Airway management (module 8)

According to the American Heart Association, the first assessment to complete for each patient is the
“ABCs” (Airway, Breathing, and Circulation). Without a patent airway, the patient is unable to maintain oxygen demands, and there is a decline in body functioning or even death.
Respiration
is the process by which the respiratory gases, oxygen and carbon dioxide, are exchanged between environmental air and the blood. There are three steps in this process:
•Ventilation
•Perfusion
•Diffusion

The exchange of respiratory gases occurs between the alveoli and the pulmonary capillaries.

Ventilation
is the process of moving respiratory gases into and out of the lungs. Ventilation must occur in coordination with the neurologic, muscular, and elastic properties of the lung and thorax. During ventilation, inspiration causes the lungs to fill with air. During expiration, the elastic recoil properties of the lung cause the lungs to deflate.
Perfusion
is the ability of the cardiovascular system to adequately pump oxygenated blood to the tissues and return deoxygenated blood from the tissues to the lungs.

Hemoglobin is the carrier for respiratory gases, and it can only carry one respiratory gas at a time. Oxygen diffuses across the alveolar capillary membrane and binds with hemoglobin to form oxyhemoglobin. Perfusion pumps the oxyhemoglobin to the tissues, where it is released. Carbon dioxide released from the tissues combines with hemoglobin and through perfusion is returned by way of the venous system to the lungs. Therefore, when hemoglobin levels are low, as with anemia or hemorrhage, there is decreased oxygen-carrying capacity, and the body tries to meet oxygen demand—for example, by increasing the heart rate.

