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)