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• Numero 02 • Anno I • Dicembre 2006 Selezione ARIR INTERNATIONAL AFFILIATE Poste italiane s.p.a. - Spedizione in Abbonamento Postale - D.L. 353/2003 (conv. In L. 27/02/2004 n.46) art.1, comma 2, DCB Milano. da e AARC Times Anatomy and Physiology of Tracheostomy Scott K Epstein MD Tracheostomy Tubes and Related Appliances Dean R Hess PhD RRT FAARC Facilitating Speech in the Patient with a Tracheostomy Dean R Hess PhD RRT FAARC EDIZIONI DIRETTORE RESPONSABILE EDITOR IN CHIEF GIOVANNI OLIVA [email protected] REDAZIONE EDITORIAL STAFF ANTONELLA SANNITI, ANDREA TETTAMANTI RESPONSABILI SCIENTIFICI SCIENTIFIC ACCOUNTEES ENRICO CLINI, ELENA REPOSSINI BOARD EDITORIALE EDITORIAL BOARD ANNA BRIVIO, PAOLA CAPONE, MARTA CORNACCHIA, PAMELA FRIGERIO, MARTA LAZZERI, GIANCARLO PIAGGI, MAURIZIO SOMMARIVA, SERGIO ZUFFO ARIR: www.arirassociazione.org AARC: www.aarc.org EDITORE EDITOR ARIR EDIZIONI ASSOCIAZIONE RIABILITATORI DELL’INSUFFICIENZA RESPIRATORIA UNITÀ SPINALE A.O. OSPEDALE NIGUARDA CA’ GRANDA MILANO PIAZZA OSPEDALE MAGGIORE 3 20162 MILANO IMPAGINAZIONE E PRESTAMPA INK GRAPHICS COMMUNICATIONS S.R.L. VIA IV NOVEMBRE, 52/A 20019 SEGURO DI SETTIMO M.SE (MI) STAMPA OFFICINA GRAFICA S.R.L. VIA DELLA MECCANICA, 6 VIGANO DI GAGGIANO 20083 (MI) REG. TRIBUNALE DI MILANO N.967 06-07-06 DEL Il periodico “Selezione ARIR da Respiratory Care e AARC Times” costituisce il secondo impegno editoriale dell’Associazione Riabilitatori dell’Insufficienza Respiratoria (ARIR). Le motivazioni di questa realizzazione si delineano nell’ambito dell’attività di didattica e aggiornamento che l’associazione svolge ormai da 20 anni. È proprio realizzando corsi per Fisioterapisti in molti ospedali italiani che l’Associazione ha conosciuto direttamente quali sono i principali problemi ed ostacoli che il Fisioterapista incontra nel processo continuo di aggiornamento in materia di Fisioterapia e Riabilitazione Respiratoria. Uno degli aspetti cruciali per mantenersi “al passo con i tempi” ,oltre a partecipare a corsi specifici, è rappresentato dalla possibilità di entrare in contatto con esperienze e realtà più evolute ma al tempo stesso applicabili alla realtà italiana. I criteri di valutazione e monitoraggio, le tecniche operative, gli approcci e le metodiche sono ciò che il Fisioterapista deve acquisire per incrementare l’efficacia del suo intervento. La realtà della Fisioterapia e Riabilitazione Respiratoria è molto diversa da paese a paese ed in particolare rispetto alla realtà americana e questo rende l’aggiornamento un’operazione complessa e difficoltosa oltre che onerosa. L’ARIR dagli inizi della sua costituzione si è posta tra i vari obiettivi anche quello di ridurre le difficoltà e facilitare l’aggiornamento dei Fisioterapisti Italiani organizzando corsi e convegni a cui ha invitato e invita numerosi colleghi stranieri, esperti nei diversi ambiti della Fisioterapia e Riabilitazione Respiratoria, promuovendo così lo scambio culturale e professionale tra le diverse realtà europee e anche extra-europee. Con la realizzazione di “Selezione ARIR da Respiratory Care e AARC Times” l’ARIR intende rispondere ulteriormente e in modo concreto ad una esigenza centrale della formazione: l’accesso alle pubblicazioni scientifiche. Questo periodico offre a chi si occupa di Fisioterapia e Riabilitazione Respiratoria la possibilità di accedere ad alcune delle pubblicazioni scientifiche della American Association for Respiratory Care (AARC), selezionando quelle più vicine alla realtà italiana. “Selezione ARIR da Respiratory Care e AARC Times” è un periodico semestrale che nasce dalla volontà congiunta di ARIR e AARC frutto dell’affiliazione delle due Associazioni e sarà distribuito gratuitamente ai soci ARIR e verrà pubblicato nel website dell’Associazione www.arirassociazione.org nello spazio riservato ai soci. A nome del Direttivo ARIR Il Presidente ARIR Ft Marta Lazzeri The review "ARIR selection from Respiratory Care and AARC Time" is the second editorial engagement of the Italian Associazione Riabilitatori della Insufficienza Respiratoria (ARIR) The reasons of this workmust be found in the educational and updating activity that the association has been developing from more than 20 years. The association has directlyknown, during its courses which are the principal problems and obstacles in many italian hospitals. Above all, the necessity of a continuous updating in physiotherapy and respiratory care. In addition to attend specific courses, one of the meaning aspect to bring up to date, is to meet more developed experiences and reality suitable to the italian ones. The evaluation criteria and the operative techniques are the elements that any physiotherapist must study to ameliorate the efficacy of his/her job. The reality of physiotherapy and respiratory care is very different from country to country, particularly from the US one, thus making the updating a very difficult and expensive operation. From the beginning, one of ARIR objective has been that of making easy the updating of the italian physiotherapists, thus organizing events on specific topics (courses and congress). So far, many foreign people, experts in physiotherapy and respiratory care, has been invited from ARIR with the goal of promoting the cultural and professional exchange from european and extra European experiences. With the realization of "ARIR selection from Respiratory Care and AARC Time", ARIR wants to answer in a concrete way to a principal exigence of the professional education: the access to the scientific articles. This review offers to people who are encharged in physiotherapy and respiratory care the access to scientific articles of the American Association for Respiratory Care (AARC), selecting the ones closer to the italian reality. "ARIR selection from Respiratory Care and AARC Time" is a six month review born from the ARIR and AARC agreement, and it will be distributed for free to the ARIR members and published in the ARIR website (www.ariassociazione.org) in the page reserved to its members. From the Board of Directors The President of Arir Marta Lazzeri PRESIDENTE PRESIDENT AND FOUNDING MEMBER DALLO STATUTO DELLA ASSOCIAZIONE FROM THE STATUTE OF THE ASSOCIATION: Art. 1: è costituita l’Associazione Riabilitatori dell’Insufficienza Respiratoria (A.R.I.R.). Art.1: The Associazione Riabilitatori dell’Insufficienza Respiratoria (A.R.I.R.) was established in Milan on October 25, 1989. MARTA LAZZERI [email protected] VICE PRESIDENTE VICE PRESIDENT AND FOUNDING MEMBER GIOVANNI OLIVA [email protected] SEGRETERIA SECRETARY ANNA BRIVIO [email protected] TESORIERE TREASORER ALESSIA COLOMBO CONSIGLIERI BOARD PAMELA FRIGERIO GIANCARLO PIAGGI ELENA REPOSSINI ANTONELLA SANNITI MAURIZIO SOMMARIVA SERGIO ZUFFO CONSIGLIERI ONORARI HONORARY BOARD ROBERTO ADONE MONICA BASSI ANDREA BELLONE ITALO BRAMBILLA Art. 3: l’Associazione non ha finalità di lucro e intende promuovere la prevenzione e la riabilitazione delle patologie respiratorie. Per il conseguimento dei suoi scopi l’Associazione concorre a: • Diffondere in campo clinico terapeutico e home care, la pratica della fisioterapia e riabilitazione respiratoria. • Organizzare la formazione, l’aggiornamento, il coordinamento, la promozione dello sviluppo professionale dei fisioterapisti con specifiche competenze in ambito respiratorio. • Sostenere in campo scientifico e sociale l’educazione e l’igiene respiratoria. • Promuovere la ricerca scientifica nel campo della fisioterapia e della riabilitazione respiratoria. Art. 4: sono soci le persone e gli enti che verranno ammessi dal Consiglio e che verseranno la quota di Associazione. Art. 5: i soci si dividono in quattro categorie: 1. soci fondatori 2. soci ordinari 3. soci sostenitori 4. soci onorari Sono soci fondatori coloro che hanno sottoscritto l’atto Costitutivo dell’Associazione e coloro i quali pur non avendo sottoscritto l’atto costitutivo sia attribuita dal Consiglio tale qualifica. Sono soci ordinari i fisioterapisti accettati dal Consiglio direttivo e che versano annualmente la quota associativa stabilita Sono soci sostenitori persone fisiche e giuridiche che intendono sostenere gli scopi che l’Associazione si prefigge. Sono soci onorari le persone e gli enti ai quali il Direttivo attribuisce tale qualifica, ritenendole in grado, per qualità, titoli o attività, di dare all’Associazione un contributo d’opera o di prestigio. Art. 6: l’Associazione trae mezzi per conseguire i propri scopi dai contributi dei soci e da ogni altro provento che le confluisca. Art. 9: i soci hanno diritto: di partecipare alle assemblee e di usufruire del materiale tecnico e didattico dell’Associazione, così come, in via prioritaria, di beneficiare delle iniziative promosse dall’Associazione, Art.3: PURPOSE OF THE ASSOCIATION ARIR is a no profit entity, promoting the prevention and rehabilitation of respiratory disease. In order to do this ARIR strives to: • Promote the practice of respiratory therapy and pulmonary rehabilitation within the clinical and therapeutic fields; • Organize the training, continuing education, coordination, and the promotion and the professional development of physiotherapist having specific competencies in the respiratory fields; • Support respiratory care understanding the hygiene within the scientific and social realms; • Promote scientific research in the field of physiotherapy and respiratory rehabilitation. Art. 4: All persons and entities that are accepted by the Board of Directors and who pay the associational fee are considered members. Art. 5: There are four categories of membership: 1. Founding members 2. Regular members 3. Sustaining members 4. Honorary members. Those who have taken part in the signing of the associational statute and those whom, thought not having signed the statute, are deemed valid candidates by the Board of Directors are founding members. Physiotherapists accepted by the Board of Directors and who pay the established yearly associational fee are considered regular members. Natural and juridical persons who wish to support the pre-established purpose of the association are considered sustaining members. Persons and entities to which the Board of Directors deems such status appropriate, for reasons of capabilities, qualities, titles or activities able to give the Association a contribution of work or prestige, are considered honorary members. Art. 6: The Association obtains the means of carrying out its purpose from the contributions of its members and from any other proceeds going towards it. Art. 9: MEMBER RIGHTS The members have the right to: participate at he assemblies, utilize the technical and teaching materials of the Association, as well as enjoy, as privileged members, the benefits of the activities promoted by the Association. New collaboration between ARIR and AARC On behalf of the American Association for Respiratory Care (AARC) I want to welcome you to the result of a new partnership between ARIR and AARC, the first issue of Selezione ARIR da Respiratory Care e AARC Times. In this publication you will find manuscripts which have been published in AARC’s peer reviewed science journal, Respiratory Care. These manuscripts have been selected by ARIR for your benefit in an effort to offer more education to those who provide respiratory care services in Italy and are members of ARIR. Even though the American Association for Respiratory Care is comprised primarily of respiratory therapists, we recognize and respect the many other health care professionals around the world such as physiotherapists, respiratory therapy physiologists, physicians and nurses who provide these services. Twenty countries from all parts of the world collaborate through the AARC International Council. ARIR is one of its members, of course. Through the Council we have engaged with the ARIR leadership and have now developed a partnership which will permit ARIR to select manuscripts published in Respiratory Care as well as articles published in another monthly publication by AARC which is called AARC Times. We hope that you will find the information contained in the first issue of Volume One to be useful in your practice. Moreover, we look forward to providing even more opportunities to learn about respiratory care by making more materials available to you from Respiratory Care Journal and AARC Times in the future. While we all recognize that throughout the world we may be separated by distance, culture, and language, we also recognize that respiratory patients deserve the best care possible. Toward that end, we are delighted to collaborate with other organizations such as ARIR in order to provide increased access to information regarding the treatment of these patients. If you wold like to subscribe to either of our publications please feel free to visit the AARC website at www.aarc.org/resources/subscritions for more information. The AARC is grateful for the recognition that ARIR has given it and we will endeavor to do our utmost to provide you with the latest information about all aspects of respiratory care. On behalf of the AARC we hope you find the new partnership with ARIR and the opportunity to access articles of interest to you in your practice of value. Sam Giordano executive director AARC executive office Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 1 Affiliation of ARIR to AARC has also been carried out through its adhesion to the International Council for Respiratory Care. ARIR is representing Italy within ICRC through Sergio Zuffo, respiratory physiotherapist member of ARIR's board of directors. www.irccouncil.org MISSION STATEMENT The International Council for Respiratory Care (ICRC) is dedicated to advancing the safe, effective and ethical practice of respiratory care worldwide through the following initiatives: • Promoting the art, science, clinical practice and educational foundation required for the attainment of high quality respiratory care outcomes in all nations; • Developing and disseminating evidence-based standards of care according to the special needs and resources of individual nations; • Facilitating interaction among and between the allied health professions, nursing, the medical specialties, hospitals and clinics, service companies and industry; • Encouraging the creation and growth of related respiratory care organizations in individual nations, and • Providing educational resources for patients, caregivers and the general public in respiratory health promotion, disease prevention and rehabilitation as appropriate in individual nations. STRATEGIC GOALS 1. 2. 3. 4. 5. 6. 7. 8. 