Airway Management Part II

1. Airway ManagementPart II RET 2275 Respiratory Care Theory 2

2. Airway Clearance - Cough • Deep inspiration • Glottis closes • Abdominal muscles contract to compress lungs • Glottis is opened • Lung contents are expelled Steps in a normal cough

3. Airway Clearance • Airway obstruction • Caused by: • Retained secretions • Cause increased airway resistance and work of breathing, hypoxemia, hypercapnia, atelectasis, infection • Foreign bodies • Airway edema • Tumors • Trauma

4. Airway Clearance - Suctioning • Airway obstruction • Retained secretions • Can be removed from the airways using mechanical aspiration – Suctioning Nasotracheal Endotracheal Oral

5. Secretion Evacuation Devices • Suction Regulator • Provide a means of reducing the high negative pressures from the supply line to safe physiological levels

6. Secretion Evacuation Devices • Suction Tubing • Connects regulator to canister, and canister to suction device (yankauer, suction catheter, etc.) • Suction Canisters • Collection device • Protects vacuum lines from infiltration of fluids

7. Secretion Evacuation Devices • Yankauer Suction Tip • AKA – Tonsillar Tip • Used to remove secretions from the oropharynx (upper airway)

8. Secretion Evacuation Devices • Suction Catheter • Used to remove secretions from the lower airway

9. Secretion Evacuation Devices • Closed Suction System • Maintains PEEP and high FiO2 when suctioning a mechanically ventilated patient • May reduce caregiver and patient risk of infectious disease exposure • Permits the suction catheter to be used multiple times, reducing cost

10. Secretion Evacuation Devices • Lukens Trap • Commonly referred to as “sputum trap” • Used to obtain sputum specimens • Placed in-line between the vacuum circuit and the suction catheter Lukens trap closed after obtaining specimen

11. Nasotracheal Suctioning

12. Nasotracheal Suctioning • Indications – Assessment of Need • The need to maintain a patent airway and remove retained secretions or foreign material from the trachea in the presence of: • Inability to clear secretions – ineffective cough • Audible evidence (auscultation) of secretions in the large airways (course crackles) that persist in spite of patient best cough effort • Signs of respiratory distress • To obtain sputum samples in patient who are unable to expectorate

13. Nasotracheal Suctioning • Contraindications • The only absolute contraindications are epiglottitis and croup • Relative Contraindications • Occluded nasal passages • Nasal bleeding • Acute head, facial, or neck injury • Coagulopathy or bleeding disorder • Laryngospasm • Irritiable airway • Upper respiratory tract infection including croup and epiglottitis • Bronchospasm

14. Nasotracheal Suctioning • Procedure • Step 1: Assess patient for indications • Auscultate • Course crackles • Ineffective cough • Step 2: Assemble and Check Equipment • Suction regulator (set pressure) • Adults:100 to -120; children: 80 to -100; infants: 60 to -80 • Suction canister with tubing • Suction catheter

15. Nasotracheal Suctioning • Procedure • Step 2: Assemble and Check Equipment (cont.) • Water-soluble lubricating jelly • Sterile gloves • Goggles, mask, gown (standard precautions) • Sterile water or saline • Oxygen delivery system (resuscitator bag/mask) and oxygen source • Nasopharyngeal airway • Minimizes nasal trauma when repeated access is needed

16. Nasotracheal Suctioning • Procedure • Step 3: Preoxygenate and Hyperinflate the Patient • Using a manual resuscitator bag/mask connected to an 100% oxygen, preoxygenate and hyperinflate the patient for at least 30 seconds prior to suctioning

17. Nasotracheal Suctioning • Procedure • Step 3: Preoxygenate and Hyperinflate the Patient • Hyperinflation fills underaerated or nonaerated segments via collateral ventilation, which helps move secretions into larger airways

18. Nasotracheal Suctioning • Procedure • Step 4: Insert the Catheter • Lubricate the catheter and gently insert it through the nostril, directing it toward the septum and floor of the nasal cavity (do apply negative pressure yet) • If you encounter resistance, gently twist the catheter. If this does not help, remove the catheter and try inserting it through the other nostril

19. Nasotracheal Suctioning • Procedure • Step 5: Move Catheter in Lower Pharynx • Have the patient assume a “sniffing” position and advance the catheter through the larynx until the patient’s coughs, or a resistance is felt much lower in the airway • Apply suction, while withdrawing the catheter using a rotating motion

20. Nasotracheal Suctioning • Procedure • Step 5: Move Catheter in Lower Pharynx (cont.) • Keep total suction time to less than 10 – 15 seconds • After removing the catheter, clear it using the sterile water/saline • If any untoward response occurs during suctioning, e.g., hypoxemia, an abrupt change in the electrocardiogram wave form, major change in heart rate or rhythm, hypotension, increased intracranial pressure, etc., immediately remove the catheter and oxygenate the patient

21. Nasotracheal Suctioning • Equipment and Procedure • Step 6: Reoxygenate and Hyperinflate the Patient • Using a manual resuscitator bag/mask connected to an 100% oxygen, reoxygenate and hyperinflate the patient for at least 60 seconds • Step 7: Monitor the Patient and Assess • Repeat steps 3 – 7 as needed until your see improvement or observe an adverse response

22. Nasotracheal Suctioning • Hazards and Complications • Hypoxia/hypoxemia • Nasal, pharyngeal, and tracheal mucosal trauma/pain • To avoid this rotate catheter while withdrawing and limit the amount of negative pressure used • Cardiac or respiratory arrest • Cardiac arrhythmias/bradycardia • Pulmonary atelectasis • Avoid this by limiting amount of negative pressure , keeping duration of suctioning as short as possible, providing hyperinflation before and after the procedure • Bronchoconstriction/bronchospasm

