trachs, vents, and passy-muir
DESCRIPTION
This is from a short inservice given to the Therapy dept. at SJRMCTRANSCRIPT
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Trachs, Vents, and Passy-Muir Valves
Charles Williams, RRT
Hillary Beck, SLP
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Types of Tubes(Most commonly seen here)
• Cuffed Shiley
• Uncuffed Shiley
• Fenesrated Trachs
• Fome Trach– Cuff inflates with negative pressure– Cuff cannot be deflated– Contraindication for PMV
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Tube Parts
• Outer Cannula• Inner Cannula (disposable and non)• Cuff (cuffed trachs only)• Pilot Balloon (cuffed trachs only)• Flange: Size and type found here• Obturator (At bedside in case of need to reinsert
the trach)• Cap (AKA Button, plug, cork)• Trach ties
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Tube Sizes• Dependent on size of patient, vent/support needs
and surgeon’s selection• Hard to ventilate patients will have larger tubes
and size will be decreased with weaning away from the tube
• Smaller people may have smaller tracheas and vice versa
• Average size is a 6• #8 or larger may contraindicate PMV placement
due to limited space around the tube through which to move air into the upper airway
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Fenestrated Tubes
• Primarily for patients without respiratory failure
• A fenestration is a hole in the outer cannula of the tube
• The fenestration allows air to go into the trach that will be directed up through the vocal cords
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Cuffed versus Uncuffed TrachsNote: Patients can sometimes voice around their trachs (if cuffless or if
the cuffed trach tube is deflated).
• Seals trachea off from vocal cords, mouth, and nose
• Allows delivery of support without resistance
• Mostly seen in vent dependent patients
• Allows airflow through vocal cords, mouth, and nose
• Mostly seen once patients are weaned off the vent and beginning the downsizing process
• Used for sleep apnea, trauma patients, etc (Patients without respiratory failure)
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Trach Cuffs
• A syringe is used to inflate and deflate the cuff via the pilot balloon.
• A cuff is fully deflated when the pilot balloon is flat and no more air comes out into the syringe
• A cuff should be re-inflated using minimal leak technique (by trained clinicians only), when no more air can be heard in the upper airway. This can also be done using a manometer.
• Over-inflation of a cuff can cause tracheal trauma and/or stenosis
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Mechanical Ventilation
Indications:
• Apnea or impending respiratory failure(ARDS, CHF, Status Asthmaticus, Neuromuscular disease)
• Acute Respiratory Failure:– Hypoxemic respiratory failure (Type I failure)
– Hypercapnic respiratory failure (Type II failure)
• Prophylactic Support:(Post-op, Post MI, Brain injury, etc.)
• Hyperventilation Therapy (Acute head injury)
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Mechanical Ventilation
Minimum required settings:– Mode (Pressure Control, SIMV, etc.)
– Respiratory rate (# breaths per minute)
– Tidal Volume (volume delivered per breath in ml’s)
– FIO2 (inspired oxygen percentage)
Additional settings: Pressure Support, PEEP
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Mechanical Ventilation
– Considerations
Pressure mode vs. Volume mode
Control mode vs. Support mode
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Modes of Ventilation
Spontaneous breathing
– Sinusoidal waveform– No ventilator support
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CPAPContinuous Positive Airway Pressure
PEEPPositive End Expiratory Pressure
Modes of VentilationCPAP/PEEP
5 5
– Applied during spontaneous breathing– Used to treat OSA
– Applied during ventilator breaths
Improves oxygenation by “holding” the alveoli open.
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Modes of VentilationPressure Support/CPAP
– Adds a set amount of pressure to spontaneous breaths to enhance tidal volume
– All breaths are patient triggered– Used alone or with other modes such as SIMV
5
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Modes of VentilationSIMV/PS
Synchronized Intermittent Mandatory Ventilation
– Weaning mode
– Allows for combined ventilator timed breaths patient triggered breaths
– Pressure support is usually added to spontaneous breaths
5
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Volume Control Pressure Control
Modes of VentilationControl Modes
5 5
– All breaths are delivered at a preset volume
– All breaths are delivered at a preset amount of pressure.– Used for stiff, non-compliant lungs, i.e. ARDS
– Control modes are not used for weaning. – Breaths that are triggered by the patient are identical to ventilator breaths.
