Airway Management Part Three Flashcards
Recommended settings for weaning
CPAP/PS- PEEP 5+, Pressure Support(PS)- 5+, FiO2 <50
IBW equation
50+2.3 (PtH - 60), then take Vt x6 and x8
Vt equation
x6 and x8 pts IBW (6-8ml/kg) then pick a number in that range
FiO2 equation
LPM x 4 = #, #+ 21= %
Ve (minute ventilation)
Vt x RR
divided by 1000= L
How to perform NIF-MIP manually with a pressure manometer
- Hyperoxygenate (O2 Breaths) the pt
- Place the ventilator on standby and disconnect the ventilator circuit
- Attach the NIP adaptor/pressure manometer to the 15mm hub of the ETT
- Have the pt breathe normally
- Inform the pt and occlude the NIF adaptor after the pt has exhaled fully
- Encourage the pt to suck in as hard as they can, the pt will feel resistance
- Watch the manometer while the pt is attempting to breath in and record the value
The NIF should be
- 20cmH2O <
- 40cmH2O
RSBI (rapid shallow breathing index)
- With the pt on CPAP/PS= PEEP +5 PS +5 FiO2 <50%
- Remove the pressure support by reducing it to zero
- This change should not disrupt the pts breathing- confirm normal breathing
- On the servo-I ventilator, scroll pt data screens until you see SBI
- Monitor and record a stable value
- Return pressure support to +5cmH2O
How to find vital capacity
Wrights spirometer
how to find NIP-MIP
Pressure manometer , RSBI
How to perform manually with the wrights spirometer (VC)
- Hyperoxygenate the pt
- Place the ventilator on standby and disconnect the ventilator circuit
- Attach the wrights spirometer to the 15mm hub of the ETT
- Have the pt breathe normal to establish a normal breathing pattern (2-5 breaths)
- Encourage the pt to take a deep breath in followed by encouragement to breathe all the way out
- Watch the wrights spirometer needle as the pt exhales and record the value for documentation
How to perform on the ventilator (VC)
- With the pt on CPAP/PS= PEEP+5 PS +5 FiO2 <50%
- Remove the pressure support by reducing it to zero
- This change should not disrupt the pts breathing pattern- confirm normal breathing
- Encourage the pt to take a deep breath in followed by encouragement to breathe all the way out
- Look at the returned exhaled tidal volume (pt data). The vital capacity effort usually shows up on the following breath, record the value for documentation
- Return pressure support to +5cmH2O
- Vital capacity should be at least > 1L for an adult OR 10 ml/kg
Vital capacity should be at least
> 1L for an adult OR 10 ml/kg
Spontaneous Awake Trial (SAT) vs. Spontaneous Breathing Trial (SBT)
SAT- Removing Sedation,
SBT- Readiness to wean, Removing/ reducing ventilation support
How long to do SAT and SBT
Do for 2 min, if pt looks good, do for 2 hours
Weaning
Reducing Support
Has the reason for intubation and mechanical ventilation resolved
Airway, Ventilation, Oxygenation
Glasgow coma scale
Decorticate posturing- abnormal flexation
Decerebrate posturing- abnormal extension
Spontaneous breathing trial
Daily sedation vacation,
Spontaneous breathing trial- assess readiness to wean (initial test)- 2-5minute test
Wean patient (can patient sustain): PEEP +5, FiO2 40%
Pressure Support: 5cmH2O ventilation
Assess Readiness to extubate
Extubation
Process of removing an artificial airway
Can the pt protect their airway if the ETT is removed
Gag reflex
Cough Strength
Quantity and thickness of secretion
Patency of upper airway- if pt can lift head off pillow for 5 seconds
You can discontinue mechanical ventilation and still continue to need an artificial airway (NBRC)
Cuff Leak test
- First subglottic suction and hyperoxygenate
- Used to predict glottic edema/ stridor post extubation
- Deflate cuff during spontaneous breathing and occlude airway to assess air movement around the deflated cuff or DEFLATE CUFF DURING POSITIVE PRESSURE VENTILATION AND ASSESS FOR AIR LEAK
NIF- WHY?
Negative inspiratory force-> diaphragm strength.
-more negative than -20cmh2o
Vital capacity- what does it tell us?
at least 1L for adult-> can pt take in enough air for a cough
RSBI= Rapid shallow breathing index=
RR/Vt (L)
<105
Weaning Parameters
NIF
Vital capacity
RSBI- F/Vt
Stregnth of pt
Equipment needed (essential in bold) for extubation
-SUCTION SUPPLIES AND YANKAUER
-OXYGEN DELIVER DEVICE. what fiO2 is the pt currently on?
