Ch 33 Airway Management – Flashcards
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what is suctioning?
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Application of negative pressure to airways through collecting tube
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what is the suctioning of trachea & bronchi is usually done through?
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endotracheal tube or tracheostomy tube
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how big should the external diameter of the suctioner compared to the internal diameter of the artificial airway?
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no more than ½ internal diameter (ID) of artificial airway
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catheter size formula to use the next bigger size
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ID x 3/2
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catheter size formula to use the next smallest size
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ID x 2
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vacuum pressure for infants
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-60 to -80 mm Hg
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vacuum pressure for children
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-80 to -100 mm Hg
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vacuum pressure for adults
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-100 to -120 mm Hg
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what r the 2 techniques for endotracheal suctioning?
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-open -closed
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what is the open endotracheal suctioning technique?
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sterile technique requires disconnecting patient from ventilator
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what is the closed endotracheal suctioning technique?
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sterile, closed, in line suction catheter which is attached to ventilator circuit
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do u need to disconnect a pt from a ventilator when u suction through the pt's endotracheal airway?
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No
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what are the steps to endotracheal suctioning?
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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
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should a pt have to be suctioned based on a schedule?
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No
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what indicates need for suctioning?
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abnormal breath sounds (e.g. coarse crackles)
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during endotrach suctioning, what do u use to hyperoxygenate a pt?
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100% oxygen
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how long should and endotrach suctioning take?
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less than 15 secs
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what helps minimize incidence of hypoxemia during suctioning?
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preoxygenation
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how do u avoid atelectasis while suctioning?
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-limiting amount of negative pressure used -keeping duration of suctioning as short as possible -using appropriate size suction catheter -avoiding disconnection from ventilator
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how do u minimize bacterial colonization during suctioning?
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-Use sterile technique during suctioning -manually ventilating patient
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when should you instill sterile normal saline into artificial airway prior to suctioning?
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when necessary to help mobilize thick secretions. otherwise never do it.
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who is nasotracheal suctioning indicated for?
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patients who retain secretions but do not have artificial airway in place
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what position do u want ur pt in when u place a catheter in their larynx and trachea?
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"sniffing position"
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what is a hazard of nasotracheal suctioning?
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may cause patient to gag or regurgitate
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when should you avoid suctioning?
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ryt after a pt has a meal
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what do u do when pt gags or vomits during suctioning?
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Prepare to reposition patient & suction oropharynx if this occurs
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whats the purpose of sputum sampling?
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identify organisms affecting airway
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what kind of pts can provide ample sputum specimen by expectorating in sterile cup?
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pts with a strong cough
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what must be maintained when touching connection points on sterile/Luken's trap?
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sterile technique
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how far into the airway does a pharyngeal airway go into?
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to the pharynx
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where are endotracheal tubes placed?
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Artificial airways placed through mouth & nose into trachea
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what is intubation?
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process of placing artificial airway into trachea
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what is orotracheal intubation?
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is when tube is passed through mouth on its way into trachea
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what is nasotracheal intubation?
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when endotracheal tube is passed through nose first
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what airway is most often placed to facilitate frequent nasotracheal suctioning?
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Nasal pharyngeal airway
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why is the nasal pharyngeal airway placed to facilitate frequent nasotracheal suctioning?
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Minimizes damage to nasal mucosa caused by suction catheter
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why should the oral pharyngeal airway be restricted to an unconscious patient?
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to avoid gagging & regurgitation
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how does an oral pharyngeal airway maintain a pt airway?
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by preventing tongue from obstructing oropharynx
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whats another use for oropharyngeal (oral) tubes?
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bite block
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2 basic types of tracheal airways
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-endotracheal tubes -tracheostomy tubes
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where are endotrach tubes inserted?
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through either mouth or nose, through larynx, & into trachea
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where are tracheostomy tubes inserted?
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through surgically created opening in neck directly into trachea
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3 types of artificial airway
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-orotracheal intubation -nasotracheal intubation -tracheotomy
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6 steps of orotracheal intubation
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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
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upon placement of an orotracheal tube, where should the tip be located?
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about 3-6 cm above carina
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with an orotracheal intubation, what should u be listening for while the pt is being ventilated?
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equal & bilateral breath sounds
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with an orottracheal intubation, what should u observe the chest wall for?
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adequate & equal chest expansion
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what happens to a pt's CO2 level when an ET tube is present with an orotracheal tube?
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CO2 levels begin to rise; seen on capnogram
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what methods and equipment can u use to assess proper placement of an endotrach tube?
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-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
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which is more difficult, orotracheal intubation or nastotracheal intubation?
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nastotracheal intubation
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what r 2 ways u can perform a nasotracheal intubation?
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-blindly -with visualization
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what instrument does a direct visualization nasotracheal intubation require?
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standard or fiberoptic laryngoscope
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what kind of intubation has similar steps to a nasotracheal intubation?
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orotracheal intubation
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what kind of tracheostomies can be performed with a neck incision?
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-traditional surgical tracheotomy -percutaneous dilatational tracheotomy
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what is an opening in the neck called?
