Transcript Amyotrophic Lateral Sclerosis

CRC 432 Subacute Care
Problem-Based Learning
Module I
Tracheostomy Care/
Amyotrophic Lateral Sclerosis
Tracheostomy Care
Tracheotomy: procedure of establishing
opening in trachea via incision.
Tracheostomy: opening created by
tracheostomy procedure (stoma = opening).
Tracheostomy Care
PURPOSES FOR TRACHEOSTOMY
Primary route for overcoming upper airway
obstruction (foreign bodies, vocal cord
paralysis, surgical edema, tumors, burns)
Patent airway overcoming trauma
Facilitation of secretion removal (severe
bronchitis in debilitated patient, paralysis of
chest muscles & diaphragm)
Tracheostomy Care
PURPOSES FOR TRACHEOSTOMY
Prevention of aspiration of gastric contents
(prolonged unconsciousness)
Prolonged mechanical ventilation
Airway for long-term care in patients with
NMD
Myasthenia gravis
Guillain-Barré syndrome
Amyotrophic lateral sclerosis
Tracheostomy Care
PURPOSES FOR TRACHEOSTOMY
Decrease WOB & increase VT by reducing
VD anat
Tracheostomy Care
IMMEDIATE
♣ Hemorrhage
♣ Pneumothorax
♣ SubQ/mediastinal
emphysema
♣ Resp/cardio collapse
♣ Dislodged tube
LATE
♠ Airway obstruction
♠ Infection
♠ Aspiration
♠ Tracheal damage
♠ Dislodged tube
♠ Hemorrhage
Tracheostomy Care
SUCTIONING
Purpose
Airway patency crucial for survival
Facilitate patient comfort
Increase ventilatory efficiency
Decrease risk of airway obstruction
Decrease risk of infection
Tracheostomy Care
SUCTIONING
Indications
Inability to cough
Mucus bubbling/gurgling in trach tube
Crackles/gurgling heard on auscultation
Audible (naked ear) gurgling
Difficulty breathing
Patient restlessness
Tracheostomy Care
SUCTIONING
Indications
Low SaO2
Cyanosis
Increased PIP-Pplateau difference
Patient request
Stridor/changes in breath sounds
Tracheostomy Care
CLEANING INNER CANNULA
Clean usually in AM and PM
Clean inner cannula PRN
Rid inner cannula of bacteria
Remove accumulated secretions & decrease
risk of infection
Tracheostomy Care
EQUIPMENT TO CLEAN
INNER CANNULA
Manual resuscitator
Spare tracheostomy tubes: same size &
one size smaller
Suction equipment
Tracheal dilators
Tracheostomy mask & O2 if in use
Tracheostomy Care
INNER CANNULA CLEANING PROCEDURE
1. Wash hands
2. Explain procedure to patient
3. Assemble equipment
4. Don gloves
5. Prepare separate basins for H2O2 and NS
6. Suction through trach tube
7. Dispose of gloves, & re-glove
8. Unlock, & remove inner cannula
Tracheostomy Care
INNER CANNULA CLEANING PROCEDURE
9. Immerse inner cannula in H2O2 basin
10. Dispose of gloves, & re-glove
11. Insert temporary inner cannula, & lock in place
12. Using H2O2, clean inner cannula with bottle
brush/pipe cleaner
13. Transfer, & immerse inner cannula to NS basin
Tracheostomy Care
INNER CANNULA CLEANING PROCEDURE
14. Shake clean inner cannula to remove excess NS
15. Remove temporary inner cannula
16. Reinsert clean inner cannula
17. Lock clean inner cannula to outer cannula
Tracheostomy Care
CHANGING TRACHEOSTOMY TUBE
PURPOSES
accidental displacement of existing tube
mucous plug in existing tube causing distress
ruptured cuff
planned tracheostomy tube change
decannulation process
change type or size of tube
Tracheostomy Care
EQUIPMENT FOR CHAGING
TRACHEOSTOMY TUBE
Manual resuscitator
Spare tracheostomy tubes: same size &
one size smaller
Suction equipment
Tracheal dilators
Tracheostomy mask & O2 if in use
Tracheostomy Care
CHANGING TRACHEOSTOMY TUBE
1.
2.
3.
4.
5.
6.
Check MD orders (size, type)
Wash hands
Assemble equipment
Explain procedure to patient
Suction airway & pharynx above cuff
Remove inner cannula from new trach
Tracheostomy Care
CHANGING TRACHEOSTOMY TUBE
7. Insert obturator, & lubricate tip
8. Assess cuff of new trach for leaks
9. Attach, & secure tie to one flange
10. Deflate cuff on indwelling trach tube
11. Cut trach ties, and remove trach tube
12. Don gloves
Tracheostomy Care
CHANGING TRACHEOSTOMY TUBE
13. Insert trach tube into trachea
14. Remove obturator
15. While holding tied flange, secure other
flange
16. Inflate cuff
17. Check intracuff pressure
18. Insert inner cannula, & lock in place
Tracheostomy Care
UNABLE TO RECANNULATE STOMA
Assess patient for adequate ventilation
Provide O2 at stoma site
Manually ventilate stoma with 100% O2
Prepare to recannulate, or to perform
endotracheal intubation
Amyotrophic Lateral Sclerosis
Referred to as Lou Gehrig’s disease
Neurodegenerative disease of upper (brain) &
lower (spinal cord) motor neurons
Motor neurons are brain & spinal cord cells that
control voluntary muscle movement
Motor neurons carry impulses from brain to
brainstem & spinal cord, then to vol. muscles
Gradual degeneration and death of motor
neurons.