-10-12cc SYRINGE AND A TOWEL
-Neb with racemic epi (readily available)
Intubation box with BVM (know where it is)-crash carts
-SUCTION
-HYPEROXYGENATE
Suction during extubation
do inline, do subglottic, and have oral ready- make sure upper airway is clean and clear of secretions
-timing is key= clean airway quickly and disconnect tube
Hyperoxygenate
100% for 1-2 minutes- 02 breaths on vent
do during inline suction= 100% O2
Remove ET tube
While stabalizing the ETT, remove the ETT holding device. Stabilize ETT and connect a 10-12ml syringe to the pilote balloon
-While asking the pt to take a deep breath IN, deflate the cuff and remove ET tube at peak inspiration, instruct the pt to cough immediately after and provide oral suction (superficially in most cases as gag reflex is strong)
After Removing ETT tube…
Apply oxygen and humidity
-Same or sometimes 10% higher fiO2 (<50)
Oxygen options after extubation?
Cool aerosol- upper airway edema NC (with bubble humidity)= 45% max fiO2? Simple mask venturi mask Heated Hi-Flo NC Room air- to pass (biggest concern=secretions) or Nebulizer tx
Assessing and re-assing
- Check sounds for good air movement
- Upper airway for stridor-LISTEN TO NECK
- RR, HR, BP, SpO2
- Breathing pattern
- Pt color
- Able to vocalize (if not, risk of aspiration)
- Have pt rest
Problems after extubation
Most common
-Cough, sore throat, hoarseness
Potential need for re-intubation
ABG- Resp failure?
- Aspiration or airway edema
- work of breathing issues unrelated to airway
- Laryngospasm
Laryngospasm
Involuntary contraction of the laryngeal muscles resulting in complete or partial closure of the glottis
- usually last a matter of seconds
- If it persists you may need to paralyze , sedate, and re-intubate
Tracheostomy, established what ways
- Tracheal access via neck incision
- Established two ways:
1. Open tracheostomy
2. Percutaneous dilation
Indications for tracheostomy
- Unable to maintain patent airway
2. Provide long term mechanical ventilation
RT’s Role of Percutaneous tracheostomy- portex
-manage ET: pull back, manage tube
-Assist with bronchoscope
-Monitor PT
-Make vent. changes
some, but O2 breaths 100% until brought down 60%
Factors to consider putting in artificial airway
- How long will pt need an artificial airway ?
- How is the pt tolerating the ET tube?
- Can the pt tolerate surgery?
- Risk of ET tube vs. tracheostomy tube?
Advantages of tracheostomy vs. continued ET intubation
- Lowers airway resistance
- Less tube movement in the trachea
- Improved pt comfort
- Allows the pt to swallow secretions and nourishment
- Pt can communicate more effectively
Disadvantages of tracheostomy vs continued ET intubation
- surgical procedure with greater morbidity and mortality risk
- Incisional hemorrhage
- Sub-q Emphysema
- Pneumothorax
- Pneumo-mediastinum
- Tracheal stenosis
- Permanent scar
Surgical procedure info
- Performed in surgery or at bedside
- endotracheal tube is withdrawn to the level of the larynx
- Incision is made over second or third tracheal ring
- Dissection to the trachea
- Trachea is cut, large enough for tracheostomy tube placement
Percutaneous dilation
- Similar prep with tracheal exposure
- ET tube is retracted with bronchoscope
- A needle and sheath are introduced into the trachea b/w the 1st and 2nd tracheal rings
- a guide wire is inserted through the sheath
- different size dilators are passed over the guide wire (small-big) until the stoma is large enough for the trach tube
- fewer complications with percutaneous
- heals better after removed
Tracheostomy Tube sizing
-2.5 to 11.5 mm I.D.