2 Establish a global, real time, bi-directional communication system Enhance and facilitate the acquisition of information relevant to the clinical practice of respiratory care Promote respiratory education Establish transparent operational policies and procedures Identify and secure appropriate resources Develop a marketing and public communications plan Assist with the development and promulgation of safe and ethical practice standards and clinical protocols for respiratory care Develop and make available educational materials for the public on health promotion and disease prevention Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 Anatomy and Physiology of Tracheostomy Scott K Epstein MD Respir Care 2005;50(3):476—482. © 2005 Daedalus Enterprises Introduction Anatomy Physiology Humidification Airflow Resistance Respiratory Mechanics in Bench Studies Tracheostomy Compared to the Native Upper Airway Tracheostomy Compared to Translaryngeal Endotracheal Intubation Summary The trachea is easily accessible at the bedside. As such it provides ready access for emergency airway cannulation (eg, in the setting of acute upper airway obstruction) and for chronic airway access after laryngeal surgery. More commonly, tracheostomy tubes are placed to allow removal of a translaryngeal endotracheal tube. Tracheostomy tubes have an important effect on respiratory physiology. The most recent and methodological robust studies indicate that these tubes reduce resistive and elastic work of breathing, when compared to endotracheal tubes. This is a result of tracheostomy tubes lessening inspiratory and expiratory airways resistance and intrinsic positive end-expiratory pressure. Whether these physiologic benefits are of clinical importance in enhancing weaning success remains to be elucidated. Key words: tracheostomy, resistance, elastance, work of breathing, mechanical ventilation, weaning, extubation. [Respir Care 2005;50(3):476 – 482. © 2005 Daedalus Enterprises] Introduction The trachea is easily accessible at the bedside. As such it provides ready access for emergency airway cannulation (eg, in the setting of acute upper-airway obstruction) and for long-term airway access after laryngeal surgery. More commonly, tracheostomy tubes are placed to allow re- Scott K Epstein MD is affiliated with the Department of Medicine, Caritas-St Elizabeth’s Medical Center, Tufts University School of Medicine, Boston, Massachusetts. Scott K Epstein MD presented a version of this paper at the 20th Annual New Horizons Symposium at the 50th International Respiratory Congress, held December 4–7, 2004, in New Orleans, Louisiana. Correspondence: Scott K Epstein MD, Department of Medicine, Caritas-St Elizabeth’s Medical Center, 736 Cambridge Street, Boston MA 02135. E-mail: [email protected]. moval of a translaryngeal endotracheal tube (ETT). The procedure can be done surgically or percutaneously, and with either technique the procedure can be performed in the operating room or at the bedside in the intensive care unit (ICU). Anatomy The lower respiratory tract starts at the vocal cords. Inferior to the vocal cords, the rigid cricoid cartilage encases a 1.5–2.0-cm region known as the subglottic space. Access to this space is possible via the cricothyroid ligament, a membrane that runs from the thyroid cartilage inferiorly to the cricoid cartilage. Inferior to cricoid is the trachea, a cylindrical tube that extends inferiorly and slightly posteriorly. The trachea is made up of 18 –22 C-shaped rings consisting of rigid cartilage anteri- Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 3 Fig. 1. Major landmarks in the neck. (From Reference 3, with permission.) orly and laterally, and a membranous posterior portion. In the average adult, the distance from cricoid to carina is approximately 11 cm in length, with a range of 10 –13 cm. On average, the trachea is 2.3 cm in width and 1.8 cm from posterior membrane to the anterior cartilaginous aspect. The trachea is wider in men than in women.1,2 In examining the landmarks of the neck, it is evident that the trachea is protected by strap muscles (sternohyoid, sternothyroid, sternocleidomastoid) and bony structures (manubrium and sternum) (Fig. 1).3 Furthermore, the trachea is positioned posterior to a number of blood vessels and the thyroid isthmus. Branches of the bronchial, inferior thyroid, innominate, and subclavian arteries provide the blood supply to the trachea.1,2 Knowledge of neck and tracheal anatomy is essential for understanding the various approaches to establishing a tracheostomy (Fig. 2).4 As an example, surgical tracheostomy tubes are typically placed in the region of the 2nd to 4th tracheal rings and may entail removal of tracheal cartilage or the creation of a cartilaginous flap. Percutaneous tracheostomy tubes are typically placed between the 1st 4 and 2nd or between the 2nd and 3rd tracheal cartilages. The technique takes advantage of the Seldinger method, followed by progressive dilation of the space between tracheal rings to provide access to the trachea. Another approach is to place a tube through the cricothyroid membrane (cricothyroidotomy).5 Though still used extensively in some centers, in other centers it has been replaced by percutaneous tracheostomy. Cricothyroidotomy can be used to gain emergency access to the airway, but its association with numerous complications has led some to advocate replacing this tube within 48 –72 hours with a standard tracheostomy. The procedure is carried out by a transverse incision through the skin and the membrane and then spreading the incision vertically to allow placement of the tube. Because the cricothyroid membrane is bounded by 2 rigid structures (thyroid cartilage and cricoid cartilage) that are not easily dilated, the height of this membrane limits the size of the tube that can be placed. In addition, the curve of a standard adult tracheostomy tube and the close soft tissue distance between anterior skin and trachea (at the level of the cricothyroid membrane) causes Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 Epiglottis Hyoid bone Thyrohyoid membrane chronic inflammatory changes.6 Lack of adequate humidification also leads to desiccation of the tracheal mucosa and reduced ciliary function. Indeed, by these actions and by diminishing effective cough and increasing secretions, tracheostomy tubes predispose to respiratory-tract infection. Furthermore, these tubes also hamper effective swallowing, thereby predisposing to aspiration. Airflow Resistance Thyroid cartilage In studying the physiologic effects of the tracheostomy tube, one may examine pristine tubes in vitro using a lung model. Alternatively, in vivo investigations have been conducted comparing the effects of tracheostomy to spontaneous breathing through the native upper airway, breathing before and after tracheostomy decannulation, or to breathing through an ETT. Investigators have also examined the work of breathing (WOB) imposed by the tracheostomy. Airflow resistance of the normal upper airway is substantial, constituting up to 80% of total airway resistance during nose breathing and 50% during mouth breathing. Theoretically, tracheostomy tubes should decrease airflow resistance, but in fact this does not occur because of the smaller radius (inner diameter 7– 8 mm) of the tubes. Tracheostomy tubes may reduce dead space by up to 100 mL, when compared to spontaneous breathing.6 This occurs because the tubes are small and bypass the glottic and supraglottic spaces. The resistance to flow of gas through a tube, represented by the Poiseuille equation, is directly proportional to length, while being inversely proportional to the radius of the tube raised to the 4th power (when flow is laminar). When flow becomes turbulent, airways resistance becomes inversely proportional to the radius of the tube raised to the 5th power. Indeed, at flows above 0.25 L/s, flow becomes turbulent when the inner diameter of a tube is ⬍ 10 mm.7 Thus, small reductions in tube radius result in large increases in resistance. Turbulent flow occurs when flow rates are high, when secretions adhere to the inside of the tube and because of tube curvature. When compared to the ETT, the tracheostomy tube has the potential to decrease the resistive WOB. Tracheostomy tubes are shorter, more rigid, less likely to be deformed in the upper airway (by being placed below the vocal cords and the rigid structures of the subglottic region), and are easier to keep clean (they more effectively facilitate airway suctioning and removal of secretions). By decreasing resistance, expiratory flow can be enhanced, and the tendency to dynamic hyperinflation and the development of intrinsic positive end-expiratory pressure (PEEP) is reduced. Therefore, when compared to ETTs, tracheostomy tubes have the potential to also reduce the elastic WOB. Humidification Respiratory Mechanics in Bench Studies As with an ETT, many changes in airway physiology occur with insertion of a tracheostomy tube. Bypassing the nasal airway, these artificial airways disturb the normal humidification and warming of inspired air. Therefore, air must be humidified using heated humidifiers or heat-andmoisture exchangers. In the absence of adequate humidification, the trachea develops squamous metaplasia and Davis et al examined WOB in a bench lung model study comparing endotracheal and tracheostomy tubes with the same inner diameter.8 “Question mark” shaped ETTs were used to simulate the tortuous route that these tubes often take in vivo. With either type of tube, WOB and pressure drop across the tube increased as flow rate increased (leads to turbulence) and as tube diameter decreased. At high Cricothyroid ligament Cricothyroidotomy Cricoid cartilage Subcricoid space Percutaneous tracheostomy 1st 2nd Standard tracheostomy Tracheal rings 3rd Fig. 2. Anterior oblique view of larynx and trachea. The preferred anatomic locations for placing standard tracheostomy, percutaneous tracheostomy, and cricothyroidotomy are indicated. (From Reference 4, with permission.) the tip of the tube to impinge on the posterior membrane of the trachea. Physiology Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 5 Tracheostomy Compared to the Native Upper Airway How does flow across the tracheostomy tube compare with that of the spontaneous airway? Older studies found that airways resistance was greater with a tracheostomy than when breathing across the normal airway.10 –12 More recently, Haberthur et al studied 10 medical ICU patients breathing spontaneously through tracheostomy tubes.13 To determine the pressure drop across the tracheostomy tube and the imposed WOB (ie, the additional WOB attributable to the tube), the investigators passed a thin, 1.6-mm catheter through the lumen of the tube. A linear interpolation algorithm was applied to correct for the pressure drop induced by this special catheter. While breathing on a continuous positive airway pressure circuit, the pressure drop across the tracheostomy tube was as high as 20 cm H2O when inspiratory flow rates exceeded 10 L/min. This represented a substantial increase in the expected pressure drop across the native upper airway, of 1.2 cm H2O at a flow of 0.3 L/s and 5.2 cm H2O at a flow of 2.0 L/s. Indeed, the imposed WOB was increased at higher flow rates, reaching a level sometimes associated with failure to wean from mechanical ventilation (Fig. 3).13 Similarly, Davis et al found that WOB increased after extubation and then was reduced again after placement of a tracheostomy tube.14 In the studies discussed thus far, physiologic calculations were made as the patient breathed through the tracheostomy. What happens when the tracheostomy is in place but the patient must breath around the tube? This exact circumstance often occurs during trials to assess readiness for decannulation, when the tracheostomy tube is capped. In a single case physiologic study, Criner et al 6 Imposed WOB (J/L) flow rates of 1–1.5 L/s, WOB was less through the tracheostomy tube. Presumably the longer ETT magnified the effects of turbulent flow on airways resistance. At lower flow rates (0.5 L/s) the benefit of shorter tube length for the tracheostomy was apparently counterbalanced by the increased curvature of those tubes, leading to no difference in the WOB. In studying ETTs, Wright et al found that in vivo resistance exceeded in vitro resistance.9 This resulted from deformation of these thermolabile ETTs and the adherence of secretions to the inner lumen of the tube (thereby increasing turbulence and narrowing the tube radius). Similarly, Yung and Snowdon demonstrated in vitro that the pressure drop across a tracheostomy tube (and therefore the resistance), at any given flow rate, was greater for a crusted tube than a clean tube.7 These investigators also compared 3 different types of tracheostomy tubes and found greatest resistance with the tube that was longer, had a shorter radius of curvature, and a rougher inner surface. Low High Minute Ventilation Fig. 3. Imposed work of breathing (WOB) during spontaneous breathing through a tracheostomy tube at 2 different levels of ventilation. (Adapted from Reference 13.) examined the effect of mouth breathing while a capped, fenestrated, tracheostomy tube was in place, with the balloon deflated.15 Airways resistance and the tension-time index were higher with the tube in place, when compared to breathing with a capped Montgomery tube or after decannulation (Fig. 4). Other studies have compared respiratory mechanics of breathing through the tracheostomy and mouth breathing (without the tracheostomy in the airway). To determine the effect of then removing the tracheostomy tube, Chadda et al examined 9 neuromuscular patients who underwent decannulation.16 With removal of the tube (eg, mouth breathing), resistance and elastance were unchanged, but dead space increased from 156 mL to 230 mL, tidal volume (VT) and minute ventilation increased (PaCO2 was unchanged), and WOB increased by 30%. Moscovici da Cruz et al studied 7 patients who underwent surgical tracheostomy for malignancy, 3 of whom had tumors of the larynx and tonsils not felt to be causing upper-airway obstruction.17 When compared to spontaneous breathing, tracheostomy was associated with a trend toward lower resistive WOB and reductions in elastic WOB, intrinsic PEEP, and pressure-time product. Tracheostomy Compared to Translaryngeal Endotracheal Intubation Tracheostomy, compared to translaryngeal endotracheal intubation, has been purported to have many physiologic benefits, including improved patient comfort, more efficient airway care (improved airway suctioning), better oral care, and provision of a more secure airway, allowing for safe patient transfer out of the acute-care ICU.18,19 One of the most important benefits is the potential to improve patient liberation from mechanical ventilation. Failure to wean often results from an imbalance between reduced Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 Tension Time Index Raw (cm H2O/L/S) WOB (J/L) PEEPi (cm H2O) Fig. 4. Airways resistance (Raw) and tension-time index while breathing through a tracheostomy tube, a Montgomery tube, and after decannulation. (Adapted from Reference 15.) Fig. 