like tracheostomy care or acute care during exacerbations. Home visits need a more complete appraisal of the situation in which prolonged mechanical ventilation (PMV) is carried out. The health care professional has more time at patient s home. With more information, it is easier to restructure care plans after the home visit, rather than after consultation in the hospital. Service coordination is very important when several professionals participate in the care of patients on HMV. 

Lloyd-Owen SJ, Donaldson GC, Ambrosino N, et al. Patterns of home mechanictil ventilation use in Europe results from the Eurovent survey. Eur Respir J 2005 25 1025-1031. Yaremchuk K. Regular tracheostomy tube changes to prevent formation of granulation tissue. 

Heffner JE. The technique of weaning from tracheostomy. Criteria for weaning practical measures to prevent failure. J Crit Illn 1995 10(10) 729-733. 

Careful patient selection prevents unsafe levels of alveolar hypoventilation with subsequent hypoxemia and hypercapnea, especially if the tidal volume leakage is >20%. Any compensatory increase in respiratory rate and shortened expiratory time, attributable to the air leakage, may aggravate dynamic hyperinflation, especially among patients with airflow obstruction (15). Ventilator-supported speech has been reported in patients with neuromuscular diseases (NMD) and intact bulbar function (16-19). The physiologic characteristics that enable this population to tolerate ventilator-supported speech include little or no decrease in chest wall or lung compliance and the absence of airflow obstmction. Therefore, patients with NMD may be ventilated with a deflated or cuffless tracheostomy tube accepting the modest compromise in alveolar ventilation (16,20-22). Patient populations, such as those with chronic obstructive pulmonary disease may be able to tolerate cuff deflation for short periods provided there is adequate supervision. 

Oxygen alone, although preventing the nocturnal desaturation, often results in unacceptably high levels of Pcx>2. Diuretics and tracheostomy alone, although providing a temporary improvement, will at best delay the need for mechanical ventilatory support. 

Klastersky J, Huysmans E, Weerts D, Hensgens C, Daneau D. EndotracheaUy administered gentamicin for the prevention of infections of the respiratory tract in patients with tracheostomy a double-blind study. Chest 1974 6 650-654. 

Under general anaesthesia tracheostomy is performed and ventilation continued via a cuffed tracheal tube. The patient is placed in the recumbent position, the skin of the mouth and nose and mucosa of the oropharynx are cleaned with iodine solution. A Whitehead retractor is placed into the mouth for a possible maximal retraction and the tongue depressed by a special attachment. The naso- and hypopharynx are packed off to prevent blood entering the paranasal sinuses or the oesophagus during operation. 

At the end of the operation a nasogastric tube is passed and is usually required for four days. The oral cavity is packed for a few days to prevent post-operative haematoma. The tracheostomy tube remains for 4-5 days, depending on the oedema of the palate and tongue. The combined antibiotic therapy commenced preoperatively, is continued in the post-operative period. 

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