Across several sites that I work I see patients with varying respiratory issues, included those who are ventilated. But how do I manage these patients...
What is Assisted Ventilation?
Sometimes known as mechanical ventilation it is when mechanical means are used to assist to replace spontaneous breathing. This can involve a machine (a ventilator) and can be invasive (through a tracheotomy) or non-invasive (through face or nasal masks).
Ventilation can be positive pressure, where air is pushed into the lungs, or negative pressure where air is sucked into the lungs by stimulating movement of the chest.
What Oral Health Problems do these Patients have?
- Dry mouth - as a result of either multiple medications or being ventilated
- Excessive oral secretions or mucous/dried secretions in the mouth - many patients are taking medication to dry up their airway secretions in order to maintain their tracheotomy. This can also affect oral secretions which can become dry and stick of mucosa
- Tooth grinding/clenching - especially if these patients have an associated brain injury
- Care resistant behaviour - if they have a brain injury or reduced cognitive ability
- Dental neglect - if patients cannot provide their own oral care they may rely on a third party to maintain their oral hygiene, which may be compromised
- Calculus build up - especially if patients are PEG fed and not having any oral intake
- Poor oral clearance due an impaired swallow
Top Tips in Managing these Patients
Managing these patients is often most suitable by Special Care Dentists or by the Community Dental Service as they may have other co-morbidities e.g. be wheelchair bound, have a reduced capacity to consent. But if you do see these patients, here are my top tips:
- When providing dental treatment for these patients, give them plenty of breaks as they may feel like they become breathless or have an impaired swallow
- If they have a tracheotomy, ensure that an appropriately trained health professional such as a nurse supervises the trache and brings the appropriate kit in case it becomes dislodged during treatment, requires suctioning or the patient attempts to pull it out
- Consider patient positioning. Many patients will be most comfortable sitting up and become breathless if laid flat
- Recommend appropriate oral health products and advise for those providing oral care. Poor oral health in these patients can increase the risk of aspiration pneumonia which has a high mortality rate. Oral health plans are therefore essential for ventilated patients and consideration should be taken whether an SLS free non-foaming toothpaste is most appropriate
- When providing dental treatment, ensure excellent suctioning when using water to reduce the risk of aspirating
- Communication can be challenging with these patients; whether it be because there is a cognitive issue from a brain injury, or simply because a patient cannot talk when they have the cuff up on their trache. Communication card aids may be useful, or liaison with the patients Speech and Language Team to work out how is best to communicate
- There may be a role for saliva replacement gels such as Biotene or Oralieve for patients who get very dry mouths. These gels are also useful when removing dried secretions - massage the gels into the secretions to break them up before removal, otherwise it can feel like pulling off a sticking plaster!
- If sedation is required for these patients, this should be provided in secondary care and the appropriate attachment should be available if oxygen is required to attach to the trache. Careful consideration should be taken whether sedation is appropriate and there should be liasion with the patients medical team.
For more information, check out a presentation I did on this topic to the Special Care MSc students at KCL click here.
Have you treated patients who are ventilated? How was it? Did you have to make an adjustments to how you treated them? Let me know in the comments below!
