Bronchopulmonary Hygiene

Question 1

Neonatal Endotracheal Tubes

Answer 1

Will be primarily uncuffed in order to eliminate cuff related problems, but this will increase the risk of aspiration

Because tubes are small they are easy to be kinked or become obstructed

Suctioning helps minimize aspiration and prevents tube occlusion

Question 2

What will reatined secretions do to breathing

Answer 2

Increase airway resistance

Increase WOB

—Can cause hypoxemia, hypercapnia, atelectasis, and infection

Question 3

Difficultly clearing secretion may be due to

Answer 3

There is loss of airway control

Increased secretion production or thickened secretions due to abnormal lung pathology

Inadequate cough

Question 4

—The ETT presence in the trachea

Answer 4

—Increases mucus secretion

—The tube cuff mechanically blocks the mucociliaryescalator.

—Movement of the tube tip and cuff can cause erosion of the tracheal mucosa and further impair mucociliaryclearance.

—Endotracheal tubes impair the compression phase of the cough reflex by preventing closure of the glottis

—Although suctioning is used to aid secretion clearance, it, too, can cause damage to the airway mucosa and thus impair mucociliarytransport.

Question 5

Indications of Suctioning

Answer 5

• —Coarse or absent Br/S on auscultation—
• —Visible secretions in the airway
• An ineffective spontaneous cough
  
  • —The need to stimulate a cough in patients unable to cough effectively secondary to changes in mental status or the influence of medication (cough effort)
• —Changes on Xray consistent with retained secretions
  
  • —Atelectasis or consolidation
• —Changes in monitored flow/pressure graphics
• —Suspected aspiration of gastric or upper airway secretions
• —Changes in oxygenation (—Colour, —Saturation, ABG
• —Endotracheal tube aspirate
• —Patency check
• —Clinically apparent increased WOB

Question 6

Coarse Crackles

Answer 6

Crackles- air moving through secretions

Very thick secretions may not move with airflow and thus may not create any adventitious sounds.

Question 7

Changes in monitored flow/pressure graphics with Increased Secretions

Answer 7

—Increased peak inspiratory pressure (PIP) on volume-control ventilation (VCV)

—Decreased tidal volume (Vt) on pressure control ventilation (PCV)

Question 8

Equitment Needed for Suctioning

Answer 8

• —Adjustable suction source/collection system
• —Sterile suction catheter
• —Personal Protective Equipment (PPE)
  
  • —Sterile glove(s)
  • —Goggles, mask, and gown (standard precautions)
• —Sterile basin
• —Sterile bulk saline*
• —Sterile saline for instillation
• —Oxygen delivery system (BMV or ventilator)

Question 9

—Continuous Suction Regulators

Answer 9

Will be either on or off

—Adjustable from 0 to ~350 mm Hg

Question 10

—Intermittent Suction Regulators

Answer 10

Designed to cycle from on to off

—Cycle time & suction can be adjusted

—Three preset ranges

• —Low 60- 80 mm Hg
• —Medium 80- 100 mm Hg
• —High 100- 120 mm Hg

—Older application: gastric tubes

—Latest application of intermittent suction: surgical drainage

Question 11

Intubated Patients: Flexible Suction Catheters Sizing

—<1kg - 3kg

Answer 11

Use size 6F

—

Question 12

Intubated Patients: Flexible Suction Catheters Sizing

—>3kg

Answer 12

Use size 8F

—

Question 13

Intubated Patients: Flexible Suction Catheters Sizing

2-5 Years

Answer 13

Size 8-10F

Question 14

Intubated Patients: Flexible Suction Catheters Sizing

6 Years

Answer 14

Size 10F

Question 15

Intubated Patients: Flexible Suction Catheters Sizing

8-16 Years

Answer 15

Size 10-12F

Question 16

Intubated Patients: Flexible Suction Catheters Sizing

18 Months

Answer 16

Size 8

Question 17

Intubated Patients: Flexible Suction Catheters Sizing

6 Months

Answer 17

Size 6-8

Question 18

Flexible Suction Catheters : Sizes

Too Large of a Size

Answer 18

—Too large can obstruct the endotracheal airway.

—Application of negative pressure evacuates lung volume and causes atelectasis and hypoxemia.