5. Work of breathing (WOB) in joules per liter (J/L) before (with endotracheal tube) and after tracheostomy (T) tube placement in 8 patients. (From Reference 25, with permission.) Fig. 6. Intrinsic positive end-expiratory pressure (PEEPi) before (with endotracheal tube) and after tracheostomy (T) tube placement in 8 patients. (From Reference 25, with permission.) respiratory muscle capacity and increased WOB.20,21 Even in patients without pre-existing lung disease, the WOB imposed by artificial airways can lead to iatrogenic weaning failure.22 In those with substantial underlying disease, slight reductions in imposed WOB resulting from placement of a tracheostomy may be important. Therefore, comparison of WOB through the ETT and the tracheostomy tube is of critical importance. In a study before and after tracheostomy in 20 mechanically ventilated patients with chronic obstructive pulmonary disease, Lin et al found that, when compared to ETTs, tracheostomy tubes were associated with a lower peak airway pressure (33 cm H2O vs 29 cm H2O), but there was no difference in WOB, pressure-time product, or airways resistance.23 Mohr et al studied 45 surgical ICU patients before and after tracheostomy during mechanical ventilation with combined synchronized intermittent mandatory ventilation and pressure support.24 No differences were found in respiratory rate, VT, minute ventilation, peak airway pressure, dead space, or blood gases. Furthermore, no differences were noted in these variables when patients weaned within 72 hours of tracheostomy were compared to those remaining on ventilation ⬎ 5 days postoperatively. In contrast to these studies, 2 superbly performed investigations indicate that tracheostomy does offer physiologic improvements, when compared to translaryngeal ETTs. Diehl et al examined 8 medical ICU patients (3 with diaphragmatic weakness, 2 with chronic obstructive pulmonary disease, 1 with asthma, 3 with coma) who had been ventilated for a mean of 31 days.25 Patients were studied 24 hours prior to and 6 hours after surgical tracheostomy, at 3 different ventilator settings: baseline pressure support; 5 cm H2O above baseline pressure support; and 5 cm H2O below baseline pressure support. The diameter of the inner cannula of the tracheostomy tube was identical to the inner diameter of the removed ETT (8 mm in 7 patients, 7 mm in 1 patient). Tracheostomy was associated with trends in reductions in VT, respiratory rate, and minute ventilation. At all pressure-support levels, tra- Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 7 Table 1. Table 2. Respiratory Variables Before and After Tracheostomy in 20 Surgical Intensive-Care Patients Inner Diameter, Length, and Dead Space of Endotracheal and Tracheostomy Tubes Variable Before Tracheostomy After Tracheostomy p Tube Type VT (mL) V̇E (L/min) f (breaths/min) PEEPi (cm H2O) PTP (cm H2O 䡠 s/min) WOB (J/L) WOB (J/min) Exp Raw (cm H2O/s) 329 ⫾ 104 9.2 ⫾ 3.0 28 ⫾ 5 2.9 ⫾ 1.7 236 ⫾ 122 0.97 ⫾ 0.32 8.9 ⫾ 2.9 9.4 ⫾ 4.1 312 ⫾ 119 8.1 ⫾ 3.1 26 ⫾ 6 1.6 ⫾ 1.0 155 ⫾ 101 0.81 ⫾ 0.46 6.6 ⫾ 1.4 6.3 ⫾ 4.5 0.47 0.26 0.51 0.02 0.09 0.09 0.04 0.07 Endotracheal No. 6.0 No. 7.0 No. 8.0 No. 8.5 Tracheostomy* Size 4 Size 6 Size 8 Size 10 VT ⫽ tidal volume V̇E ⫽ minute volume f ⫽ respiratory rate PEEPi ⫽ intrinsic positive end-expiratory pressure PTP ⫽ pressure-time product WOB ⫽ work of breathing Exp Raw ⫽ expiratory airway resistance (From Reference 14, with permission.) cheostomy was associated with a decrease in the airwayocclusion pressure, a measure of respiratory drive. Moreover, reductions in both resistive WOB (Fig. 5) and elastic WOB, as indicated by a reduction in intrinsic PEEP (Fig. 6), occurred with placement of the tracheostomy. The latter physiologic benefits may explain the improvement in patient-ventilator synchrony seen in 3 patients who had frequent trigger asynchrony while breathing through an ETT. Davis et al studied 20 surgical ICU patients (14 men, 6 women, mean age 58 years) with acute lung injury, ventilated for a mean of 16 days, who met extubation criteria but had failed extubation twice before the decision was made to proceed with tracheostomy.14 Eighty percent of these patients had a #8 (8 mm inner diameter) ETT, while the remainder had a #7 (7 mm inner diameter) tube. Physiologic measurements were made 6 – 8 hours before and 10 –12 hours after placement of a surgical tracheostomy. Tracheostomy was associated with trends in reduction in pressure-time product and expiratory airways resistance (Table 1). Importantly, as in the study by Diehl et al,25 WOB (J/min) and intrinsic PEEP decreased after placement of the tracheostomy. Assuming equivalent inner diameter, reductions in resistive WOB most likely result from the reduction in tube length in going from ETT to tracheostomy tube (Table 2). Although dead space is also lower with tracheostomy, the magnitude is quite limited. Tracheostomies differ from ETTs because the former may have a removable inner cannula. This inner cannula allows for easy removal and cleaning and occludes the fenestration to allow for effective mechanical ventilation. Cowan et al used a lung model to compare the physiologic effects of nonfenestrated tubes with and without the inner cannula.26 Tubes of various sizes were studied during different ventilator settings (respiratory rate 12, 24, and 36 8 ID (mm) Length (cm) Dead Space (mL) 6.0 7.0 8.0 8.5 31.5 34.5 35.5 36.5 11.0 15.0 18.0 24.0 5.0 7.0 8.5 9.0 10.0 12.0 12.0 12.0 3.0 5.0 6.0 8.0 *Tracheostomy tube size is not equal to inner diameter. ID ⫽ inner diameter (From Reference 14, with permission.) breaths/min, VT 300 and 500 mL). Not unexpectedly, WOB decreased when the inner cannula was removed. Summary Tracheostomy tubes have an important effect on respiratory physiology. The most recent and methodological robust studies indicate that these tubes reduce resistive and elastic WOB when compared to ETTs. This is a result of tracheostomy tubes lessening inspiratory and expiratory airways resistance and intrinsic PEEP. Whether these physiologic benefits are of clinical importance in enhancing weaning success remains to be elucidated. REFERENCES 1. Rood S. Anatomy for tracheotomy. In: Myers E, Stool SE, Johnson JT, editors. Tracheotomy. New York: Churchill Livingstone; 1985: 89–97. 2. Streitz JM Jr, Shapshay SM. Airway injury after tracheotomy and endotracheal intubation. Surg Clin North Am 1991;71(6):1211–1230. 3. Heffner JE, Sahn SA. The technique of tracheostomy and cricothyroidotomy. J Crit Illness 1987;2(1):79–87. 4. Silvestri GA, Colice GL. Deciding timing and technique for tracheostomy. Contemp Intern Med 1993;5(3):20–31. 5. Johnson J. Alternatives to tracheotomy: cricothyroidotomy. In: Myers E, Stool SE, Johnson JT, ed. Tracheotomy. New York: Churchill Livingstone; 1985:83–88. 6. Motoyama E. Physiologic alterations in tracheostomy. In: Myers E, Stool SE, Johnson JT, editors. Tracheotomy. New York: Churchill Livingstone; 1985:177–200. 7. Yung MW, Snowdon SL. Respiratory resistance of tracheostomy tubes. Arch Otolaryngol 1984;110(9):591–595. 8. Davis KJ, Branson RD, Pormebka D. A comparison of the imposed work of breathing with endotracheal and tracheostomy tubes in a lung model. Respir Care 1994;39(6):611–616. 9. Wright PE, Marini JJ, Bernard GR. In vitro versus in vivo comparison of endotracheal tube airflow resistance. Am Rev Respir Dis 1989;140(1):10–16. Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 10. Cavo J, Ogura JH, Sessions DG, Nelson JR. Flow resistance in tracheotomy tubes. Ann Otol Rhinol Laryngol 1973;82(6):827–830. 11. Cullen JH. An evaluation of tracheostomy in pulmonary emphysema. Ann Intern Med 1963;58:953–960. 12. Kim BM FH. Tracheostomy and physiologic dead space in emphysema. Clin Res 1962;10:258. 13. Haberthur C, Fabry B, Stocker R, Ritz R, Guttmann J. Additional inspiratory work of breathing imposed by tracheostomy tubes and non-ideal ventilator properties in critically ill patients. Intensive Care Med 1999;25(5):514–519. 14. Davis K Jr, Campbell RS, Johannigman JA, Valente JF, Branson RD. Changes in respiratory mechanics after tracheostomy. Arch Surg 1999;134(1):59–62. 15. Criner G, Make B, Celli B. Respiratory muscle dysfunction secondary to chronic tracheostomy tube placement. Chest 1987;91(1):139–141. 16. Chadda K, Louis B, Benaissa L, Annane D, Gajdos P, Raphael JC, Lofaso F. Physiological effects of decannulation in tracheostomized patients. Intensive Care Med 2002;28(12):1761–1767. 17. Moscovici da Cruz V, Demarzo SE, Sobrinho JB, Amato MB, Kowalski LP, Deheinzelin D. Effects of tracheotomy on respiratory mechanics in spontaneously breathing patients. Eur Respir J 2002; 20(1):112–117. 18. Astrachan DI, Kirchner JC, Goodwin WJ Jr. Prolonged intubation vs. tracheotomy: complications, practical and psychological considerations. Laryngoscope 1988;98(11):1165–1169. 19. Heffner JE. Tracheotomy application and timing. Clin Chest Med 2003;24(3):389–398. 20. Vassilakopoulos T, Zakynthinos S, Roussos C. The tension-time index and the frequency/tidal volume ratio are the major pathophysiologic determinants of weaning failure and success. Am J Respir Crit Care Med 1998;158(2):378–385. 21. Jubran A, Tobin MJ. Pathophysiologic basis of acute respiratory distress in patients who fail a trial of weaning from mechanical ventilation. Am J Respir Crit Care Med 1997;155(3):906–915. 22. Kirton OC, DeHaven CB, Morgan JP, Windsor J, Civetta JM. Elevated imposed work of breathing masquerading as ventilator weaning intolerance. Chest 1995;108(4):1021–1025. 23. Lin MC, Huang CC, Yang CT, Tsai YH, Tsao TC. Pulmonary mechanics in patients with prolonged mechanical ventilation requiring tracheostomy. Anaesth Intensive Care 1999;27(6):581–585. 24. Mohr AM, Rutherford EJ, Cairns BA, Boysen PG. The role of dead space ventilation in predicting outcome of successful weaning from mechanical ventilation. J Trauma 2001;51(5):843–848. 25. Diehl JL, El Atrous S, Touchard D, Lemaire F, Brochard L. Changes in the work of breathing induced by tracheotomy in ventilator-dependent patients. Am J Respir Crit Care Med 1999;159(2):383–388. 26. Cowan T, Op’t Holt TB, Gegenheimer C, Izenberg S, Kulkarni P. Effect of inner cannula removal on the work of breathing imposed by tracheostomy tubes: a bench study. Respir Care 2001;46(5):460– 465. Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 9 Tracheostomy Tubes and Related Appliances Dean R Hess PhD RRT FAARC Respir Care 2005;50(4):497—510. © 2005 Daedalus Enterprises Introduction Metal Versus Plastic Tracheostomy Tubes Tracheostomy Tube Dimensions Tracheostomy Tube Cuffs Changing the Tracheostomy Tube Fenestrated Tracheostomy Tubes Dual-Cannula Tracheostomy Tubes Percutaneous Tracheostomy Tubes Subglottic Suction Port Stoma Maintenance Devices Mini-Tracheostomy Tubes Summary Tracheostomy tubes are used to administer positive-pressure ventilation, to provide a patent airway, to provide protection from aspiration, and to provide access to the lower respiratory tract for airway clearance. They are available in a variety of sizes and styles, from several manufacturers. The dimensions of tracheostomy tubes are given by their inner diameter, outer diameter, length, and curvature. Differences in length between tubes of the same inner diameter, but from different manufacturers, are not commonly appreciated but may have important clinical implications. Tracheostomy tubes can be angled or curved, a feature that can be used to improve the fit of the tube in the trachea. Extra proximal length tubes facilitate placement in patients with large necks, and extra distal length tubes facilitate placement in patients with tracheal anomalies. Several tube designs have a spiral wire reinforced flexible design and have an adjustable flange design to allow bedside adjustments to meet extra-length tracheostomy tube needs. Tracheostomy tubes can be cuffed or uncuffed. Cuffs on tracheostomy tubes include high-volume low-pressure cuffs, tight-toshaft cuffs, and foam cuffs. The fenestrated tracheostomy tube has an opening in the posterior portion of the tube, above the cuff, which allows the patient to breathe through the upper airway when the inner cannula is removed. Tracheostomy tubes with an inner cannula are called dualcannula tracheostomy tubes. Several tracheostomy tubes are designed specifically for use with the percutaneous tracheostomy procedure. Others are designed with a port above the cuff that allows for subglottic aspiration of secretions. The tracheostomy button is used for stoma maintenance. It is important for clinicians caring for patients with a tracheostomy tube to understand the nuances of various tracheostomy tube designs and to select a tube that appropriately fits the patient. Key words: airway management, fenestration, inner cannula, tracheostomy button, tracheostomy tube, cuff, tracheostomy, suction, stoma. [Respir Care 2005;50(4):497–510. © 2005 Daedalus Enterprises] Dean R Hess PhD RRT FAARC is affiliated with the Department of Respiratory Care, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts. Dean R Hess PhD RRT FAARC presented a version of this paper at the 20th Annual New Horizons Symposium at the 50th International 10 Respiratory Congress, held December 4–7, 2004, in New Orleans, Louisiana. Correspondence: Dean R Hess PhD RRT FAARC, Respiratory Care, Ellison 401, Massachusetts General Hospital, 55 Fruit Street, Boston MA 02114. E-mail: [email protected]. Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 Fig. 1. Components of a standard tracheostomy tube. (Courtesy of Smiths Medical, Keene, New Hampshire.) Fig. 2. Tracheostomy tube with inner cannula and obturator. Introduction Tracheostomy tubes are used to administer positivepressure ventilation, to provide a patent airway in patients prone to upper-airway obstruction, to protect against aspiration, and to provide access to the lower respiratory tract for airway clearance. Tracheostomy tubes are available in a variety of sizes and styles from several manufacturers. The inner diameter (ID), outer diameter (OD), and any other distinguishing characteristics (percutaneous, extra length, fenestrated) are marked on the flange of the tube as a guide to the clinician. Some features are relatively standard among typical tracheostomy tubes (Fig. 1). However, there are many nuances among them. It is important for clinicians caring for patients with a tracheostomy tube to understand these differences and to use that understanding to select a tube that appropriately fits the patient. Surprisingly little has been published in the peerreviewed literature on the topic of tracheostomy tubes and related appliances.1–3 This paper describes characteristics of tracheostomy tubes used in adult patients. Metal Versus Plastic Tracheostomy Tubes Tracheostomy tubes can be metal or plastic (Fig. 2). Metal tubes are constructed of silver or stainless steel. Metal tubes are not used commonly because of their expense, their rigid construction, the lack of a cuff, and the lack of a 15-mm connector to attach a ventilator. A smooth rounded-tip obturator passed through the lumen of the tracheostomy tube facilitates insertion of the tube. The obturator is removed once the tube is in place. Plastic tubes are most commonly used and can be made from polyvinyl chloride or silicone. Polyvinyl chloride softens at body temperature (thermolabile), conforming to patient anatomy and centering the distal tip in the trachea. Silicone is naturally soft and unaffected by temperature. Some plastic tracheostomy tubes are packaged with a tracheal wedge (Fig. 3). The tracheal wedge facilitates removal of the Fig. 3. The tracheal wedge is used to disconnect the ventilator circuit while minimizing the risk of dislodgement of the tracheostomy tube. (Courtesy of Smiths Medical, Keene, New Hampshire.) ventilator circuit while minimizing the risk of dislodgement of the tracheostomy tube. Tracheostomy Tube Dimensions The dimensions of tracheostomy tubes are given by their ID, OD, length, and curvature. The sizes of some tubes are given by Jackson size, which was developed for metal tubes and refers to the length and taper of the OD. These tubes have a gradual taper from the proximal to the distal tip. The Jackson sizing system is still used for most Shiley dual-cannula tracheostomy tubes (Table 1). Single-cannula tracheostomy tubes use the International Standards Organization method of sizing, determined by the ID of the outer cannula at its smallest dimension. Dual-cannula tracheostomy tubes with one or more shaft sections that are straight (eg, angled tubes) also use the International Standards Organization method. The ID of the tube is the functional ID. If an inner cannula is required for connection to the ventilator, the published ID is the ID of the inner cannula. The OD is the largest diameter of the outer cannula. When selecting a tracheostomy tube, the ID and OD must be considered. If the ID is too small, it will increase the resistance through the tube, make airway clearance more difficult, and increase the cuff pressure required to create a seal in the trachea. Mullins et al4 estimated the Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 11 Table 1. Jackson Tracheostomy Tube Size Table 2. Jackson Size Inner Diameter With IC (mm) Inner Diameter Without IC (mm)* Outer Diameter (mm) 4 6 8 10 5.0 6.4 7.6 8.9 6.7 8.1 9.1 10.7 9.4 10.8 12.2 13.8 *The inner diameter of the outer cannula is for narrowest portion of the shaft. IC ⫽ inner cannula (Adapted from Shiley Quick Reference Guide, courtesy of Tyco Healthcare, Pleasanton, California.) resistance through Shiley tracheostomy tubes at 11.47, 3.96, 1.75, and 0.69 cm H2O/L/s for size 4, 6, 8, and 10 adult tubes, respectively. If the OD is too large, leak with the cuff deflated will be decreased, and this will affect the ability to use the upper airway with cuff deflation (eg, speech). A tube with a larger OD will also be more difficult to pass through the stoma. A 10-mm OD tube is usually appropriate for adult women, and an 11-mm OD tube is usually appropriate for adult men as an initial tracheostomy tube size. Differences in tracheostomy tube length between tubes of the same ID but from different manufacturers are not commonly appreciated (Table 2), and this can have important clinical implications (Fig. 4). Tracheostomy tubes can be angled or curved (Fig. 5), a feature that can be used to improve the fit of the tube in the trachea. The shape of the tube should conform as closely as possible to the anatomy of the airway. Because the trachea is essentially straight, the curved tube may not conform to the shape of the trachea, potentially allowing for compression of the membranous part of the trachea, while the tip may traumatize the anterior portion. If the curved tube is too short, it can obstruct against the posterior tracheal wall (Fig. 6), which can be remedied by using either a larger tube, an angled tube, a tube with a flexible shaft, or a tube with extra length. Angled tracheostomy tubes have a curved portion and a straight portion. They enter the trachea at a less acute angle and may cause less pressure at the stoma. Because the portion of the tube that extends into the trachea is straight and conforms more closely to the natural anatomy of the airway, the angled tube may be better centered in the trachea and cause less pressure along the tracheal wall. Tracheostomy tubes are available in standard length or extra length. Extra-length tubes are constructed with extra proximal length (horizontal extra length) or with extra distal length (vertical extra length) (Fig. 7). In the case of one manufacturer, extra distal length is achieved by a double cuff design (Fig. 8 and Table 3). This design also allows the cuffs to be alternatively inflated and deflated, which may reduce the risk of tracheal-wall injury, although this has never been subjected to appropriate clinical study. 12 Dimensions of Portex Flex DIC and Shiley SCT Tracheostomy Tubes* Portex Flex DIC Shiley SCT ID (mm) OD (mm) Length (mm) ID (mm) OD (mm) Length (mm) 6.0 7.0 8.0 9.0 10.0 8.2 9.6 10.9 12.3 13.7 64 70 74 80 80 6.0 7.0 8.0 9.0 10.0 8.3 9.6 10.9 12.1 13.3 67 80 89 99 105 *Note that the principal difference between the tubes is in their length. The Portex tube can be used with an inner cannula, which reduces the inner diameter (ID) by 1 mm. DIC ⫽ disposable inner cannula SCT ⫽ single cannula tube. OD ⫽ outer diameter Extra proximal length facilitates tracheostomy tube placement in patients with a large neck (eg, obese patients). Extra distal length facilitates placement in patients with tracheal malacia or tracheal anomalies. Care must be taken to avoid inappropriate use of these tubes, which may induce distal obstruction of the tube. Rumbak et al5 reported a series of 37 patients in whom substantial tracheal obstruction (tracheal malacia, tracheal stenosis, or granulation tissue formation) caused failure to wean from mechanical ventilation. In 34 of the 37 patients, the obstruction was relieved by use of a longer tube, which effectively bypassed the tracheal obstruction. Several tube designs have a spiral wire reinforced flexible design (Fig. 9 and Table 4). These also have an adjustable flange design to allow bedside adjustments to meet extra-length tracheostomy tube needs. These tubes are not compatible with lasers, electrosurgical devices, or magnetic resonance imaging. Because the locking mechanism on the flange tends to deteriorate over time, use of these tubes should be considered a temporary solution. For longterm use, the adjustable-flange tube should be replaced with a tube that has a fixed flange. Custom-constructed tubes are available from several manufacturers to meet this need. Low-profile tracheostomy tubes (Fig. 10) can be used in patients with laryngectomy or sleep apnea. They have a small discreet flange, and they can be cuffed or uncuffed. One of 2 inner cannulae can be used. A low-profile inner cannula is used for spontaneous breathing, and an inner cannula with a 15-mm connector can be used to attach a ventilator. Tracheostomy Tube Cuffs Tracheostomy tubes can be cuffed or uncuffed (Fig. 11). Uncuffed tubes allow airway clearance but provide no Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 8 Portex DIC; 74 mm Long 8 Shiley SCT; 89 mm Long Fig. 4. A patient with a Portex 8 tracheostomy tube in place. Note the poor fit on both the anterior-posterior film and the transverse section by computed tomography (left). Note the improved fit when the tube was changed to a Shiley 8 single-cannula tube (SCT). The principal difference between the tubes is their length. DIC ⫽ disposable inner cannula. Angled Curved Fig. 5. Angled versus curved tracheostomy tubes. Note that the angled tube has a straight portion and a curved portion, whereas the curved tube has a uniform angle of curvature. protection from aspiration. Cuffed tracheostomy tubes allow for airway clearance, offer some protection from aspiration, and positive-pressure ventilation can be more effectively applied when the cuff is inflated. Although cuffed tubes are generally considered necessary to provide effective positive-pressure ventilation, a cuffless tube can be used effectively in long-term mechanically ventilated patients with adequate pulmonary compliance and sufficient oropharyngeal muscle strength for functional swallowing and articulation.6 Specific types of cuffs used on tracheostomy tubes include high-volume low-pressure cuffs, tight-to-shaft cuffs (low-volume high-pressure), and foam cuffs (Fig. 12). High-volume low-pressure cuffs are most commonly used. Tracheal capillary perfusion pressure is normally 25–35 mm Hg. High tracheal-wall pressures exerted by the inflated cuff can produce tracheal mucosal injury (Fig. 13).7–15 Because the pressure transmitted from the cuff to tracheal wall is usually less than the pressure in the cuff, it is generally agreed that 25 mm Hg (34 cm H2O) is the maximum acceptable intra-cuff pressure. If the cuff pressure is too low, silent aspiration is more likely.16,17 Therefore, it is recommended that cuff pressure be maintained at 20 –25 mm Hg (25–35 cm H2O) to minimize the risks for both tracheal-wall injury and aspiration. A leak around the cuff is assessed by auscultation over the suprasternal notch or the lateral neck. Techniques such as the minimum occlusion pressure or the minimum leak technique are not recommended. In particular, the minimum leak technique is not recommended because of the risk of silent aspiration of pharyngeal secretions. Intra-cuff pressure should be monitored and recorded regularly (eg, once per shift) and more often if the tube is changed, if its position changes, if the volume of air in the cuff is changed, or if a leak occurs. Cuff pressure is measured with a syringe, stopcock, and manometer (Fig. 14). This method allows cuff pressure to be measured simultaneously with adjustment of cuff volume. Methods in which the manometer is attached directly to the pilot bal- Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 13 Fig. 6. A curved tracheostomy tube in which the distal end abuts the posterior tracheal wall. There is a hint of this on the anterior-posterior chest radiograph (left), and this was confirmed by bronchoscopy (right). Approaches to this problem include replacing the tube with one that is larger, angled, or of extra length. Standard Vertical Extra Length Portex Horizontal Extra Length Double Cuff Shiley XLT Extra Length Poor Position Proximal Extra Length Distal Extra Length Horizontal Extra Length Fig. 8. Extra-length tracheostomy tubes. (Courtesy of Smiths Medical, Keene, New Hampshire and Tyco Healthcare, Pleasanton, California.) Fig. 7. Position of extra-length tracheostomy tubes in the trachea. Note that inappropriate use of an extra-length tube can cause distal tracheostomy-tube obstruction. (From Reference 5, with permission.) loon are discouraged because they cause air to escape from the cuff to pressurize the manometer. Commercially available systems can also be used to measure cuff pressure. A common cause of high cuff pressure is that the tube is too small in diameter, resulting in overfilling of the cuff to achieve a seal in the trachea. If the volume of air in the cuff needed to achieve a seal exceeds the nominal volume of the cuff, this suggests that the tube diameter is too small. The nominal cuff volume is the volume below which 14 the cuff pressure is ⬍ 25 mm Hg ex vivo. Another common cause of high cuff pressure is malposition of the tube (eg, cuff inflated in the stoma). Other causes of high cuff pressure include overfilling of the cuff, tracheal dilation, and use of a low-volume high-pressure cuff. A cuff management algorithm is shown in Figure 15.18 The tight-to-shaft cuff minimizes airflow obstruction around the outside of the tube when the cuff is deflated. It is a high-pressure low-volume cuff intended for patients requiring intermittent cuff inflation. When the cuff is deflated, speech and use of the upper airway is facilitated. The cuff is constructed of a silicone material. It should be inflated with sterile water because the cuff will automatically deflate over time in-situ due to gas permeability. Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 Table 3. Inner Diameter (mm) Dimensions of Several Commercially Available Extra Length Tracheostomy Tubes Outer Diameter (mm) Length (mm) Portex Extra Horizontal Length Blue Line Tracheostomy Tubes 7.0 9.7 84 (horizontal length 18) 8.0 11.0 95 (horizontal length 22) 9.0 12.4 106 (horizontal length 28) Portex Double Cuff Blue Line Tracheostomy Tubes (Extra Vertical Length) 7.0 9.7 83 (vertical length 41) 8.0 11.0 93 (vertical length 45) 9.0 12.4 103 (vertical length 48) 10.0 13.8 113 (vertical length 52) Shiley TracheoSoft XLT Proximal Extension Tracheostomy Tubes 5.0 9.6 90 (20 proximal, 37 radial, 33 distal) 6.0 11.0 95 (23 proximal, 38 radial, 34 distal) 7.0 12.3 100 (27 proximal, 39 radial, 34 distal) 8.0 13.3 105 (30 proximal, 40 radial, 35 distal) Shiley TracheoSoft XLT Distal Extension Tracheostomy Tubes 5.0 9.6 90 (5 proximal, 37 radial, 48 distal) 6.0 11.0 95 (8 proximal, 38 radial, 49 distal) 7.0 12.3 100 (12 proximal, 39 radial, 49 distal) 8.0 13.3 105 (15 proximal, 40 radial, 50 distal) Table 4. Dimensions of Flexible Tracheostomy Tubes With an Adjustable Flange Inside Diameter (mm) Outside Diameter (mm) Rusch Ulr TracheoFlex With Adjustable Flange 7.0 10.8 8.0 11.7 9.0 12.7 10.0 13.7 11.0 14.2 Bivona Mid-Range Adjustable Neck Flange 6.0 8.7 7.0 10.0 8.0 11.0 9.0 12.3 Length (mm) 82 107 137 137 137 110 120 130 140 Fig. 10. Low-profile tracheostomy tube. (Courtesy of Smiths Medical, Keene, New Hampshire.) Fig. 9. Flexible tracheostomy tubes with adjustable flange. Hv ⫽ high-volume. LP ⫽ low-pressure. Fig. 11. Uncuffed and cuffed tracheostomy tubes. (Courtesy of Smiths Medical, Keene, New Hampshire and Tyco Healthcare, Pleasanton, California.) A foam cuff consists of a large-diameter high-residualvolume cuff composed of polyurethane foam covered by a silicone sheath (Fig. 16).19,20 The concept of the foam cuff was designed to address the issues of high lateral tracheal- wall pressures that lead to complications such as tracheal necrosis and stenosis. Before insertion, air in the cuff is evacuated by a syringe attached to the pilot port. Once the tube is in place, the syringe is removed to allow the cuff to Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 15 Low Pressure Tight to Shaft Foam Fig. 12. Examples of low-pressure, tight-to-shaft, and foam-filled tracheostomy tube cuffs. Fig. 14. Diagram of the equipment used to measure cuff pressure. Fig. 13. Anterior-posterior chest radiograph of a patient with substantial tracheal dilation at the site of the tracheostomy tube cuff. re-expand against the tracheal wall. The pilot tube remains open to the atmosphere, so the