ETTs & Tracheotomies

Question 1

indications

Answer 1

• ventilatory/ repsiratory failure (primary reason)
• failure to protect airway (coma, vegetative state)
• failure to clear airway (inability to cough up secretions)

Question 2

airway access

Answer 2

• oropharyngeal & nasopharyngeal airways
• endotrachea tube
• tracheotomy (for prolonged intubation)
• non-invasive ventilation (face mask)
• LMA

Question 3

oropharyngeal & nasopharyngeal airways

Answer 3

• oro-usually only used if unresponsive- will activate gag reflex (coma, chemically paralyzed, unresponsive)
• used for upper airway passages
• easy to use
• low risk of complications
• should be well lubricated with water-soluble gel before insertion
• measurement for correct airway size:
  naso: ear to nose, if too long= aspiration& vomiting

Question 4

oropharyngeal airway

Answer 4

-stimulates gag reflex

only used on pts with altered level of consciousness

Question 5

nasopharyngeal airway

Answer 5

• inserted through nare
• tolerated better by alert pts
• -frequent oral and nare care to prevent breakdown
• reposition in other nare every 8 hrs
• not to be used with facial fractures, esp. orbital fractures. (could go into brain tissue)

Question 6

laryngeal mask airway

Answer 6

“advanced airway”

-seals around airway

Question 7

ETT (endotrachial tube)

Answer 7

• most common in pts who have had general amnesia or who are in an emergency situation (resp. failure, etc.)
• inserted by PCP, CRNA, anesthesiologist, or RT with specialized education
• passes through epiglottis and glottis so pt is unabe to speak
• air-filled cuff to prevent air leakage
• always pay close attention to where it is

Question 8

ETT placement

Answer 8

• via laryngoscope
• may be oral or nasal
• taped into place after confirmation

Question 9

indications for ETT

Answer 9

• airway protection: prevents occlusion by tongue D/T cognitive changes
• airway occlusion- D/T trauma, edema, tracheal atresia, paralysis or injury to face
• failure to wean or prolonged ventilatory support

Question 10

Trachs

Answer 10

• plastic or metal
• different sizes
• with or with out cuffs (kids will not get cuff)
• non-fenestrated or fenestrated (has holes in it, pt can talk)

Question 11

Trach care

Answer 11

provide trachc are to: maintain patency of tube, reduce risk of infection

• assess for airway clearance (suction & gurgling)
• watch for coughing, rsp distress, rhonchi, decreased O2 stats (destat=need suctioning)
• Q shift trach care (dont change trach ties first 24 hrs)
• watch for pulsations
• freqent suctioning using sterile technique (q4hrs until secretions stop significantly)
• humidify O2 therapy (helps loosens secretions)
• relieve anxiety
• subQ emphezema if not placed correctly

Question 12

trach care relieve anxiety:

Answer 12

• explain everything to pts
• provide simple means of communication
• encourage frequent family visits
• emphasize importance of talking to pt
• provide distractions
• attend to physical needs promptly and completely
• reassure pt

Question 13

when does a pt need suctioning?

Answer 13

• when pts have difficulty handling secretion
• when an artificial airway is in place
• to clear passages
• -when pt is unable to cough up secretions or is in respiratory distress
• dyspnea
• bubbling/rattling breath sounds
• cyanosis/ poor skin color
• decreased O2 saturation

Question 14

suctioning

Answer 14

oral and oropharyngeal suctioning removes secretions from upper respiratory tract
-nasopharyngeal and nasotracheal suctioning requires sterile technique

Question 15

complications of suctioning

Answer 15

• hypoxemia
• trauma to airway
• nosocomial infection
• cardiac dysrhythmia

Question 16

how to minimize/decrease complications of suctioning

Answer 16

• hyperinflation: give breaths 1-1.5X set VT, & give 3-5 breaths before and after each pass of catheter
• hyperoxygenation: increase O2 flow before and between suction attempts
• *tp prevent hypoxia when suctioning a tracheostomy or ETT, the outer diameter of the suction catheter should not exceed 1/2 the internal diameter of trach or ETT

Question 17

speaking with trach

Answer 17

• fenestrated trach
• speaking trach tube (two pigtails)
• speaking trach valve (Passy-muir)

Question 18

critical airway considerations

Answer 18

• pt anatomy suggesting difficulty airway and/or physica limitations
• previously documented difficult intubations
• type of trach or ETT in use
• any adult with a fresh trach with mechanical ventilation will be considered a “critical airway” for 72 hrs unless other wise indicated
• in peds, a fresh trach is considered a critical airway for 7 days with or without mechanical ventilation unless otherwise ordered.

Question 19

critical airway precautions

Answer 19

• a MD order is required to initiate and DC “critical airway precautions”
• report should include notification of CAP
• place CAP sign above head of bed
• document presence of CAP on daily care in EMR or fowsheet

Question 20

CAP: safety considerations

Answer 20

• a specific RN or RT will be assigned to assess and stabilize critical airway when pt is moved
• whole new trach at bedside
• new operator taped to bed
• trach ties usually changed every 48 hrs
• supplemental O2 in room
• all new trach supplies will accompany pt at all times

Question 21

decannulation

Answer 21

• suction before plugging and deflating
• pt needs to pass aspiration test
• plug trach for prolonged periods of time, increasing as ordered
• deflate cuff before plugging
• when pt tolerates trach plugged at all times it can come out

Question 22

decannulation prcedure

Answer 22

slide trach out

• cover with sterile, dry, occlusive dressing
• hole will close in a few days
• may use tape strips to cover hole if ordered
• instruct pt to splint stoma with fingers when coughing, swallowing or speaking
• watch for airway obstruction & anxiety

Question 23

discharge

Answer 23

provide referrals to: home health

• respiratory care (O2 at home)
• occupational therapy
• counseling
• provide lots of education