-Most common adult sizes=
Shiley- 8mm I.D. cuffed tracheostomy tube
-Size should fill 2/3 to 3/4 of the pts internal tracheal diameter
-Normal diameter of an adult trachea is 2-2.5cm
-Tracheostomy tubes are sometimes downzised as the pt gets better
(can go down steps of 2 until out)
Obturator - what is it used for
- Put inside trach only when putting trach into stoma
- doesnt go through inner cannula
- Taped above pts head of bed just in case of need
- Right obturator with right trach
- eases insertion: bottome of trachs are sharp, avoids trauma and inflammation
Commonly used trachs
Portex trach, Shiley trach
Inflated cuff can use
positive pressure ventilation, seals off upper airway
Cuff delated or trach with no cuff
Using both trach and mouth , air will take path of least resistance
Communication with a trach tube
-One way valve (Passy-muir)
Passy muire
-Cuff must be deflated-CRITICAL
-Air trapping
-Involved in successful use: RT, Speech pathologist, Otolaryngologist
-Pt has to be able to control secretions
-Benefits=
Better function of vocal cords, sense of smell, fewer secretion problems, improved swallowing, less aspiration
Benefits of Passy Muir
Better function of vocal cords, sense of smell, fewer secretion problems, improved swallowing, less aspiration
Specialty Tracheostomy Tubes
- Jackson= silver, stainless steal
- Bivona= foam cuff
- XL Proximal and distal
- Fenestrated= holes in it
- TTS-tight to shaft= filled with sterile water, not saline
Jackson
long term trach pt, for patent airway, silver stainless steal used to PREVENT INFECTION
Foam cuff- use why
Molds to trach and minimizes cuff pressure
- grows with kids
- reduces trach injury
Foam cuff- warning
Cant use passy muir -ABSOLUTE
Cant guarantee cuff is deflated/ inflated- self inflates exposed to O2
What to use when there is an obstruction or cant get cuff to seal
XL Distal
Fat/ long neck use
XL proximal
Long neck use
XL distal
Fenestrated
Holes in tube- allows airflow
- Reduces resistance of tube in trach
- allows more air to pass through
- Fascilitates weaning or breathing through upper airway
TTS-Tight to shaft
Pts that use trach colar during day and vent at night, filled with sterile water not saline
-know amount of water to fill cuff to relay on
Patient with no cuff is in severe resp distress?
Attach ambu bag to trach and deliver ventilation: bag to tube
-put trach with cuff in and inflate cuff and provide effective resp
Trach management
Used to document/ validate pt airway patency, airway hydration, characteristics of secretions, skin assessment
Critical documentation and bedside cares
- Spare trach tube in room, preferably same size or 1 size smaller
- Obturator above head of bed
- Validate appropriate humidity and oxygen therapy, recommend or change if needed- cont aerosol-change drain beg
- Validate trach supplies (Sterile qtips, guaze, ect)
- Suction catheter kits
- Presence of BVM
- Skin assessment- around the neck and stoma site
Grape in a tach trap
working space
Trach care how often?
once a shift
- prevent infection
- pt is at higher risk
- ALWAYS STABILIZE
Cleaning Equipment
- Trach care kit
- New inner cannula
- New trach ties if needed
- Hydrogen peroxide and sterile water (or normal saline) (50/50 ratio)
- Precut gauze (trach dressing)
Cleaning Trach steps
- Equipment
- Explain procedure to pt
- Suction pt (PRN)
- Clean permanent inner cannula/ dry
- Clean stoma site/ place new gauze
(always start from inside out, go in 1/4ths) - change the ties if needed (loose enough to fit 1 or 2 fingers underneath)
- replace inner cannula
- Reassess the pt
(Breath sounds/ pattern, Vital signs, O2 sat)
Reasons for changing a trach
- Problems develop(blown cuff)
- Different size or type needed- facilitate weaning
- Periodically replaced - medicare (3 months)
- First change usually done by physician
- Intubation equipment should be readily available (crash cart)
- If trach tube does not have a inner cannula, it may need to be replaced periodically
Stitches for trach last
5-7 days, 1st trach change- 2 weeks
Steps for changing a trach
- Prepare equipment (new trach/ lube)
- Explain procedure
- Prepare equipment
- Prepare pt
- Remove old tube
- Insert new tube
- Secure the tube
- Reassess pt
Equipment prepared for trach change
- Maintaing a sterile tube (only touch outer parts)
- Test the cuff
- With the inner cannula remove, insert obturator
- attach one side of trach tie
- Lubricate the cuff and bottom half of tube
How to prepare pt for trach change
- Extend neck to access trach (Semi-fowlers or supine)
- Suction (prn) and hyperoxygenate pt if needed
How to remove old tube during trach change
- Remove/cut trach ties and deflate cuff
- remove tube following the curve of the tube
- inspect the site for problems (skin, stoma)
