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LA VENTILAZIONE DEL PAZIENTE TRACHEOSTOMIZZATO

PNEUMOTRIESTE 2016. LA VENTILAZIONE DEL PAZIENTE TRACHEOSTOMIZZATO. Andrea Vianello U.O. Fisiopatologia Respiratoria Ospedale – Università di Padova. TRACHEOSTOMY IN ALS. Course of ALS patient to trach. Technical aspect. Survival and QoL after trach. Trajectory 2: Progressive RF

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LA VENTILAZIONE DEL PAZIENTE TRACHEOSTOMIZZATO

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  1. PNEUMOTRIESTE 2016 LA VENTILAZIONE DEL PAZIENTE TRACHEOSTOMIZZATO Andrea Vianello U.O. Fisiopatologia Respiratoria Ospedale – Università di Padova

  2. TRACHEOSTOMY IN ALS Course of ALS patient to trach Technical aspect Survival and QoL after trach

  3. Trajectory 2: Progressive RF A progressive, reasonably predictable RF developing over a period of months. Course of Respiratory Failure in ALS Lung function Trajectory 1: Acute RF An unpredictable, acute, often severe RF requiring admission to hospital and intensive treatment. Lung function

  4. Respiratory complications related to bulbar dysfunction in motor neuron disease. S. HADJIKOUTIS, C. M. WILES ACTA NEUROLOGICA SCANDINAVICA Severe bulbar involvement Swallowing problems Ineffective cough Repeated aspiration Atelectasis Superimposed bacterial infection Acta Neurol Scand 2001;103: 207–213.

  5. ARF in ALS patients in the Respiratory Intermediate care unit/ICU • May have extreme ventilator dependency • May have severe inability to cough • May have severe risk of inhalation

  6. Reasons why it may be considered inappropriate to proceed to intubation in patients with ALS • The risk of increasing dependence on respiratory support, causing distressing and unwanted prolongation of life • The difficulty in managing the terminal stages of the disease • The tremendous demand on carers and relatives

  7. Reasons why patients with ALS and Acute Respiratory Failure usually undergo intubation and mechanical ventilation • The patient or relatives have expressed no preference about treatment and the admitting doctor is uncertain about their wishes • The patient has expressed a wish for full support in the event of respiratory failure • The disease is undiagnosed

  8. The ALSFRS predicts survival in ALS patients on invasive mechanical ventilation D. LO COCO, V. LA BELLA, T. PICCOLI, A. LO COCO Outcome of 33 Patients with Amyotrophic Lateral Sclerosis administered Endotracheal Intubation None of the patients was weaned from MV The median lenght of hospital stay was 59 days Chest, 2007;132:64-69

  9. We believe that the ability to adequately protect the upper airway is crucial to the success and safety of the weaning process and that extubation remains problematic for a significant proportion of patients with neuromyopathic conditions because of the severe risk of aspiration of food and saliva.

  10. Complications of endotracheal intubation and tracheotomy J.L. STAUFFER ONGOING RISKS FROM PROLONGED TRANSLARYNGEAL INTUBATION Respir Care 1999;44:828-843

  11. Mechanical ventilation beyond the intensive care unit AMERICAN COLLEGE OF CHEST PHYSICIAN INDICATIONS FOR INVASIVE HMV Need for round-the-clock (>20h) ventilatory support Uncontrollable airway secretions despite use of noninvasive expiratory aids 3.Impaired swallowing leading to chronic aspiration and repeated pneumonias Chest 1998;113:289s-344s

  12. TECHNICAL ASPECT • TRACHEOSTOMY TECHNIQUE • MANAGEMENT OF TRACHEAL CANNULA

  13. PERCUTANEOUS VS SURGICAL TRACHEOSTOMY

  14. Early complications of Tracheostomy. C.G.DUBIN Frequency of reported complications in RCT comparing ST and PDT Respir Care 2005;50:511-515

  15. 1 hour after decannulation 4 hours after decannulation 8 hours after decannulation

  16. Long-term follow-up of patients administered MV via percutaneous tracheostomy: personal experience There is convincing evidence to conclude that surgical tracheostomy should be preferred over the percutaneous technique.

  17. MANAGEMENT OF TRACHEAL CANNULA • CUFF MANAGEMENT • MALPOSITION • PHONATION

  18. MANAGEMENT OF TRACHEAL CANNULA • CUFF MANAGEMENT • MALPOSITION • PHONATION

  19. Courtesy of R. Marchese

  20. Excessively high cuff pressure Abnormal cuff position Courtesy of R. Marchese

  21. Constant pressure of the inflated cuff on the tracheal wall Infection Risk factors for loss of cartillagineous support in patients administered endotracheal intubation or indwelling tracheotomy with inflatable cuffs

  22. Pooling of contaminated secretions above the endotracheal tube cuff

  23. Leakage of subglottic secretions along the folds of the cuff Additional radiological contrast within the cuff area is due to occurring folds (arrows) Dullenkopf A et al. Intensive Care Med 2003;29:1849-53