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Weaning Indicators
– Resolution of acute phase of disease– FIO2 of 40% or less, Peep 5-10– Stable vital signs– Stable ABG’s (minimal acidosis)– No continuous IV sedation– Adequate cough– RSBI less than 100
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Weaning Indicators RSBI (Rapid Shallow Breathing Index)
– Reliable predictor of weaning outcomes– Pt is allowed to breath without vent support for 1
minute, RR is then divided by exhaled tidal volume– Normal value is < 100– Performed on all vent patients every a.m. in
conjunction RN sedation vacation– Not performed on patients in Pressure Control mode
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Ventilator WeaningControl mode Combined Support mode
Pressure ControlVolume Control
PRVC
SIMV/PS Pressure Support/CPAP
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Approaches to Weaning
– Spontaneous Breathing Trials
– Decreasing levels of Pressure Support
– Decreasing SIMV rate
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Approaches to Weaning
Spontaneous Breathing Trials:
The patient is removed from the vent and placed on T-Bar or left attached to the ventilator and placed on Flow-By mode.
The patient’s vitals are monitored during the trial, usually for 30-120mins
Example order: May attempt SBT on T-Bar x 30 min as tolerated, BID
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Approaches to Weaning
Decreasing Levels of Pressure Support:
Pressure Support level is slowly decreased over time
When the patient has tolerated a pressure support level of 5 -7cm H2O for 2-4 hours, the patient is considered weaned
Example order: Wean pressure support by 2 every 6-8 as tolerated. Maintain RSBI < 100. Lowest pressure 5cm H2O.
*PS of 5 maintained to overcome airway resistance from breathing tube
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Approaches to Weaning
Decreasing SIMV rate:
The SIMV rate is decreased by 2 breaths/min every 4-6 hours as tolerated
When the SIMV rate is down to 4, and is tolerated for 2-4 hours , the patient is then considered for extubation or changing to pressure support mode
Example order: Wean IMV rate by 2, every 4-6 hours as tolerated. Maintain RR < 30 w/ no respiratory distress
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Passy Muir Valves (PMV)
• When is the patient ready?– The patient is alert and attempting to
communicate AND/OR– The patient is weaning OR
• Usually (at a minimum) to SIMV, if rate is low enough
– The patient has weaned to T-bar and would benefit from the stimulation of hearing their own phonation
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PMV
• One way valve– Allows air/support in through trach tube– Prevents air/support out through trach tube– Redirects expiration through cords, mouth, nose (upper
airway)– Restores positive airway pressure for swallowing– Reduces aspiration – Reduces tracheal secretions– Allows phonation– Reduces vent weaning and decannulation time
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PMV Contraindications
• Inflated cuff or fome cuff
• Unconscious/comatose patients
• Severely medically unstable patients
• Airway obstruction/stenosis
• Unmanageable secretions
• Severe aspiration risk
• Severely reduced lung compliance
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PMV Placement
• Select appropriate valve (Aqua or purple)– We try to fit those who will wean with purple
• Suction as needed• Deflate cuff fully• Suction as needed• Try finger occlusion phonation trials• Place PMV with or without adaptor with a quarter,
clockwise turn– Replace tubing or collar
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PMV Trial
• Closely monitor patient and vitals– O2 Sats– Respiratory rate– Effort of breathing– Heart rate– Color of patient– Signs of distress– Negative changes
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Reasons for Failure with/Intolerance to PMV
• Trach tube is too large• Stenosis, granulation tissue, or vocal fold paralysis• Patient needs more training to relearn phonation
with the PMV• Thick and/or copious secretions• Inability to tolerate cuff deflation• Vent requirements/support needs too high for
PMV placment
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PMV and PT/OT/Nursing• Once a patient has been cleared by SLP to wear
the valve without supervision, it should be worn during all waking hours (unless otherwise indicated)
• Ask nursing to place the PMV if you are not comfortable doing so yourself
• Benefits– Improves communication– Builds confidence– Reduces anxiety– Facilitates independence and improves locus of control
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What if the PMV pops off?• The valve can come off due to hard coughing or
the weight of the T-bar• If there are visible secretions, have the patient
suctioned or the trach wiped clean before replacing the valve
• Reattach the valve using a ¼ clockwise turn. Do Not force it on.
• If you are not comfortable ask nursing/SLP to replace the valve
• Feel free to arrange cotreatments with speech anytime