Avoiding silent aspira0on!

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1 Avoiding silent aspira0on! Mulier J P. AZ Sint- Jan Brugge- Oostende AV, Belgium 32 nd int symp Intensive Care and Emergency Med. Silver Hall 14:25 32 int symp Int Care Emerg Med

2 Prevent aspiration pneumonia? 32 int symp Int Care Emerg Med

3 In vitro tests A B C Runs through stop on top runs & stop 32 int symp Int Care Emerg Med

4 above cuff below cuff trachea Hi Lo 6,5 cuffed ETT below cuff 6,5 cuffed ETT Taperguard 32 int symp Int Care Emerg Med

5 Human Methylene blue leak test Obese patients, CMV 5-10 peep after 5 minutes when blue is visible above cuff 9 patients excluded as no blue above cuff 12 Bronchoscopic visualized methylene blue leak number of patients Hi contour Mallinckrodt 32 int symp Int Care Emerg Med Hi contour Mallinckrodt with KY gel TaperGuard Mallinckrodt leak no leak

6 Large Fluid Collections Can Be Prevented by Subglottic Secretion Drainage Accumulated secretions Evacuation lumen Suction port location 32 int symp Int Care Emerg Med

7 Conclusion 1. Silent aspiration happens with regular endotracheal tubes 1. Gel helps shortly and not with everyone 2. Special cuff material or shape design helps but 3. Subglottic drainage lowers fluid collections 4. What happens when suctioning the ETT 1. Open 2. Closed suctioning system 32 int symp Int Care Emerg Med

8 What happens when suctioning the ETT? 32 int symp Int Care Emerg Med

9 Suction catheter size depends on ETT size Use a catheter with an outer diameter that is about half the inner diameter of the artificial airway this will allow air to enter around it during suctioning. Multiply the artificial airways diameter in millimeters by two to find the French suction catheter. For example, 8 mm X 2 = 16, so a 16 French catheter is safe for a tube 8,0 or larger. (aspiration guidelines for nurses) 32 int symp Int Care Emerg Med

10 However 16 F suction catheter is frequently used in smaller ETT. Black 10 F White 12 F Green 14 F Red 16 F 32 int symp Int Care Emerg Med

11 Suction flow with aspiration device at 0,6 bar catheter diameter liter/min minimum ETT blue 8 Ch 2,7 mm 4 4 black 10 Ch 3,3 mm 13 5 whit 12 Ch 4,0 mm 21 6 green 14 Ch 4,7 mm 25 7 orange 16 Ch 5,3 mm int symp Int Care Emerg Med

12 Impact of CPAP on suctioning 32 int symp Int Care Emerg Med

13 Effect of negative pressures in the trachea Lung collaps ETT cuff leak with pharyngeal fluid aspirated into the trachea before being aspirated. Below 10 cmh20 always aspiration pressure in trachea cmh Hi LO 8,0 dry Hi Lo 8,0 with gel taperguard 8, J P Mulier int symp Int Care Emerg Med

14 Airway pressures during closed system suctioning. Taggart JA Heart Lung Sep;17(5): The benefits of CSS include the maintenance of positive pressure ventilation, oxygen supply, and PEEP. However, some evidence indicates that negative airway pressure may develop during CSS if inappropriate ventilator settings are selected. 32 int symp Int Care Emerg Med

15 Warning! Suctioning. A lung model evaluation of closed suctioning systems. Stenqvist O, Acta Anaesthesiol Scand Feb;45(2): Closed system suctioning, CSS, has been advocated to avoid alveolar collapse. However Pressures could drop down to -92 cm H2O during suctioning if ventilator can not follow. When inserting the catheter through a 7 ETT, PEEP rose from 11 to 23 cm H2O. During suctioning the alveolar pressure fell to 10 cm H2O below the set PEEP level. Pressure changed less in PCV than during VCV. This is an intensive care ventilator not an anaesthesia ventilator! 32 int symp Int Care Emerg Med

16 The impact of closed endotracheal suctioning systems on mechanical ventilator performance. El Masry A Respir Care Mar;50(3): There are large differences between the ventilators (11 critical-care ventilators) evaluated. End-expiratory pressure decreased in all modes, peak flow increased in all modes except VCV Closed suctioning can decrease end-expiratory pressure during suctioning. Closed tracheal suction systems versus open tracheal suction systems for mechanically ventilated adult patients. Subirana M Cochrane Database Syst Rev Oct 17;(4):CD trials: suctioning with either closed or open tracheal suction systems did not have an effect on the risk of ventilator- associated pneumonia or mortality. 32 int symp Int Care Emerg Med

17 Tracheal pressures during aspiration ETT size 6 8,5 closed ventilation 6 6,5 7 7,5 8 8,5 blue 8 Ch black 10 Ch whit 12 Ch green 14 Ch orange 16 Ch Closed aspiration no peep Open 6 6,5 7 7,5 8 8,5 ETT open to air aspiration blue 8 Ch -1-0, safe black 10 Ch ,5-0,5 dangerous whit 12 Ch not done? green 14 Ch orange 16 Ch CPAP 10 Vygon 6 6,5 7 7,5 8 8,5 CPAP 10 blue 8 Ch black 10 Ch whit 12 Ch green 14 Ch orange 16 Ch int symp Int Care Emerg Med

18 Safe suctioning without neg pressures below -10 no boussignac CPAP with Boussignac CPAP Larger suctioning tubes and np deconnection 32 int symp Int Care Emerg Med

19 Conclusion 1. Silent aspiration happens with regular endotracheal tubes 1. Gel helps shortly and not with everyone 2. Special cuff material or shape design helps but 2. Aspiration through an ETT 1. Again leak of fluid into trachea and risk for atelectasis! 2. Open ETT 1. Use a suction tube with very small size, very short time 3. Closed suctioning with larger suction tube. 1. High PEEP or high flow CPAP ( Boussignac) to avoid pressure drop, suction short time or intermittent 32 int symp Int Care Emerg Med

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