airway management part iii ret 2275 respiratory care theory 2

Airway ManagementPart III

RET 2275

Respiratory Care Theory 2

Tracheostomy Tubes

A long-term airway placed through an incision made between the 2nd and 3rd tracheal rings and inserted directly into the trachea

Tracheostomy Tubes

Indications for tracheostomy: Airway obstruction due to the following:

Inflammatory disease Benign laryngeal pathology, e.g., webs, cysts, papilloma) Malignant laryngeal tumors Laryngeal trauma or stenosis Tracheal stenosis

Pulmonary toilet Obstructive sleep apnea

Tracheostomy Tubes

Advantages over prolonged translaryngeal

intubation: Eases airway care and suctioning Eliminates the ongoing risks of oral, nasal, pharyngeal, and

most laryngeal complications of translaryngeal intubation Reduces risk of tracheal extubation Eases tube reinsertion Facilitates oral communication and speech Improves oral, nasal, and facial hygiene

Tracheostomy Tubes

Advantages over prolonged translaryngeal

intubation: Raises patient comfort level Improves patient appearance Facilitates nursing care of the overall airway Improves patient mobility Eases disposition to long-term care facility Less airway resistance

Tracheostomy Tubes

Most experts agree that patients requiring ET intubation

for more than 7 days should have a tracheostomy

Some evidence indicates that a tracheostomy performed early, i.e., within 3 days of intubation, may decrease the risk for pneumonia, the length of mechanical ventilation,

and the length of stay in the ICU

Tracheostomy Tube

Outer Cannula; primary structural unit of the tube, to which is attached the cuff and flange

Flange; prevents tube slippage into the trachea and provides means to secure the tube to the neck

Inner Cannula; cannula within the outer cannula that can be removed for routine cleaning – can be locked in place

Tracheostomy Tube

Cuff; seals off the lower airway, either for protection from aspiration or to provide positive pressure ventilation – inflation tube (aka: pilot tube) leads from the cuff to a pilot balloon and spring loaded valve.

Tie strings; stabilizes the tube at the stoma site - attached to the flange and is tied around the neck

Tracheostomy Tube

Obturator; placed within the outer cannula with its tip extending just beyond the far end of the tube – minimizes mucosal trauma during insertion

Radiopaque Indicator; helps confirm tube position on radiograph

Airway Trauma with Tracheal Tubes

Laryngeal Lesions Glottic edema Vocal cord inflammation

Both are transient changes that occur as a result of pressure from the ETT, or trauma during intubation

Symptoms include hoarseness and stridor

Primarily a concern after extubation and can worsen over 24 hours


Laryngeal Lesions Laryngeal and vocal cord ulcerations

May cause hoarseness after extubationSymptoms usually resolve spontaneously

Vocal cord polyps and granulomasDevelop more slowly – taking weeks or monthsSymptoms include:

Difficulty swallowing Hoarseness Stridor May have to be removed surgically


Laryngeal Lesions Vocal cord paralysis

Symptoms may resolve within 24 hours If obstructive symptoms continue, tracheotomy

may be indicated

Laryngeal stenosisNormal tissue is replaced by scar tissue, which

causes strictureSymptoms include stridor and hoarsenessSurgical correction is usually required


Tracheal Lesions Granulomas

Circumscribed mass of cells (mainly histiocytes) normally associated with the presence of chronic infecton or inflammation

Tracheomalacia Softening of the cartilaginous

rings, which causes collapse of the trachea during inspiration


Tracheal Lesions Tracheal stenosis

Narrowing of the lumen of the trachea, which can occur a fibrous scarring causes the airway to narrow

With ETT, most often occurs at the site of the cuff

With tracheostomy tubes, occurs at the cuff, tube tip, or stoma site (most common)


Tracheoesophageal fistula A direct communication

between the trachea and esophagus

Development is related to sepsis, malnutrition, tracheal erosion from the cuff and tube and esophageal erosion from nasogastric tubes


