Transition from Tracheostomy to NIV

UK Paediatric LTV Group Study Day 21/03/13

Andrew Morley (BSc Hons, RPSGT) Chief Respiratory Physiologist Royal Hospital for Sick Children, Glasgow

Transition from Tracheostomy to NIV Why change to NIV? What are the issues? When to decannulate? How to do it? What makes using NIV tricky?

Transition from Tracheostomy to NIV History of NIV 1981 Professor Colin Sullivan first developed the Continuous Positive Airway Pressure (CPAP)

Transition from Tracheostomy to NIV Non-invasive home mechanical ventilation (HMV) via a mask has become a wellestablished therapeutic option for Chronic respiratory conditions.

Transition from Tracheostomy to NIV Benefits of changing to NIV Noninvasive - Tracheostomy is Invasive (Loss of normal upper airway defenses & humidification, requires suction)

Risk of infection -

Tracheostomy complications , site (stoma) can become infected, bleed or develop inflammatory tissue (granulations) that need to be removed

Safety

- Tube blocking, Tracheostomy changes

Care

- Easier, less complicated & less stress

Transition from Tracheostomy to NIV Benefits of changing to NIV Equipment

- Less parts, Less maintenance & less cleaning

Cost

- Less Equipment, cheaper ventilators? , Staff +/-

Asthetics

- Makes them look more “normal”

Quality of Life

- Social functioning – e.g. Speech - Sleep disturbance?? – Less secretions

- Swim

Transition from Tracheostomy to NIV Issues with NIV • • • • • •

Anxiety Sub-optimal therapy Compliance issues Maturity Growth concerns Parental concerns

Transition from Tracheostomy to NIV Drawbacks with NIV Sub-optimal therapy Non invasive ventilation proving insufficient TransCO2 climbing despite high pressures.

Transition from Tracheostomy to NIV Drawbacks with NIV • Maturity • Intellectual age • Staff (+/-) • Attention (Like to make the machine beep)

Transition from Tracheostomy to NIV Drawbacks with NIV Growth defects as a result of daily use

Transition from Tracheostomy to NIV When to decannulate? • No consensus statement • Transition from invasive ventilation generally performed, not earlier than 6-8 years of age

(Children who are ventilated only during sleep) • Patients 24 hours dependent, considered later 10-12 years of age. (Potentially using phrenic nerve stimulation while awake and non invasive ventilation during sleep)

Transition from Tracheostomy to NIV When to decannulate? Physician led •

Age

•

Patient’s wishes

•

Level of Maturity

•

Intellectual / developmental delay

•

Manage their oral secretions without a risk of aspiration

Transition from Tracheostomy to NIV Transition onto NIV

• Can be a slow process • Patient confidence- For therapy to be effective the patient has to be a willing participant

• May require multiple preparatory visits/attempts

Transition from Tracheostomy to NIV NIV Transition Algorithm

ENT Assessment (Prior to admission)

Familiarisation Admission Continuous monitoring (At home)

Follow up

Admission (Multiple nights)

Transition from Tracheostomy to NIV NIV Transition Algorithm

ENT Assessment (Prior to admission)

Familiarisation Admission

Baseline Cap off Tracheostomy & Reduce size + Limited channel study ( TransCO2 & Oxygen saturation) Titrate ventilation 2-3nights +

Continuous monitoring (At home)

Step down process for tracheostomy (daytime spot checks)

Decannulation

Post decannulation monitoring (2 normal nights)

Follow up

Admission (Multiple nights)

Transition from Tracheostomy to NIV Transition onto NIV ENT Assessment Microlaryngoscopy and bronchoscopy (MLB)- 6 weeks prior •

Nasal patency

•

Large suprastomal granulation – diameter of the airway above the tracheostomy site Implications for Mouth/nose breathing patient.