—Never suction a patient with a catheter whose outer diameter is greater than one half the internal diameter of the artificial airway

—

Question 19

Indications For Closed System (aka Multiuse or Inline) Catheters

Answer 19

—Hemodynamic instability

—High ventilatory requirements

—On isolation (mechanically ventilated patient with active TB)

—Receiving inhaled agents (e.g., nitric oxide, helium/oxygen , anesthetic gases)

—Frequent suctioning (≥6/day)

Question 20

High Ventilatory Requirements

Answer 20

• Positive end-expiratory pressure ≥10 cm H2O
• Mean airway pressure ≥20 cm H2O
• Inspiratorytime ≥1.5 seconds
• Fraction of inspired oxygen ≥0.60

Question 21

Maintaining Oxygenation During Suctioning

Answer 21

—Inflation pressures & respiratory rate

—Adults: traditions-100%, “preoxygenate”

—Neonates: same FIO2 as ventilator settings or 10% above

Preoxygenation/hyperoxygenation are more effective when done through the ventilator, as opposed to a manual resuscitator.

This appears especially true for patients on high levels of support, such as PEEP.

Moreover, a BVM cannot always provide 100% oxygen or deliver a consistent tidal volume. Maintaining sterile technique and PEEP levels is difficult with some of these devices.

Question 22

Inserting the Catheter

Answer 22

—Adults: no markings vs with markings

—Neonates: always use the markings!!!

Egan’s: Insert the catheter carefully, until it can go no farther. Then withdraw the catheter a few centimeters before applying suction. Predetermined length or until resistance & then pulled back 0.5-1.5 cms.

Apply suction, while withdrawing the catheter using a rotating motion. Keep the time actually suctioning to less than 15 to 20 seconds. Total time shouldn’t exceed 30 seconds. Some people say hold your breath, when you want to breath, your patient probably does as well. Is this scientific? How about someone who is critically ill? Best way to decide this is to watch how your patient is tolerating it.

If any untoward response occurs during suctioning, immediately remove the catheter and oxygenate the patient.

Question 23

ETT Suction Levels for Adults

Answer 23

—Adult 80-120mmHg (open)

—Adults ~160 mmHg (closed)

Question 24

ETT Suction Levels for Children

Answer 24

—Children 80-100 mmHg (open & closed)

Question 25

ETT Suction Levels for Infants

Answer 25

—Infants 60-80mmHg (open & closed)

Question 26

—Withdrawal of Catheter with Suctioning

Answer 26

—Adults ~15-20 seconds —Children ~10-15 seconds —Infants ~5 seconds Some people moisten the catheter with saline before suctioning: Lubricates & allows you to check your suction

Question 27

Entire Procedure Time from Discommect to Reconnect

Answer 27

—Adults ~30 seconds —Children ~25 seconds —Infants \< 20 seconds Times are probably on the high side. Don’t go too quickly. No real reference. \<10 secs per pass; \< 5secs with vacuum Some people moisten the catheter with saline before suctioning: Lubricates & allows you to check your suction —

Question 28

Preoxygenation

Answer 28

100% of pre-oxygenation should be avoided in infants who are \<1 month—. This is due to the risk of hyperoxemia and ROP —We can raise FiO2 by 10-15% for at least 1 min prior —Duration of Sxn 5 seconds or less

Question 29

Flush and Clearing Catheter

Answer 29

Rinsing the catheter helps keep it clear of secretion build up. Secretion build up in the catheter = increased resistance to flow & decreasing ability to effectively remove secretions. Perhaps making you suction more times than should be necessary. Increasing risk to the patient. Same reason we don’t use too small of a catheter. Chart COCA —Amount = quantity = quantified via # times suctioned.

Question 30

COCA

Answer 30

COCA: colour, odour, consistency, amount

Question 31

After Suctioning Getting Oxygenation and Ventilation Back to Normal

Answer 31

Suction level will have a direct effect on lung pressures Lung Volume ► Atelectasis ► Hypoxemia ► Hypoxia Oxygenation 30 seconds to 3 mins pre, between passes, post

Question 32

The Three S of Suctioning

Answer 32

—Stop —Stay —Stable

Question 33

Repeating Suctioning as Necessary

Answer 33

* —Assess if instillation of normal saline is required & ventilate post instillation * Not routinely done only done is indication (tenacious secretions, bloof clots, etc) * —Repeat suctioning until airway clear * —Reassess patient * —Return patient to previous oxygen therapy * —Clean up area * —Record procedure in chart (COCA) If deemed unstable, you will eventually learn to discriminate and decide if they are unstable because of copious secretions or not tolerating the

Question 34

Absolute Contrindications to Suctioning

Answer 34

—Routine/schedule suctioning of mechanically ventilated neonates is discouraged —When indicated, there are no absolute contraindications for endotracheal suctioning —

Question 35

‘Caution’ Regarding High Suction Levels

Answer 35

The rate of suction flow is proporitonal to the suction level when flow is smooth and laminar 50% increase in suction level = 50% increase in suction flow rate Flow within the suction system is turbulent and disorderly meaning that when the suction level increases by 50% flow may only incease by 20-25% —Trying to increase suction flow by increasing magnitude of suction level (not the best approach/wrong)