intra-cuff pressure is at ambient levels. The open pilot port also permits compression and expansion of the cuff during the ventilatory cycle. The degree of expansion of the foam is a determining factor of the degree of tracheal-wall pressure. As the foam further expands, lateral tracheal-wall pressure increases. When used properly, this pressure does not exceed 20 mm Hg. The proper size is important to maintain a seal and the benefit from the pressure-limiting advantages of the foamfilled cuff. If the tube is too small, the foam will inflate to its unrestricted size, causing loss of ventilation and loss of protection against aspiration. If a leak occurs during positive-pressure ventilation with the foam cuff, it can be attached to the ventilator circuit so that cuff pressure approximates airway pressure. If the tube is too large, the foam is unable to expand properly to provide the desired 16 cushion, with increased pressure against the tracheal wall. The manufacturer recommends periodic cuff deflation to determine the integrity of the cuff and to prevent the silicone cuff from adhering to the tracheal mucosa. Despite the long availability of this cuff type, it is not commonly used. Its use is often reserved for patients who have already developed tracheal injury related to the cuff. Changing the Tracheostomy Tube Occasionally a tracheostomy tube must be changed (eg, if the cuff is ruptured or if a different style of tube is needed). The need for routine tracheostomy tube changes is unclear. In an observational study, Yaremchuk21 reported fewer complications due to granulation tissue after implementation of a policy in which tracheostomy tubes were changed every 2 weeks. Changing the tracheostomy tube is usually straightforward once the stoma is well formed, which may require 7–10 days after the tracheostomy is first placed. If the tube must be changed before the stoma is well formed, it is Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 Fig. 15. Algorithm to address issues with an artificial airway cuff leak. (From Reference 18.) advisable that the physician who performed the initial placement perform the tracheostomy tube change. In these cases it is also important that an individual skilled in endotracheal intubation is available in the event that the tracheostomy tube cannot be replaced. Generally, it is easier to replace the tube with one that has a smaller OD. The new tracheostomy tube can usually be inserted using the obturator packaged with the tube. If difficulty is anticipated during a tracheostomy tube change, a tube changer can be used to facilitate this procedure. The tube changer is passed through the tube into the trachea. The tube is then withdrawn while keeping the tube changer in place and the new tube is then passed over the tube changer into the trachea. Fenestrated Tracheostomy Tubes The fenestrated tracheostomy tube is similar in construction to standard tracheostomy tubes, with the addition of an opening in the posterior portion of the tube above the cuff (Fig. 17). In addition to the tracheostomy tube with a Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 17 Fig. 16. Foam cuff design. (Courtesy of Smiths Medical, Keene, New Hampshire.) Fig. 17. Fenestrated tracheostomy tubes. Note the 2 styles of fenestration. Fig. 18. With fenestrated tracheostomy tube and cuff deflation, the patient can breathe through the upper airway. (Courtesy of Smiths Medical, Keene, New Hampshire.) fenestration, a removable inner cannula and a plastic plug are supplied. With the inner cannula removed, the cuff deflated, and the normal air passage occluded, the patient can inhale and exhale through the fenestration and around the tube (Fig. 18). This allows for assessment of the patient’s ability to breathe through the normal oral/nasal route (preparing the patient for decannulation) and permits air to 18 Fig. 19. Examples of decannulation caps (below) and associated inner cannulae (above). (Courtesy of Tyco Healthcare, Pleasanton, California.) Fig. 20. Measurement for fenestration. A: Hyperextend head for good visualization. B: Bedside measurements with sterile pipe cleaners, anterior and posterior wall-to-skin measurement. C. Measurements determine location of fenestration on tracheostomy tube. (From Reference 1, with permission.) pass by the vocal cords (allowing phonation). Supplemental oxygen administration to the upper airway (eg, nasal cannula) may be necessary if the tube is capped. The cuff must be completely deflated by evacuating all of the air before the tube is capped. The decannulation cap (Fig. 19) is then put in place to allow the patient to breathe through the fenestrations and around the tube. Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 Fig. 21. Inspiratory pressures required to generate flows with fenestrated and nonfenestrated tracheostomy tubes. (From Reference 23, with permission.) Table 5. Comparison in Tube Dimensions for Shiley Single-Cannula Tube and Dual-Cannula Tube* Shiley SCT Inner Diameter (mm) 6.0 8.0 10.0 Fig. 22. Airway resistance during tracheostomy-tube occlusion. CF, CI ⫽ cuffed fenestrated, cuff inflated. CF, CD ⫽ cuffed fenestrated, cuff deflated. NC, F ⫽ uncuffed fenestrated. (From Reference 24, with permission.) Fig. 23. An example of an inner cannula in which the 15-mm ventilator attachment is connected to the inner cannula. If the inner cannula is removed, it is not possible to attach the ventilator. Unfortunately fenestrated tracheostomy tubes often fit poorly. The standard commercially available tubes can substantially increase flow resistance through the upper airway if the fenestrations are not properly positioned. The Shiley DCT Outer Diameter (mm) Size 8.3 10.9 13.3 6 8 10 Inner Diameter (mm) Outer Diameter (mm) 6.4 (8.1 without IC) 7.6 (9.1 without IC) 8.9 (10.7 without IC) 10.8 12.2 13.8 *Note: Inner diameter of outer cannula is for narrowest portion of the shaft. SCT ⫽ single-cannula tube DCT ⫽ dual-cannula tube IC ⫽ inner cannula risk of this complication may be decreased if a tube with several fenestrations rather than a single fenestration is used. Techniques have been described to assure proper placement of the fenestrations within the airway (Fig. 20). Moreover, custom-fenestrated tubes can be ordered from several manufacturers. Even with these measures, the fenestrations may become obstructed by the formation of granulation tissue, resulting in airway compromise.22 Proper position of the fenestrations in the airway should be inspected regularly. Hussey and Bishop23 reported that the effort required for gas flow across the native airway in the absence of a fenestration can be substantial (Fig. 21). Beard and Monaco24 reported that the presence of a cuff, either inflated or deflated, can increase the amount of ventilatory work required of the patient (Fig. 22). They recommended that Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 19 Fig. 24. Imposed work of breathing (WOB) for Shiley size 6, 8, and 10 tracheostomy tubes, with tidal volumes of 500 and 300 mL and respiratory rates of 12, 24, and 32 breaths/min. Black bars denote WOB with the cannula in place. Open bars denote WOB with the cannula removed. (From Reference 26, with permission.) Portex Per-fit Fig. 26. Standard (top left) and modified (top right) Portex Per-fit percutaneous tracheostomy tubes. Bronchoscopic views of the distal tracheostomy tube opening from the standard (bottom left) and modified (bottom right) tracheostomy tubes. (From Reference 27, with permission.) Shiley Perc Fig. 25. Portex and Shiley percutaneous tracheostomy tubes. (Courtesy of Smiths Medical, Keene, New Hampshire and Tyco Healthcare, Pleasanton, California.) Table 6. Dimensions of Tracheostomy Tubes Designed Specifically to Be Inserted Using Percutaneous Technique Tube Inner Diameter (mm) Outer Diameter (mm) Length (mm) Portex Per-fit 7 Portex Per-fit 8 Portex Per-fit 9 Shiley 6 PERC Shiley 8 PERC 7.0 (6.0 with IC) 8.0 (7.0 with IC) 9.0 (8.0 with IC) 6.4 7.6 9.6 10.9 12.3 10.8 12.2 82.0 86.0 93.0 74 79 IC ⫽ inner cannula uncuffed tubes should be used to decrease patient work of breathing when the tube is capped, to improve patient comfort during the process of decannulation. If the cuff is deflated or an uncuffed tube is used, the patient must be observed carefully for potential aspiration of upper-airway secretions or oral fluids. Upper-airway reflexes should be carefully assessed before attempts at cuff deflation and decannulation. Dual-Cannula Tracheostomy Tubes Some tracheostomy tubes are designed to be used with an inner cannula, and these are called dual-cannula 20 tracheostomy tubes. In some cases, the 15-mm attachment is on the inner cannula, and a ventilator cannot be attached unless the inner cannula is in place (Fig. 23). The inner cannula can be disposable or reusable. The use of an inner cannula allows it to be cleaned or replaced at regular intervals. It has been hypothesized that this may reduce biofilm formation and the incidence of ventilator-associated pneumonia. However, data are lacking to support this hypothesis, and the results of one study suggested that changing the inner cannula on a regular basis in the critical care unit is unnecessary.25 The inner cannula can be removed to restore a patent airway if the tube occludes, which may be an advantage for long-term use outside an acute care facility. If a fenestrated tracheostomy tube is used, the inner cannula occludes the fenestrations unless there are also fenestrations on the inner cannula. One potential issue with the use of an inner cannula is that it reduces the ID of the tracheostomy tube (Table 5) and thus the imposed work of breathing for a spontaneously breathing patient is increased. This was investigated by Cowan et al26 in an in vitro study, in which they reported a significant decrease in imposed work of breathing when the inner cannula was removed (Fig. 24). They concluded that increasing the ID of the tracheostomy tube by removing the inner cannula may be beneficial in spontaneously breathing patients. Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 Fig. 27. Portex Blue Line Ultra Suctionaid tracheostomy tube. The arrow indicates the position of the suction port above the cuff. (Courtesy of Smiths Medical, Keene, New Hampshire.) Table 7. Dimensions of Portex Blue Line Ultra Suctionaide Tracheostomy Tube Designed for Subglottic Suction Inner Diameter (mm) 6.0 7.0 7.5 8.0 8.5 9.0 Outer Diameter (mm) Length (mm) 9.2 10.5 11.3 11.9 12.6 13.3 64.5 70.0 73.0 75.5 78.0 81.0 Fig. 28. Olympic tracheostomy button (Olympic Medical, Seattle, Washington) positioned against the anterior tracheal wall. The tube is occluded with a solid plug (A) and fitted exactly to length with spacing washers (B). On the right is shown the distal flower-petal flanges (C) that expand to fit the tube into the trachea without sutures or ties. A positive-pressure adapter (D) can be attached to allow assisted ventilation. (From Reference 3, with permission.) a low-profile cuff designed to reduce insertion force and more readily conform to the patient’s anatomy. Although the design of the cuff makes insertion of the tube easier, the cuff characteristics resemble those of a low-volume high-pressure cuff rather than a low-pressure high-volume cuff. The Shiley PERC tracheostomy tube has a tapered distal tip and inverted cuff shoulder for easier insertion. It is designed specifically to be used with the Cook Percutaneous Tracheostomy Introducer Set. This cuff provides a low-pressure seal. Trottier et al27 reported that 57% of patients with a Portex Per-Fit tracheostomy tube placed percutaneously had a ⱖ 25% obstruction of the tracheostomy tube, and ⱖ 40% obstruction was visualized in 41% of the patients (Fig. 26). The cause of the partial tracheostomy-tube obstruction was the membranous posterior tracheal wall encroaching on the tracheostomy tube lumen. Several patients displayed a dynamic component to the obstruction, such that when the patient’s intrathoracic pressure increased, the degree of obstruction also increased. One patient displayed clinical signs and symptoms of tracheostomy-tube obstruction. This patient was obese and had a large neck, such that the tracheostomy tube was too short for the patient. These findings prompted the investigators to recommend modifications to the tube to lessen the degree of partial tracheostomytube obstruction. The standard tracheostomy tube was modified to include a shortened posterior bevel (the longest portion of the tracheostomy tube posteriorly) and a decreased length and angle of the tracheostomy tube. Following this modification, ⱖ 25% tube obstruction was observed in only 1 of 17 patients. Subglottic Suction Port Percutaneous Tracheostomy Tubes Several tracheostomy tubes are designed specifically for insertion as part of the percutaneous dilatational tracheostomy procedure (Fig. 25 and Table 6). The Portex Per-fit flexible tube features a tapered distal tip and Endotracheal tubes have been available for some time with a port above the cuff to facilitate aspiration of subglottic secretions, minimize their aspiration past the cuff, and thus decrease the risk of ventilator-associated pneumonia. Subglottic secretion drainage is associated with decreased incidence of ventilator-associated pneumonia, Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 21 Fig. 29. Montgomery T-tube (left) and Montgomery silicone tracheal cannula (right). (From Reference 1, with permission.) especially early-onset pneumonia.28 –33 Based on this evidence, it has been recommended that clinicians consider the use of subglottic secretion drainage.34 A tracheostomy tube capable of subglottic suction has recently become available (Fig. 27). To date, there has been no report of the effectiveness of this tube. One consideration in its use is that a larger OD of the tube is necessary to facilitate the suction port (Table 7). Stoma Maintenance Devices Several approaches can be used for stomal maintenance in patients who cannot be decannulated. One of the easiest approaches is to use a small cuffless tracheostomy tube (eg, 4 cuffless). Another approach is to use a tracheostomy button (Fig. 28).32 These appliances are generally made of Teflon and consist of a hollow outer cannula and an inner solid cannula. This device fits from the skin to just inside the anterior wall of the trachea. With the solid inner cannula in place, the patient breathes through the upper airway. When the inner cannula is removed, the patient can breathe through the button, and a suction catheter can be passed through the button to aid airway clearance. Since a tracheostomy button does not have a cuff, its use is limited when there is a risk of aspiration or during positive-pressure ventilation. Other devices used for stomal maintenance include the Montgomery T-tube and the Montgomery silicone tracheal cannula (Fig. 29). Mini-Tracheostomy Tubes The mini-tracheostomy tube is a small bore cannula (4.0 mm ID) inserted into the trachea through the cricothyroid membrane or the tracheal stoma after decannulation. It can be used for oxygen administration. However, it is used primarily for patients with airway clearance issues35 because it allows bronchial lavage and suctioning with a 10 French suction. It is uncuffed and generally unsuitable for provision of positive pressure ventilation. Summary Tracheostomy tubes are available in a variety of sizes and styles. It is important for respiratory therapists and 22 physicians caring for patients with tracheostomy tubes to understand these differences and select a tube that appropriately fits the patient. ACKNOWLEDGMENT I wish to thank the staff of the Respiratory Acute Care Unit (RACU) who have taught me that selection of the correct tracheostomy tube makes a difference. REFERENCES 1. Wilson DJ. Airway appliances and management. In: Kacmarek RM, Stoller JK. Current respiratory care. Philadelphia: PC Decker; 1988. 