Ch 33 Airway Management

what is suctioning?
Application of negative pressure to airways through collecting tube
what is the suctioning of trachea & bronchi is usually done through?
endotracheal tube or tracheostomy tube
how big should the external diameter of the suctioner compared to the internal diameter of the artificial airway?
no more than ½ internal diameter (ID) of artificial airway
catheter size formula to use the next bigger size
ID x 3/2
catheter size formula to use the next smallest size
ID x 2
vacuum pressure for infants
-60 to -80 mm Hg
vacuum pressure for children
-80 to -100 mm Hg
vacuum pressure for adults
-100 to -120 mm Hg
what r the 2 techniques for endotracheal suctioning?
-open
-closed
what is the open endotracheal suctioning technique?
sterile technique requires disconnecting patient from ventilator
what is the closed endotracheal suctioning technique?
sterile, closed, in line suction catheter which is attached to ventilator circuit
do u need to disconnect a pt from a ventilator when u suction through the pt’s endotracheal airway?
No
what are the steps to endotracheal suctioning?
1.assess pt for indications
2. Assemble & check equipment
3. Hyperoxygenate patient
4. Insert catheter
5. Apply suction/clear catheter
6. Reoxygenate patient
7. Monitor patient & assess outcomes
should a pt have to be suctioned based on a schedule?
No
what indicates need for suctioning?
abnormal breath sounds (e.g. coarse crackles)
during endotrach suctioning, what do u use to hyperoxygenate a pt?
100% oxygen
how long should and endotrach suctioning take?
less than 15 secs
what helps minimize incidence of hypoxemia during suctioning?
preoxygenation
how do u avoid atelectasis while suctioning?
-limiting amount of negative pressure used
-keeping duration of suctioning as short as possible
-using appropriate size suction catheter
-avoiding disconnection from ventilator
how do u minimize bacterial colonization during suctioning?
-Use sterile technique during suctioning
-manually ventilating patient
when should you instill sterile normal saline into artificial airway prior to suctioning?
when necessary to help mobilize thick secretions. otherwise never do it.
who is nasotracheal suctioning indicated for?
patients who retain secretions but do not have artificial airway in place
what position do u want ur pt in when u place a catheter in their larynx and trachea?
“sniffing position”
what is a hazard of nasotracheal suctioning?
may cause patient to gag or regurgitate
when should you avoid suctioning?
ryt after a pt has a meal
what do u do when pt gags or vomits during suctioning?
Prepare to reposition patient & suction oropharynx if this occurs
whats the purpose of sputum sampling?
identify organisms affecting airway
what kind of pts can provide ample sputum specimen by expectorating in sterile cup?
pts with a strong cough
what must be maintained when touching connection points on sterile/Luken’s trap?
sterile technique
how far into the airway does a pharyngeal airway go into?
to the pharynx
where are endotracheal tubes placed?
Artificial airways placed through mouth & nose into trachea
what is intubation?
process of placing artificial airway into trachea
what is orotracheal intubation?
is when tube is passed through mouth on its way into trachea
what is nasotracheal intubation?
when endotracheal tube is passed through nose first
what airway is most often placed to facilitate frequent nasotracheal suctioning?
Nasal pharyngeal airway
why is the nasal pharyngeal airway placed to facilitate frequent nasotracheal suctioning?
Minimizes damage to nasal mucosa caused by suction catheter
why should the oral pharyngeal airway be restricted to an unconscious patient?
to avoid gagging & regurgitation
how does an oral pharyngeal airway maintain a pt airway?
by preventing tongue from obstructing oropharynx
whats another use for oropharyngeal (oral) tubes?
bite block
2 basic types of tracheal airways
-endotracheal tubes
-tracheostomy tubes
where are endotrach tubes inserted?
through either mouth or nose, through larynx, & into trachea
where are tracheostomy tubes inserted?
through surgically created opening in neck directly into trachea
3 types of artificial airway
-orotracheal intubation
-nasotracheal intubation
-tracheotomy
6 steps of orotracheal intubation
1. Assemble & check equipment
2. Position patient
3. Preoxygenate & ventilate patient
4. Insert laryngoscope
5. Visualize glottis
6. Displace epiglottis
7. Insert tube
8. Assess tube position
9. Stabilize tube/confirm placement
upon placement of an orotracheal tube, where should the tip be located?
about 3-6 cm above carina
with an orotracheal intubation, what should u be listening for while the pt is being ventilated?
equal & bilateral breath sounds
with an orottracheal intubation, what should u observe the chest wall for?
adequate & equal chest expansion
what happens to a pt’s CO2 level when an ET tube is present with an orotracheal tube?
CO2 levels begin to rise; seen on capnogram
what methods and equipment can u use to assess proper placement of an endotrach tube?
-auscultation of chest and abdomen
-observation of chest movement
-tube length (cm to teeth)
-esophageal detection device
-light wand
-capnometry
-colorimetry
-fiberoptic laryngoscopy or bronchoscopy
-videolaryngoscopy
which is more difficult, orotracheal intubation or nastotracheal intubation?
nastotracheal intubation
what r 2 ways u can perform a nasotracheal intubation?
-blindly
-with visualization
what instrument does a direct visualization nasotracheal intubation require?
standard or fiberoptic laryngoscope
what kind of intubation has similar steps to a nasotracheal intubation?
orotracheal intubation
what kind of tracheostomies can be performed with a neck incision?
-traditional surgical tracheotomy
-percutaneous dilatational tracheotomy
what is an opening in the neck called?
tracheostomy
who should perform a tracheostomy?
physicican or surgeon
when should a tracheostomy be done?
after the pt’s airway is stabilized
what factors does the selection of a tracheostomy tube depend on?