Question 36

Oral and pharyngeal suctioning of infants

Answer 36

—Can be done with a bulb syringe, flexible catheter, or modified infant ‘yankauer’ type catheter. —Routine suctioning not recommended, only as needed —-60 to -80 mmHg for neonates —-80 to -100 mmHg larger infants and children NPA’s are for adults only►Restricted activity, requires a physician’s order An OPA does not require restricted activity

Question 37

—A DeLeetrap or a Mechanical Vacuum Source with Catheter

Answer 37

—A DeLeetrap or a mechanical vacuum source with catheter may be used for nasopharyngeal and nasotrachealsuctioning of neonates. Can be used for suctioning meconium

Question 38

Nasal Suction of Infants

Answer 38

Nasal suction of infants should be done cautiously. Fishing with a flexible catheter may cause more swelling & compound the problem.

Question 39

Nasal Suctioning Equitment

Answer 39

Flexible Catheter or Bulb

Question 40

Oral Suctioning Equitment

Answer 40

—Rigid (aka tonsillar, aka Yankauer)-we do not usually use a rigid on an infant Bulb Flexible

Question 41

Lower Airway Suctioning Equitment

Answer 41

—Lower airway (trachea and bronchi)àflexible —Single use (open) —Multi use (aka inline, aka closed)

Question 42

Oropharyngeal Suctioning When Not to Be Done

Answer 42

Not to be done in an awake patient with a gag reflex

Question 43

When is Nasopharyngeal suctioning Preferred

Answer 43

Nasopharyngeal suctioning preferred route in an awake non-intubatedpatient: Flexible suction catheter inserted through external naresor in adults, through a nasopharyngeal airway (NPA)

Question 44

Monitoring during Suctioning

Answer 44

* —Observe your patient & check cardiac monitor if one is available… * —Hemodynamic parameters (ICU) * —ECG tracing , heart rate, blood pressure (if available) * —Oxygen saturation & requirements * —Pulse oximetry * —Skin color * —Respiratory rate and pattern * —Cough effort * —Sputum characteristics

Question 45

Suctioning Complication and Hazards

Answer 45

—Hypoxia or hypoxemia —Atelectasis —Blood pressure changes (Increase or Decrease) ——Cardiac dysrhythmias —Cardiac or respiratory arrest

Question 46

What to Do if Complication Arise

Answer 46

—Should complications arise (eg. dropped HR) cease suction and ventilate at previous settings.

Question 47

Depth of Insertion

Answer 47

—Match the markings from the ETT to the markings on the suction catheter. Suction catheter should only goes as far as the end of the ETT, not beyond —Often a piece of tape cut to the desired insertion depth is placed at the head of the warmer or isolette

Question 48

Bland Aerosol Administration

Answer 48

—Includes the delivery of * —Hypotonic saline * —Isotonic (normal) saline * —Hypertonic saline * —Sterile/distilled water —FYI: Bland aerosol administration may or may not be accompanied by oxygen administration.

Question 49

Indications for a Bland Aerosol

Answer 49

—Minimizing humidity deficit when the upper airway has been bypassed —The use of cool, bland aerosol therapy is primarily indicated for upper airway edema —Sputum induction or secretion mobilization

Question 50

What Size Particles for Bland Aerosol

Answer 50

By passed airway: 2-10 microns MMAD Cool bland \>5 microns MMAD * Laryngotracheobronchitis,Subglottic edema, Post-extubationedema Sputum induction 1-5 microns

Question 51

Sputum Induction Procedure

Answer 51

1. —Standard precautions (N95 mask) & negative pressure room 2. —AM sample\*3 3. Prepare equipment 4. —Introduction & identification 5. —Explain procedure for deep cough 6. —Provide sterile container 7. **—Have patient rinse mouth & pretreat with a bronchodilator aerosol if needed** 8. —Place solution in neb and have patient breath from neb 9. —On insp patient inhales through mouth and on exp patient exhales through nose 10. ——Slow inspiration and breath hold 11. —Continued until either acceptable sputum specimen collected or patient unable to tolerate procedure

Question 52

Chest Physical Therapy

Answer 52

Chest physical therapy is a combination of lung expansion techniques and bronchial hygiene used to prevent or correct atelectasis and prevent secretion accumulation. ## Footnote —Cough techniques —Postural drainage —Percussion —Vibration —Incentive spirometry and adjuncts —Breathing techniques

Question 53

Cough Tachniques

Answer 53

—Bronchial hygiene depends on an effective cough —Some disease states inhibit or blunt the cough reflex, making it ineffective —Patients that have no effective cough need to learn cough techniques in order to improve their cough or to clear secretions —The most commonly taught techniques are the directed cough and the forced expiratory technique

