Intubation and Artificial Airway Lecture Notes PDF - University of Canberra

11857 Health Across Lifespan - High acuity care needs Mini Lecture – Intubation and assessing an artificial airway Kate Steirn 11857 Health Across Lifespan - High acuity care needs Lecture Objectives Intubation (ETT and Tracheostomy) indications for Risks of checking correct p...

11857 Health Across Lifespan - High acuity care needs Mini Lecture – Intubation and assessing an artificial airway Kate Steirn 11857 Health Across Lifespan - High acuity care needs Lecture Objectives Intubation (ETT and Tracheostomy) indications for Risks of checking correct placement Assessment of artificial airways (ETT and Trachy) Documenting an artificial airway Nursing responsibilities Emergency equipment check Airway suctioning When to intubate Impending cardiorespiratory arrest – MET call Vomiting or haematemesis Multi -organ failure requiring extensive Recent facial/ENT/Upper GI or neurological monitoring surgery, trauma, or deformity Haemodynamic instability with hypotension or Acute burn with possible airway involvement unstable cardiac arrhythmia Barotrauma Untreated pneumothorax Allergic reaction to materials of the face/nose Pneumonia in immunocompromised patients mask Reduced level of consciousness and inability to protect airways Confusion requiring sedative medications or physical restraints to apply NIV Induction Medications Sedative (Midazolam, propofol) – induction and infusion Paralytic (Succinycholine, Vecuronium, Rocuronium) - induction and possibly infusion thereafter depending on patient condition Analgesic (Fentanyl, morphine) – induction and infusion Intubation- Endotracheal Tube (ETT) 2 routes: Orotracheal Nasotracheal 1. Size (internal diameter in mms) 2.0-12.0 (0.5 increments) 2. Length 3. Radiopaque line (shows on CXR) 4. Inflated cuff and Pilot tube 5. Connector (standard 15mm) 6. Subglottic suction Risks of intubation - ETT Infection – pneumonia or Ventilator Acquired Pneumonia (VAP) Tooth dislodgement Bleeding Perforation oropharynx Oesophageal placement – immediate removal and re-placement in trachea Vocal cord damage – prolonged use, extubation without deflating balloon Tracheal mucosa ischaemia- increased cuff inflation pressures Indicators for a tracheostomy There are several reasons why a patient may have a tracheostomy tube: To bypass upper airway obstruction – subglottic, glottic, supraglottic (e.g. tumours, foreign bodies, vocal cord paralysis and following head and neck surgery.) Uncontrolled aspiration e.g. decreased conscious state, inability to manage secretions Prolonged intubation To facilitate long term ventilator support/airway management To facilitate weaning from ventilator support Assessing an Artificial Airway Type of artificial airway (ETT, NTT or Tracheostomy) Size - diameter (both) Length at teeth (ETT only) Cuff pressure (both) Assess securing device (tapes, anchorfast, sutures) – is it adequate, not too tight or too loose (2 fingers space) Suctioning - frequency and description of secretions, cough reflex present? +/- Dressing (trachy) other cares (oral/mouth care both) Pressure area assessment (lips, mouth, neck, face) NB: ventilator settings and circuit/system set up assessment is a function of Breathing NOT airway. (covered in next lecture) Assessing an Artificial Airway Checking correct placement Auscultate - bilateral breath sounds; Bilat rise and fall of chest Auscultate epigastric (on insertion) End tidal CO2 is gold standard, method for confirming ETT placement (on insertion) Capnography is even more reliable and a requirement for continuous monitoring as per anaesthesia and resuscitative guidelines CXR (daily) 2cm above carina or above biofication of bronchus Documenting Artificial Airway Nursing: Assumed care of patient at 0700hrs. Airway: Patient airway maintained via size 7.5 ETT/ Patient intubated with size 7.5 ETT. [choose either], ETT 22cm at teeth, cuff pressure 24cm H2O, ETT secured with anchorfast/tapes [choose], suctioned 2nd hourly with mod amounts thick creamy secretions. Minimal cough reflex during suctioning. Oral cares attended to 2nd hourly APP. Oral mucosa, pink, clean, nil Pressure areas to lips. Breathing: Nursing: Assumed care of patient at 0700hrs. Airway: Patient airway maintain via size 7.0 portex trachy/ Patient intubated with size 7.0 portex trachy [choose either], cuff pressure 24cmH2O, trachy secured with ribbon tapes/ trachy secured with sutures and ribbon tapes [choose]. Suctioned prn with minimal clear secretions. Patient has strong spontaneous cough. Trachy dressing clean and intact.[if dressing present] Breathing: Bedside Emergency Equipment Check All different size ETT or tachy’s should have one of each size available Bag valve mask (BVM) without face mask attached Face masks for BVM available Cuff monitor device (manometer) and 10ml syringe Trachy dressing equipment Securing devices (spare tapes or anchorfast depending on type of airway) Tracheal dilators (for tracheostomy patients) Suctioning equipment – circuit + Catheters + Yanker sucker (oral cares) Sterile N/Saline for suctioning /gloves Oral care equipment: Lip cream/tooth brush, tooth paste/ mouth swabs Nursing responsibilities Tracheostomy dressings and strappits are not changed for 24 hours postoperatively. This is due to the risk of accidental dislodgement before there is a fully formed tract. A second nurse is required to assist during the procedure in order to stabilise the airway (ETT or Trachy) when moving patient for pressure area cares and other cares (incl: trachy dressing changes). Provide daily care of the patient including tracheostomy/respiratory needs (e.g. suctioning, dressings, stoma care, respiratory monitoring, monitoring ventilation parameters and liaising with team as required). ACT Health policy Suctioning via ETT or Tracheostomy Indication of suction - need to remove Audible upper respiratory tract noises accumulated pulmonary secretions as evidenced Deterioration of ABGs or SpO2 by one or more of the following: Suspected aspiration Coarse breath sounds on auscultation Clinically apparent increased work of breathing Tactile fremitus (palpable secretions in chest) CXR changes consistent with sputum retention Inability to generate an effective spontaneous The need to obtain a sputum specimen cough Reversible increased peak inspiratory pressures As part of a respiratory assessment during volume controlled ventilation or The need to maintain patency and integrity of decreased tidal volume on pressure controlled the artificial airway. ventilation Visible secretions in the tracheostomy References ACT Health (2023) Tracheostomy Management Adult patients. Retrieved from https://www.canberrahealthservices.act.gov.au/about-us/policies-and-guidelines Aitken, L., Marshall, A., & Buckley, T. (2024). Critical Care Nursing (5th ed). Elsevier Al-metwalli, R.R., Fallatah, S.M., & Alghamdi, T.M. (2021). Endotracheal tube cuff pressure: An overlooked risk. Anaesth. pain intensive care. Vol 25, Iss, 1. pp, 88-97. Dorman Wagner, K., & Hardin-Pierce, (2015). High-Acuity Nursing Global Edition, (6th ed.). Pearson Knights, K., Darroch, S., Rowland, A., & Bushell, M. (2023). Pharmacology for health professionals (6th ed) Elsevier  The University of Canberra acknowledges the Ngunnawal people, traditional custodians of the lands where Bruce Campus is situated. We wish to acknowledge and respect their continuing culture and the contribution they make to the life of Canberra and the region. We also acknowledge all other First Nations Peoples on whose lands we gather.