2. Wilson DJ. Airway management of the ventilator-assisted individual. Probl in Respir Care 1988;1(2):192–203. 3. Godwin JE, Heffner JE. Special critical care considerations in tracheostomy management. Clin Chest Med 1991;12(3):573–583. 4. Mullins JB, Templer JW, Kong J, Davis WE, Hinson J. Airway resistance and work of breathing in tracheostomy tubes. Laryngoscope 1993;103(12):1367–1372. 5. Rumbak MJ, Walsh FW, Anderson WM, Rolfe MW, Solomon DA. Significant tracheal obstruction causing failure to wean in patients requiring prolonged mechanical ventilation: a forgotten complication of long-term mechanical ventilation. Chest 1999;115(4):1092–1095. 6. Bach JR, Alba AS. Tracheostomy ventilation: a study of efficacy with deflated cuffs and cuffless tubes. Chest 1990;97(3):679–683. 7. Cooper JD, Grillo HC. The evolution of tracheal injury due to ventilatory assistance through cuffed tubes: a pathologic study. Ann Surg 1969;169(3):334–348. 8. Cooper JD, Grillo HC. Experimental production and prevention of injury due to cuffed tracheal tubes. Surg Gyn Obs 1969;129(6): 1235–1241. 9. Cooper JD, Grillo HC. Analysis of problems related to cuffs on intratracheal tubes. Chest 1972;62(2):21S–27S. 10. Knowlson GT, Bassett HF. The pressures exerted on the trachea by endotracheal inflatable cuffs. Br J Anaesth 1970;42(10):834–837. 11. Dobrin P, Canfield T. Cuffed endotracheal tubes: mucosal and tracheal wall blood flow. Am J Surg 1977;133(5):562–568. 12. Bernhard WN, Yost L, Joynes D, Cothalis S, Turndorf H. Intracuff pressures in endotracheal and tracheostomy tubes: related cuff physical characteristics. Chest 1985;87(6):720–725. 13. Dunn CR, Dunn DL, Moser KM. Determinants of tracheal injury by cuffed tracheostomy tubes. Chest 1974;65(2):128–135. 14. Seegobin RD, van Hasselt GL. Endotracheal cuff pressure and tracheal mucosal blood flow: endoscopic study of effects of four large volume cuffs. BMJ 1984;288(6422):965–968. Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 15. Honeybourne D, Costello JC, Barham C. Tracheal damage after endotracheal intubation: comparison of two types of endotracheal tubes. Thorax 1982;37(7):500–502. 16. Pavlin EG, Van Mimwegan D, Hornbein TF. Failure of a highcompliance low-pressure cuff to prevent aspiration. Anesthesiology 1975;42(2):216–219. 17. Bernhard WN, Cottrell JE, Sivakumaran C, Patel K, Yost L, Turndorf H. Adjustment of intracuff pressure to prevent aspiration. Anesthesiology 1979;50(4):363–366. 18. Hess DR. Managing the artificial airway. Respir Care 1999;44(7): 759–772. 19. Kamen JM, Wilkinson CJ. A new low-pressure cuff for endotracheal tubes. Anesthesiology 1971;34(5):482. 20. King K, Mandava B, Kamen JM. Tracheal tube cuffs and tracheal dilatation. Chest 1975;67(4):458–462. 21. Yaremchuk K. Regular tracheostomy tube changes to prevent formation of granulation tissue. Laryngoscope 2003;113(1):1–10. 22. Siddharth P, Mazzarella L. Granuloma associated with fenestrated tracheostomy tubes. Am J Surg 1985;150(2):279–180. 23. Hussey JD, Bishop MJ. Pressures required to move gas through the native airway in the presence of a fenestrated vs a nonfenestrated tracheostomy tube. Chest 1996;110(2):494–497. 24. Beard B, Monaco MJ. Tracheostomy discontinuation: impact of tube selection on resistance during tube occlusion. Respir Care 1993; 38(3):267–270. 25. Burns SM, Spilman S, Wilmoth D, Carpender R, Turrentine B, Wiley B, et al. Are frequent inner cannula changes necessary? A pilot study. Heart Lung 1998;27(1):58–62. 26. Cowan T, Op’t Holt TB, Gegenheimer C, Izenberg S, Kulkarni P. Effect of inner cannula removal on the work of breathing imposed by tracheostomy tubes: a bench study. Respir Care 2001;46(5):460– 465. 27. Trottier SJ, Ritter S, Lakshmanan R, Sakabu SA, Troop BR. Percutaneous tracheostomy tube obstruction: warning. Chest 2002;122(4): 1377–1381. 28. Valles J, Artigas A, Rello J, Bonsoms N, Fontanals D, Blanch L, et al. Continuous aspiration of subglottic secretions in preventing ventilator-associated pneumonia. Ann Intern Med 1995;122(3):179–186. 29. Metz C, Linde HJ, Gobel L, Gobel F, Taeger K. Influence of intermittent subglottic lavage on subglottic colonisation and ventilatorassociated pneumonia. Clin Intensive Care 1998;9:20–24. 30. Mahul P, Auboyer C, Jospe R, Ros A, Guerin C, el Khouri Z, et al. Prevention of nosocomial pneumonia in intubated patients: respective role of mechanical subglottic secretions drainage and stress ulcer prophylaxis. Intensive Care Med 1992;18(1):20–25. 31. Kollef MH, Skubas NJ, Sundt TM. A randomized clinical trial of continuous aspiration of subglottic secretions in cardiac surgery patients. Chest 1999;116(5):1339–1346. 32. Smulders K, van der Hoeven H, Weers-Pothoff I, VandenbrouckeGrauls C. A randomized clinical trial of intermittent subglottic secretion drainage in patients receiving mechanical ventilation. Chest 2002;121(3):858–862. 33. Dodek P, Keenan S, Cook D, Heyland D, Jacka M, Hand L, et al. Evidence-based clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med 2004;141(4): 305–313. 34. Long J, West G. Evaluation of the Olympic trach button as a precursor to tracheostomy tube removal (abstract). Respir Care 1980; 25(12):1242–1243. 35. Bonde P, Papachristos I, McCraith A, Kelly B, Wilson C, McGuigan JA, McManus K. Sputum retention after lung operation: prospective, randomized trial shows superiority of prophylactic minitracheostomy in high-risk patients. Ann Thorac Surg 2002;74(1):196–202; discussion 202–203. Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 23 Facilitating Speech in the Patient With a Tracheostomy Dean R Hess PhD RRT FAARC Respir Care 2005;50(4):519—525. © 2005 Daedalus Enterprises Introduction Facilitation of Speech in the Ventilator-Dependent Patient With a Tracheostomy Talking Tracheostomy Tube Cuff Down With Speaking Valve Cuff Down Without Speaking Valve Patients Not Mechanically Ventilated Talking Tracheostomy Tube Cuff-Down Finger Occlusion Cuff Down With Speaking Valve Summary A tracheostomy tube decreases the ability of the patient to communicate effectively. The ability to speak provides an important improvement in the quality of life for a patient with a tracheostomy. In mechanically ventilated patients, speech can be provided by the use of a talking tracheostomy tube, using a cuff-down technique with a speaking valve, and using a cuff-down technique without a speaking valve. Speech can be facilitated in patients with a tracheostomy tube who are breathing spontaneously by use of a talking tracheostomy tube, by using a cuff-down technique with finger occlusion of the proximal tracheostomy tube, and with the use of a cuff-down technique with a speaking valve. Teamwork between the patient and the patient care team (respiratory therapist, speech-language pathologist, nurse, and physician) can result in effective restoration of speech in many patients with a long-term tracheostomy. Key words: speaking valve, speech, talking tracheostomy tube, tracheostomy, mechanical ventilation, complications. [Respir Care 2005;50(4):519 –525. © 2005 Daedalus Enterprises] Introduction Placement of a tracheostomy facilitates long-term mechanical ventilation, minimizes large-volume aspiration, and bypasses upper-airway obstruction. However, it also decreases the ability of the patient to communicate effectively. It is possible to restore voice in many patients with Dean R Hess PhD RRT FAARC is affiliated with the Department of Respiratory Care, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts. Dean R Hess PhD RRT FAARC presented a version of this paper at the 20th Annual New Horizons Symposium at the 50th International Respiratory Congress, held December 4–7, 2004, in New Orleans, Louisiana. 24 tracheostomy who are cognitively intact and free of laryngeal or pharyngeal dysfunction. The ability to speak provides an improvement in the quality of life for a patient with a tracheostomy. In order to achieve adequate voice, a subglottic (tracheal) pressure of a least 2 cm H2O is required.1–3 In normal persons the tracheal pressure is 5–10 cm H2O during speech. Flow through the upper airway during normal speech is 50 –300 mL/s (3–18 L/min).4,5 There are a variety of techniques to achieve this in tracheostomized patients who are either ventilator-dependent or Correspondence: Dean R Hess PhD RRT FAARC, Respiratory Care, Ellison 401, Massachusetts General Hospital, 55 Fruit Street, Boston MA 02114. E-mail: [email protected]. Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 Fig. 1. Talking tracheostomy tube. Note that gas flow exits above the cuff and provides flow through the upper airway to facilitate speech. The arrow indicates the point of gas flow into the trachea above the cuff. (Adapted from illustrations provided courtesy of Smiths Medical, Keene, New Hampshire.) breathing spontaneously. The purpose of this paper is to describe these methods. Facilitation of Speech in the Ventilator-Dependent Patient With a Tracheostomy Talking Tracheostomy Tube The talking tracheostomy tube (Fig. 1) was designed to assist the patient to speak in a low, whispered voice.6 –13 With the cuff inflated, a gas line with a thumb port is connected to a gas source. The flow is adjusted to 4 – 6 L/min and the thumb port is occluded by the patient or caregiver. Gas passes through the larynx, allowing the patient to speak in a soft whisper. Note that the talking tracheostomy tube allows the use of voice with the cuff inflated. Thus, this technique decouples speech and breathing. There is no loss of ventilation during speech with this device, and the inflated cuff reduces the risk of aspiration. There are several limitations to the use of the talking tracheostomy tube, and for these reasons this tube is not commonly used. Unless this tube is inserted at the time of the tracheostomy procedure, the use of this tube requires a tube change. In many cases, the voice quality is not good—a whisper at best. Voice quality may improve with higher flows,10,11 but this can be associated with a potentially greater risk of airway injury. If the resistance to airflow retrograde through the stoma is less than that through the upper airway, much of the added flow may leak from the stomal site and not be available for speech.12 One study reported stoma complications associated with a talking tracheostomy tube, but the tube used in that study is no longer commercially available (Communi-Trach I).13 Upper-airway secretions can interfere with the quality of voice, and secretions above the cuff can lead to a clogged gas flow line.11,12 An important limitation is the need for an assistant to control gas flow in many patients.12 It has also been observed that several days of use may be necessary before the patient is able to develop voice with this de- Fig. 2. The voice tracheostomy tube. The cuff expands with positive pressure from the ventilator, which results in inflation of the lungs without a leak through the upper airway. On exhalation, the cuff deflates and some of the exhaled gas exits through the vocal cords, allowing the patient to speak. (From Reference 14, with permission.) vice.10,11 Practice and training may be necessary to master the use of this device, and even with such, some patients cannot develop adequate voice.11 A voice tracheostomy tube, not yet commercially available, has been described.14 It is specially configured so that the cuff inflates with positive pressure and deflates during the expiratory phase (Fig. 2). This tube was used in 16 patients, and all but one were able to speak with this tube. There were no changes in PaO2 or PaCO2 with the use of this tube. Cuff Down With Speaking Valve When using a speaking valve with the cuff deflated or with a cuffless tube, gas flows from the ventilator into the tracheostomy tube during inhalation but exits through the upper airway during exhalation (Fig. 3). In other words, the speaking valve is a one-way valve designed to attach to the proximal opening of the tracheostomy tube. Before placing the speaking valve, the cuff must be completely deflated. It may be necessary to increase the tidal-volume delivery from the ventilator to compensate for volume loss through the upper airway during the inspiratory phase. Some patients are able to control oropharyngeal muscle tone sufficiently to minimize the leak through the upper airway during the inspiratory phase. The alarms on most critical-care ventilators are intolerant of a speaking valve. This can be addressed by using a Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 25 Fig. 4. Airflow during ventilator-supported speech. The black circles represent occlusions and the gray circle represents higherthan-usual impedance. During inhalation (left), air flows both toward the lungs and through the larynx. During usual exhalation (center), most of the air flows toward the ventilator. This is because the impedance of the ventilator circuit is much lower than that of the laryngeal pathway during speech production. With positive end-expiratory pressure (PEEP) (right), the impedance of the ventilator circuit is higher than usual, so that more air flows through the larynx. (From Reference 18, with permission.) Fig. 3. Placement of a speaking valve between the ventilator and the tracheostomy tube results in the exhaled gas passing through the upper airway (rather than into the ventilator circuit). (Adapted from illustrations courtesy of Passy-Muir, Irvine, California.) 