Question 54

Directed Cough

Answer 54

—Position the patient sitting up —Have the patient take a slow big breath in through the nose using diaphragmatic breathing —Have the patient then bear down against the glottis (Valsalva), but this expiratory bearing down may have to be staged in short bursts for some patients to decrease fatigue and increase effectiveness —The bearing down mimics a spontaneous cough —This technique should be modified for COPD’ers: have them breathe in only moderately and breathe out via pursed lip breathing while bending forward slightly – this forward flexion should help mimic a cough “huff, huff, huff”

Question 55

Assisted Cough

Answer 55

—Useful for assisting patients with restrictive or paralytic disorders that impair lung excursion and increase the risk of secretion clearance failure —Have the patient take 3 breaths in and force out a cough —During the cough phase, the practitioner applies force 2 inches below the xiphoid and pushes up towards the head of the patient

Question 56

Forced Expiratory Technique (FET)

Answer 56

* —A modified directed cough – a huff cough * —Consists of two forced exhalations without closing the glottis followed by relaxation and diaphragmatic breathing * —Verbal huffing during exhalation keeps glottis open

Question 57

Forced Expiratory Technique (FET) Modification

Answer 57

Active Cycle of Breathing —Breathing control: relaxed diaphragmatic breathing —Thoracic expansion: deep inspirations X3 with passive exhalation —FET’s X2 followed by relaxed breathing —Done in cycles of 2 to 4 times

Question 58

Postural Drainage

Answer 58

—Also called autogenic drainage Postural drainage involves positioning the patient using gravity to drain secretions from lung segments into the central airways for expulsion by coughing or suctioning —This is accomplished by using the patient’s bed and pillows to position the patient, and also includes turning

Question 59

Principles and Techniques of Postural Drainage

Answer 59

—MAKE SURE THE DOCTOR’s ORDER IS WRITTEN AND CONFIRMED BEFORE POSTURAL DRAINAGE IS STARTED —Check that pain control has been initiated for the comfort of the patient —Check recent X-rays and oxygen requirements —Explain the procedure to the patient Check the patient’s vital signs and breath sounds

Question 60

Postural Drainage Procedure

Answer 60

—Ensure that clothing, IV lines, and O2 tubing will be moveable when re-positioning —Position the patient in the prescribed position, and check that the patient is tolerating the positioning well without adverse side effects HEAD DOWN 25º OR UP 45º —Maintain the position for 3 - 15 minutes, depending on hospital policy and the tolerance of the patient —Restore the patient to their pre-treatment position and monitor their vital signs and breath sounds —The patient should be encouraged to cough during and after postural drainage —NOTE: Turning the patient from side to side using a rotational bed or pillows is also used in some hospitals to improve lung expansion, but is not considered actual postural drainage

Question 61

When is proning commonly used

Answer 61

Proningis used extensively in ICU patients with refractory hypoxemia – improves V/Q by shifting blood from shunt areas

Question 62

Position and What Lobe is Being Drained

Answer 62

Remeber that whatever part of the lung is being lifted up is the segment that is being drained

Question 63

Percussion and Vibration

Answer 63

* —Percussion and vibration both utilize the application of energy (manual or mechanical) to the skin’s surface above the lung segment to be drained * —Percussion and vibration are designed to encourage secretion clearance: * —Percussion jars retained secretions loose from the tracheobronchial tree so they can be removed by coughing or suctioning * —Vibration moves secretions into the larger airways during exhalation for removal by coughing or suctioning

Question 64

Percussion and Vibration Indications

Answer 64

To be used an adjunct to postural drainage and coughing when these alone cannot provide adequate secretion clearance

Question 65

Percussion and Vibration Contraindications

Answer 65

* Subcutaneous emphysema, any lung or skin injury/surgery * Recent epidural or spinal anesthesia * New subcutaneous or transvenous pacers * TB * Bronchospasm * Osteomyelitis or osteoporosis * Bleeding disorders * Chest wall pain

Question 66

Percussion and Vibration Hazrds

Answer 66

—Pain and discomfort to the patient —SOB —Hypoxia —Rib fractures

Question 67

Percussion and Vibration Precautions

Answer 67

—Never percuss directly over breast or bone —Precautions associated with postural drainage are indicated here as well

Question 68

Percussion and Vibration Principles and Techniques of Percussion:

Answer 68

* —Percussion manually done by an experienced therapist is considered the most effective method used in clinical practice * —Manual percussion is performed with the hands in a cupped position, with fingers and thumbs closed inward * —This creates an energy wave with a cushion of air between the hand and the patient’s chest wall * —The wrists are loose, rhythmically clapping the patient’s chest in a waving motion * —This manual technique is easy, but requires practice to develop a rhythm and pattern that is effective and comfortable to use * —Percussion regimen’s differ from hospital to hospital, but the length of time required for postural drainage is also adequate in percussion

