Chapter 53 – Airway Management

Chapter 53 – Airway Management Airway Management   Oxygen helps maintain adequate cellular oxygenation for clients who have many acute and chronic resp problems or at risk for developing hypoxia Maintain pts airway is PRIORITY o Mobilizing secretions, suctioning airway, and managing artificial airways Pulse Oximetry  Pulse oximeter is a device with sensor probe that attaches to fingertip, toe, bridge of noes, earlobe, or forehead with a clip or band  Is measured in SpO2 through a wave of infrared light that measures light absorbed by oxygenated and deoxygenated hemoglobin if SaO2 is greater than 70%  95-100% is the goal with using least amount of supplemental O2  Noninvasive monitoring  Considerations for less than 90%: o Confirm placement of probe o Confirm that O2 delivery is functioning and client is receiving prescribed levels o Semi-Fowler’s or Fowler’s to promote chest expansion and to maximize ventilation o Encourage deep breathing o Remain with client for emotional support  Interpretation of findings: o Expected range 95-100% o 91-100% is acceptable o illnesses can allow 85-89% o less than 90% - hypoxemia o slightly lower values for older and dark skin clients o additional reasons for low reading: hypothermia, poor peripheral blood flow, too much light, low hemoglobin levels, jaundice, movement, edema, and nail polish Oxygen Therapy  Therapeutc gas that treats hypoxia.  Need a prescription to administer and adjust  Manifestations of hypoxia o Early  Tachypnea/-cardia  Restlessness, anxiety, confusion  Pale skin and mucus membranes  Elevated BP  Use of accessory muscles, nasal flaring, tracheal tugging, adventitious lung sounds o Late  Stupor  Cyanotic skin and mucus membranes  Bradypnea/-cardia  Hypotension  Cardiac dysrhythmias  Considerations: o Monitor resp rate and pattern, level of consciousness, SpO2, and ABG o Provide O2 at lowest, functional level 1 Chapter 53 – Airway Management o Monitor for increased CO2 levels (hypoxia and hypercarbia) o Auscultate lung sounds (crackles, rhonchi, wheezing, etc) o Promote oral hygiene – can lead to obstructed airway o Breathing exercises – turning, coughing, deep breathing, using incentive spirometry, and suctioning o Discontinue supplemental O2 gradually 2 Low-flow Oxygen Delivery Systems  Nasal cannula – tubing with 2 small prongs inserted into nares o FiO2: 24-44% at 1-6 L/min o Advantages: simple, safe, and easy-to-apply. Comfortable and well tolerated. Easy to do ADL o Disadvantages: FiO2 varies with flow rate and rate and depth of breathing. Skin breakdown and dryness (provide humid.) o Nursing actions: Prongs fit in nose properly. Water-soluble gel to prevent dry nares. Humidification for 4L/min and greater  Simple face mask – covers pt nose and mouth snuggly o FiO2: 40-60% at 5-8 L/min o Advantages: can be more comfortable than nasal cannula. Simple. Provide humidified O2 o Disadvantages: lower than 5L.min can result in rebreathing CO2. Pt with anxiety/claustrophobia do not tolerate. Impaired with eating, drinking, and talking. Skin breakdown o Nursing actions: secure over nose and mouth. Wear NC when eating. Caution for pt with high risk aspiration or airway obstruction  Partial rebreather mask – covers pt nose and mouth snuggly with bag attached o FiO2: 40-70% at 6-10 L/min o Advantages: allows client to rebreathe up to 1/3 of exhaled air. Has no valve with bag o Disadvantages: Same as simple face mask. Complete deflation of bag leads to buildup of CO2. FiO2 varies with pt breathing patterns o Nursing action: same as face mask. Adjust the O2 flow rate to keep reservoir bag 1/3 to 1/2 full on inspiration. Skin breakdown.  Nonrebreather mask – covers pt nose and mouth snuggly with bag attached and flaps covered o FiO2: 60-100% at 10-15 L/min with bag 2/3 full during inspiration and expiration o Advantages: delivers highest O2 concentration. One-way valve between mask and bag allows pt to inhale maximum O2 from bag. Has flaps over ports on mask preventing room air to enter mask o Disadvantages: same as face mask. Valve and flaps must be intact and functional during each breath. o Nursing actions: same as face mask. Assess hourly of valves and flaps. High-flow Oxygen Delivery Systems  Venturi mask – Covers pt nose and mouth with different adapters allowing specific amount of air to mix with O2 o FiO2: 24-60% at 4-12 L/min o Advantages: most precise O2 concentration. Humidification not required. Best for pt with chronic lung disease o Disadvantages: expensive and impaired with eating, drinking, and talking o Nursing actions: same as face mask. Assess frequently. Make sure no kinks in tubing.  