  24. Excessively high cuff pressures above 25 to 35 cm H2O can result in compression of mucosal capillaries, which promotes mucosal ischemia, tracheal stenosis and malacia • Overly low cuff pressures < 18 cm H2O , may cause the cuff to develop longitudinal folds, promote microaspiration of secretions collected above the cuff, and increase the risk for nosocomial pneumonia. • Tracheostomy/endotracheal tube cuff pressures in a range of 15 to 30 cm H2O

  25. Subglottic aspiration of pooled secretions

  26. MANAGEMENT OF TRACHEAL CANNULA • CUFF MANAGEMENT • MALPOSITION • PHONATION

  27. TRACHEOARTERIAL FISTULA IN YOUNG PATIENTS WITH CHRONIC TRACHEOSTOMY TUBES: A NOTE OF CAUTION. 10 March 2006 Andrea Vianello, Giovanna Arcaro, Fausto Braccioni, Cesare Cutrone Respiratory Pathophysiology Unit, Azienda Ospedaliera di Padova, Padova, Italy, In fact, retrospective analysis of a large population of long-term tracheostomised patients followed up at our Department for over ten years revealed that the incidence of fatal tracheal haemorrhage due to TAF was clearly higher in young patients (age < 30 yrs) affected with various kinds of neuromuscular disease (9/36; 25%) compared to older patients (age > 30 yrs) with parenchymal lung and/or chest wall disorder (0/170). In particular, the incidence of TAF was surprisingly high in young patients with Duchenne Muscular Dystrophy (DMD), 29% (7/24) of whom developed a massive tracheal haemorrhage at a mean age of 20.8 ± 3.2 yrs.

  28. Tracheoinnominate fistula in a Duchenne muscular dystrophy patient: successful management with an endovascular stent. A. VIANELLO, R. RAGAZZI, L. MIRRI, G. ARCARO, C. CUTRONE, C. FITTA’ Neuromusc Dis 2005;15:569-71

  29. MANAGEMENT OF TRACHEAL CANNULA • CUFF MANAGEMENT • MALPOSITION • PHONATION

  30. PHONATION • REQUIRED A SUBGLOTTIS PRESSURE OF AT LEAST 2-3 cmH2O • REQUIRED A FLOW THROUGH THE UPPER AIRWAY > 3 L/min

  31. INSPIRATION ESPIRATION - ZEEP

  32. Comparative effects of two ventilatory modes on speech in tracheostomized patients with neuromuscular disease. H. PRIGENT, C. SAMUEL, B. LOUIS, M.F. ABINUN, F. ZERAH-LANCNER, M. LEJAILLE, J.C. RAPHAEL, F. LOFASO AJRCCM 2003;167:114-9

  33. Comparative effects of two ventilatory modes on speech in tracheostomized patients with neuromuscular disease. H. PRIGENT, C. SAMUEL, B. LOUIS, M.F. ABINUN, F. ZERAH-LANCNER, M. LEJAILLE, J.C. RAPHAEL, F. LOFASO p=0.002 AJRCCM 2003;167:114-9

  34. ? Survival and Quality of Life after tracheotomy

  35. The mean time between intubation and death was 7.4 months, (median 2.8 months, range 1 week to 3.5 years)

  36. The ALSFRS predicts survival in ALS patients on invasive mechanical ventilation D. LO COCO, V. LA BELLA, T. PICCOLI, A. LO COCO Median survival time: 48 months Median survival time: 10 months Long-term survival after TIPPV according to ALSFRS score Chest, 2007;132:64-69

  37. 2010, July 22 non bulbar 60 patients 1 bulbar 0.9 0.8 0.7 Median: 24.2 mo 0.6 0.5 Probability 0.4 0.3 Median: 19.2 mo 0.2 0.1 0 0 1 2 3 4 5 6 7 8 9 10 Survival (yrs) Mean time between tracheostomy and death The median survival after tracheostomy was 21.1 months. The survival rate was 65% by 1 year, and 45% by 2 years

  38. Pts liberated from MV and tracheostomy Pts liberated from MV Partially dependent pts Ventilator-dependent pts Hospital and Long-term Outcome After Tracheostomy for Respiratory Failure M. ENGOREN C. ARSLANIAN-ENGOREN, N..FENN-BUDERER 24% hospital survivors died by 100 days, 30% died by 6 months Chest. 2004;125:220-227

  39. Non-bulbar pts Bulbar pts Total No readmission 4 (22%) 4 (36%) 8 (28%) Less than one readmission/yr 11 (61%) 7 (64%) More than one readmission/yr 3 (17%) Emergency readmission after tracheostomy 18 (62%) - 3 (10%) [Personal data]

  40. 50% HOME ALTERNATIVE FACILITIES 48% 45% 40% 34% 35% 30% 25% 20% 15% 10% 7% 4% 5% 3% 2% 2% 0% Self Family Non Professional Nursing Residential Nursing sufficient carers professional non nursing care care home carers carers Eurovent 2002

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