Diffusion
the process that moves the respiratory gases across the capillary membranes to the blood. Normally, the partial pressure of oxygen is greater in the alveoli than in the capillary blood, and the partial pressure of carbon dioxide is greater in the blood than in the alveolar air.
major respiratory abnormalities are
•Hypoxia (inadequate tissue oxygenation with adequate blood supply)
•Hyperventilation (abnormal pulmonary ventilation that causes an increased amount of air exchange in the pulmonary alveoli and results in decreased arterial carbon dioxide levels)
•Hypoventilation (abnormal pulmonary ventilation that reduces the amount of air exchanged in the pulmonary alveoli and results in increased arterial carbon dioxide levels)
Hypoxia
inadequate tissue oxygenation with adequate blood supply
Hyperventilation
abnormal pulmonary ventilation that causes an increased amount of air exchange in the pulmonary alveoli and results in decreased arterial carbon dioxide levels
Hypoventilatio
abnormal pulmonary ventilation that reduces the amount of air exchanged in the pulmonary alveoli and results in increased arterial carbon dioxide levels
tachypnea
rate greater than 20
bradypnea
less than 12
apena
lack of respiration for greater than 15 seconds, intermittent
kussmaul’s
rapid deep labored
cheyne-stokes
varying periods of increasing depth interspersed with apnea
elevated pulse rate increase oxygen delivery to the tissues
an increase in pulse rate is an adaptive response to meet the body’s oxygen demand. The increased pulse rate may occur in conjunction with an increased respiratory rate that attempts to increase oxygen supply
Atelectasis
Alveoli collapse and prevent the normal exchange of oxygen and carbon dioxide from occurring.
Chronic obstructive pulmonary disease (COPD)
Patients with COPD have adapted to chronically low oxygen levels and high carbon dioxide levels, so their acid-base balance remains normal. The low oxygen levels stimulate the COPD patient to breathe. For some patients with COPD, excessive oxygen administration meets the patient’s oxygen requirement, but the stimulus to breathe is negated. High concentrations of oxygen (e.g., greater than 24% to 28% or 1 to 2 liters per minute) prevent the oxygen level from falling, obliterate the stimulus to breathe, and result in hypoventilation.
Huff cough
This type of cough stimulates the natural cough reflex. It is helpful in clearing the large central airways such as the tracheobronchial tree. During expiration, the patient states the word “huff,” which opens the glottis. With continued practice, the patient can progress to the more-effective cascade cough.
Cascade cough
The patient takes a slow, deep breath and holds it for 2 seconds. At the same time, the patient tightens the upper abdominal muscles. The patient should then open the mouth and carry out a succession of coughs during expiration. This technique promotes airway clearance in patients with large volumes of sputum.
Quad cough
used with patients who lack control of their abdominal muscles—for example, patients with spinal cord injuries and patients with recent abdominal surgery. As the patient is breathing out with as much force as possible, you push inward and upward on the abdominal muscles in the direction of the diaphragm. This action “replaces” the muscle tension lost in the abdominal wall.
Which of the following patients would have the greatest potential for an alteration in respiration?
A) A 15-year-old male with a migraine headache.
B) A 44-year-old female with anemia.
C) A 19-year-old female with diarrhea.
D) A 32-year-old male with an ear ache
B) A 44-year-old female with anemia.
Feedback: Hemoglobin carries about 97% of oxygen to the tissues. Anemia lowers the oxygen-carrying capacity of the blood and potentially leads to hypoxia.
Which of the following, if exhibited by the patient, would indicate late hypoxia?
A) Restlessness.
B) Anxiety.
C) Eupnea.
D) Cyanosis.
D) Cyanosis.
Feedback: Restlessness and anxiety are early indicators of hypoxia. Cyanosis is a late indicator of hypoxia. Eupnea is normal respiration.
Which of the following would lead to an increase in oxygen demand?
A) A fever.
B) Sleep.
C) Taking a narcotic.
D) Postural drainage.
A) A fever
Feedback: Increased metabolic activity associated with a fever increases tissue oxygen demand. Postural drainage is an intervention used to mobilize secretions and maintain an open airway.
What nursing intervention is appropriate for the patient with a large amount of sputum?
A) Perform nasotracheal suctioning every hour.
B) Encourage the patient to cough every hour while awake.
C) Place the patient on fluid restriction.
D) Avoid all milk products.
B) Encourage the patient to cough every hour while awake.
Feedback: A patient with a large amount of sputum should be encouraged to cough every hour while awake. Adequate fluids should be maintained to help keep secretions thin and easier to expectorate. Although milk has a protein structure similar to sputum, it does not increase sputum production and plays an important role in nutrition. Suctioning should be performed on an as-needed basis.
An elderly woman is hospitalized with pneumonia and anemia. She is weak and has a poor cough effort. She has a history of cardiomyopathy. Her current vital signs are temperature 100.2 ˚F, pulse 114, respiration 26, blood pressure 106/58. She has oxygen ordered at 2 liters by nasal cannula. Her oxygen saturation measures 88% when on room air, 93% with supplemental oxygen. She develops shortness of breath on any activity and eats little because it is difficult for her to eat and breathe at the same time. Which of the following are risk factors for this patient developing hypoxia? (Select all that apply.)
A) Anemia.
B) Tachycardia.
C) Increased secretions with weak cough.
D) Impaired cardiac function.
E) Shortness of breath.
F) Pneumonia.
A,C,D,F
Feedback: Hypoxia results when there is inadequate tissue oxygenation at the cellular level. Lowered oxygen-carrying capacity from anemia can lead to hypoxia. A diminished concentration of inspired oxygen, such as with an obstructed airway from secretions, results in lowered oxygen saturation. Impaired cardiac function results in poor tissue perfusion with oxygenated blood. With pneumonia there is decreased diffusion of oxygen from the alveoli to the blood, leading to inadequate tissue oxygenation. An increase in pulse rate is an adaptive response to meet the body’s oxygen demand. Shortness of breath (dyspnea) is a symptom of decreased oxygenation.
You are caring for a patient who underwent major abdominal surgery 24 hours ago. The 72-year-old male patient is weak and lethargic because of large doses of medication for pain control. After noting audible gurgling on inspiration and expiration, you complete a respiratory assessment. Which assessment parameters indicate the need for oral suction?
A) Unusual restlessness.
B) Gagging.
C) Gurgling and adventitious lung sounds.
D) Evidence of emesis in the mouth.
E) Persistent coughing
G) Weakness and lethargy accompanied by drooling.
The following signs indicate the need for oropharyngeal suctioning: (1) restlessness, especially if it is new or unusual for your patient; (2) obvious, excessive oral secretions as evidenced by drooling and/or gagging; (3) gurgling and/or audible crackles and wheezes that occur on inspiration and/or expiration; (4) evidence of gastric contents and/or emesis in the mouth; (5) persistent coughing that fails to clear the upper airway; and (6) weakness and lethargy accompanied by drooling and gagging. Persistent complaints of pain are more likely related to the surgery.
You are busy performing routine assessments of the patients on the unit. You note audible gurgling on inspiration and expiration of the stable postoperative patient. Which of the following tasks can you delegate to competent NAP?
A)Performing oral suctioning.
B) Assessing the adequacy of respiratory functioning.
C) Evaluating the outcome of oral suctioning.
D) Performing nasotracheal suctioning.
A) Performing oral suctioning.