23. Nasotracheal Suctioning • Hazards and Complications (cont.) • Infection (patient and/or caregiver) • Mucosal hemorrhage • Elevated intracranial pressure • Uncontrolled coughing/laryngospasm • Hyper/hypotension • Gagging/vomiting

24. Nasotracheal Suctioning • Assessment of Outcome • Effectiveness should be reflected by removal of secretions • Effectiveness should be reflected by improved breath sounds

25. Nasotracheal Suctioning • Monitoring • The following should be monitored before, during, and after the procedure: • Breath sounds • SpO2 • Respiratory rate and pattern • Pulse rate, BP, ECG (if available) • Sputum (color, volume, consistency, odor) • Presence of bleeding (evidence of trauma) • ICP (if indicated and available)

26. Endotracheal Suctioning

27. Endotracheal Suctioning • Equipment

28. Endotracheal Suctioning • Indications – Assessment of Need • The need to maintain a patent airway and remove retained secretions • Audible evidence (auscultation) of secretions in the large airways (course crackles) • Clinically apparent work of breathing • Increased peak inspiratory pressures on volume-controlled ventilation; decreased VT on pressure control ventilation • To obtain sputum samples for microbiological or cytologic examination • Should be a routine part of a patient/ventilator check

29. Endotracheal Suctioning • Contraindications • When indicated, there is no absolute contrindication to endotracheal suctioning because abstaining from suctioning in order to avoid possible adverse reaction may, in fact be lethal

30. Endotracheal Suctioning • Procedure • Step 1: Assess patient for indications • Auscultate • Course crackles • Ineffective cough • Step 2: Assemble and Check Equipment • Suction regulator (set pressure) • Adults:100 to -120 • Children: 80 to -100 • Infants: 60 to -80

31. Endotracheal Suctioning • Procedure • Step 2: Assemble and Check Equipment (cont.) • Suction canister with tubing • Suction catheter • OD must be less than ½ of ID of ET tube • Example: 8.0 mm ID tube 8 X 2 = 16 next smallest size is 14 French

32. Endotracheal Suctioning • Procedure • Step 2: Assemble and Check Equipment (cont.) • Sterile gloves • Goggles, mask, gown (standard precautions) • Sterile water or saline • Oxygen delivery system (resuscitator bag/mask, ventilator) and oxygen source

33. Endotracheal Suctioning • Procedure • Step 3: Preoxygenate and Hyperinflate the Patient • Using a manual resuscitator bag/mask connected to an 100% oxygen, preoxygenate and hyperinflate the patient for at least 30 seconds • If the patient is on a ventilator, adjust the FiO2 to 100% and use machine breaths to hyperinflate the patient • Step 4: Insert the Catheter • Insert the catheter carefully until it can go no farther • Do not contaminate the catheter by touching it to the outside of the ET tube or any other surface • Withdraw the catheter a few centimeters before applying suction

34. Endotracheal Suctioning • Procedure • Step 5: Apply Suction / Clear Catheter • Apply suction, while withdrawing the catheter using a rotating motion • Keep total suction time to less than 10 – 15 seconds • After removing the catheter, clear it using the sterile water/saline • Closed suction catheter systems have an adapter for saline vials to be placed inline with device (the catheter is cleared by squeezing the saline vial and applying suction at the same time)

35. Endotracheal Suctioning • Procedure • If any untoward response occurs during suctioning, e.g., hypoxemia, an abrupt change in the electrocardiogram wave form, major change in heart rate or rhythm, hypotension, increased intracranial pressure, etc., immediately remove the catheter and oxygenate the patient

36. Endotracheal Suctioning • Equipment and Procedure • Step 6: Reoxygenate and Hyperinflate the Patient • Using a manual resuscitator bag/mask connected to an 100% oxygen, reoxygenate and hyperinflate the patient for at least 60 seconds • If the patient is on a ventilator, adjust the FiO2 to 100% and use machine breaths to hyperinflate the patient • Step 7: Monitor the Patient and Assess Outcomes • Repeat steps 3 – 7 as needed until your see improvement or observe an adverse response

37. Endotracheal Suctioning • Hazards and Complications • Hypoxia/hypoxemia • Tracheal or bronchial mucosal trauma • To avoid this rotate catheter while withdrawing and limit the amount of negative pressure used • Cardiac or respiratory arrest • Cardiac arrhythmias • Pulmonary atelectasis • Avoid this by limiting amount of negative pressure , keeping duration of suctioning as short as possible, providing hyperinflation before and after the procedure

38. Endotracheal Suctioning • Hazards and Complications (cont.) • Bronchoconstriction/bronchospasm • Infection (patient and/or caregiver) • Mucosal hemorrhage • Elevated intracranial pressure • Hyper/hypotension

39. Endotracheal Suctioning • Assessment of Outcome • Removal of pulmonary secretions • Improvement in breath sounds • Decreased peak inspiratory pressures on volume control ventilation • Increased VT on pressure control ventilation • Decreased airway resistance • Improvement in ABG values or SpO2

40. Endotracheal Suctioning • Monitoring • The following should be monitored before, during, and after the procedure: • Breath sounds • SpO2 • Respiratory rate and pattern • Pulse rate, BP, ECG • Sputum (color, volume, consistency, odor) • Ventilation parameters • ICP (if indicated and available)