Question 69

Incentive Spirometry

Answer 69

* —Increases transpulmonary P gradients by decreasing Ppl * —Incentive spirometry (IS): same as SMI - sustained maximal inspiration (American) * —Used for lung expansion therapy - mimics physiologic sighing through slow deep breathing patterns * —Achievement of visual goals (markers/floats on the IS device) encourages the patient to continue and meet their predicted goal settings * The big I causes a drop in Ppl due to expansion of the thorax – this drop transmits to the alveoli, negative Palvallows for more gas flow to the alveoli and lung expansion.

Question 70

Incentive Spirometry Indications

Answer 70

—Documented atelectasis —Impending atelectasis: thoracic/abdominal/cardiac surgery, post-op —Restrictive diseases/movement

Question 71

Incentive Spirometry Contraindications

Answer 71

—Uncooperative or unable to perform procedure —Unable to understand instructions —Too weak or sick VC less than 10 ml/kg

Question 72

Incentive Spirometry Hazards

Answer 72

—Hyperventilation and respiratory alkalosis —Discomfort due to poor pain control —Barotrauma —Hypoxemia if O2 has to be removed —Bronchospasm —Fatigue —Vagal stimulation

Question 73

Incentive Spirometry Instruction

Answer 73

—Setting an IS goal for a specific patient differs with hospital policy - some hospitals use the inserts that are included with IS units that determine the patients predicted values based on their height and age and some hospitals use the patient’s pre-surgery IS levels as their goals —IS should be done 5 - 10 maneuvers/hour post surgery as the patient can tolerate

Question 74

Incentive Spirometry How Do You Know You Work

Answer 74

Subjective patient improvement: decreased respiratory rate, remission of fever, normal pulse, and improved breath sounds Improvement of atelectasis on X-Ray

Question 75

Incentive Spirometry Follow Up By RRT

Answer 75

Observation of patient’s technique Additional instruction if needed Making sure the device is within the patient’s reach and that they are using it on their own Setting new and increased inspiratory goals every day if improving Vital signs and breath sound assessment

Question 76

Lung Volume Recruitment

Answer 76

—Recruitment maneuver used in patients with paralytic disorders like ALS that have high risks of atelectasis and secretion clearance failure —Uses a resuscitation bag to stack breaths to achieve maximum insufflation and promote alveolar recruitment (“stretch”) and allow for a strong cough on exhalation if required —Often followed by assisted cough maneuvers to promote secretion clearance —Refer to handout for technique

Question 77

Breathing Techniques

Answer 77

Some patients require training in order to breath more effectively to: * —Encourage more use of the diaphragm and less use of accessory inspiratory muscles * —Decrease the tendency to use gasping respirations * —Teach patients to cope with dyspnea * —Decrease muscle inefficiency * —Coordinate breathing with motion and daily activities * —Relieve exertional dyspnea * —Improve cardiopulmonary fitness and exercise tolerance

Question 78

Artificial Cough Devices:

Answer 78

Most common is the chest vest oscillator Works by rapidly oscillating air volumes within the vest to rapidly compress and vibrate the chest of the patient Generally used for patients with CF Effective chest physical therapy is more efficient

Question 79

In-Exsufflator

Answer 79

—The CoughAssistimproves secretion clearance by gradually applying a positive pressure to the airway, and then rapidly shifts to negative pressure —The rapid shift in pressure produces a high expiratory flow from the lungs, simulating a cough —Useful in patients with Neuromuscular disease and a weak cough

Question 80

Flutter Valves

Answer 80

—HFOA, Uses expiratory pressure and high frequency oscillation through the valve —On exhalation, the expiratory pressure created ranges from 10 - 25 cmH2O, and the oscillations (15 Hz) created are transmitted into the chest wall Very effective for CF and CB patients in cycles of 10 – 20 breaths at a time

Question 81

SUCTIONING ENDOTRACHEAL TUBES Closed Suctioning

Answer 81

Closed in-line suction catheters will be used for routine secretion management for all mechanically ventilated infants whose expected duration of ventilation is greater than 12 hours. Closed in-line suction requires a dedicated suction regulator which will not be used for any other suctioning (eg. oral). Closed in-line suction is the standard form of secretion clearance for use in mechanically ventilated infants. A sterile closed suction system is also preferred for endotracheal secretion sample retrieval.

