Resp Care
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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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Tracheostomy is one of the most common intensive care unit procedures performed. The advantages include patient comfort, safety, ability to communicate, and better oral and airway care. Patients may have shorter intensive care unit stays, days of mechanical ventilation, and hospital stays. ⋯ As soon as the need for prolonged airway access is identified, the tracheostomy should be considered. Generally, this decision can be made within 7-10 days. Bedside techniques allow rapid tracheostomy with low morbidity.
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The respiratory therapist plays an integral role in tracheostomy tube decannulation. Removal of the tracheostomy tube should be considered only if the original upper-airway obstruction is resolved, if airway secretions are controlled, and if mechanical ventilation is no longer needed. ⋯ Tracheostomy decannulation requires caution, particularly following a prolonged period of tracheostomy use. The tracheostomy tube decannulation process is well suited for therapist-implemented protocols.
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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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No hypothesis relating to respiratory care in the intensive care unit has proved more difficult to study in an objective fashion than the commonly held belief that tracheostomy hastens weaning from ventilatory support. Tracheostomy might facilitate weaning by reducing dead space and decreasing airway resistance, by improving secretion clearance, by reducing the need for sedation, and by decreasing the risk of aspiration. Available evidence indicates that dead space and airway resistance are in fact reduced, although whether the magnitude of these reductions explains the clinical observation of more rapid weaning after tracheotomy is less certain. ⋯ The most recent clinical trial found that percutaneous dilational tracheotomy performed in the first 2 days in patients projected to need > 14 days of ventilatory support greatly reduced ventilator and intensive care unit days, and decreased both the incidence of pneumonia and overall mortality, in comparison with tracheostomy done after day 14. Conducting such trials is difficult because of investigator and clinician bias, the inability to predict which patients will actually require prolonged mechanical ventilation, and several other factors discussed in this article. Tracheotomy probably does aid in liberating some patients from ventilatory support, but this may be as much from its effect on clinician behavior as from any physiologic impact.