26 Fig. 5. Left: Changes in speaking rate (syllables per minute) for lengthened inspiratory time (TI), positive end-expiratory pressure (PEEP), and lengthened TI plus PEEP. Right: Changes in speaking rate with 5, 8, and 12 cm H2O PEEP. (From Reference 18, with permission.) Tracheal Pressure (cm H2O) ventilator with a speaking valve mode (eg, Puritan Bennett 760) or a portable home-care ventilator. Heated humidifiers can be used with a speaking valve. However, a heatand-moisture exchanger should not be used, because no exhaled gas passes through it if a speaking valve is in place. If an in-line closed suctioning system is used, the speaking valve should be connected to the side port to allow the catheter to easily pass into the tracheostomy tube. The volume of dead space in the ventilator circuit is unimportant when a speaking valve is used, because there is no potential for rebreathing in the circuit. Adequate cuff deflation, tracheostomy tube size, tracheostomy tube position, and upper-airway obstruction should be assessed if the patient is unable to exhale adequately through the upper airway. Some patients complain of discomfort due to airflow through the upper airway when the speaking valve is in place. This can result from drying of the pharyngeal membranes, inability to ventilate adequately, and increased noise levels. This may be the result of decreased pharyngeal or laryngeal tone due to weakness or atrophy from lack of flow through the upper airway during prolonged mechanical ventilation. This can be addressed by using a slow cuff deflation over several minutes. Initial placement of the speaking valve may stimulate coughing, which may be the result of secretions pooled above the cuff. This can be minimized by clearance of pharyngeal and tracheal secretions before the cuff is deflated. Some patients can communicate during both the inspiratory and expiratory phase of the ventilator. This is only problematic if it results in inadequate ventilation dur- Fig. 6. Tracheal pressure waveforms generated during speech production with a one-way valve and with a positive end-expiratory pressure (PEEP) valve set to 15 cm H2O. (From Reference 18, with permission.) ing speech. A speech-language pathologist can help patients who have difficulty adjusting to the speaking valve. Passy et al15 reported their experience in a series of 15 ventilator-dependent patients in whom a speaking valve was used. In all 15 patients there was an improvement in speech intelligibility, speech flow, elimination of speech Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 Fig. 7. Left: Recording from a patient during a vowel-holding trial with continuous mandatory ventilation (CMV) and pressure-support ventilation (PSV). Note the increase in inspiratory time during speech and the improvement in speech duration during both inhalation and exhalation with PSV, compared with CMV. PT ⫽ tracheal pressure. Right: Distribution of maximum speech duration over the phases of the respiratory cycle during a reading test with CMV and PSV. (From Reference 21, with permission.) hesitancy, and speech time. In a series of 10 chronically ventilator-dependent patients, Manzano et al16 reported that a speaking valve was effective in improving communication in 8 of the 10 patients. In one patient, use of the speaking valve was not possible because adequate ventilation was not possible with the cuff deflated. In a second patient, the speaking valve was not effective because of laryngopharyngeal dysfunction. Cuff Down Without Speaking Valve Hoit et al17–20 have published several papers related to cuff-down techniques to facilitate speech without the use of a speaking valve. They have shown that simple manipulations on the ventilator allow the patient to speak during both the inspiratory phase and expiratory phase. Moreover, the lack of a speaking valve may increase safety should the upper airway become obstructed. If the cuff is deflated, gas can escape through the upper airway during the inspiratory phase (Fig. 4). During speech, this has been shown to be about 15% of the delivered tidal volume, which may cause a small increase in PCO2 (⬍ 5 mm Hg).17 This leak results in the ability to speak during the inspiratory phase. It has been shown that increasing the inspiratory time setting on the ventilator increases breathing rate (syllables per minute) (Fig. 5).18,19 If the positive end-expiratory pressure (PEEP) setting on the ventilator is zero, most of the exhaled gas exits through the ventilator circuit rather than the upper airway. In this situation, there is little ability to speak during the expiratory phase. If PEEP is set on the ventilator, then expiratory flow is more likely to occur through the upper airway, which increases speaking rate. The use of a longer inspiratory time and higher PEEP are additive in their ability to improve speaking rate (see Fig. 5).18 Tracheal pressure (important for speech) is similar with the use of PEEP and the use of a speaking valve (Fig. 6). By prolonging the inspiratory time and using PEEP, mechanically ventilated patients with a tracheostomy may be able to use 60 – 80% of the breathing cycle for speaking.17–20 Anecdotally, I have observed such patients who are able to speak throughout the entire ventilatory cycle without any pauses for breathing. This is unlike normal subjects without tracheostomy tubes, who speak only during the expiratory phase. The ventilator is normally flow-cycled during pressuresupport ventilation. In the presence of a leak through the upper airway, the ventilator may fail to cycle appropriately, and thus result in a prolonged inspiratory phase. Although this would usually be considered undesirable, it might facilitate speech. Prigent et al21 reported that pressure support with PEEP and the cuff deflated resulted in an increase in inspiratory time during speech, and this improved speech duration during both the inspiratory and expiratory phase (Fig. 7). This occurred with minimal effect on gas-exchange variables. Patients Not Mechanically Ventilated Talking Tracheostomy Tube Although not common practice, a talking tracheostomy tube can be used in a patient with a tracheostomy who is not mechanically ventilated. For example, this may be considered in a patient who is cognitively able to speak but is at risk for aspiration if the cuff is deflated. Cuff-Down Finger Occlusion With the cuff down (or with a cuffless tube), the patient (or caregiver) can place a finger over the proximal opening of the tracheostomy tube to direct air through the upper airway and thus produce speech (Fig. 8).22 Some patients Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 27 Table 1. Speaking Valve Contraindications Unconscious or comatose patient Inflated tracheostomy tube cuff Foam-cuffed tracheostomy tube Thick and copious secretions Severe upper-airway obstruction Abnormal lung mechanics that prevent sufficient exhalation (high resistance, high compliance) Speaking valves are not intended for use with endotracheal tubes Fig. 8. Finger occlusion technique to direct exhaled gas through the upper airway rather than through the tracheostomy tube. (From Reference 22, with permission.) Fig. 10. Equipment used to measure tracheal pressure when a speaking valve is applied. Fig. 9. Speaking valves for use with a tracheostomy tube. Arrows indicate gas flow during inhalation and exhalation. (Adapted from illustrations courtesy of Passy-Muir, Irvine, California and Tyco Healthcare, Pleasanton, California.) are quite facile with this technique, but many do not have the coordination to master this method. Cuff Down With Speaking Valve In the spontaneously breathing patient, a speaking valve directs the exhaled gas through the upper airway, which may allow the patient to speak (Fig. 9). This is probably the most common method used to facilitate speech in spontaneously breathing patients with tracheostomy tubes. Al- 28 though many patients can use this method effectively, there are several contraindications to the use of a speaking valve (Table 1). The speaking valve should be used only for a patient who is awake, responsive, and attempting to communicate. The patient must be able to exhale around the tracheostomy tube and through the upper airway. The patient should be medically stable and must be able to tolerate cuff deflation. Although the speaking valve may facilitate oral expectoration of secretions, airway clearance issues may occur if the patient has abundant secretions. The patient’s risk for aspiration should be evaluated before the speaking valve is placed. The speaking valve is generally considered inappropriate in a patient at risk of gross aspiration. However, silent aspiration may occur even with the cuff inflated.23 The input of a speech-language pathologist and use of techniques such as fiberoptic endoscopic evaluation of swallowing can be valuable to assess the risk of aspiration with cuff deflation. The patient must be able to exhale effectively around the tracheostomy tube when the speaking valve is placed. This can be assessed by measuring tracheal pressure with the speaking valve in place (Fig. 10). If the tracheal pressure is ⬎ 5 cm H2O during passive exhalation (without speech) with the speaking valve in place, this may indicate excessive expiratory resistance.24 The upper airway should Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 Fig. 11. Pressure and flow through a tracheostomy tube with 3 brands of speaking valve. Note that the bias-open design (Olympic) allows flow through the valve during exhalation, whereas the bias-closed design does not. The bias-closed design thus directs more gas flow through the upper airway to facilitate speech. (From Reference 26, with permission.) be assessed for the presence of obstruction (eg, tumor, stenosis, granulation tissue, secretions). The size of the tracheostomy tube should be evaluated and consideration given to downsizing the tube. The cuff on a tracheostomy tube can also create an obstruction, even when deflated. Consideration should be given to the use of an uncuffed tube or a tight-to-shaft cuff. The use of a fenestrated tracheostomy tube can also be considered. Before placing the speaking valve, the cuff must be completely deflated. Before cuff deflation the upper airway should be cleared of secretions. A slow cuff deflation often facilitates a smoother transition for the patient to airflow in the upper airway. The lower respiratory tract may need to be suctioned after cuff deflation because of aspiration of secretions from above the cuff. The ability of the patient to tolerate the speaking valve can be briefly assessed by finger occlusion of the tracheostomy tube after cuff deflation. Once the speaking valve is placed, carefully assess the patient’s ability to breathe. Many patients initially tolerate short periods of speaking-valve-placement until they become acclimated. If the patient experiences difficulty with airway clearance when the speaking valve is in place, the valve should be removed to allow the patient to be suctioned. If the patient exhibits signs of respiratory distress, remove the speaking valve immediately and reassess upper-airway patency. Oxygen can be administered while the speaking valve is in place, using a tracheostomy collar or an oxygen adapter on the speaking valve. The patient may inhale through the upper airway when the speaking valve is in place. This is most likely with a small tracheostomy tube, in which inspiratory resistance through the tube may be greater than the resistance through the upper airway. When this occurs, oxygen administration to the upper airway may be required (eg, nasal cannula). Humidity can be applied using a tracheostomy collar, but a heat-and-moisture exchanger filter should not be used, because the patient will not ex- hale through the heat-and-moisture exchanger. If inhaled aerosol medications are given, the speaking valve should be removed during this therapy. There have been several evaluations of the aerodynamic characteristics of speaking valves.25–27 The inspiratory resistance through speaking valves has been reported at about 2.5 cm H2O/L/s at a flow of 0.5 L/s, and is similar among valves from several manufacturers.26 Speaking valves can be either bias open or bias closed. The bias-open design may result in incomplete closure during exhalation, resulting in expiratory flow through the valve (Fig. 11), which limits flow through the upper airway and the ability to speak.26,27 In addition to allowing speech, the use of a speaking valve may have other benefits. Some studies have suggested that the speaking valve may improve swallow and decrease the risk of aspiration,28 –33 although this has been debated by others.34 Because the patients inhales through the tracheostomy tube and exhales through the upper airway, rebreathing (dead space) may be reduced, but this has not been studied. The use of a speaking valve may also allow the patient to control exhalation (eg, pursed lips in the patient with chronic obstructive pulmonary disease), but this also has not been adequately studied. Improvements in olfaction have also been reported with the use of a speaking valve.35 Summary The ability to speak is an important aspect of the quality of life for patients with a tracheostomy. A variety of techniques to achieve this are available for either mechanically ventilated or spontaneously breathing patients. Teamwork between the patient and the patient care team (respiratory therapist, speech-language pathologist, nurse, physician) can result in restoration of speech in many patients with long-term tracheostomies. Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 29 ACKNOWLEDGMENT I wish to thank the patients and staff in the Respiratory Acute Care Unit (RACU) of the Massachusetts General Hospital, who have taught me most of what I share in this paper. REFERENCES 1. Draper MH, Ladefoged P, Whitteridge D. Expiratory pressures and air flow during speech. Brookhaven Symp Biol 1960;5189:1837– 1843. 2. Lieberman P, Knudson R, Mead J. Determination of the rate of change of fundamental frequency with respect to subglottal air pressure during sustained phonation. J Acoust Soc Am 1969;45(6):1537– 1543. 3. Murry T, Brown WS Jr. Subglottal air pressure during two types of vocal activity: vocal fry and modal phonation. Folia Phoniatr (Basel) 1971;23(6):440–449. 4. Holmberg EB, Hillman RE, Perkell JS. Glottal airflow and transglottal air pressure measurements for male and female speakers in soft, normal, and loud voice. J Acoust Soc Am 1988;84(2):511–529. Erratum in: J Acoust Soc Am 1989;85(4):1787. 5. Bard MC, Slavit DH, McCaffrey TV, Lipton RJ. Noninvasive technique for estimating subglottic pressure and laryngeal efficiency. Ann Otol Rhinol Laryngol 1992;101(7):578–582. 6. Safar P, Grenvik A. Speaking cuffed tracheostomy tube. Crit Care Med 1975;3(1):23–26. 7. Saul A, Bergstrom B. A new permanent tracheostomy tube: speech valve system. Laryngoscope 1979;89(6 Pt 1):980–983. 8. Kluin KJ, Maynard F, Bogdasarian RS. The patient requiring mechanical ventilatory support: use of the cuffed tracheostomy “talk” tube to establish phonation. Otolaryngol Head Neck Surg 1984;92(6): 625–627. 9. Levine SP, Koester DJ, Kett RL. Independently activated talking tracheostomy systems for quadriplegic patients. Arch Phys Med Rehabil 1987;68(9):571–573. 10. Leder SB, Traquina DN. Voice intensity of patients using a Communi-Trach I cuffed speaking tracheostomy tube. Laryngoscope 1989; 99(7 Pt 1):744–747. 