Resp Care
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The trachea is easily accessible at the bedside. As such it provides ready access for emergency airway cannulation (eg, in the setting of acute upper airway obstruction) and for chronic airway access after laryngeal surgery. More commonly, tracheostomy tubes are placed to allow removal of a translaryngeal endotracheal tube. ⋯ The most recent and methodological robust studies indicate that these tubes reduce resistive and elastic work of breathing, when compared to endotracheal tubes. This is a result of tracheostomy tubes lessening inspiratory and expiratory airways resistance and intrinsic positive end-expiratory pressure. Whether these physiologic benefits are of clinical importance in enhancing weaning success remains to be elucidated.
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A tracheostomy tube decreases the ability of the patient to communicate effectively. The ability to speak provides an important improvement in the quality of life for a patient with a tracheostomy. ⋯ Speech can be facilitated in patients with a tracheostomy tube who are breathing spontaneously by use of a talking tracheostomy tube, by using a cuff-down technique with finger occlusion of the proximal tracheostomy tube, and with the use of a cuff-down technique with a speaking valve. Teamwork between the patient and the patient care team (respiratory therapist, speech-language pathologist, nurse, and physician) can result in effective restoration of speech in many patients with a long-term tracheostomy.
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Comparative Study Clinical Trial
Accuracy of physiologic dead space measurements in patients with acute respiratory distress syndrome using volumetric capnography: comparison with the metabolic monitor method.
Volumetric capnography is an alternative method of measuring expired carbon dioxide partial pressure (P(eCO2)) and physiologic dead-space-to-tidal-volume ratio (V(D)/V(T)) during mechanical ventilation. In this method, P(eCO2) is measured at the Y-adapter of the ventilator circuit, thus eliminating the effects of compression volume contamination and the need to apply a correction factor. We investigated the accuracy of volumetric capnography in measuring V(D)/V(T), compared to both uncorrected and corrected measurements, using a metabolic monitor in patients with acute respiratory distress syndrome (ARDS). ⋯ Volumetric capnography measurements of V(D)/V(T) in mechanically-ventilated patients with ARDS are as accurate as those obtained by metabolic monitor technique. .
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Tracheostomy tubes are used to administer positive-pressure ventilation, to provide a patent airway, to provide protection from aspiration, and to provide access to the lower respiratory tract for airway clearance. They are available in a variety of sizes and styles, from several manufacturers. The dimensions of tracheostomy tubes are given by their inner diameter, outer diameter, length, and curvature. ⋯ Others are designed with a port above the cuff that allows for subglottic aspiration of secretions. The tracheostomy button is used for stoma maintenance. It is important for clinicians caring for patients with a tracheostomy tube to understand the nuances of various tracheostomy tube designs and to select a tube that appropriately fits the patient.
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Tracheostomy may be associated with numerous acute, perioperative complications, some of which continue to be relevant well after the placement of the tracheostomy. A number of clinically important unique late complications have been recognized as well, including the formation of granulation tissue, tracheal stenosis, tracheomalacia, tracheoinnominate-artery fistula, tracheoesophageal fistula, ventilator-associated pneumonia, and aspiration. ⋯ Treatment modalities vary depending upon the nature of the complication. For the most frequent complication, tracheal stenosis, a multidisciplinary approach utilizing bronchoscopy, laser, airway stents, and tracheal surgery is most effective.