Autor : Carlos H. Bevilacqua1
1 Associate Editor RAMR
https://doi.org/10.56538/ramr.CHCV5037
Correspondencia
This
edition of the RAMR includes an interesting retrospective study on “tracheostomy
and dysphagia in patients with COVID-19 and their impact on the decannulation
process.”1
The
authors show the extremely high incidence of swallowing disorders observed when
attempting to decannulate patients who are ventilated for COVID-19 pneumonia.
While the observed group included 65 cases of tracheostomized patients, it is
known that prolonged intubation can also cause serious injuries to the upper
airway.
The
possibility of reducing the time spent with a tracheostomy is also important in
the prophylaxis of injuries that are “distant” from the airway. Critical
tracheal obstructions due to granulomas, narrowing or cartilage injury are not
uncommon, requiring dilation with bougies, resection, or “tracheoplasty” with
resection of one or more tracheal cartilages.
It
is therefore agreed that every effort should be made to reduce the time of
connection to the ventilator via an artificial airway.
As
shown by the researchers, fiberoptic laryngoscopes are now more accessible and
extremely helpful in detecting and monitoring the presence and progression of
laryngotracheal injuries secondary to prolonged ventilation. They also allow
the visualization of resultant swallowing disorders and the assessment of their
potential rehabilitation. Otherwise, the development of aspiration pneumonia
would be a serious complication during refeeding or upon discharge, even from
the aspiration of the patient’s own saliva.
With
apologies for exceeding the “limits” appropriately set by the authors, I will
briefly refer to some topics related to the experience with artificial airways
in the field of critical care.
It
is not advisable to prolong the presence of the endotracheal tube beyond 7-10
days. However, this decision will depend on the expected progression, according
to the disorder that led to the intervention. The decision will be different
for a patient with prospects of rapid improvement compared to those in whom we
assume in advance that their progression will not allow for a rapid weaning
(neurological disorders), and in such cases, it would be preferable to make an
earlier decision to indicate a tracheostomy.2
With
respect to these procedures, it will always be more comfortable for the patient
to tolerate ventilation through a tracheostomy, avoiding the “costly” airflow
resistance and subsequent increase in respiratory effort imposed by an endotracheal
tube after several days of insertion. This choice will reduce the requirements
for central nervous system depressants and facilitate access to physiotherapy,
secretion aspiration, important communication with the patient, and will potentially
allow for early weaning from mechanical ventilation.
When
ventilating patients, we often face the challenge of resolving the “mismatch”
between the patient and their ventilator. This means preventing or improving a
manifest asynchrony between the patient and the equipment that controls or
assists them.
In
this situation, reducing the administered doses of central nervous system
depressants and/ or muscle relaxants will allow for quicker weaning and
decannulation processes. This will be the best prophylaxis against complex
airway injuries that can later affect swallowing and/or spontaneous
ventilation.3
In
the vast majority of cases, this will depend on factors to be corrected that
obviously cannot be appropriately solved remotely (“remote control”), and will
always require a thorough examination of the patient-ventilator relationship
“in situ”. This approach drastically reduces the time spent on mechanical ventilation.
It
is clear that the indication of deeper sedation, and the potential
administration of muscle relaxants under these circumstances will be inappropriate
to improve adaptation (in cases where the reason for the mismatch has not been
solved), but it will also significantly delay or impede the possibilities of
disconnection attempts.
An
elementary list of controls in these conditions should include ruling out
and/or solving any of the following problems:
–
Presence of secretions in the artificial airway, which in the case of the
endotracheal tube will excessively increase flow resistance, thus increasing
the respiratory work. It will require more frequent and effective aspirations
to clear the difficulty. The frequent response of “I just suctioned it” does
not mean that the airway is clear. At most, it will mean that it should be
aspirated more frequently or more effectively. Always use a well humidified
inspired mixture at the proper temperature.
–
Fever. The presence of hyperthermia in these patients is a frequent issue: it
increases the respiratory rate, facilitates mismatch, and is easy to solve
with the administration of antipyretics by central route.
–
Sometimes we can detect subcutaneous emphysema or asymmetry during
auscultation of vesicular murmur, and this will alert us to the possible
presence of a pneumothorax in individuals subjected to positive pressure
ventilation. The chest X-ray will either confirm or remove our suspicion, and
will allow for the pertinent solutions.
–
The system may become less airtight due to an air leak, if the balloon is
deflated or displaced. This can be detected just putting our ear close to the
patient’s mouth. It will be necessary to insufflate the balloon with the
minimum amount of air that “seals” this leak. Never exceed pressures over 30
mmHg, which could result in mucosal ischemia. In some more uncomfortable
cases, airtightness will not be achieved due to balloon leakage and it will be
necessary to replace it with a tube or cannula. Also, an endotracheal tube may
have been displaced distally, usually to the right main bronchus for anatomical
reasons. This is verified during auscultation of the chest, and is confirmed
and resolved by partial removal of the tube.
–
Auscultation may show bronchospasm, which can be quickly resolved by
administrating bronchodilator aerosols, using the extensible portion of the
inspiratory tubing.
–
Another alternative is that the patient may no longer tolerate the ventilatory
mode being used due to changes in his/her evolution or consciousness, thus
requiring changes in the tidal volumes used, an adequate titration of positive
end-expiratory pressure (PEEP), or the use of a spontaneous ventilatory mode,
such as pressure support, to “manage” his/her own respiratory rate. There is a
wide range of alternatives offered by microprocessor controlled ventilators,
and finding a more “comfortable” ventilatory mode is not difficult in a patient
in whom other causes of asynchrony have been previously excluded.
The
recent urge to use various forms of non-invasive ventilation (NIV) in the
treatment of patients with acute or chronic pneumopathies is a valuable attempt
to avoid the serious complications that artificial airways produce in the
larynx and trachea. However, these techniques are not yet applicable to the
most severe forms of bilateral pneumonia or “severe distress”, such as those
observed during the COVID-19 pandemic. In this case, or with other infectious
diseases, strict isolation of the expiratory port is also required.4
The
proper and safe use of this technique requires highly experienced nurses,
kinesiologists and physicians.
REFERENCES
1.
Falduti A, Catini ME, Chiappero G. Traqueostomía y disfagia en
pacientes con COVID-19. Su impacto en el proceso de decanulación. Rev Am
Med Resp 2024;24:76-84 https://doi.org./10.56538/ramr.PTWI9302
2.
Andriolo BN, Andriolo RB, Saconato H, Atallah ÁN, Valente O.
Traqueostomía temprana versus tardía para pacientes
críticamente enfermos. Sistema de base de datos Cochrane Rev.
2015;1:CD007271. https://doi.org/10.1002/14651858.CD007271.pub3.
3.
Mussa CC, Gomaa D, Rowley DD, Schmidt U, Ginier E, Strickland SL. Guía
de práctica clínica de la AARC: Manejo de pacientes adultos con
traqueostomía en el entorno de cuidados intensivos. Cuidado
respiratorio. 2021;66:156-69.
4.
Cristóbal KL. Decanulación de traqueotomía. Cuidado
respiratorio. 2005;50:538-41.