Pamela V. ONeal PhD, RN Ellise D. Adams, PhD, CNM Emanuel Waddell PhD University of Alabama in Huntsville College of Nursing and College of Science Palliative Practices to Promote Airway Clearance

Purpose Purpose is to focus on integrating palliative care practices to assist children, adults, and older adults in – Promoting airway clearance – Managing respiratory compromise – Providing supportive pulmonary care at the end of life

Learning Objective Discuss functional oral mobility to effectively manipulate secretions Describe interprofessional collaborative work to address a clinical issue Examine involvement of healthcare providers and caregivers in assisting with simple, effective, airway clearance practices

Palliative Care Impact Addresses Pain and Suffering Across the Lifespan National Hospice and Palliative Care Organization (NHPCO) – 1.5million patients in 2013 received hospital services – Female (55%) – Age 85+ (41%) – Less than 24years (0.4%)

Top Noncancer Diseases Requiring Palliative Care Dementia (15%) Heart Disease (13%) Lung Disease (10%) All diseases involve sequelae associated with airway clearance – Dysphagia – Dyspnea – Respiratory Compromise

Common Child Oral Concerns Fragile mucosa (chemotherapy or radiation) Hypersalivation – drooling is apparent Oral mucositis – pain, inflammation, and ulceration or oral cavity Halitosis – pathological (related to disease) or physiological (decayed food) Stomatis – inflammation of mucus lining Xerostomia – dry mouth (Sargeant & Chamley, 2013)

End of Life and Death Rattle Noisy breathing is heard Secretions accumulate in the back of the throat Muscles in the back of the throat may relax Usually unconscious, “sleeping,” not aware Reposition, remove oral secretions, administer medications Comfort measures are more for the Careprovider (Nunn, 2014).

Secretion Management Lack of oral secretion management may cause – Excessive oropharyngeal secretions – Transit of tracheobronchial secretions – Social isolation related to Drooling – Potentially life threatening (Elman, Dubin, Kelly, McCLuskey, 2005)

Swallowing, Coughing, and Secretion Production Swallowing and coughing involves – Central and Peripheral nervous system – Skeletal muscles and Sensory function Normal daily salivary volume produced by salivary glands is 1.5L Daily mucus volume produced by orophayrngeal and tracheobronchial gland is 2L Ineffective swallowing and coughing can lead to poor secretion management and airway clearance compromise

Oropharyngeal Anatomy

Anatomy of Swallowing

Oral Secretion Accumulation Oral secretions accumulate Functional ability to manipulate secretions diminishes with age and/or disease process Secretions may change molecular structure – Increase in Viscosity (thickness) Dehydration – volume status Medications – Decrease in Viscosity Not as common- overhydration

Orophyarngeal Secretion Accumulation Migration of secretions to pharyngeal area Aspiration of secretions Outcomes – Pneumonia

Oral Secretion Removal Oral secretion removal is critical – External removal when patient is unable to assist in adequate secretion management (Elman, Dubin, Kelley, & McCluskey 2005) Lack of effective swallow Viscosity (too thin or too thick) compromises functional manipulation by tongue Muscular atrophy of tongue and facial muscles impacts effective swallow Neurological impairment – can be seen in children

Soft-tipped Manual Aspirator

Interprofessional Collaboration Nursing – Direct involvement with patient and careprovider Chemistry – Fabrication of prototypes to improve secretion removal and assess secretion viscosity Microbiology – Effective cleaning of device Engineering – Suction efficiency and effectiveness

Interprofessional Research Team College of Nursing, Sciences, and Engineering are collaborating on the following projects: – Pathogen identification in manual aspirators – Recommended cleaning and storage – Knowledge acquisition of patient and careprovider related to use of suction device – Retention of learned suctioning techniques – Microfluid viscometer, new design consider hydrophobic properties – Optimal compressibility location to yield maximal secretion removal based on viscosity of fluid – Practice guidelines in using a manual suction device

CLEAR Project Clearance of the Airways Ellise D. Adams, PhD, CNM Emanuel Waddell, PhD

Healthcare Provider and Caregiver Involvement in Effective Airway Clearance Practices Secretion management is critical in preventing pulmonary compromise Manual aspirator has a soft tipped-end and can be used in children, adults, and older adults Manual aspirator is easy to use and requires no wall suction

Outcomes of Effective Secretion Removal Promotes effective airway clearance Relieves deleterious effects of poor oxygenation Provides comfort support through manual secretion removal with a soft-tipped suction device

Summary Pulmonary compromise occurs regardless of primary disease Secretion management assists with promoting pulmonary hygiene Secretions can be removed with a soft-tipped manual aspirator Comfort goals obtained for both the Patient and Caregiver

References Elman, L, Dubin, R., Kelly, M., McCluskey, L. (2005) Management of oropharyngeal and tracheobronchial secretions in patietns with neurologic disease. Journal of Palliative Medicine, 8 (6), Nunn, C. (2014). It’s not just about pain: Symptom management in palliative care. Nurse Prescribing 12 (7), Sargeant, S., and Chamley, C. (2013). Oral health assessment and mouth care for children and young people receiving palliative care. Part one. Nursing Children & Young People, 25 (2), Towney, S., and Dowling, M. (2013). Managemetn of death rattle at end of life. British Journal of Nursing, 22(2),

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