Aerosol mask – two types:  Face tent: fits loosely around face and neck 3 Chapter 53 – Airway Management  Tracheostomy collar: small mask that covers the surgical created opening of trach o FiO2 24-100% at least 10 L/min o Provides high humidification with O2 o Advantages: for pts who do not tolerate masks well. Useful for pt who have facial trauma, burns, and thick secretions o Disadvantages: high humidification requires frequent monitoring o Nursing actions: empty condensation from tubing often. Ensure adequate water in canister. Ensure aerosol mist leaves from the vents during inspiration and expiration. Make sure does not pull on trach Complications  Oxygen toxicity – result from high concentration of oxygen (greater than 50%), long durations (>24-48 hrs), and severity of lung disease o Manifestations: nonproductive cough, substernal pain, nasal stiffness, nausea, vomiting, fatigue, headache, sore throat, and hypoventilation o Nursing actions: use lowest level of O2 needed. Monitor ABGs. Decrease FiO2 as SpO2 improves  Oxygen-induced hypoventilation – pts with conditions that cause alveolar hypoventilation can be sensitive to the administration of O2 o Nursing actions: monitor resp rate and pattern, level of consciousness, and SpO2. Provide O2 at lowest level that manages hypoxemia. Use Venturi mask for precise levels. Notify provider of impending resp depression  Combustion – O2 is combustible around smoke and if falls on ground o Nursing action: post sign to alert others of fire hazard. Know where closest fire extinguisher is. Educate smoking with O2. Pt wear cotton gown bc synthetic or wool can create static. All electric devices are working well. Electric machinery is grounded (sparks). Do not volatile, flammable materials near pt getÝng O2. Specimen Collection and Airway Clearance  Mucosal secretion buildup or aspiration of emesis can obstruct a pts airway  Provide adequate hydration and encourage to cough to help maintain airway  Interventions promote adequate gas exchange gas exchange and lung expansion -Indications  Clients at risk for developing airway compromise o Infants, pt with neuromuscular disorders, quadriplegic, or have CF  Clients that need help maintaining airway clearance o Hypoxemia, adventitious breath sounds, visible secretions, absence of spontaneous cough -Considerations  Humidification moistens the airways, loosens and mobilizes pulmonary secretions  Neb tx break up meds that disperse through resp tract and improves clearance -Nursing Actions  Collect sputum specimens by suctioning during coughing  Encourage coughing  Suction only when pt needs it (orally, nasally, and endotrach) Sputum specimen collection  Indications o Cytology to identify aberrant cells or cancer o Culture and sensitivity (C&S) to grow and identify microorganisms and antibiotics effective 4 Chapter 53 – Airway Management o Identify acid-fast bacillus (AFB) to diagnose tuberculous (requires 3 consecutive morning samples)  Considerations o Obtain in early morning o Wait 1-2 hrs after eating to obtain o Use sterile specimen container, label, and a lab requisition slip, biohazard bag for delivery, clean gloves, and mask and goggles if needed  Routine C&S and AFB o Use container with preservative for cytology o If pt cannot cough up specimen, collect by endotrach suctioning o Older adults have a weak cough reflex and decreased muscle strength and may require suctioning for sputum specimen collection Chest physiotherapy  Used to loosen respiratory secretions and move them into the central airways where coughing or suctioning can remove them  For clients with thick secretions and unable to clear airways  Contraindication for pts who are pregnant; have rib, chest, head, or neck injury; have increased intracranial pressure; have had recent abdominal surgery; have pulm embolism; or have bleeding disorder or osteoporosis  Percussion: use cupped hands to clap on chest to break up secretions  Vibration: shaking movement during exhalation to help remove secretions during exhalation  Postural drainage: various positions to allow secretions to drain by gravity -Nursing actions  Schedule tx 1 hr before or 2 hr after meals and at bedtime to decrease the likelihood of vomiting or aspirating  Give bronchodilator medication or neb tx 30 min to 1 hr prior to postural drainage  Keep pt in each position for 10-15 mins to allow time to percussion, vibration, and postural drainage  Discontinue if pt reports of faintness or dizziness  Older adults have decreased muscle strength and chest wall compliance, puts them at risk for aspiration and require more frequent change in position -Positioning  High Fowler’s for both lobes  SitÝng at EOB for apical segment of both lobes  Supine if upper lobes effected Suctioning - Nursing actions  Don required PPE  Assist pt to high Fowler’s or semi Fowler’s position  Deep breathing and coughing in attempt to clear secretions without artificial suctioning  Obtain baseline breath sounds and vitals (especially SpO2)  For oropharyngeal suctioning, use Yankauer or tonsil tipped rigid suction catheter and move around mouth, gum line, and pharynx  Nasopharyngeal and nasotracheal suctioning use flexible catheter and lubricate the distal end 6-8 cm with water-soluble lube  Endotracheal suctioning, use a suction catheter, and do not exceed one half the of the internal diameter of endotracheal tube – prevent hypoxia – don’t use biggr than 16 Fr catheter Chapter 53 – Airway Management 5 o Hyperoxygenate the pt using bag-valve-mask (BVM) or specialized ventilator function with FiO2 of 100%  Medical asepsis for suctioning of mouth  Surgical asepsis for all other types  Suction pressure no higher than 120-150 mmHg  Limit each time for no longer than 10-15 seconds to avoid hypoxemia o No longer than 5 mins total time -Additional guidelines for nasopharyngeal and nasotracheal suctioning  Insert into naris during inhalation – no suction applied during insertion  Follow naris and slightly slant catheter downward when advancing it  Advance the catheter the approximate distance from tip of the nose to base of earlobe  Apply intermittent suction for 10-15 sec  Apply suction when withdrawing, and