Feedback: Since the patient is stable, the task of performing oral suctioning may be delegated to NAP. However, the responsibility for assessing the adequacy of respiratory functioning and evaluating the patient outcome of oral suctioning remains with you. Nasotracheal suctioning requires sterile technique and cannot be delegated to NAP.

You are teaching the spouse of a patient how to perform oral suctioning for when they return home. Which of the following statements, if made by the spouse, indicates further instruction is needed?
A) “It would be abnormal to obtain bloody secretions.”
B) “Because oral secretions are thick, suction settings should be set on high.”
C) “I should be careful to avoid touching the back of the throat with the tip of the suction catheter.”
D) “I should encourage fluids to help keep secretions thin.”
“Because oral secretions are thick, suction settings should be set on high.”
Suction settings should be low to ensure that the oral tissue is uninjured during suctioning. Bloody secretions may be an indication of mucosal damage. The oropharynx should be assessed for any tissue injury, and the frequency of suctioning should be evaluated. Touching the back of the throat can stimulate the gag reflex. Unless contraindicated, fluids should be encouraged to reduce the viscosity of secretions.
Which of the following patients is most likely to experience some difficulty with effective coughing?
A) The COPD patient whose pulse oximetry remains the same after oropharyngeal suctioning.
B) The patient with absence of adventitious lung sounds on inspiration and expiration.
C) The patient who demonstrates less drooling after being suctioned.
D) The patient with presence of blood in the secretions.
D) The patient with presence of blood in the secretions.

Feedback: Bloody secretions are an unexpected outcome. The cause should be investigated. The removal of secretions helps to improve the oxygen saturation level. In patients with chronic pulmonary diseases such as COPD, the pulse oximetry value may remain the same. The absence of adventitious sounds are an expected finding. An expected outcome of oropharyngeal suctioning is lessened or absence of drooling.

Which of the following patients may likely require oropharyngeal suctioning? (Select all that apply.)
A) A patient who had maxillofacial surgery.
B) A patient who had trauma to the mouth.
C) A patient with impaired swallowing from neurologic injury.
D) A patient who has been diagnosed with lung cancer.
E) A patient with an artificial airway who requires oral hygiene.
F) A patient who has a nasogastric feeding tube.
G) A patient with pneumonia.
A) A patient who had maxillofacial surgery.
B) A patient who had trauma to the mouth.
C) A patient with impaired swallowing from neurologic injury.
E) A patient with an artificial airway who requires oral hygiene.
The Yankauer suction device is useful in the removal of secretions from the mouth in patients after oral and maxillofacial surgery, trauma to the mouth, neurovascular injury and/or cerebrovascular accident causing hemiparesis and drooling, or impaired swallowing. Patients with artificial airways and impaired swallowing ability may require use of the Yankauer suction device to promote oral hygiene. Patients with lung cancer or pneumonia may be able to cough up or swallow secretions on their own.
Which of the following should NOT be delegated to NAP?
A) Oropharyngeal suctioning.
B) Nasotracheal suctioning on a stable patient.
C) Pulse oximetry.
D) Oral care.
B) Nasotracheal suctioning on a stable patient.
Feedback: Because sterile technique and critical thinking skills are required, it is inappropriate to delegate tracheal suctioning to NAP. The other tasks can be performed by NAP on stable patients.
The nurse desires to suction the patient’s left main stem bronchus. In what position should the patient be placed?
Turn the patient’s head to the right.

Feedback: To effectively suction the left main stem bronchus, turn the patient’s head to the right.

Which of the following is a potential complication for a patient who is having nasotracheal suctioning?
A significant drop in oxygen concentration.
B) A decrease in heart rate.
C) Dysrythmias.

The patient is at risk for developing hypoxemia at any point from assessment of airway secretions to a short time after the suctioning procedure. The suctioning procedure itself removes oxygen from the airways. A patient may experience bradycardia as a result of vagal stimulation. Dysrhythmias are a potential complication of nasotracheal suctioning. Coughing is an expected outcome of nasotracheal suctioning and will aid in clearing the airways.

