112 Exam 2 Flashcards
3 Indications for Suctioning
- Secretion Retention
- Inability to clear secretions
- Audible evidence of secretions
(5) Assessment of need for suctioning
- Lung Sounds
- Tactile Fremitus
- Ineffective cough
- Change in Vital Signs
- Change in ABG or SPO2
What is the Suctioning Procedure (Pre, During, Post)
Pre:
Assemble equipment, Sterile Environment, Proper ET tube, Preoxygenate with nasal cannula or mask at 6 LPM for minimum of 30 seconds.
During:
Lube Catheter, check suction is working, insert in nasal passageway bevel facing toward septum to lower pharynx, Pt in Sniffing position. Do not suction on the way in, only on the way out. Suction maximum 10-15 seconds. Remove ET Suction and clear with sterile water.
Post:
Reoxygenate Pt minimum of 1 minute. Reassess vital signs, lung sounds, Pt Color, SPO2, check for Trauma, increase ICP (on monitor) and cough effectiveness. If sputum sounds still heard, re-suction.
What are the proper sizes for ET Suction tubing (Adult, Peds, Infant)
Adult: 12-18 Fr
Peds: 8-10 Fr
Infant: 5-8 Fr
11 Hazards/Complications of suctioning and how to avoid them
- Hypoxia/Hypoxemia - Oxygenate
- Tissue/Trauma - Gentle insertion
- Bradycardia - Oxygenate
- Cardiac Dysrhythmias - Oxygenate
- Hypo/Hypertension - Oxygenate
- Cardiac Arrest
- Nasal Bleeding
- Bronchoconstriction or spasm
- Atelectasis - oxygenate
- Respiratory Arrest
- Increased ICP - Provide numbing agent to reduce/eliminate cough reflex
7 Contraindications of suctioning
- Epiglottitis
- Laryngospasms
- Irritated Airway
- Upper Resp. infection
- Occluded nasal passage
- Acute Head/Neck/Face injury
- Coagulopathy
4 Contraindications of Pulmonary Rehab
- Cardiovascular instability requiring monitoring
- Malignant neoplasm of Resp. System
- Severe arthritis
- Neuromuscular abnormalities
3 Team members of Pulmonary Rehab Team
- Psychological
- Nutritional
- Vocational
4 Qualifications for Pulmonary Rehab
- Symptomatic Moderate COPD
- Both obstructive & restrictive defects
- Chronic mucociliary clearance issues
- Exercise limitations due to severe dyspnea
2 Goals of pulmonary Rehab
- Maximize Pt Functional Ability
- Minimize disease impact on Pt, family and community
4 indications for intubation
- Inability to oxygenate
- Inability to ventilate
- Unable to protect their airway (such as drug overdose)
- inability to maintain patent airway (such as a tumor)
1 Contraindication for intubation
When Pt. clearly expresses and documents the desire to not be resuscitated
5 Hazards/Complications of intubation with examples
- Failure to establish or locate airway or intubation into esophagus
- Damage to larynx, airway, tongue, teeth etc.,
- Bronchospasms or Laryngospasms
- Increase/Decreased HR/BP, bleeding, ulcerations
- ET Tube issues, kinking/biting, sizing, cuff/pilot balloon issues, occlusions
2 Predictors of a difficult airway
- Mallampati= Class III or IV (Visual of airway is reduced to almost nothing)
- Thyromental Distance= measured from upper edge of thyroid cartilage to chin with head fully extended. Should be more than 6 cm or 3-4 Finger widths
What equipment is needed for intubation (11 items)
- O2 flowmeter
- MRB & Mask
- Blade and Handle (Mac vs miller)
- ET Tube (3 sizes)
- 10 mL syringe
- Stylet or bougie
- Lube
- Tape or ET holder
- Suctioning supplies
- Cuff Pressure manometer
- PPE
8 Steps to intubate
- Sniffing Position
- Preoxygenate. Suction as needed
- Insert Laryngoscope/blade
- Visualize glottis
- Displace glottis
- Insert tube 2-4 cm past vocal cords
- Confirm correct placement by listening and hearing equal/bilateral lung sounds. CXR 3-6 cm above carina
- Stabilize tube with tape or holder
Labeling the 6 parts of an ET Tube
From Bottom to Top of tube
- Bevel
- Murphy’s eye
- Cuff
- Radiopaque Line (seen on Xray)
- Cuff filling tube
- Cuff pilot balloon
Labeling the Larynx
From Top to bottom
Tongue–Vallecula–Epiglottis–Glottis–Vocal Cords–Arytenoid Cartilage
When and why and How to use a bougie
When/Why= Difficult Airway, ET tube change out
How= Place the bougie in the vocal cords all the way to the carina, slide ET tube over bougie until inside vocal cords then pull bougie out and secure ET Tube.