Tracheal Lesions Tracheoinnominate fistula

Occurs when a tracheostomy tube causes tissue erosion through the innominate artery

Results in hemorrhage and, in most cases, death

Prevention of Tracheal Lesions

Limit Tracheal Tube Movement Sedation

Nasotracheal tube intubation

Swivel adaptors for equipment attached to tracheostomies

Tracheostomy collars instead of T-tubes

Prevention of Tracheal Lesions

Selection of correct size airway

Limit cuff pressure

Maintain sterile technique when caring for tracheal tubes to limit infection

Good and regular tracheostomy care

Providing for Patient Communication

To help facilitate communication between healthcare givers and patients who cannot speak because of having an endotracheal or standard tracheostomy tube in place, various devices can be utilized

Providing for Patient Communication

Communication Board

Talking Tracheostomy Tube

Provides a separate inlet for compressed gas, which escapes above the tube allowing phonations

Passy-Muir Speaking Valves

Passy-Muir Speaking Valves

A one-way valve on the external end of the tracheostomy tube that allows the patient to inhale through the tube and exhale through the larynx The cuff on the

tracheostomy tube must be deflated)

Passy-Muir Valve

Candidates for PMV

Awake and alert tracheostomized (ventilator or non-ventilator dependent patients) – adult, pediatric and neonatal

Passy-Muir Valve

Benefits Tracheostomized and

ventilator dependent patients can produce clearer speech

Improved swallowing due to increased pharyngeal/laryngeal sensation decreasing the need for tube feeding

Decreased need for suctioning by enabling the patient to produce a stronger, effective cough

Passy-Muir Valve

Benefits Decreased aspiration due to

increased pharyngeal/laryngeal sensation

Improved weaning by improving physiologic PEEP, which can improve oxygenation

Reduces decannulation time by allowing the patient to begin to adjust to a more normal breathing pattern through the upper airway

Decreased length of stay

Passy-Muir Valve

Contraindications

Unconscious and/or comatose patients Inflated tracheostomy tube cuff Foam filled cuffed tracheostomy tube Severe airway obstruction which may prevent sufficient

exhalation Thick and copious secretions Severely reduced lung elasticity that may cause air

trapping This device is not intended for use with endotracheal

tubes

Ensuring Adequate Humidity

Artificial airways (ETT/Tracheostomy tubes) bypass the normal humidification, filtration, and heating function of the upper airway, which can cause:

Secretions to thicken

Impairment of ciliary function

Impairment of mucocilary clearance Secretion retention

Ensuring Adequate Humidity

Heated humidification Large volume nebulizer Heat and moisture exchanger (HME)

Minimizing Nosocomial Infection

Patient with tracheal airways (ETT/Tracheostomy tube) are susceptible to bacterial colonization and infection of the lower respiratory tract

Minimize by: Consistently wash hands before

and after each patient contact Adhering to sterile technique

during suctioning Use only aseptically clear or sterile

respiratory equipment for each patient

Care of the Tracheostomy Tube

Tracheostomy tubes require daily care

1. Assemble and check equipment PPE; masks, goggles, gown, gloves Suction equipment Oxygen, manual resuscitator

Tracheostomy cleaning kit



2. Suction the patient

3. Clean the inner cannula Remove the inner cannula and place in the

basin with hydrogen peroxide to soak Insert a disposable inner cannula if on

mechanical ventilator

Clean inside and outside of cannula with a brush and rinse with sterile water

Allow to dry



4. Clean the stoma site Remove the patient’s gauze dressing and

discard in a biohazard container Using cotton-tipped applicators, or sterile

gaze dipped in a hydrogen-sterile water solution to clean under the flange and around the stoma

Using a sterile gauze dipped only in sterile water, rinse stoma site



5. Clean the stoma site (cont.) Place a clean gaze under the flange

Do not cut gauze for this purpose as fibers may loosen and become caught in the stoma

