Review of NIV

masks/tracheostomies and

respiratory equipment (Phew!) KATY BUCHAN

NIV LEAD/ SENIOR RESPIRATORY PHYSIOTHERAPIST BRISTOL HOME NIV SERVICE UNIVERSITY HOSPITALS BRISTOL NHS TRUST

Aims

NIV Masks

MAC

LVR

MI:E

Tracheostomy

NIV Masks

Leak: Is mouth gaping open?: Can cause decreased tolerance with dry mouth:

consider type of mask, humidifier, chin strap

Consider more than one mask to preserve bridge of nose or Mouth Piece

Ventilation: nasal pillows and bridge avoiding mask

Consider Tissue viability: sill tape/Comfeel dressing/barrier cream/change mask

Consider if care giver willing to apply NIV, turn on/off (never assume)

Consider magnet masks if UL function reduced: Wisp, N20, F20

Cough Assessment and

management

Based on cough mechanics

Treatment clinically reasoned

Treatment individualised

Treatment should be reviewed regularly for effectiveness evaluation

MAC: Key messages

Achieve maximum inspiratory pressure/volume

The more restricted the VC/PCF the more significant improvement

when combining MI:E with MAC

Timing of cough is essential

Use thoracic thrust, thoraco-abdominal thrust, or bilateral

costophrenic angle thrust, forearm (think body position, wrist

position reduce to avoid injury)

Need; cooperative patient, good coordination, adequate physical

effect

Most carers achieve the same MAC as therapists (Shikawa, 2008)

Manually assisted cough

Can be used easily and effectively

Expiration only

Abdominal thrust/anterior chest compression (research shows more effective): aim for up and in direction.

Bilateral costophrenic thrust (Good in wheelchairs, but check breaks are on!): aim for down and in direction.

Under utilized!!

Manually assisted cough

Problems:

Post abdominal surgery/Osteoporosis

Severe scoliosis/Obesity

PEG’s/RIG’s

Suprapubic Catheters

Labour intensive

Requires synchronisation

Can injure carer

Manually assisted cough

If patients have a decreased vital capacity, manually assisted

cough is not optimal unless preceded by a maximal lung insufflation.

LVR

Equipment (single patient use)

Bag valve mask (BVM) (1.5L bag)but with 1 way valve (lets air in/not

out so you can breath stack

50cc tubing

Catheter mount fused on the end

Filter (infections)

Mouthpiece or facemask

Not for resuscitation label

May have safety pressure release valve

How often should LVR be used?

Optimum daily frequency is unknown. In DMD at least twice daily

decreased rate of decline of VC.

Often recommended 1-4 times/day of 3-5 breath cycles and prn

Avoid

Hyperventilation (at least 10 minutes between sessions): symptoms of

dizziness/light-headedness

Fatigue

Less than 1 hour use after food

Recipe for success

Patient signal should be followed to avoid volume trauma

Maintain eye contact with patient

Synchronise with the patients breath

Use correct interface

MI:E Treatment

Insufflation (positive pressure on breath in) for approximately 2 seconds

Exsufflation (negative pressure) between 3-6 seconds (usually 3)

At least 1 second between cycles

4-6 breaths in one cycle

Manual v. automatic v. cough track mode

Advise the prophylactic benefit of daily use 2-4 x/day

Can combine manually assisted cough on ex-sufflation

+40: -40cmH20 recommended pressure (always use high flow), consider oscillation (Bach group recommends higher 60+!)

May need valve system on Peg if trapped air problematic

Technique

Before begin explain procedure to patient and establish a signal for full insufflation (Hand raise or eye widening)

Sitting/half lying-30-45 degrees head up

Head supported

Ensure a good mask seal/nose clip if using mouth piece (monitor skin integrity)

Encourage patient to breathe in and hold whilst gently squeezing the bag to enhance their inspiration. This breath stack may need between 2-4 times to achieve maximum insufflation (patient may feel stretch)

Remove to a0llow cough (or exhalation)

Combine with manually assisted cough (MAC)

Consider expectoration/suction

Mechanical insufflation: Exsufflation

(MI:E)

Detailed assessment by an experienced respiratory physiotherapist is

essential

Mask size selection essential

Outcome measure: Thoracic expansion, cough quality, augmented

PCF, number of infections

Always set multiple programmes for patients to self treat during infections

Continually Re-assess Cough

Check PCF with adjunct

Auscultate and feel for expansion

Add in MAC if sub-optimal cough

Can the patient use the treatment, do you need to train carer’s

Care of LVR, MI: E: mask washing etc.

Tracheostomy

Sancho et al. (2011): over 50% of patients had the tracheostomy during

an acute chest infection following intubation (Not on NIV).

The mean survival after tracheostomy was 10.76 months, which was

similar to the mean survival when tracheostomy was carried out

electively.

Of 24 patients who had a tracheostomy and invasive ventilation 90% said they would choose this again!

Physiological effects

Decreases upper airway dead space by 150ml that’s 50%

Therefore decrease WOB and improves alveolar ventilation

Local irritation causes increased mucous production

Splinting of larynx by tube causes difficulty swallowing

Loss of natural humidification/ Bypass nose and mouth

Tracheostomy verses Mouthpiece

Regular debate at congress

Bulbar function in-tact?