• • • •

Suprastomal collapse Active vocal cord abduction Subglottic stenosis Cysts The Children’s Hospital of Philadelphia website

Transition from Tracheostomy to NIV Transition onto NIV Familiarisation • Clinic • Play therapist • Psychology • Physiologist • Hypnosis?? - Pilot study 9 patients Medical hypnosis as a tool to acclimatize children to non-invasive positive pressure ventilation: a pilot study Vincent Delord, MSN; Sonia Khirani, PhD; Adriana Ramirez, MSc; Erick Louis Joseph, AS; Clotilde Gambier, MSN; Maryse Belson, MSN; Francis Gajan, MD; Brigitte Fauroux, MD, PhD CHEST. February 7, 2013 doi:10.1378/chest.12-2259

Transition from Tracheostomy to NIV Admission

Admission

Admission (Multiple nights)

Baseline Cap off Tracheostomy & Reduce size & CRSS/ Limited channel study ( TransCO2 & Oxygen saturation) Titrate ventilation 2-3nights &

Step down process for tracheostomy including daytime spot checks Decannulation

Post decannulation monitoring (2 normal nights)

(Original Size

3.0mm)

Transition from Tracheostomy to NIV Initiating NIV • Anxiety - Patients can initially experience a sensation of shortness of breath once decannulated

• Coordination of breathing • What type of mask to use? - Nasal mask ideal in theory - FFM in practice

Transition from Tracheostomy to NIV Capped off study During the first night monitoring:• Oxygen levels • CO2 levels • Heart rate Also observe • Respiratory rate • Work of breathing • Restlessness • Diaphoresis (excessive sweating ) • Ability to clear secretions while capped off

Transition from Tracheostomy to NIV Admission Baseline

Admission (Multiple nights)

Cap off Tracheostomy & Reduce size & Limited channel study ( TransCO2 & Oxygen saturation) Titrate ventilation 2-3nights &

Step down process for tracheostomy including daytime spot checks

Decannulation Post decannulation monitoring (2 normal nights)

(Original Size

3.0mm)

Transition from Tracheostomy to NIV Continuous Monitoring - Dependant on condition

Follow up - LTV team liaise with family - 1/12 inpatient review (inc.Ventilation check)

(Appropriate follow-up is the key to patient compliance)

Transition from Tracheostomy to NIV Discharge planning • Training - Parents - Carers/family - Staff • Monitors

Transition from Tracheostomy to NIV Challenges of NIV

• Physical • Physiological • Psychological

Transition from Tracheostomy to NIV Physical issues:• Sensation – Not easy to use • • • • •

Pressure Sores- ulceration of the bridge of the nose Eczema- irritation of the skin Rhinitis Aspiration risk - with FFM & Mouthpiece ventilation Swallowing of air -leading to gastric distention/bloating, flatulence.

• • • •

Air leaks- in the eyes & through the mouth e.g. Corneal drying Ear ache - due to pressure Growth abnormalities – facial changes e.g. underbite Interference with talking

Transition from Tracheostomy to NIV Physical cont. Sensation

Patient - “NIV is like trying to breath while having your head stuck out the car window”

Transition from Tracheostomy to NIV Physical cont. Sensation • Uncomfortable • Claustrophobic • Line of sight – Glasses, Claustrophobia • Communication -

Talking difficult

, anxiety

Transition from Tracheostomy to NIV Interfaces on the market • • • • •

Nasal mask Full Face Mask Helmet Oral interface Nasal Pillows

Transition from Tracheostomy to NIV Mask issues Masks are too big & built for adults!!!!

Transition from Tracheostomy to NIV Physical cont. Mask Leak • Poor fitted mask • Poorly sized mask • Facial hair – Moustache , Beards Side effects •

Corneal drying

•

Eye watering

•

Suboptimal therapy

Transition from Tracheostomy to NIV Physical cont. Ease of use • Patients do not always an find this an easy therapy to use. • Medical/Health care professionals often underestimate patient concerns

Patient: “It was like an endurance test every night”

Transition from Tracheostomy to NIV Physical cont. Pressure Sores

Transition from Tracheostomy to NIV Pyscho/social issues • Trust • Patient motivation • Look • Noisy

Transition from Tracheostomy to NIV Summary Transition to NIV therapy from Tracheostomy is a very successful treatment for numerous clinical scenarios.

However, the level of skill, time & effort required to make this an effective treatment should not be underestimated.