Question 82

SUCTIONING ENDOTRACHEAL TUBES PPE

Answer 82

All care providers must perform hand hygiene and don nonsterile gloves prior to closed in- line suction procedure. Hand hygiene must also be performed following the procedure. **For Assisting Care Provider** * non-sterile gloves * goggles, * mask * a barrier gown is optional when body fluid exposure is anticipated performing care provider: **For Performing Care Provider** * face protection: mask with shield or mask and goggles * non-sterile glove on the non-dominant hand * sterile glove on the dominant hand * a barrier gown is optional when body fluid exposure is anticipated.

Question 83

SUCTIONING ENDOTRACHEAL TUBES Suction Order

Answer 83

The infant’s hypopharynx must be suctioned prior to endotracheal suctioning to prevent aspiration.

Question 84

SUCTIONING ENDOTRACHEAL TUBES When are Closed Inline Suction Cather Changed

Answer 84

Closed in-line suction catheters will be changed every 72h and prn. The following conditions will necessitate a non-routine catheter change : * Visible soiling on the external or internal surface of the catheter * Mechanical failure of the suction control valve * Inability to move the catheter freely * Air filling of the closed in-line suction catheter’s sleeve * Mechanical failure of the one-way valve on the instill port. * If ETT secretions culture is positive for a pathogen, in-line suction catheters should be changed on a daily basis for at least 3 days.

Question 85

SUCTIONING ENDOTRACHEAL TUBES If an Infant is Diagnosed with VAP​

Answer 85

If the infant has been diagnosed with a ventilator associated pneumonia (VAP), continue daily in-line suction catheter changes until the infant’s condition improves (as evidenced by decreased FiO2 requirements, decreased ventilatory pressures, decreased secretions, etc), then return to changing the in-line suction every 72 hours

Question 86

SUCTIONING ENDOTRACHEAL TUBES If an Infant is Diagnosed with VAP​

Answer 86

If the positive ETT culture is thought to be a result of colonization of the ETT, and if there are no signs or symptoms of VAP, change the in-line suction catheter every day for 3 days, and then return to changing it every 72 hours.

Question 87

SUCTIONING ENDOTRACHEAL TUBES If closed in-line suction does not remove the secretions

Answer 87

If the closed in-line suction catheter does not adequately remove infant’s secretions, the following steps must be attempted prior to the use of open suction: * Ensure proper vacuum pressures * Rinse catheter with sterile normal saline * Ensure the valve is properly depressed * Verify patency of catheter (ie. not kinked) and of the suction system.

Question 88

SUCTIONING ENDOTRACHEAL TUBES Open ETT Suctioning

Answer 88

Open endotracheal suctioning is intended for use when closed in-line suctioning is unsuccessful at clearing secretions, when an adequate sample cannot be obtained with a closed system, or when a closed system is unavailable at sites that care for short term ventilation prior to extubation or transfer.

Question 89

SUCTIONING ENDOTRACHEAL TUBES Suction Catheter Size

Answer 89

Ensure the appropriate sized catheter is selected for the specific size of airway present. A 6.0 French catheter is to be used on #2.5 ETT, 8.0 French catheter is to be used on a #3.0 or #3.5 ETT.

Question 90

SUCTIONING ENDOTRACHEAL TUBES Instillation

Answer 90

Instillation of saline is not to be done routinely. Instillation may be indicated if secretion removal is ineffective without it (ie. tenacious secretions).

Question 91

SUCTIONING ENDOTRACHEAL TUBES Personnal

Answer 91

For either open or closed suctioning, it is recommended that two trained personnel perform the procedure to prevent accidental extubation and to allow for changes in ventilator settings as indicated by patient status (eg. increasing FiO2 for desaturation).

Question 92

SUCTIONING ENDOTRACHEAL TUBES Higher Suction Levels

Answer 92

Higher suction levels (100-120mmHg) are required with in-line suction catheters due to the higher resistance levels.

Question 93

SUCTIONING ENDOTRACHEAL TUBES Disconnection

Answer 93

The suction tubing must be disconnected from the closed in-line catheter whenever the infant is being mobilized or is at high risk of self-extubation. The tip of the suction catheter connector and the end of the suction tubing must be kept sterile while disconnected. If either is contaminated in the process they must be replaced with new product.

Question 94

SUCTIONING ENDOTRACHEAL TUBES Directional Indicator Line

Answer 94

Ensure that the blue directional indicator line on the endotracheal tube remains in a left facing position prior to and after the procedure.