rotate catheter  Do not perform more than 2 passes with catheter – allow 1 min between each pass -Additional guidelines for endotracheal suctioning  Remove bag or ventilator from trach or endotracheal tube and insert catheter into lumen of airway. Advance catheter until meets resistance at carina  Pull catheter back 1 cm prior to applying suction  Apply intermittent suction for 10-15 sec  Apply suction when withdrawing, and rotate catheter  Rinse catheter and suctioning tubing with sterile saline until clear  Do not reuse suction catheter for other sessions Artificial Airways and Tracheostomy Care Tracheotomy is a sterile surgical incision into the trachea through skin and muscles to establish airway  Can be placed for emergency or scheduled surgical procedure; temp or perm  Artificial airways can be placed orotracheally, nasotracheally, or through a tracheostomy to assist with respiration  Trach tubes can vary in their composition (plastic, steel, silicone), number of parts, size (long vs short), and shape (50°-90° angle)  Diameter of trach must be smaller than trachea  Airflow in and out of trach without air leakage, bypasses the vocal cords, resulting in inability to produce sound or speech  Uncuffed tubes and fenestrated tubes, in place or capped, allow speech  Indications for a trach include acute/chronic upper airway obstruction, edema, anaphylaxis, burns, trauma, head/neck surgery, copious secretions, obstructive sleep apnea refractory to conventional therapy, and the need for long-term mechanical ventilation or reconstruction after laryngeal trauma or laryngeal cancer surgery - Single-lumen (cannula): long, single- cannula tube for clients who have long or thick necks. o Not used for excessive secretions Double-lumen (cannula): an outer cannula fits into the stoma and keeps the airway open. Inner cannula fits snugly into the outer cannula and locks into place. Obturator is a thin, solid tube the provider places inside the trach and uses as a guide for inserting the outer cannula, and removes immediately outer cannula o Allow removing, cleaning, reusing, discarding, and replacing the inner cannula o Used for excessive excretions 6 Chapter 53 – Airway Management - Cuffed tube: balloon that inflates around the outside of the distal segment of the tube to protect the lower airway by making a seal between upper and lower airway o Permits mechanical ventilation o Prevents aspiration of oropharyngeal secretions o Cuff does not hold tube in place o Cuff pressures must be monitored to prevent tracheal tissue nercrosis o Unable to speak o Children do not require - CufÒess tube: no balloon and is for pts who have long-term airway management needs o Low risk for aspiration o Not for clients on mechanical ventilation o Able to speak - Fenestrated tube with cuff: large or multiple openings (fenestrations) in posterior wall of the outer cannula with a balloon around the outside of the distal segment of the tube o Allows mechanical ventilation o Removing inner cannula allows the fenestrations to permit air flow through the openings o Able to speak - Fenestrated tube without cuff: one larger or multiple openings in posterior wall of the outer cannula with no balloon. Also has inner cannula o Holes in tube help wean client rom trach o Removing inner cannula allows fenestrations to permit air to flow through the openings o Able to speak -Considerations  Keep 2 extra trach tubes (pts size and one smaller), the obturator for existing tube, an O2 source, suction catheters and a suction source, and a BVM  Methods to communicate with staff – pen and paper; dry erase board  Provide emergency call system and call light  Hydration to thin secretions and reduce risk of mucous plugs  Oral care q2hr  Provide trach care at least q8hr to prevent breakdown and infection o Remove soiled dressings and excess secretions o Apply O2 source loosely o Use qtip and gauze to clean exposed outer cannula surfaces. Clean from inside stoma out in circular motion o Surgical asepsis to remove and clean the inner cannula o Clean stoma site and then trach plate o Place fresh split-gauze trach dressing o Replace trach ties if they are wet or soiled, must place new ties before removing old ones o If a knot is needed, tie a square knot that is visible on the side of the neck  Change non disposable trach tubes every 6-8 weeks or per protocol  Reposition q2hr  If can eat, put pt upright and tip chin to chest to enable swallowing Accidental decannulation  If happen after first 72 hr after surgery it is an emergency bc trach tract has not matured, and replacement can be difÏcult o Trach obturator and 2 spare trach tubes at bedside 7 Chapter 53 – Airway Management o Unable to replace the trach tube, administer O2 through stoma  If happens after first 72 hrs, immediately hyperextend the neck and with the obturator inserted into the trach tube, quickly and gently replace the tube and remove obturator o Secure tube o Assess placement by auscultating for bilateral breath sounds Damage to the trachea  Tracheal stenosis: narrowing of the tracheal lumen due to scar formation resulting from irritation of the tracheal mucosa from the tracheal tube cuff o Keep cuff pressure between 14-20 mmHg o Check pressure at least every 8 hr o Tube in midline position  Tracheal wall necrosis: tissue damage that results when the pressure of the inflated cuff impairs blood flow to the tracheal wall