Endotracheal Tube Maintenance PDF

ENDOTRACHEAL TUBE MAINTENANCE ET MAINTENANCE 1. Securing the airway and confirming placement 2. Providing for patient communication 3. Ensuring adequate humidification 4. Minimizing nosocomial infection 5. Facilitating secretion clearance 6. Providing cuff care 7. Troubleshooting airway emergenci...

ENDOTRACHEAL TUBE MAINTENANCE ET MAINTENANCE 1. Securing the airway and confirming placement 2. Providing for patient communication 3. Ensuring adequate humidification 4. Minimizing nosocomial infection 5. Facilitating secretion clearance 6. Providing cuff care 7. Troubleshooting airway emergencies 1. SECURING THE TUBE AND MAINTAINING ITS PROPER PLACEMENT The most common way to secure endotracheal tubes is with tape. The tape is secured to one side of the face, then wound around the tube and airway once or twice before the end is secured to the skin again. 1. SECURING THE TUBE AND MAINTAINING ITS PROPER PLACEMENT Proper placement of an endotracheal or tracheostomy tube normally is confirmed by radiograph. The tube tip should be about 4 t o 6 cm (8th ed) 3 to 6 cm (10th ed) above the carina, or between the second and fourth tracheal rings. As an alternative to using chest films to confirm tube placement, a practitioner trained in fiberoptic laryngoscopy or bronchoscopy may confirm the position of the tube visually. 2. PROVIDING FOR PATIENT COMMUNICATION One of the most frustrating aspects of caring for a patient with a tracheal tube is his or her inability to talk. Phonation requires moving vocal cords, resulting in airflow between them. Endotracheal tubes prevent vocal cord movement and airflow through the cords. As an alternative, the alert patient may write messages on paper or some other writing surface. A better solution is a letter, phrase, or picture board. These devices allow patients to communicate by simple pointing. Large and simple drawings are particularly important for patients who cannot clearly see print. 2. PROVIDING FOR PATIENT COMMUNICATION In conscious patients with a long -term tracheostomy, communication can be enhanced with a "talking" tracheostomy tube. These special airways provide a separate inlet for compressed gas, which escapes above the tube, thereby allowing phonation. An alternative to the speaking tracheostomy tube is to place a one-way valve on the external opening o f the tracheostomy tube. With this device, the patient inhales through the tube and exhales through the larynx. Speech is coordinated with exhalation through the larynx. 2. PROVIDING FOR PATIENT COMMUNICATION Assessment of heart rate, respiratory rate, and saturation should follow initial placement of the valve for all patients. Expiratory effort should also be assessed. The trache tube cuff must always be deflated before a speaking valve is placed on the trache tube 3. ASSURING ADEQUATE HUMIDIFICATION To deliver humidity, we normally use either a heated humidifier or a large-volume jet nebulizer or heat and moisture exchangers (HME). These devices can provide saturated gas to the airway at temperatures between 32° and 35° C.  Ultimately, the selection of a humidification device should be based on patient needs and assessment of the airway, to include the volume and thickness of secretions and the history of mucus plugging or tube occlusions. 3. ASSURING ADEQUATE HUMIDIFICATION 4. MINIMIZING THE POSSIBILITY OF INFECTION Patients with tracheal airways are very susceptible to bacterial colonization and infection of the lower respiratory respiratory tract. The presence of infection is suggested by changes in the patient's sputum, breath sounds, and/or chest radiograph. Additional changes associated with bacterial infection include fever, increased heart rate, and leukocytosis. 4. MINIMIZING THE POSSIBILITY OF INFECTION Why Tracheal Airways Increase the Incidence of Pulmonary Infection Bypassed upper airway filtration Increased aspiration of pharyngeal secretions Contaminated equipment or solutions Impaired mucociliary clearance in trachea Increased mucosal damage due to tube or suctioning Ineffective clearance via cough 4. MINIMIZING THE POSSIBILITY OF INFECTION To guard against infection, you should first avoid introducing organisms into the airway. This is done by (1) adhering to sterile technique during suctioning, (2) ensuring that only aseptically clean or sterile respiratory equipment is used for each patient, (3) consistently washing hands between patient contacts 5. FACILITATING SECRETION CLEARANCE Airway obstruction can be caused by retained secretions, foreign bodies, and structural changes such as edema, tumors, or trauma. Retained secretions increase airway resistance and the work of breathing and can cause hypoxemia, hypercapnia, atelectasis, and infection. Difficulty in clearing secretions may be due to their thickness or amount, or to the patient's inability to generate an effective cough. 5. FACILITATING SECRETION CLEARANCE Equipment and Procedure The procedure described below is for endotracheal suctioning of adults or children. Two techniques: OPEN and CLOSE Two methods: DEEP and SHALLOW 5. FACILITATING SECRETION CLEARANCE  Open , sterile technique requires disconnecting the patient from the ventilator.  Close, uses a sterile in-line suction catheter. 