Artificial Airway Management - EXAM 3

Question 1

What is an endotracheal tube? (ET)

Answer 1

A tube is placed into the trachea VIA the mouth of nose past the larynx. An oral ET tube is placed with the aid of a laryngoscope through the mouth. A nasal ET tube is placed blindly through the nose.

Question 2

What are the common indications for ET intubation?

Answer 2

• Upper airway obstruction
• Apnea
• High risk of aspiration
• Ineffective risk of aspiration
• Ineffective clearance of secretions
• Respiratory distress

Question 3

How is ET tube placement initially determined?

Answer 3

• Auscultate for bilateral breath sounds
• Observe for symmetric chest wall movement
• Measure amount of exhaled CO2 using end-tidal CO2 detector
• Assess for stable or improved SpO2
• Obtain portable chest x-ray to confirm tube location

Question 4

How does the RN know that correct ET tube placement is being maintained?

Answer 4

• Confirm that exit marks remain constant
• Observe for symmetric chest movements
• Auscultate for bilateral lung sounds

Question 5

Collecting a sputum specimen using a specimen trap

Answer 5

1. Peel open package and remove sterile product
2. Tighten cap to seal specimen trap
3. Insert the distal end of the catheter inside long flexible tube
4. Attach suction tubing to ridid connector. Do not touch cap with suction tubing if suction tubing is non-sterile.
5. Turn suction on and collect specimen inside vial
6. When specimen is collected, remove suction tubing along with rigid connector to expose small sterile chimney on cap
7. Remove catheter from long flexible tube and push tube over small chimney to seal specimen trap
8. Label specimen per agency policy and send specimen to lab

Question 6

What are the indications for the use of a sputum specimen trap?

Answer 6

• Patients with a weak cough (not mechanically ventilated)
• Patients unable to follow directions to cough (ex. comatose, mechanically ventilated)

Question 7

Goal of nasotracheal/bronchial/or deep endotracheal suctioning

Answer 7

The removal of obstructing material (mucus, blood, vomitus) from the lower airways, thereby facilitating ventilation

Question 8

Indications of nasotracheal/bronchial or deep endotracheal suctioning

Answer 8

• Patient’s cough is insufficient to remove secretions from the lower respiratory tract
• Patient does not have an endotracheal or tracheostomy tube in place
• May be due to narcotic medications, chest pain, or cessation of ciliary movement of secretions up and out of the lower respiratory tract
• May be indicated in patients with decreased neurological function

Question 9

Potential Complications of nasotracheal/bronchial or deep endotracheal suctioning

Answer 9

• Increases the incidence of laryngospasm
• Contraindicated in patients with blood clotting disorders, chronic liver disease, prior h/o laryngospasm, h/o nasal polyps
• Contraindicated in situations of suspected epiglottitis or cervical vertebral trauma

Question 10

Procedure of Nasotracheal/bronchial or deep endotracheal suctioning

Answer 10

1. Patient’s neck is hyperextended and the tongue is protruded
2. Catheter is introduced either through either of the nares and advanced into the nasopharynx
3. As the catheter approaches the trachea, the patient may be stimulated to involuntarily cough (this may acheive the goal of the deep suctioning attempt and the procedure can be terminated)
4. If patient does not cough or if the cough is non-productive, advancing the catheter during a cough or an inspiration will result in opening of the epiglottis and an opportunity to advance the catheter into the trachea and bronchi
5. When the catheter is past the epiglottis the following may happen:
   
   1. The patient’s voice may change or become absent
   2. Air may be felt coming from the catheter during expiration
   3. Tehe patient may demonstrate marked anxiety
6. While the catheter is in place in the trachea, the right main bronchus can be cannulated by turning the patient’s head to the left and the left main bronchus may be suctioned by turning the head to the right
7. Intermittent suction is applied for no more than 12 seconds

Question 11

Tracheostomy

Answer 11

The stoma (opening) that results from a tracheotomy.

Question 12

Tracheotomy

Answer 12

A surgical incision into the trachea for the purpose of establishing an airway. The stoma (opening) that results is a tracheostomy.