The nurse is orienting a new graduate nurse to common procedures performed on the unit. Which statement, if made by the graduate nurse, indicates understanding of nasotracheal suctioning?
A) “The maximum duration to suction is 20 seconds.”
B) “The bacterial count in the nasotracheal pathway is higher than in the oral cavity, so whenever possible, you should suction the trachea through the mouth.”
C) “A 1- to 2- minute interval should be allowed between suctioning passes.”
D) “Intermittent suction is applied during insertion of the catheter.”
C) “A 1- to 2- minute interval should be allowed between suctioning passes.”
D) “Intermittent suction is applied during insertion of the catheter.”
Feedback: Intermittent suction up to 15 seconds safely removes pharyngeal secretions. The maximum time to suction the trachea is 10 seconds, with a 1- to 2-minute interval in between suctioning passes for reoxygenation. The mouth carries the highest bacterial count. Whenever possible, suction via the nasotracheal route. To avoid tissue damage, intermittent suction is applied as the catheter is being withdrawn.
A discussion is taking place on the unit regarding the application of lubricant to the suction catheter before passing it through the nasal passage. Which statement is accurate?
“Water-soluble lubricant should be used because oil based lubricants increase the risk for aspiration and pneumonia.”

Feedback: Oil-based lubricants increase the risk for aspiration and pneumonia. Water-soluble lubricant is applied to the catheter to ease insertion and prevent tissue trauma. It is unrelated to the patient’s fluid status. Suctioning a small amount of sterile normal saline from the basin ensures that the suction system is working correctly. It is unnecessary to lubricate the end of the suction catheter when performing oropharyngeal suctioning.

The dead space in milliliters is approximately equal to the patient’s ideal body weight in pounds?
true, anatomic dead space in milliliters is approximately the same as the patient’s ideal body weight in pounds.
The pilot ballon allows for inflation and deflation of the cuff of an endotracheal/tracheotomy tuby
The pilot balloon allows medical care workers to inflate or deflate the cuff. The cuff should be inflated for mechanical ventilation or to prevent aspiration while eating.
What is anatomic dead space?
Anatomic dead space is the area in the trachea, bronchi, and lower airways that contain air unavailable to the alveoli for diffusion. A tracheostomy tube has less dead space than an endo tracheal tube.
You have a 36-year-old female patient with severe asthmatic bronchitis after a short course of influenza. The patient was admitted to your unit and intubated with an oral endotracheal tube. She was placed on mechanical ventilation for respiratory support and the instillation of aerosolized medication. Which of the following demonstrates correct understanding of endotracheal tubes?
A) Endotracheal tubes are designed for long-term use.
B) Endotracheal tubes are fenestrated so that she will be able to talk when she is feeling better.
C) Endotracheal tubes for adults are cuffed and must be inflated for mechanical ventilation to be effective.
Feedback: The cuff on the endotracheal tube must be inflated while the patient is on mechanical ventilation to deliver the correct amount of oxygen to the lungs under the correct amount of pressure.
D) The patient with an endotracheal tube will require less attention to airway patency than the patient who is without an endotracheal tube.
C) Endotracheal tubes for adults are cuffed and must be inflated for mechanical ventilation to be effective.
Feedback: The cuff on the endotracheal tube must be inflated while the patient is on mechanical ventilation to deliver the correct amount of oxygen to the lungs under the correct amount of pressure
The primary purpose of an oral airway is:
A) To prevent obstruction of the trachea by displacement of the tongue into the oropharynx.
Feedback: An oral airway is used to prevent obstruction of the trachea by displacement of the tongue into the oropharynx. It is often used in patients who are lethargic and/or unconscious.
What is one advantage of a tracheostomy tube over an endotracheal tube?
A) With a tracheostomy tube, the amount of anatomic dead space is decreased and thereby increases the patient’s oxygen levels.
The staff nurse instructs the student nurse to keep the obturator of the tracheostomy tube at the patient’s bedside. How does the student nurse know which is the obturator?
The obturator is more slender and longer than the inner or outer cannula, and is rounded at the tip.
A student is giving a brief review in clinical post-conference on the different types of artificial airways and how to perform open suctioning. Which statement would require correction?
A) “Oral airways are frequently used for patients returning from surgery who are able to breathe spontaneously but are not fully awake.”
Feedback: This is an accurate statement. Oral airways maintain a patent airway until the patient is fully awake and can spit the oral airway out.
B) “You should not hyperoxygenate the patient with a head injury prior to suctioning.”
C) “Tracheostomy tubes can be used long term or permanently.”
D) “Pediatric tracheostomy tubes are cuffless.”
Oral airways are frequently used for patients returning from surgery who are able to breathe spontaneously but are not fully awake.”
Feedback: This is an accurate statement. Oral airways maintain a patent airway until the patient is fully awake and can spit the oral airway ou
The nurse is caring for a patient with a tracheostomy who has audible gurgling and requests to be suctioned. Assessment prior to suctioning indicates pulse 84, respirations 24, and pulse oximetry 93%. Which of the following is an indication that the nurse should stop suctioning and oxygenate the patient?
The patient’s pulse decreases to 60 beats per minute.