Muscles unable to contract
Causes muscular atrophy & fasciculations
Amyotrophic Lateral Sclerosis
At the age of 32, Lou Gehrig had already made his
name as one of the greatest baseball players of all
time. He was a two-time MVP, had become the
league leader in BA, HRs, & RBIs, and had not
missed a game in over 12 yrs with the NY
Yankees. Yet, by ’38, his teammates and fans
noticed that something was wrong. He was
dragging his feet during practice, and his batting
average was slipping drastically. Day by day, he
grew weaker.
Amyotrophic Lateral Sclerosis
By 1939, Gehrig was too frail to play any
longer. At last, a doctor delivered the bad
news: he had ALS. Gehrig died just two
years later – one of the finest athletes the
world had ever seen, unable to move a
single muscle, or to draw another breath.
Lou Gehrig died in 1941.
Amyotrophic Lateral Sclerosis
Stephen Hawking said, "ALS has not
prevented me from having a very attractive
family, and being successful in my work . . .
I have been lucky that my condition has
progressed more slowly than is often the
case. But it shows that one need not lose
hope."
Amyotrophic Lateral Sclerosis
Eventually, all muscles under voluntary
control are affected
Motor neurons die, and muscles waste
away
Patients lose their strength and the
ability to move their arms, legs, and
body.
Patients lose ability to breathe when
diaphragm and chest wall muscles fail
Ventilatory support then needed
Amyotrophic Lateral Sclerosis
Aspiration pneumonia and medical
complications of immobility contribute to
morbidity.
ALS occurs in about 5 of 100,000 people
Onset usually occurs in patients aged 40-60
years
Progressive fatal illness
Death 1 to 3 years after diagnosis
Amyotrophic Lateral Sclerosis
Bulbar symptoms: first notices slurring of words
or choking during meals; aspiration events or
acute respiratory symptoms of air hunger occur.
Somatic symptoms: wrist drop interfering with
work performance; may find reduced finger
dexterity, cramping, stiffness, weakness or
wasting of intrinsic hand muscles; develop foot
drop resulting in a fall or sprain; sensory neurons
unaffected.
Amyotrophic Lateral Sclerosis
LOWER MOTOR NEURON SYMPTOMS
Weakness & muscle wasting
Fasciculations & muscle twitching
Signs of increased muscle irritability
Fasciculations: benign when no muscle
weakness or atrophy occur
Fasciculations: pathologic with ALS
symptoms
Amyotrophic Lateral Sclerosis
UPPER MOTOR NEURON SYMPTOMS
Spasticity, stiffness in lower limb, jaw, face
Walking difficulties
heaviness
fatigue
stiffness
lack of coordination
Laughter/crying outbursts with minimum
provocation (emotional lability)
Amyotrophic Lateral Sclerosis
Amyotrophic Lateral Sclerosis
Bulbar involvement causes speech and
swallowing difficulties
May be only manifestation of ALS
Some ALS patients have bulbar
involvement, but normal strength in arms,
legs, & respiratory muscles
Difficulty controlling saliva
Amyotrophic Lateral Sclerosis
Not abnormal amount of saliva produced
Mouth & tongue cannot cope with handling
normal amount of saliva
Drooling (sialorrhea) occurs
Medications used to decrease saliva production:
glycopyrrolate
tricyclic antidepressants
amitriptyline
nortriptyline
atropine
scopolamine patch
Amyotrophic Lateral Sclerosis
Extreme, uncontrollable laughter or crying;
called emotional lability
Amyotrophic Lateral Sclerosis
DIAGNOSIS
Clinical diagnosis (No specific tests)
Worsening of symptoms
Symptoms of both brain & spinal cord
Stiffness in legs, face, jaw
Decreased coordination
Fatigue
Exaggerated reflexes
Uncontrolled laughter and crying
Amyotrophic Lateral Sclerosis
DIAGNOSIS
Electromyography (EMG): detects electrical
activity in muscles
Magnetic resonance imaging (MRI): creates
images of brain & spinal cord
Nerve conduction velocity (NCV): how fast
nerves transmit impulses
Amyotrophic Lateral Sclerosis
No loss of anal sphincter tone occurs
Cardiac and smooth muscle are not involved.
Course is progressive, and initial symptoms
primarily are those of weakness.
Ocular musculature is not involved.
Quick definitive diagnosis is rare.
Neurologists need many months to exclude other
diagnoses in patient presenting with upper and
lower motor neuron signs.
Amyotrophic Lateral Sclerosis
ALS does not affect
the senses
personality
thought
memory
Amyotrophic Lateral Sclerosis
10% familial/genetic
Familial/genetic = 2+ cases in same
bloodline
No family history = sporadic ALS
Gene defect superoxide dismutase 1
(SOD1) accounts for 10% ALS
Amyotrophic Lateral Sclerosis
TREATMENT
No cure
Rilutek (brand name); riluzole (generic
name)