-pt’s age
-pt’s height
-pt’s weight
-pt’s airway anatomy
what r the 2 most common sites of injury with a tracheostomy?
-larynx
-trachea
what r some common larngeal injuries associated with tracheostomy?
-glottic edema
-vocal cord inflammation
-Laryngeal/vocal cord ulcerations
-Vocal cord polyps or granulomas
what r some more rare but more common laryngeal injuries associated with tracheostomy?
-vocal cord paralysis & stenosis
what are some tracheal injuries associated with tracheostomy?
-granulomas
-tracheomalacia
-tracheal stenosis
-Tracheoesophageal & tracheoinominate artery fistula
what is the primary cause of injury in tracheal tubes?
tube movement
with tracheostomy, what can help avoid self extubation?
sedation
what kind of trach tubes are easy to stabilize?
nasotracheal tubes
with tracheostomy, what can reduce tube traction?
swivel adapter
with a trach tube, what pressure must be maintained to avoid tracheal wall injury?
25 to 35 cm H2O
what r 3 alternative cuff designs for trach tubes?
-Lanz tub
-Foam cuff
-tight to shaft cuff
what is a lanz tub cuff?
incorporates external pressure regulating valve & control reservoir
how much cuff pressure is limited in a lanz tub?
between 16 & 18 mm Hg
what pressure in the cuff does a foam cuff use to seal the trachea?
atmospheric pressure
what kind of pt’s is the foam cuff not commonly used on?
pts with tracheal injury
what design does a tight-to-shaft cuff have?
low-volume, high pressure cuff design that maximizes airflow around tube when deflated
What r the roles of the RT in airway maintenance?
-Secure tube & maintain placement
-Provide for patient communication
-Ensure adequate humidification
-Minimize possibility of infection
-Aide in secretion clearance
-Provide appropriate cuff care
-Troubleshoot airway-related problems
Steps in tracheostomy care
Step 1: Assemble & check equipment
Step 2: Explain procedure to patient
Step 3: Suction patient
Step 4: Remove & clean inner cannula
Step 5: Clean & examine stoma site
Step 6: Change ties/holder
Step 7: Replace clean inner cannula (if present)
Step 8: Reassess patient
what do u assess for in the pt with tracheostomy care?
-adequate breath sounds
-VS
-oxygenation
-adverse effects
what can cause a tube obstruction?
-kinking or biting tube
-Herniation of cuff over tip
-Obstruction of tube orifice against tracheal wall
-Mucus plugging
how do u prevent tube kinking and biting?
move patient’s head & neck or reposition tube
how do u fix a herniation of the cuff over the tip?
-deflate cuff
-If deflating cuff fails to overcome obstruction, try to pass suction catheter through tube
how do u fix a tube plugged with mucus?
Suction tube if instillation of sterile normal saline is not necessary
what is the primary problem associated with a tracheostomy for a pt on mechanical ventilation?
cuff leaks
what does a cuff leak do to todal volume?
reduces tidal volume
if pilot tube or valve is leaking, when does the tube need to be changed?
As soon as possible
with a pilot tube or valve damage, whats an alternative to changing the tube?
using a pilot valve repair kit. it permits the insertion of replacement valve into pilot tubing
how do u deal with a ruptured cuff?
-extubation and re-intubation
-using endotracheal tube exchanger
what is an endoracheal tube exchanger?
is semi-rigid guide, over which damaged tube can be removed & new tube inserted
how can u detect partial displacement of airway out of trachea?
-Decreased breath sounds
-Decreased airflow through tube
-Decreased ability to pass catheter past end of tube
where can u hear airflow with positive pressure ventilation?
through mouth & nose or into stomach
how do u deal with an accidental extubation?
Completely remove tube & provide ventilatory support by manual resuscitator & mask as needed until patient can be reintubated or tracheostomy tube reinserted
what is extubation?
Process of removing oral or nasal endotracheal airway
what is decannulation?
Process of removing tracheostomy tube
what do u assess to kno a pt is rdy for extubation or decannulation?
-Original problem is no longer present
-Quantity & thickness of secretions
-Upper airway patency
-Presence of intact gag reflex
-Ability to clear airway secretions
what r the steps of extubation?
Step 1: Assemble needed equipment
Step 2: Suction endotracheal tube & pharynx above cuff
Step 3: Oxygenate patient
Step 4: Deflate cuff
Step 5: Remove tube
Step 6: Apply appropriate oxygen & humidity therapy
Step 7: Assess/reassess patient
when extubating, what do u administer to the pt along with O2?
cool mist
what tubes do u use with the weaning process?
-Fenestrated tubes
-Progressively smaller tubes
-Tracheostomy buttons
what is an LMA?
Laryngeal mask airway. Consists of short tube & small mask that is inserted deep into oropharynx
Where does the open surface of an LMA face?
laryngeal opening
with an LMA, where is ventilation directed?
lungs
what is an LMA size for adults?
5
LMA size for infants?
1
What are some disadvantages of an LMA?
-Cannot be used in conscious or semi-comatose patients due to stimulation of gag reflex
-If ventilation pressure greater than 20 cm H2O is needed, gastric distention may occur
whats another name for a double lumen airway?
combitube
where is a double lumen airway inserted?
blindly through oropharynx & into trachea or esophagus
features of a double lumen airway?
-2 external openings
-2 15mm adapters
-2 lumens
-2 cuffs
why does a double lumen airway need 2 cuffs?
One cuff seals oropharyx & second seals trachea or esophagus
what is a bronchoscopy?
Insertion of visualization instrument endoscope into bronchi