Question 95

SUCTIONING ENDOTRACHEAL TUBES Potential Complications During Procedure

Answer 95

Bradycardia Hypoxia Hypercarbia Tracheal mucosal damage

Question 96

SUCTIONING ENDOTRACHEAL TUBES Potential Complications After Procedure

Answer 96

De-recruitment and atelectasis Decreased compliance resulting in hypercarbia Increased oxygen requirements Tracheal stenosis Infection

Question 97

SUCTIONING ENDOTRACHEAL TUBES Procedure: Open Suctioning

Answer 97

It is recommended that 2 trained personnel perform the procedure 1. PPE 2. Prepare suction catheter and **verify suction at 80-100 mmHg** 3. Peroxygenate (FiO2 10% above for ~20 sec) 4. **Disconnect and suspend ventilator circuit on the ventilator suspension arm. DO NOT turn the ventilator off and DO NOT allow the open end of the circuit to contact any surface.** 5. Initiate PPV using a bagging unit or T-piece resuscitator. 6. Determine the appropriate depth of catheter insertion by using the suctioning guide or by measuring the ETT. The catheter’s distal end should protrude approximately 0.25 – 0.50cm past the distal end of the endotracheal tube. 7. Insert the suction, apply suction while withdrawing the catheter, using a twisting motion. 8. Place patient back on the ventilator or bagging unit between suction attempts to ensure adequate ventilation and oxygenation. 9. Aspirate several mLs of sterile water after each pass to clear catheter and suction line. 10. Reassess patient and repeat suctioning as required. 11.

Question 98

SUCTIONING ENDOTRACHEAL TUBES Procedure: Closed Suctioning

Answer 98

It is recommended that 2 trained personnel perform the procedure 1. PPE 2. Verify suction at 100-120 3. Silence vent alarms 4. Peroxygenate (FiO2 10% above for ~20 sec) 5. Determine appropraite catheter depth 6. Insert suction and then apply continuous suction for 1-3 second before slowly withdrawing in a straight motion to prevent kinking 7. Rinse catheter-Always remove and discard the normal saline rinse from the instill port 8. Withdrawal catheter to the suction port elbow 9. Allow 20-30 seconds and reassess patient

Question 99

SUCTIONING ENDOTRACHEAL TUBES Depth

Answer 99

Determine the appropriate depth of catheter insertion by using the suctioning guide or by utilizing the markings on the endotracheal tube. The catheter’s distal end should protrude approximately 0.25 – 0.50cm past the distal end of the endotracheal tube

Question 100

SUCTIONING ENDOTRACHEAL TUBES Suction Time

Answer 100

Time from insertion to complete withdrawal should not exceed 5 seconds.

Question 101

Lung Volume Recruitment PPE

Answer 101

Lung volume recruitment is a high-risk procedure that may generate droplets, exposing staff to respiratory pathogens. Appropriate Personal Protective Equipment (PPE) must be applied to reduce exposure to respiratory secretions.

Question 102

Lung Volume Recruitment

Answer 102

A physician order is required prior to initiating Lung Volume Recruitment (LVR) with a modified resuscitation bag. LVR is used to improve peak expiratory cough flow (PCF) and vital capacity (VC) by reaching maximum insufflation capacity (MIC) in patients with paralytic/restrictive disorders. Lung Volume Recruitment (LVR) refers to breath stacking, techniques allowing a maximum insufflation capacity.

Question 103

Lung Volume Recruitment Disorders that it is used on

Answer 103

These disorders include spinal cord injuries and neuromuscular diseases such as ALS, Guillain-Barré Syndrome (GBS), myasthenia gravis, muscular dystrophy, multiple sclerosis, post polio, kypho-scoliosis, and syringomyelia.

Question 104

Assisted Cough Manoeuvers

Answer 104

A manually Assisted Cough Manoeuvre involves the application of an abdominal thrust or costal lateral compression using various hand placements after an adequate spontaneous inspiration or maximal insufflation.

Question 105

Glossopharyngeal Breathing

Answer 105

Glossopharyngeal Breathing (GPB) is a method of breathing, which consists of stroke- like action of the tongue along with constricting action of the pharynx pumping air through the larynx into the lungs.

Question 106

The Maximum Insufflation Capacity

Answer 106

The Maximum Insufflation Capacity measurement (L) is the max volume of air stacked in the patient’s lungs beyond spontaneous vital capacity. MIC is attained when the patient takes a deep breath, holds his breath and then breath stacking is applied using a LVR resuscitation bag, a volume ventilator or glossopharyngeal breathing (GPB). When measuring a MIC, the therapist should assist the patient with his/her optimal insufflation technique, introduce the spirometer in the post mode and instruct the patient to completely exhale the MIC volume through the spirometer. The documented volume must be clearly identified as a MIC and not a post bronchodilator study.

Question 107

Peak Cough Flow

Answer 107

Peak Cough Flow (PCF) is measured by using a peak flow meter. The PCF is the velocity of air being expelled from the lungs after a cough manoeuvre. This measurement can be expressed in L/min or L/sec (L/min divided by 60). The PCF correlates well with the actual FEF Max (L/sec) measurement commonly measured with the spirometer. Multiply your FEF value by 60 to obtain a PCF measurement in L/min.

