Palliative Practices to Promote Airway Clearance Pamela V

Palliative Practices to Promote Airway Clearance Pamela V. ONeal Ph. D, RN Ellise D. Adams, Ph. D, CNM Emanuel Waddell Ph. D 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. 5 million patients in 2013 received hospital services – Female (55%) – Age 85+ (41%) – Less than 24 years (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, Mc. CLuskey, 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. 5 L • Daily mucus volume produced by orophayrngeal and tracheobronchial gland is 2 L • 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, & Mc. Cluskey 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, Ph. D, CNM Emanuel Waddell, Ph. D

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. , Mc. Cluskey, 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 onealp@uah. edu