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tracheostomy
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who should perform a tracheostomy?
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physicican or surgeon
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when should a tracheostomy be done?
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after the pt's airway is stabilized
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what factors does the selection of a tracheostomy tube depend on?
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-pt's age -pt's height -pt's weight -pt's airway anatomy
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what r the 2 most common sites of injury with a tracheostomy?
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-larynx -trachea
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what r some common larngeal injuries associated with tracheostomy?
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-glottic edema -vocal cord inflammation -Laryngeal/vocal cord ulcerations -Vocal cord polyps or granulomas
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what r some more rare but more common laryngeal injuries associated with tracheostomy?
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-vocal cord paralysis & stenosis
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what are some tracheal injuries associated with tracheostomy?
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-granulomas -tracheomalacia -tracheal stenosis -Tracheoesophageal & tracheoinominate artery fistula
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what is the primary cause of injury in tracheal tubes?
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tube movement
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with tracheostomy, what can help avoid self extubation?
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sedation
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what kind of trach tubes are easy to stabilize?
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nasotracheal tubes
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with tracheostomy, what can reduce tube traction?
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swivel adapter
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with a trach tube, what pressure must be maintained to avoid tracheal wall injury?
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25 to 35 cm H2O
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what r 3 alternative cuff designs for trach tubes?
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-Lanz tub -Foam cuff -tight to shaft cuff
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what is a lanz tub cuff?
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incorporates external pressure regulating valve & control reservoir
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how much cuff pressure is limited in a lanz tub?
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between 16 & 18 mm Hg
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what pressure in the cuff does a foam cuff use to seal the trachea?
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atmospheric pressure
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what kind of pt's is the foam cuff not commonly used on?
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pts with tracheal injury
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what design does a tight-to-shaft cuff have?
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low-volume, high pressure cuff design that maximizes airflow around tube when deflated
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What r the roles of the RT in airway maintenance?
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-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
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Steps in tracheostomy care
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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
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what do u assess for in the pt with tracheostomy care?
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-adequate breath sounds -VS -oxygenation -adverse effects
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what can cause a tube obstruction?
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-kinking or biting tube -Herniation of cuff over tip -Obstruction of tube orifice against tracheal wall -Mucus plugging
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how do u prevent tube kinking and biting?
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move patient's head & neck or reposition tube
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how do u fix a herniation of the cuff over the tip?
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-deflate cuff -If deflating cuff fails to overcome obstruction, try to pass suction catheter through tube
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how do u fix a tube plugged with mucus?
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Suction tube if instillation of sterile normal saline is not necessary
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what is the primary problem associated with a tracheostomy for a pt on mechanical ventilation?
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cuff leaks
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what does a cuff leak do to todal volume?
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reduces tidal volume
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if pilot tube or valve is leaking, when does the tube need to be changed?
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As soon as possible
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with a pilot tube or valve damage, whats an alternative to changing the tube?
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using a pilot valve repair kit. it permits the insertion of replacement valve into pilot tubing
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how do u deal with a ruptured cuff?
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-extubation and re-intubation -using endotracheal tube exchanger
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what is an endoracheal tube exchanger?
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is semi-rigid guide, over which damaged tube can be removed & new tube inserted
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how can u detect partial displacement of airway out of trachea?
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-Decreased breath sounds -Decreased airflow through tube -Decreased ability to pass catheter past end of tube
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where can u hear airflow with positive pressure ventilation?
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through mouth & nose or into stomach
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how do u deal with an accidental extubation?
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Completely remove tube & provide ventilatory support by manual resuscitator & mask as needed until patient can be reintubated or tracheostomy tube reinserted
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what is extubation?
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Process of removing oral or nasal endotracheal airway
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what is decannulation?
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Process of removing tracheostomy tube
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what do u assess to kno a pt is rdy for extubation or decannulation?
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-Original problem is no longer present -Quantity & thickness of secretions -Upper airway patency -Presence of intact gag reflex -Ability to clear airway secretions
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what r the steps of extubation?
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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
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when extubating, what do u administer to the pt along with O2?
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cool mist
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what tubes do u use with the weaning process?
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-Fenestrated tubes -Progressively smaller tubes -Tracheostomy buttons
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what is an LMA?
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Laryngeal mask airway. Consists of short tube & small mask that is inserted deep into oropharynx
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Where does the open surface of an LMA face?
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laryngeal opening
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with an LMA, where is ventilation directed?
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lungs
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what is an LMA size for adults?
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5
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LMA size for infants?
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1
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What are some disadvantages of an LMA?
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-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
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whats another name for a double lumen airway?
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combitube
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where is a double lumen airway inserted?
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blindly through oropharynx & into trachea or esophagus
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features of a double lumen airway?
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-2 external openings -2 15mm adapters -2 lumens -2 cuffs
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why does a double lumen airway need 2 cuffs?
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One cuff seals oropharyx & second seals trachea or esophagus
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what is a bronchoscopy?
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Insertion of visualization instrument endoscope into bronchi
