Airway Management: Nursing Skills

• Airway management focuses on essential nursing skills to maintain natural or artificial airways for compromised clients.

Introduction

• The respiratory system's primary function is ventilation, facilitating oxygen and carbon dioxide exchange at the cellular level.
• A clear airway is essential for adequate ventilation.
• Factors like increased or thick mucus, fatigue, decreased consciousness, ineffective cough, and impaired airway can compromise airway patency.

Gerontologic Considerations

• Respiratory disorders are common and life-threatening for older adults; chronic pulmonary diseases intensify with age.
• Older adults may have histories of smoking, exposure to pollutants, or living in areas with high toxic emissions.
• Assess older adults for coughing, duration, and sputum characteristics.
• Persistent dry coughs can cause fatigue.
• Reduced air exchange and ventilation efficiency are age-related respiratory changes.
• The larynx's muscular structures can atrophy with age, impacting airway clearance.
• Older adults often have less lung ventilation at the bases, leading to secretion retention, decreased air exchange, and compromised ventilation.
• Respiratory cilia become less efficient, increasing pneumonia risk.
• Diminished respiratory muscle strength, chest wall rigidity, and diminished cough reflex impair effective coughing.
• Dysphagia increases vulnerability to aspiration pneumonia.
• Deep breathing exercises can improve respiratory secretion clearance.
• Older adults are more prone to cardiac dysrhythmias during suctioning due to pre-existing hypoxemia and age-related ventilation changes.

Natural Airway Management

• Common methods include liquefying respiratory secretions, promoting mobilization and expectoration via chest physiotherapy, and mechanically clearing mucus through suctioning.
• Adequate hydration keeps mucous membranes moist and mucus thin, promoting expectoration.

Pharmacologic Considerations

• Acute bronchospasm can cause airway constriction.
• Quick-relief medications include inhaled short-acting beta-2 agonists (SABAs) and oral steroids; Albuterol is an example of a SABA drug.
• Long-acting bronchodilators like salmeterol, used daily for asthma prevention, are not for emergent situations.

The Airway

• The upper airway includes the nose and pharynx, subdivided into nasopharynx, oropharynx, and laryngopharynx.
• The lower airway comprises the trachea, bronchi, bronchioles, and alveoli.
• The epiglottis, tracheal cartilage, mucous membrane, and cilia protect the airway.
• The epiglottis directs fluid and food toward the esophagus during swallowing.
• Tracheal cartilage rings keep the trachea open.
• The mucous membrane traps particulate matter, and cilia move debris upward.
• Sneezing, nose blowing, coughing, expectoration, and swallowing keep the airway open.

Liquefying Secretions

• Water volume affects mucus viscosity; hydration keeps mucus thin and promotes expectoration.
• Inhalation therapy provides oxygen, humidification, and aerosolized medications directly to the lungs, improving breathing and encouraging coughing.

Mobilizing Secretions

• Chest physiotherapy, including postural drainage, percussion, and vibration, helps mobilize secretions from distal airways, suitable for those with chronic respiratory diseases and thick mucus.

Postural Drainage

• Postural drainage uses positioning to promote secretion drainage from various lung lobes or segments.

Percussion

• Percussion rhythmically strikes the chest wall to dislodge adherent respiratory secretions.
• The nurse cups hands and strikes the chest wall, avoiding the breasts and areas of injury.

Vibration

• Vibration uses the palms of hands to shake underlying tissue, loosening retained secretions during exhalation.

Suctioning Secretions

• Suctioning uses negative pressure to remove liquid secretions with a catheter; the amount of negative pressure varies.

Collection of Sputum Specimen

• Collect sputum specimens after waking or aerosol treatment when mucus is abundant and thinner.
• Use a sterile sputum specimen cup to prevent contamination.
• Sitting promotes increased inspired air and forceful coughing to expel mucus.
• Mouth rinsing removes microorganisms and food residue.
• Explain the specimen should be from deep within the respiratory passages, not saliva.
• Several deep breaths and a forceful cough help mobilize secretions from the lower airway.
• At least 1-3 mL of the specimen is needed for analysis.
• Use a suction catheter with a mucus trap if the client cannot produce sputum.
• Wear gloves, cover/detach the mucus trap, and enclose the specimen container in a clear plastic bag to reduce microorganism transmission.
• Offer oral hygiene for comfort.

Nasopharyngeal Suctioning

• Removing secretions from the throat through a nasally inserted catheter.
• More common than nasotracheal suctioning.
• A nasopharyngeal airway or "trumpet" can protect the nostril if frequent suctioning is needed.

Oropharyngeal Suctioning

• Removing secretions from the throat through an orally inserted catheter.
• Oral suctioning is performed using a Yankauer-tip or tonsil-tip catheter.

Artificial Airway Management

• Clients at risk of airway obstruction or needing long-term ventilation are candidates for artificial airways like oral airways and tracheostomy tubes.

Oral Airway

• Curved device to keep the relaxed tongue forward and prevent upper airway obstruction.
• Commonly used in unconscious clients or those recovering from anesthesia or a seizure.
• Nurses insert oral airways for a brief time.

Tracheostomy

• Clients requiring prolonged mechanical ventilation or with upper airway obstruction are candidates for a tracheostomy.
• A tracheostomy is a surgically created opening into the trachea.
• A tube is inserted through the opening to maintain the airway and provide ventilation.

Tracheostomy Tube

• Also called a cannula.
• It has largely replaced older metal tubes with silicone or polyvinyl chloride ones that soften at body temperature.
• It has an inner cannula, outer cannula, and obturator.
• The outer cannula remains in place and has a flange for cloth ties and a locking mechanism.
• The inner cannula is removed for cleaning.
• The obturator is a curved guide used during insertion to prevent trauma.
• The obturator is then removed and kept at the bedside.
• Tracheostomy tubes may have a balloon cuff to prevent aspiration and provide more efficient ventilation.
• Clients with a tracheostomy tube cannot speak unless they have a fenestrated tube or speaking valve.
• Communication typically includes writing or lip reading.
• Check on clients frequently because they cannot call for help.
• Providing a bell can reduce anxiety.

Tracheostomy Suctioning

• It is often required because tracheostomy tubes irritate the tracheal tissue.
• Although clients can cough, the cough may not clear the airway effectively.
• When suctioning, the catheter is inserted through the tracheostomy tube rather than the nose.
• The catheter is inserted a shorter distance and raised slightly after resistance is met.

Tracheostomy Care

• Cleaning the skin around the stoma, changing the dressing, and cleaning the inner cannula.
• Performed at least every eight hours or as needed.

Nursing Implications

• Maintaining an open airway is a priority because oxygen deprivation leads to death or brain damage within minutes.
• Relevant nursing diagnoses: ineffective airway clearance, impaired gas exchange, infection risk, acute anxiety, and knowledge deficiency.