Question 108

Clinical Indication for Lung Volume Recruitment

Answer 108

An established diagnosis as paralytic/restrictive disorder (refer to the Policy Statement section). A spontaneous PCF less than 280 L/min (2), with or without assisted cough manoeuvre (at the Ottawa Hospital Rehabilitation Centre (OHRC)- PCF sp must be less than 350 L/min). The FVC less than 50% predicted (1) (OHRC-FVC must be less than 70%).

Question 109

Absolute Contr-Indications for Lung Volume Recruitment

Answer 109

* Presence of haemoptysis, untreated or recent pneumothorax, bullous emphysema, nausea, severe COPD or asthma and recent lobectomy. * Increased intra-cranial pressure (ICP), including ventricular drains. * Impaired consciousness / inability to communicate. * If the patient has an inflated tracheal cuff, DO NOT perform LVR with the Manual resuscitation bag. * Sufficient airflow around the deflated cuff is required if LVR is introduced via the tracheostomy. * DO NOT perform LVR with a resuscitation bag when your patient has an endotracheal tube in place.

Question 110

Relative Contra-Indications for Lung Volume Recruitment

Answer 110

Therapy immediately following meals History of COPD and pneumothorax. Large pleural effusion LVR with a modified resuscitation bag in patients with intrinsic lung diseases (such as COPD, bronchiectasis, CF, pulmonary fibrosis, and asthma to name a few) where secretions may be abundant should be introduced with caution and at times may not be indicated. The efficacy of the treatment in this instance must be monitored by a physician specialized in lung physiology such as a staff respirologist or intensivist.

Question 111

Lung Volume Recruitment Manuvers Precautions

Answer 111

Patients known to have cardiac instability should be monitored for arrhythmias (especially acute SCI), Sp02, dyspnea, vital signs, and symptoms of cardiac instability. Patients with a combination of intrinsic diseases and paralytic/restrictive disorders must be referred to a staff respirologist or intensivist for consultation. A pressure manometer, in line with the LVR equipment, is required to minimize maximal insufflation pressure for patients with a combination of primary lung diseases and paralytic/restrictive disorders, unless an order from a staff respirologist or intensivist is written that the manometer is not indicated. Patients with long-standing thoracic cage restriction who may have severely reduced thoracic compliance will require slow incremental insufflations during the initial LVR introductory period.

Question 112

Equitment for LVR with Resuscitation Bag

Answer 112

* Appropriate PPE * Resuscitation bag, disposable if possible, clearly identified not for CPR * 50 cc corrugated tube * One way valve closest to the bag * One way valve with the inner silicone piece removed, but with the inner screen intact * (The modified valve is positioned closest to the patient. * Mouthpiece or mask * Nose clip (optional)

Question 113

Lung Volume Recruitment Manuver Position of the patient

Answer 113

The LVR technique is best performed in the sitting position; however, this technique can be done in supine. C-spine stabilization must be assessed and the head and neck must always be supported if an assisted cough manoeuvre is performed in coordination with the LVR technique. Assemble the necessary equipment.

Question 114

Lung Volume Recruitment Manuver are usually performed

Answer 114

QID and prn if secretions are present, to a maximum of Q10 minutes to avoid hyperventilation Ideally before meals and at bedtime With assisted cough BID or PRN when indicated

Question 115

Lung Volume Recruitment Manuver Procedure

Answer 115

1. Have patient in optimal position 2. Introduce therapy to pt 3. Establish a signal the pt can use when MIC is reached 4. With nose clips in place, ask the patient to take a deep breath and hold. 5. Ask the patient to place lips tightly around the mouthpiece to prevent air from escaping. 6. Gently sqeeze resuscitation bag and try to coordinate with pt inspiration 7. Pay attention to possible leaks between the mouthpiece and the mouth. Squeeze the bag 2-5 times until you feel the lungs are full or when the patient sends you a signal that MIC is reached. The patient may feel a stretch in the chest or slight discomfort. 8. Once the patient’s lungs are full, take the mouthpiece out of the mouth, ask the patient to hold the maximum insufflation for 3 to 5 seconds, and then allow the patient to exhale gently. 9. Repeat steps 5-8, 3 to 5 times. 10. If secretions are present, ask the patient to produce a strong cough or include an assisted cough manoeuvre when indicated (i.e., instead of gently letting the air out).

Question 116

Lung Volume Recruitment Manuver Helpful Hints

Answer 116

If air escapes around the patient’s mouth, assess the method of delivery and selection of interface. As the patient becomes proficiency with LVR, nose clips may not be necessary.