Use precut gauze or folded 4 x 4 gauze pads

6. Change ties

7. Replace clean inner cannula

Extubation / Decannulation

For most patients, tracheal intubation is a temporary measure

The process of removing an artificial tracheal airway is called extubation

Assessing Readiness to Extubate

Original need to for the artificial airway no longer exists

Able to protect airway Presence of a gag reflex

Able to manage secretions Cough strength Quantify and thickness of secretions Patency of the upper airway

Orotracheal / Nasotracheal Tubes

Procedure1. Assemble Equipment

Suction apparatus O2 / Lg. volume nebulizer Resuscitator/mask SVN with racemic epinephrine and NSS Intubation tray


Procedure2. Suction ETT and pharynx to above the cuff

After use, prepare rigid tonsillar (yankauer) suction tip

3. Oxygenate the patient well after suctioning Give 100% oxygen for 1 – 2 minutes

4. Deflate the cuff


Procedure5. Remove the tube

Method 1 Give a large breath with manual resuscitator

and remove tube at peak inspiration

Method 2 Ask the patient to take a deep breath and

cough, pull the tube during the expulsive expiratory phase


Procedure6. Apply appropriate oxygen and humidity

Patients who have been receiving mechanical ventilation may still require oxygen therapy, usually a higher FIO2

If humidity therapy is indicated, most clinicians suggest a cool mist aerosol, which helps reduce the swelling that normally occurs after extubation

Encourage the patient to cough


Procedure7. Assess/Reassess the patient

Air movement Auscultate and listen for good air movement; stridor

or decreased air movement after extubation indicates upper airway problems

RR, HR, BP, SpO2 ABG as needed


ComplicationsThe most common problems after extubation are hoarseness, sore throat, and cough – these are benign and will resolve with time

Laryngospasm, a rare but serious complication associated with extubation, is usually transient and treatable with high FiO2 and application of positive pressure. If it persists, a neuromuscular blocking agent may have to be given, which will necessitate manual ventilation or reintubation

Tracheostomy Tube Removal

There are several approaches to removing tracheostomy tubes (“decannulation”) – the method used will be depend on the patient’s needs

Abrupt - removed in one step

Weaning Fenestrated tubes Progressively smaller tubes Tracheostomy buttons

Fenestrated Tracheostomy Tube

The fenestrated tracheostomy tube has a removable inner cannula. However, the outer cannula has a hole in its posterior wall - a fenestration

With the inner cannula removed and the cuff deflated, the patient may breathe through the upper airway, via the fenestration - allowing for increasing use of the upper airway

Fenestrated Tracheostomy Tube

In the event mechanical ventilation is required, the cuff can be inflated and inner cannula replaced; in this configuration, the tube performs like a regular cuffed tracheostomy tube

Progressively Smaller Tubes

A second airway weaning technique is to use progressively smaller and smaller tracheostomy tubes

Indicated in patients who airway is too small for a fenestrated tube

May facilitate better healing of the stoma

Problems Increases in airway resistance May impair coughing Smaller tubes may result in the curve of the tube

impacting the posterior tracheal wall

Tracheostomy Button

Used to maintain a tracheal stoma

Tracheostomy Button

Fits from the skin to just inside the anterior wall of the trachea

Avoids added resistance to the airway

Use: Relieving airway

obstruction Removing secretions

Tracheostomy Button

Has an adaptor for provision of IPPB or mechanical ventilation

An optional one-way valve on the external end of the button allows for speech

Assessment After Decannulation

Vocal cord evaluation Abnormalities can result in aspiration or acute

airway obstruction Symptoms

Stridor Retractions Inability to feel airflow through the upper airway

Have a replacement tracheostomy tube and suctioning equipment available

airway management part iii ret 2275 respiratory care theory 2

Documents

airway trauma

tracheostomy tube obturator

airway resistance slide

tracheostomy tubes advantages

pilot tube

neck slide

trachea slide

tracheostomy tube cuff