3 reasons why would we do a nasal intubation
- Access to the mouth not available
- Oral surgery or trauma
- When mouth cannot open due to:
- TMJ
- mandibular fixation
- trauma
6 Contraindications for nasal intubation
- Suspected basilar skull facture
- Nasal fracture
- Nasal polyps
- Epistaxis
- Coagulopathy
- Planned thrombolysis
Advantages and Disadvantages of nasal intubation
Advantages:
- better tube stability
- better oral hygiene
- better tolerated in conscious and semi-conscious pt’s
- smaller tube size, less pressure on glottis
Disadvantages:
- Smaller/Longer tubes
- necrosis of nose/septum
- sinusitis
- otitis media
- epistaxis
- feeding is problematic
3 Hazards/complications of nasal intubation
- Damage to nose/septum resulting in bleeding
- Trauma to naso/oro pharynx and larynx
- hypoxemia, hypercapnia, bradycardia, cardiac arrest
When would we use a combitube
Difficult airways where we cannot see. Combitube allows guaranteed ventilation by forcing air to trachea even when intubated through esophogus
When would we use a double lumen tube
when the need to ventilate both lungs independently arises
2 indications of proper ET tube placement
- 3-6 cm or 2-3 fingertips above the carina as seen on CXR
- tube movement is in line with head/neck movement
4 ways for Pts to communicate while intubated and what should we as RT always do
- Lip Reading
- Paper/Pencil
- Dry Erase
- Letter/Picture board
We should always talk to our pt no matter what even when unconscious
3 ways we assure adequate humidification and 3 reasons why
- Gas Temp: AARC 34’-41’ C (we set to 37’C)
- Humidification device is pt dependent
- inspired air is at least 30 mq/L water vapor
Why:
1. Thickened secretions
2. decreased ciliary action
3. maintain as close to Body Temp Pressure Saturation (BTPS)
5 ways to prevent hospital acquired infections (HAIs)
- Sterile suctioning
- aseptically or sterile equipment
- Hand hygiene
- Decrease pharyngeal aspiration
- Prevent retention secretions
What is VAP and what is the VAP/VAE RT’s do
Ventilator acquired Pneumonia
VAP/VAE is a checklist or 5 items we do daily
What are the 5 items we do on the VAP/VAE checklist daily
- Head of bed at 30’
- Daily sedative interruption and daily assessment of readiness to extubate
- PUD paraphylaxis
- DVT paraphylaxis
- Daily oral care with chlorhexidine
Cuff pressures
What is acceptable?
When does it occur?
What happens at <20cmH2O
acceptable= 20-30 cmH2O
Damage at= 42 cmH2O
<20 cmH2O= micro aspiration can occur
Troubleshooting emergencies in intubated pts and how to do a quick check for occlusions
- Tube obstruction=
- Kinking or biting
- Cuff folded over tip
- Tube stuck on trachea
- mucus plugging - Clinical Signs=
Partial
- Decreased airflow/breath sounds
Complete
- Severe distress
- no breath sounds/airflow
to check= pass suction down through ET tube, if it cannot pass, there is occlusion
Cuff Leaks
How to tell of a cuff leak (2 ways)
Whats the biggest reason for cuff leak and how to correct
- Small Leaks=
- Decrease in pressure overtime
- if pilot balloon issue, correct with blunt end needle and stopcock - Large Leaks=
- rapid onset
- attempt to deflate cuff and/or reintubate
Biggest Reason= ET Tube movement up or down. Check cm location in notes at time of intubation and if different, move tube back into proper place by first deflating cuff
5 Indications for extubation
- The need has resolved
- Protective reflexes are intact (cough, gag)
- Spontaneous vent is adequate
- Airway patency is adequate
- Pt can manage secretion without suction
2 Extubating hazards/complications
What can happen if we extubate improperly
- Hypoxemia
- Atelectasis, upper resp obstruction, edema, aspirations, hypoventilation - Hypercapnia
- Resp weakness, excessive WOB, Bronchospasms
What can happen= Death can occur
7 steps to extubate
- assemble/check equipment
- inline suctioning and pharynx suctioning
- oxygenate pt after suctioning
- deflate cuff
- Remove Tube (2 ways)
- Large breath w/ MRB and remove tube
- most common- deep breath and cough, while pt coughs, pull tube - oxygenate and humidify
- Assess and Reassess
Common complications of extubating and treatment
Glottic edema & Stridor
Tx= racemic epinephrine
Major but Rare complications of Extubating and treatment
Laryngospasms
Tx= oxygenate and positive pressure
6 Rare complications of extubating
- Laryngeal lesions
- stenosis
- vocal cord paralysis
- ulcerations
- tracheoesophageal fistula
- tracheoinominate artery fistula (can be life threatening)