Question 13

Purpose of Tracheostomy

Answer 13

• Bypass upper airway obstruction
• Facilitate removal of secretions
• Permit long-term mechanical ventilation
• Permit oral intake and speech

Question 14

Advantages of Tracheostomy

Answer 14

• Less risk of long term damage to airway
• Increased patient comfort than with an endotracheal tube
• Patient can eat
• Mobility is increased

Question 15

Parts/Equipment of Tracheostomy

Answer 15

• Trach tube with cuff (inflated or deflated)
  
  • Purpose of inflated cuff = risk of aspiration, mechanical ventilation
• Faceeplate secured with tracheostomy ties
• Inner cannula (disposable or nondisposable)
• Obturator used for insertion/reinsterion; readily accessible at bedside
• Replacement tube (current size and one size smaller)
• Sterile normal saline
• Ambu bag
• Trach care supplies and suction equipment
• Humidification with air or oxygen

Question 16

Indications for Suctioning

Answer 16

• Coarse crackles
• Moist cough
• High pressure alarm on mechanical ventilation
• Restlessness/aggitation
• Increased HR, Increased RR
• Patient Request
• Visible secretions

Question 17

Frequency of Tracheostomy Suctioning

Answer 17

Assess need every 2 hours; not a set schedule prn for indications on for suctioning

Question 18

Pre-procedure Tracheostomy Suctioning

Answer 18

• Explain procedure to patient
• Preoxygenation for 3-4 breaths or at least 1 minute. Can be delivered from ventilator, menual resuscitation bag, or having patient take deep breaths while administering increased O2
• Give 100% oxygen for patients without COPD and 60% for patient with COPD
• Amount of suction/negative pressure
  
  • Adults = negative 120-150 mm Hg with tubing occluded
  • Children = negative 60-100 mm Hg
• Sterile saline may be instilled to thin out thick and tenacious secretions but it is not routinely administered (no evidence support of its effectiveness and can contribute to bacteria in the lungs)

Question 19

Procedure of Tracheostomy Suctioning

Answer 19

• Sterile technique imperative
• 10 seconds suction time with each pass of catheter for adults, 5 seconds for children
• 30 seconds or 3-4 breaths between suction passes
• Suction until airway is clear, limit to as few as needed
• Indications for discontinuing procedure:
  
  • If the HR decreases by 20 or increases by 40
  • If cardiac dysrhythmias develop
  • If SpO2 decreases below 90%

Question 20

Post-Procedure of Tracheostomy Suctioning

Answer 20

• Return O2 to prior setting
• Assess effectiveness of procedure
• Note LOC, color, R. status
• Rinse catheter with NS; dispose after single use
• Document time of suctioning, response to suctioning including VS, SpO2 and lung sounds, and character and amount of secretions

Question 21

Purpose of tracheostomy care

Answer 21

To prevent infection

Question 22

Equipment/Procedure of Tracheostomy Care

Answer 22

• Sterile technique is imperative
• Waterproof container/barrier: used to maintain sterility
• Cleaning the inner cannula, stoma, and faceplate:
  
  • Remove inner cannula first
  • Use sterile NS and/or H20 to cleanse all areas
  • Shake, pat, or let air dry
  • Assess tracheostomy site for drainage and excoriation
• Tracheostomy Dressing:
  
  • Avoid unless excessive dainage
  • DO NOT CUT GAUZE (to avoid release of fibers)
• Tracheostomy Ties:
  
  • Two person technique is optimal to avoid accidental decannulation
  • Leave room for 1 finger under tie
  • Velcro ties not appropriate for children or confused patients

Question 23

Complications of Tracheostomy

Answer 23

• Avoid infection with aspectic technique and proper trach care
• Avoid obstruction with suction, humidification, adequate hydration, cough and deep breath, clean/change inner cannula
• Prevent accidental decannulation by securing tube in place
• Communication:
  
  • Hand signals
  • Communication on board
  • One way speaking valve: closes on exhalation, remove during sleep
  • Artificial voice boxes for laryngectomy patients
• Assessing Swallowing:
  
  • Inflate cuff (can deflate for subsequent feedings if no aspiration detected)
  • Suction mouth
  • Raise HOB, tip head forward
  • Have suction equipment ready

Question 24

What are the benefits of suctioning using the close-suction technique VS the open suction technique?

Answer 24

With CST, oxygenation and ventilation can be maintained during suctioning and exposure to secretions is reduced