11. Leder SB. Verbal communication for the ventilator-dependent patient: voice intensity with the Portex “Talk” tracheostomy tube. Laryngoscope 1990;100(10 Pt 1):1116–1121. 12. Sparker AW, Robbins KT, Nevlud GN, Watkins CN, Jahrsdoerfer RA. A prospective evaluation of speaking tracheostomy tubes for ventilator dependent patients. Laryngoscope 1987;97(1):89–92. 13. Leder SB, Astrachan DI. Stomal complications and airflow line problems of the Communi-Trach I cuffed talking tracheotomy tube. Laryngoscope 1989;99(2):194–196. 14. Nomori H. Tracheostomy tube enabling speech during mechanical ventilation. Chest 2004;125(3):1046–1051. 15. Passy V, Baydur A, Prentice W, Darnell-Neal R. Passy-Muir tracheostomy speaking valve on ventilator-dependent patients. Laryngoscope 1993;103(6):653–658. 16. Manzano JL, Lubillo S, Henriquez D, Martin JC, Perez MC, Wilson DJ. Verbal communication of ventilator-dependent patients. Crit Care Med 1993;21(4):512–517. 30 17. Shea SA, Hoit JD, Banzett RB. Competition between gas exchange and speech production in ventilated subjects. Biol Psychol 1998; 49(1–2):9–27. 18. Hoit JD, Banzett RB, Lohmeier HL, Hixon TJ, Brown R. Clinical ventilator adjustments that improve speech. Chest 2003;124(4):1512– 1521. 19. Hoit JD, Banzett RB. Simple adjustments can improve ventilatorsupported speech. Am J Speech Lang Pathol 1997;6(1):87–96. 20. Hoit JD, Shea SA, Banzett RB. Speech production during mechanical ventilation in tracheostomized individuals. J Speech Hear Res 1994;37(1):53–63. 21. Prigent H, Samuel C, Louis B, Abinun MF, Zerah-Lancner F, Lejaille M, et al. Comparative effects of two ventilatory modes on speech in tracheostomized patients with neuromuscular disease. Am J Respir Crit Care Med 2003;167(2):114–119. 22. Godwin JE, Heffner JE. Special critical care considerations in tracheostomy management. Clin Chest Med 1991;12(3):573–583. 23. Leder SB. Incidence and type of aspiration in acute care patients requiring mechanical ventilation via a new tracheotomy. Chest 2002; 122(5):1721–1726. 24. Minh H, Aten JL, Chaing JT, Light RW. Comparison between conventional cap and one-way valve in the decannulation of patients with long-term tracheostomies. Respir Care 1993;38(11):1161–1167. 25. Fornataro-Clerici L, Zajac DJ. Aerodynamic characteristics of tracheostomy speaking valves. J Speech Hear Res 1993;36(3):529–532. 26. Zajac DJ, Fornataro-Clerici L, Roop TA. Aerodynamic characteristics of tracheostomy speaking valves: an updated report. J Speech Lang Hear Res 1999;42(1):92–100. 27. Leder SB. Perceptual rankings of speech quality produced with oneway tracheostomy speaking valves. J Speech Hear Res 1994;37(6): 1308–1312. 28. Dettelbach MA, Gross RD, Mahlmann J, Eibling DE. Effect of the Passy-Muir Valve on aspiration in patients with tracheostomy. Head Neck 1995;17(4):297–302. 29. Eibling DE, Gross RD. Subglottic air pressure: a key component of swallowing efficiency. Ann Otol Rhinol Laryngol 1996;105(4):253– 258. 30. Stachler RJ, Hamlet SL, Choi J, Fleming S. Scintigraphic quantification of aspiration reduction with the Passy-Muir valve. Laryngoscope 1996;106(2 Pt 1):231–234. 31. Elpern EH, Borkgren Okonek M, Bacon M, Gerstung C, Skrzynski M. Effect of the Passy-Muir tracheostomy speaking valve on pulmonary aspiration in adults. Heart Lung 2000;29(4):287– 293. 32. Suiter DM, McCullough GH, Powell PW. Effects of cuff deflation and one-way tracheostomy speaking valve placement on swallow physiology. Dysphagia 2003;18(4):284–292. 33. Gross RD, Mahlmann J, Grayhack JP. Physiologic effects of open and closed tracheostomy tubes on the pharyngeal swallow. Ann Otol Rhinol Laryngol 2003;112(2):143–152. 34. Leder SB. Effect of a one-way tracheotomy speaking valve on the incidence of aspiration in previously aspirating patients with tracheotomy. Dysphagia 1999;14(2):73–77. 35. Lichtman SW, Birnbaum IL, Sanfilippo MR, Pellicone JT, Damon WJ, King ML. Effect of a tracheostomy speaking valve on secretions, arterial oxygenation, and olfaction: a quantitative evaluation. J Speech Hear Res 1995;38(3):549–555. Selezione ARIR da RESPIRATORY CARE e AARC TIMES • Dicembre 2006 • N. 02 DIRETTORE RESPONSABILE EDITOR IN CHIEF GIOVANNI OLIVA [email protected] REDAZIONE EDITORIAL STAFF ANTONELLA SANNITI, ANDREA TETTAMANTI RESPONSABILI SCIENTIFICI SCIENTIFIC ACCOUNTEES ENRICO CLINI, ELENA REPOSSINI BOARD EDITORIALE EDITORIAL BOARD ANNA BRIVIO, PAOLA CAPONE, MARTA CORNACCHIA, PAMELA FRIGERIO, MARTA LAZZERI, GIANCARLO PIAGGI, MAURIZIO SOMMARIVA, SERGIO ZUFFO ARIR: www.arirassociazione.org AARC: www.aarc.org EDITORE EDITOR ARIR EDIZIONI ASSOCIAZIONE RIABILITATORI DELL’INSUFFICIENZA RESPIRATORIA UNITÀ SPINALE A.O. OSPEDALE NIGUARDA CA’ GRANDA MILANO PIAZZA OSPEDALE MAGGIORE 3 20162 MILANO IMPAGINAZIONE E PRESTAMPA INK GRAPHICS COMMUNICATIONS S.R.L. VIA IV NOVEMBRE, 52/A 20019 SEGURO DI SETTIMO M.SE (MI) STAMPA OFFICINA GRAFICA S.R.L. VIA DELLA MECCANICA, 6 VIGANO DI GAGGIANO 20083 (MI) REG. TRIBUNALE DI MILANO N.967 06-07-06 DEL Il periodico “Selezione ARIR da Respiratory Care e AARC Times” costituisce il secondo impegno editoriale dell’Associazione Riabilitatori dell’Insufficienza Respiratoria (ARIR). Le motivazioni di questa realizzazione si delineano nell’ambito dell’attività di didattica e aggiornamento che l’associazione svolge ormai da 20 anni. È proprio realizzando corsi per Fisioterapisti in molti ospedali italiani che l’Associazione ha conosciuto direttamente quali sono i principali problemi ed ostacoli che il Fisioterapista incontra nel processo continuo di aggiornamento in materia di Fisioterapia e Riabilitazione Respiratoria. Uno degli aspetti cruciali per mantenersi “al passo con i tempi” ,oltre a partecipare a corsi specifici, è rappresentato dalla possibilità di entrare in contatto con esperienze e realtà più evolute ma al tempo stesso applicabili alla realtà italiana. I criteri di valutazione e monitoraggio, le tecniche operative, gli approcci e le metodiche sono ciò che il Fisioterapista deve acquisire per incrementare l’efficacia del suo intervento. La realtà della Fisioterapia e Riabilitazione Respiratoria è molto diversa da paese a paese ed in particolare rispetto alla realtà americana e questo rende l’aggiornamento un’operazione complessa e difficoltosa oltre che onerosa. L’ARIR dagli inizi della sua costituzione si è posta tra i vari obiettivi anche quello di ridurre le difficoltà e facilitare l’aggiornamento dei Fisioterapisti Italiani organizzando corsi e convegni a cui ha invitato e invita numerosi colleghi stranieri, esperti nei diversi ambiti della Fisioterapia e Riabilitazione Respiratoria, promuovendo così lo scambio culturale e professionale tra le diverse realtà europee e anche extra-europee. Con la realizzazione di “Selezione ARIR da Respiratory Care e AARC Times” l’ARIR intende rispondere ulteriormente e in modo concreto ad una esigenza centrale della formazione: l’accesso alle pubblicazioni scientifiche. Questo periodico offre a chi si occupa di Fisioterapia e Riabilitazione Respiratoria la possibilità di accedere ad alcune delle pubblicazioni scientifiche della American Association for Respiratory Care (AARC), selezionando quelle più vicine alla realtà italiana. “Selezione ARIR da Respiratory Care e AARC Times” è un periodico semestrale che nasce dalla volontà congiunta di ARIR e AARC frutto dell’affiliazione delle due Associazioni e sarà distribuito gratuitamente ai soci ARIR e verrà pubblicato nel website dell’Associazione www.arirassociazione.org nello spazio riservato ai soci. A nome del Direttivo ARIR Il Presidente ARIR Ft Marta Lazzeri The review "ARIR selection from Respiratory Care and AARC Time" is the second editorial engagement of the Italian Associazione Riabilitatori della Insufficienza Respiratoria (ARIR) The reasons of this workmust be found in the educational and updating activity that the association has been developing from more than 20 years. The association has directlyknown, during its courses which are the principal problems and obstacles in many italian hospitals. Above all, the necessity of a continuous updating in physiotherapy and respiratory care. In addition to attend specific courses, one of the meaning aspect to bring up to date, is to meet more developed experiences and reality suitable to the italian ones. The evaluation criteria and the operative techniques are the elements that any physiotherapist must study to ameliorate the efficacy of his/her job. The reality of physiotherapy and respiratory care is very different from country to country, particularly from the US one, thus making the updating a very difficult and expensive operation. From the beginning, one of ARIR objective has been that of making easy the updating of the italian physiotherapists, thus organizing events on specific topics (courses and congress). So far, many foreign people, experts in physiotherapy and respiratory care, has been invited from ARIR with the goal of promoting the cultural and professional exchange from european and extra European experiences. With the realization of "ARIR selection from Respiratory Care and AARC Time", ARIR wants to answer in a concrete way to a principal exigence of the professional education: the access to the scientific articles. This review offers to people who are encharged in physiotherapy and respiratory care the access to scientific articles of the American Association for Respiratory Care (AARC), selecting the ones closer to the italian reality. "ARIR selection from Respiratory Care and AARC Time" is a six month review born from the ARIR and AARC agreement, and it will be distributed for free to the ARIR members and published in the ARIR website (www.ariassociazione.org) in the page reserved to its members. From the Board of Directors The President of Arir Marta Lazzeri PRESIDENTE PRESIDENT AND FOUNDING MEMBER DALLO STATUTO DELLA ASSOCIAZIONE FROM THE STATUTE OF THE ASSOCIATION: Art. 1: è costituita l’Associazione Riabilitatori dell’Insufficienza Respiratoria (A.R.I.R.). Art.1: The Associazione Riabilitatori dell’Insufficienza Respiratoria (A.R.I.R.) was established in Milan on October 25, 1989. MARTA LAZZERI [email protected] VICE PRESIDENTE VICE PRESIDENT AND FOUNDING MEMBER GIOVANNI OLIVA [email protected] SEGRETERIA SECRETARY ANNA BRIVIO [email protected] TESORIERE TREASORER ALESSIA COLOMBO CONSIGLIERI BOARD PAMELA FRIGERIO GIANCARLO PIAGGI ELENA REPOSSINI ANTONELLA SANNITI MAURIZIO SOMMARIVA SERGIO ZUFFO CONSIGLIERI ONORARI HONORARY BOARD ROBERTO ADONE MONICA BASSI ANDREA BELLONE ITALO BRAMBILLA Art. 3: l’Associazione non ha finalità di lucro e intende promuovere la prevenzione e la riabilitazione delle patologie respiratorie. Per il conseguimento dei suoi scopi l’Associazione concorre a: • Diffondere in campo clinico terapeutico e home care, la pratica della fisioterapia e riabilitazione respiratoria. • Organizzare la formazione, l’aggiornamento, il coordinamento, la promozione dello sviluppo professionale dei fisioterapisti con specifiche competenze in ambito respiratorio. • Sostenere in campo scientifico e sociale l’educazione e l’igiene respiratoria. • Promuovere la ricerca scientifica nel campo della fisioterapia e della riabilitazione respiratoria. Art. 4: sono soci le persone e gli enti che verranno ammessi dal Consiglio e che verseranno la quota di Associazione. Art. 5: i soci si dividono in quattro categorie: 1. soci fondatori 2. soci ordinari 3. soci sostenitori 4. soci onorari Sono soci fondatori coloro che hanno sottoscritto l’atto Costitutivo dell’Associazione e coloro i quali pur non avendo sottoscritto l’atto costitutivo sia attribuita dal Consiglio tale qualifica. Sono soci ordinari i fisioterapisti accettati dal Consiglio direttivo e che versano annualmente la quota associativa stabilita Sono soci sostenitori persone fisiche e giuridiche che intendono sostenere gli scopi che l’Associazione si prefigge. Sono soci onorari le persone e gli enti ai quali il Direttivo attribuisce tale qualifica, ritenendole in grado, per qualità, titoli o attività, di dare all’Associazione un contributo d’opera o di prestigio. Art. 6: l’Associazione trae mezzi per conseguire i propri scopi dai contributi dei soci e da ogni altro provento che le confluisca. Art. 9: i soci hanno diritto: di partecipare alle assemblee e di usufruire del materiale tecnico e didattico dell’Associazione, così come, in via prioritaria, di beneficiare delle iniziative promosse dall’Associazione, Art.3: PURPOSE OF THE ASSOCIATION ARIR is a no profit entity, promoting the prevention and rehabilitation of respiratory disease. In order to do this ARIR strives to: • Promote the practice of respiratory therapy and pulmonary rehabilitation within the clinical and therapeutic fields; • Organize the training, continuing education, coordination, and the promotion and the professional development of physiotherapist having specific competencies in the respiratory fields; • Support respiratory care understanding the hygiene within the scientific and social realms; • Promote scientific research in the field of physiotherapy and respiratory rehabilitation. Art. 4: All persons and entities that are accepted by the Board of Directors and who pay the associational fee are considered members. Art. 5: There are four categories of membership: 1. Founding members 2. Regular members 3. Sustaining members 4. Honorary members. Those who have taken part in the signing of the associational statute and those whom, thought not having signed the statute, are deemed valid candidates by the Board of Directors are founding members. Physiotherapists accepted by the Board of Directors and who pay the established yearly associational fee are considered regular members. Natural and juridical persons who wish to support the pre-established purpose of the association are considered sustaining members. Persons and entities to which the Board of Directors deems such status appropriate, for reasons of capabilities, qualities, titles or activities able to give the Association a contribution of work or prestige, are considered honorary members. Art. 6: The Association obtains the means of carrying out its purpose from the contributions of its members and from any other proceeds going towards it. Art. 9: MEMBER RIGHTS The members have the right to: participate at he assemblies, utilize the technical and teaching materials of the Association, as well as enjoy, as privileged members, the benefits of the activities promoted by the Association. • Numero 02 • Anno I • Dicembre 2006 Selezione ARIR INTERNATIONAL AFFILIATE Poste italiane s.p.a. - Spedizione in Abbonamento Postale - D.L. 353/2003 (conv. In L. 27/02/2004 n.46) art.1, comma 2, DCB Milano. da e AARC Times Anatomy and Physiology of Tracheostomy Scott K Epstein MD Tracheostomy Tubes and Related Appliances Dean R Hess PhD RRT FAARC Facilitating Speech in the Patient with a Tracheostomy Dean R Hess PhD RRT FAARC EDIZIONI