Transcript Journal of Palliative Medicine, 8 - 2nd International Conference on

Palliative Practices to
Promote Airway Clearance
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
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), 1150-1159.
• Nunn, C. (2014). It’s not just about pain: Symptom
management in palliative care. Nurse Prescribing 12 (7), 338344.
• 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), 29-34.
• Towney, S., and Dowling, M. (2013). Managemetn of death
rattle at end of life. British Journal of Nursing, 22(2), 81-85.
Questions
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