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Airway ManagementPart II
RET 2275
Respiratory Care Theory 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
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
Airway Clearance - Suctioning
Airway obstruction Retained secretions
Can be removed from the airways using mechanical aspiration – Suctioning
Oral
Nasotracheal
Endotracheal
Secretion Evacuation Devices
Suction Regulator Provide a means of
reducing the high negative pressures from the supply line to safe physiological levels
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
Secretion Evacuation Devices
Yankauer Suction Tip AKA – Tonsillar Tip Used to remove secretions
from the oropharynx (upper airway)
Secretion Evacuation Devices
Suction Catheter Used to remove
secretions from the lower airway
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
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
Nasotracheal Suctioning
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
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
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
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
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
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
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
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
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
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
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
Nasotracheal Suctioning
Hazards and Complications (cont.) Infection (patient and/or caregiver) Mucosal hemorrhage Elevated intracranial pressure Uncontrolled coughing/laryngospasm Hyper/hypotension Gagging/vomiting
Nasotracheal Suctioning
Assessment of Outcome
Effectiveness should be reflected by removal of secretions
Effectiveness should be reflected by improved breath sounds
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)
Endotracheal Suctioning
Endotracheal Suctioning
Equipment
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
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
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
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
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
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
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)
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
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
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
Endotracheal Suctioning
Hazards and Complications (cont.) Bronchoconstriction/bronchospasm Infection (patient and/or caregiver) Mucosal hemorrhage Elevated intracranial pressure Hyper/hypotension
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
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)