How to insert new trach tube
- Dont touch the part of the tube that enters and sits in the trach
- insert tip of obturator into stoma and advance following curve of tube
- apply pressure to obturator to keep in place
- Once flange against neck, remove obturator (immediate)
- Assess for airflow before inflating cuff
High pressures and low volumes on vent =
trach in tissue not lungs
Removing a trach tube (weaning goal)
Goal is to reduce trach tube dependence
- Fenestrated tube- reduces airway resistance when the pt is asked to use their upper airway exclusively
- Progression to smaller tubes
- Resistance could be a problem resulting in failure
- Be aware of posterior tracheal irritation
- May allow for better healing of stoma - Trach bottons (many types)/ plug
- Red cap used to temp block trach tube, upper airway only
How is trach buttons different from passy muire
Passy muir- can breath through- one way valve
Airway Trauma caused by
pressure- potential for ischemia and ulcerations
Friction-Leading to irritation from movement of head, neck, or artificial airway-stabilizing airway
-Artificial airway=INVASIVE
Complications- Specific to ET tubes
- Laryngeal lesions
- Glottic Edema and vocal cord inflammation
- Laryngeal polyps and granulomas- develop more slowly
- Vocal cord paralysis
- Laryngeal stenosis
Laryngeal lesion complications examples
- glottic edema
- vocal cord inflammation
- Laryngeal/ vocal cord ulcerations
- Vocal cord polyps (fluid filled lesion)
- Vocal cord granuloma (vascular lesion most common on arytenoid cartilage)
- Vocal cord paralysis
- Laryngeal stenosis
Glottic edema and vocal cord inflammation
-Hoarseness
-stridor;
*Indicative of a decrease in diameter of the airway
*treated with racemic epi (vaponephrine)
*steroids may also be given
+ if pt has complication with swelling, IV steroids may be given 24 hours before an extubation attempt (in combination with cuff leak test)
Normal Racemic Epinephrine dosage
.5ml with 2.5 normal saline
Laryngeal polyps and granulomas
- Weeks to month to develop
- difficulty swallowing
- Hoarseness
- stidor
- can be removed surgically
Vocal cord paralysis
- stridor and or hoarseness that doesnt resolve with treatment or in time
- may need a tracheostomy if severe
Laryngeal Stenosis (narrowing)
- Occurs when normal tissue of the larynx forms scar tissue
- Symptoms with stridor and or hoarseness
- Onset of dyspnes within one year of intubation may be the cause
- Need surgical attention and or perm trach
Tracheal lesions that can occur with ETT and Trach tube
- Granulomas
- Tracheomalacia
- Tracheal Stenosis
- Tracheoesophageal fistula
- Tracheoinnominate fistula
Granulomas
-Usually near tip of airway and can lead to chronic changes
Tracheomalacia
- Softening of cartilage rings causing collapse of trachea during inspiration
- can occur along with tracheal stenosis
Tracheal stenosis
- Narrowing of trachea
- Commonly occurs at cuff site (ET tube)
- For trach pt, can occur at cuff site and stoma site, stoma is more common
- Stoma site too large
- Infection of stoma
- Movement of tube, frequent tube changes, advanced age
Tracheoesophageal fistula
-Tunnel between 2 organs- pH of stomach
Needs surgical repair
Tracheoinnominate fistula
Emergency!!! massive hemorrhage (surgical repair) loop for pulsating trach tube
-Caused by rubbing of airway on innominate artery/vein
Prevention of complications
Tube movement may play a large role
- Sedation-calms
- Nasotracheal tubes- more stable than oral
- Swivel adapters
- Tracheostomy collars vs briggs t-Reduces friction
Correct articial airway size and type
- assess need for cuff
- Monitor cuff pressures- every 4 hours (20-30cmH2O)
- Sterile technique
- good trach hygiene
Causes of tube obstruction
- Kinking or biting (ET tube)
- Herniation of cuff over tip
- Tip colliding with posterior tracheal wall (higher risk=trach tube)
- Mucus plugging
Cuff leak
- Problems are usually seen with vent pts
- small leak detected with decrease cuff pressures over time (can be positional)
- Large leak indicative of cuff rupture airflow will be felt through the mouth with positive pressure ventilation (BVM)
Troubleshooting cuff leak
- First try to inflate the balloon, assess the pilot tubing and pilot balloon valve
- you can patch a leak found in valve or tubing
- If there is a rupture you must replace the tube-use bouijee
- A malposition ET tube can stimulate a cuff leak
Accidental Extubation
- Partial displacement
- Cuff above vocal cords- remove, below-push back down to depth
- Decreased breath sounds
- decreased volumes-esp volumes on vent low
- Ability to pass catheter without meeting resistance -not hitting carina
- Increased resp distress
- don not be afraid to remove the tube and provide manual-airway, ventilation, and O2 support