5. FACILITATING SECRETION CLEARANCE  Deep suctioning – is when the catheter is inserted until resistance is met and then withdrawn approximately 1cm before applying suction.  Shallow suctioning - is when the catheter is advanced to a predetermined depth, usually the length of the airway plus the adapter. 5. FACILITATING SECRETION CLEARANCE Step 1: Assess the Patient for Indications. A patient should never be suctioned by a preset schedule. However, although breath sounds are clear, you still should pass a suction catheter occasionally to ensure that the tip of the tube is not plugged. Step 2: Assemble and Check Equipment. 5. FACILITATING SECRETION CLEARANCE Equipment Needed for Suctioning Vacuum source Calibrated, adjustable regulator Collection bottle and connecting tubing Sterile suction catheter with thumb port Disposable gloves: Sterile for open, clean for close Goggles, mask, and gown (standard precautions) Sterile basin Sterile water or saline and cup (open) Sterile saline for instillation Oxygen delivery system (BVM or ventilator) Pulse oximeter Stethoscope 5. FACILITATING SECRETION CLEARANCE Set the suction pressure as low as possible, yet high enough to effectively clear secretions. adults, -120 to -150 mmHg children, -100 to -120 mmHg infants, -80 to -100 mmHg 5. FACILITATING SECRETION CLEARANCE To quickly estimate the proper size of suction catheter to use with a given tracheal tube, first multiply the tube's inner diameter by 2. Then use the next smallest size catheter. Example: 6.0 mm endotracheal tube: 2 x 6 = 12; next smallest catheter is 10 French Example: 8.0 mm endotracheal tube: 2 x 8 = 1 6 ; next smallest catheter is 14 French 5. FACILITATING SECRETION CLEARANCE Step 3: Preoxygenate and Hyperinflate the Patient. To preoxygenate the patient, give 100 % oxygen for at 30 to 60 seconds, adult and pediatric. Manual ventilation is not recommended, difficult to deliver 100% O2 this way. When working with patients with chronic obstructive pulmonary disease ( COPD ), you may need to hyperinflate them without increasing the FIO2. 5. FACILITATING SECRETION CLEARANCE Step 4 : Insert the Catheter. Shallow suctioning, to prevent tracheal mucosal trauma, especially in infants. Step 5: Apply Suction/Clear Catheter. Apply suction, while withdrawing the catheter using a rotating motion. Keep total suction time less than 15 seconds. 5. FACILITATING SECRETION CLEARANCE Step 6: Reoxygenate the Patient. Reapply oxygen and repeat Step 3. Maintain the Increased FIO2 for at least 1 minute. Step 7: Monitor the Patient and Assess Outcomes. Repeat Steps 3 through 7 as needed until you see improvement or observe an adverse response. 6. PROVIDING CUFF CARE A key aspect of airway care is cuff pressure measurement and adjustment. The goal is to keep cuff pressures below the tracheal mucosal capillary perfusion pressure, estimated to range between 25 and 30 mm Hg. Higher pressure will cut off mucosal blood flow and cause tissue damage. Recommended 20 to 25 mmHg or 25 to 35cmH2O 6. PROVIDING APPROPRIATE CUFF CARE MINIMAL OCCLUSION VOLUME (MOV) TECHNIQUE MINIMAL LEAK TECHNIQUE, A three-way stopcock. (Courtesy of Smith Industries Medical Systems, Keene, NH.) Cuff pressure measurements using an aneroid manometer. To inflate the cuff to obtain MOV pressure, first turn the valve so that the open port (patient) is off. Pressurize the manometer and tubing to 20 cm H2O by adding air from the syringe. Attach the cuff manometer to the pilot tube by pushing the connectors together. Rotate the valve so that it is opposite the syringe. Add or subtract air using the syringe just until no leak is heard at the patient’s mouth. Measure the cuff pressure. To inflate the cuff to obtain MINIMAL LEAK PRESSURE, first turn the valve so that the open port (patient) is off. Pressurize the manometer and tubing to 20 cm H2O by adding air from the syringe. Attach the cuff manometer to the pilot tube by pushing the connectors together. Rotate the valve so it is opposite the syringe. Add or subtract air using the syringe just until a small leak is heard at the patient’s mouth during a positive-pressure breath. Measure the cuff pressure. Cuff pressure measurements using a Posey Cufflator™. The Posey Cufflator combines the functions of a syringe, stopcock, and pressure manometer into one single unit. The silver port is connected to the pilot tube of the artificial airway. Once they are connected, cuff pressure is recorded on the manometer. If there is insufficient air in the cuff, you may squeeze the bulb, adding air into the cuff. If too much pressure is present, the red toggle valve on the side of the device may be depressed, venting excess pressure to the atmosphere. Both addition and subtraction of pressure may be accomplished using one hand. The MOV, MOP, or minimal leak technique may be employed with this device. 7. TROUBLESHOOTING AIRWAY-RELATED PROBLEMS. Emergency situations: tube obstructions, cuff leaks and accidental extubation. Obstruction of the tube is one of the most common causes of airway emergencies. Tube obstruction can be caused by (1)kinking of or biting on the tube, (2)herniation of the cuff over the tube tip (3) jamming of the tube orifice against the tracheal wall, and (4) mucus plugging (1) the kinking of the tube or the patient biting on the tube, (2) herniation of the cuff over the tube tip, (3) obstruction of the tube orifice against the tracheal wall, (4) mucus plugging