Able to protect airway?

Patient preference

Tolerance of NIV

Community support

Tracheostomy

Need a circuit compatible cuffed tube for use with positive pressure

and prevent aspiration

Cuffed Tubes Considerations

1. Cuff should be inflated if on NIV, Cuff should be inflated until no leak is heard

2. Cuff should not be over inflated (25mmhg)

3. Cuff should be re-inflated for resuscitation and MHI

4. If the patients Tracheostomy is occluded/blocked off and the cuff is up the patient will not be able to breathe

5. The cuff needs to be deflated for speaking, eating and drinking following a SALT assessment.

Humidification

Tracheostomy bypasses the natural warming and moistening of the air.

Humidification occurs in the ciliated epithelial cells in the nose and upper airways.

Artificial moistening is required. Tracheostomy patients are often on O2, which is a cold dry gas.

Methods: HME, Humidified O2 or protector

Ventilator

Licencing tracheostomy

24 hour Licence

Adult v Kids

Battery power

Ease of use

Fits on wheelchair etc..

Alarm’s

Service/breakdown cover

Dual limb/ single limb

Single limb with expiratory port

Double limb: inspiratory limb and expiratory limb

Day/night circuits

Humidified

Sputum clearance

Nebulized agents

Tracheostomy: Checklist

Have you optimised ventilation

Capacity and decisions

Is the home situation and home care appropriate

Optimising overall health pre-op

Plan the hospital admission

Correct ventilator, circuit and tube essential

Patient communication method

Post-op optimisation: could include lower Vent/MI:E settings

Carer training/equipment sourcing

Safe facilitation of discharge

Problem Solving

If a patient with a Tracheostomy is in distress – Always check the tube for a blockage: give O2, change inner tube and suction.

If patient is still distressed – The outer tube may need changing

If patient arrest – Remember their airway is the Tracheostomy tube therefore bag over stoma and ensure cuff is inflated.

If the Tracheostomy tube falls out – Dilators, O2, put in tube or one smaller, fast bleep anaesthetist if in hospital

Check ventilator working, check circuit, check air entry, change ventilator.

Questions?

References

Bach (1993) 104 (5) 1553-1562

BTS/ACPRC guidelines (2009) Thorax 64 Supp. 1

Ishikawa (2008) AJ Phy Med rehab 87 (9) p726-730

Kang (2005) Yonsei Medical Journal 46 (2) 233-238

Kang and Bach (2000) A J Phy Med Rehab 79 (3) 222-227

Sivasothy (2001) Thorax 56 438-444

Touissant (2009) Respiratory care 54 (3) p359-366

References

American Thoracic Society (ATS) Clinical practice guidelines

Bach J.R. Eur Respi J. 2003;21:385-386

Concalves M.R.Am. J. Phys. Med. Rehabil. Vol 84, 2:90-91

Concalves M.R. Secretion management. Ventilatory support for chronic respiratory failure. 2008

Vanello A.,Corrado A., Gallan et al. Am j Phys Med Rehabil 2005; 84: 83-88.

Winck J.C., Concalves M.R et al. Chest 2004: 126:774-780

Tracheostomies: an overview.

Reference List

Anderson, Anderson and Glanze (1998). Mosby’s medical, nursing and allied health dictionary. Fifth edition. Harcourt Brace and Co Ltd.

Bach, J. R. (1993) IPPV via the mouth as an alternative to tracheostomy for 257 vent users. Chest, 101: 174-182.

Buglass, E (1999). ‘Tracheostomy care: tracheal suctioning and humidification’ British Journal of Nursing, 8, 8, 500-504.

Dixon, L (2001). ‘Tracheostomy: Postoperative Recovery.’ Perspectives in nursing www.perspectivesinnursing.org/v1n1/Dixon.html

Elpern, E H, Borkgren-Okonek, M, Bacon, M, Gerstung, C and Skr\ynski, M (2000). ‘Effect of the Passy-Muir tracheostomy speaking valve on pulmonary aspiration in adults.’ Heart and Lung, 29, 4, 287-292.

Harkin, H (1998). ‘Tracheostomy management.’ Nursing Times, May 27, 94, 21, 56-58.

Heffner, J E (1995). ‘Critical procedures: number 115: The technique of weaning from tracheostomy.’ The Journal of Critical Illness, 10, 10, 729-733.

Heffner, J E and Hess, D (2001). ‘Tracheostomy management in the chronically ventilated patient.’ Clinics in ches medicine, 22, 1, 55-69.

Lyons, RJ and Yuska, C M (no date given). Tracheostomy Care. Shiley Inc, USA and Shiley Howmedica, Belgium.

McConnell, EA (2000). ‘Do’s and Don’t’s: Suctioning a tracheostomy tube.’ Nursing 2000, 30, 1, 80.

Pijl-Zieber (1997). Tracheostomy Care: An Introduction. www.langara.bc.ca/vnc/tach.htm