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

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

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

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

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

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

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

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

10. We believe that the ability to adequately protect the upper airway is crucial to the success and safety of the weaning process and that extubation remains problematic for a significant proportion of patients with neuromyopathic conditions because of the severe risk of aspiration of food and saliva. 10

11. ONGOING RISKS FROM PROLONGED TRANSLARYNGEAL INTUBATION
Complications of endotracheal intubation and tracheotomy
J.L. STAUFFER
ONGOING RISKS FROM PROLONGED TRANSLARYNGEAL INTUBATION
Inadvertent decannulation
Nosocomial pneumonia and sinusitis
Inability to communicate
Anxiety
Oversedation
Limited ability to mobilize
Compromised nutrition
Poor oral care
Prolonged ICU stay
Respir Care 1999;44:

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

16. TECHNICAL ASPECT
TRACHEOSTOMY TECHNIQUE
MANAGEMENT OF TRACHEAL CANNULA

17. PERCUTANEOUS VS SURGICAL TRACHEOSTOMY

18. Frequency of reported complications in RCT comparing ST and PDT
Early complications of Tracheostomy.
C.G.DUBIN
Frequency of reported complications in RCT comparing ST and PDT
Complications ST
(%)
PDT
Minor hemorrhage
0-80
0-20
Major hemorrhage
0-7
Pneumothorax
0-4
Accidental decannulation
Subcutaneous emphysema
Stoma infection
Difficult insertion
0-15
0-63
0-10
0-27
False placement
Hypoxia
Loss of airway/death
0-8
0-25
Respir Care 2005;50:

19. 1 hour after decannulation
4 hours after decannulation
8 hours after decannulation

21. Long-term follow-up of patients administered MV via percutaneous tracheostomy: personal experience
Aetiology
Follow-up
(months)
Side effects 1
Guillain-Barrè Syndrome 6
Tracheal stenosis 2
COPD 25 - 3
DMD 10 4
Accidental decannulation
(Surgical trach) 5
COPD + stroke
( Re-dilation)
ALS 7
Kyphoscoliosis 8
Sudden death 9
Cervical trauma
There is convincing evidence to conclude that surgical tracheostomy should be preferred over the percutaneous technique.

22. MANAGEMENT OF TRACHEAL CANNULA
CUFF MANAGEMENT
MALPOSITION
PHONATION

23. MANAGEMENT OF TRACHEAL CANNULA
CUFF MANAGEMENT
MALPOSITION
PHONATION

24. Courtesy of R. Marchese

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

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

28. Pooling of contaminated secretions above the endotracheal tube cuff

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

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

31. Subglottic aspiration of pooled secretions

32. MANAGEMENT OF TRACHEAL CANNULA
CUFF MANAGEMENT
MALPOSITION
PHONATION

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

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

36. MANAGEMENT OF TRACHEAL CANNULA
CUFF MANAGEMENT
MALPOSITION
PHONATION

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

40. INSPIRATION
ESPIRATION - ZEEP

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

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

43. ?
Survival and Quality of Life after tracheotomy

44. The mean time between intubation and death was 7. 4 months, (median 2
The mean time between intubation and death was 7.4 months, (median 2.8 months, range 1 week to 3.5 years)

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

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

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

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

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

51. Life Satisfaction Index –11 (Italian Version)
The Life Satisfaction Index – 11 is a short form of LSI questionnaire providing
a cumulative score acknowledged as an index of quality of life

52. 1,57 1,60 3 4,14 4,10 4 2,85 3,15 TRACH ALS ALS NORMAL SUBJECT
2010, July 22
TRACH ALS
ALS
NORMAL SUBJECT
Mood tone
1,57
1,60 3
Zest for life
4,14
4,10 4
Congruence between desired and achieved goals
2,85
3,15

53. 11 ALS pts discharged on TIPPV
All patients informed in advance (9/11) have a positive view of the treatment!

54. Conclusions
When a patient with ALS is ventilated acutely, weaning from the ventilator is rarely achieved and tracheostomy often becomes mandatory;
People with ALS can live for many years beyond ARF if ventilation via tracheostomy is used;
Although many tracheostomised patients are happy with their choiche, further debate is required on the desiderability of long-term TIPPV for both the patient and the family.