Airway management

An airway can become obstructed by secretions, blood and vomitus, potentially leading to aspiration. Suction is used to minimize these risks.

Definition of Suctioning:

Is aspiration of secretions through a catheter connected to a suction machine or wall suction outlet.

Rational for suctioning include:

1. To maintain oral hygiene and comfort for the patient.

2. To remove secretions that obstructs the airway.

3. To facilitate ventilation (either via nasopharynx, oropharynx, endotracheal tube and tracheostomy).

4. To obtain secretions for diagnostic purposes.

5. To prevent infection that may result from accumulated secretions.

Complications of suctioning:

1. Hypoxemia.

2. Trauma to the airway.

3. Nosocomial infection.

4. Cardiac dysrhythmia (related to the hypoxemia).

Positioning:

Or pharyngeal suctioning in semi-Fowlers position with head turned to one side.

Nasopharyngeal suctioning in semi-fowler's position with the neck hyper-extended, this will facilitate insertion of the catheter and help prevent aspiration.

Checklist of Oro nasopharyngeal suction

Equipment:-

1-Suction set. 2- Sterile normal saline.

3- Sterile gloves. 4- Lubricant, dry gauze.

5- Disposable sterile suction catheter (mouth-nose.)

Not Done

partial Done

Done

Procedure

Pre suctioning:

1. Prepare equipments.

2. Wash hands.

3. Position the patient in semi-fowler's position.

4. Wear gloves (non sterile) and use mask.

5. Connect the suctioning catheter to connection tube.

6. Check that equipment is functioning properly by suctioning a small amount of saline.

7. Moisten suction catheter with lubricant.

Suctioning:

1. Close suction catheter and insert it smoothly into nasal cavity.

2. Open the suction catheter to aspirate secretion and (no more than 10 sec).

3. Rotate catheter while withdrawing it.

4. Suction the other nares and repeat the procedure.

5. Connect a new sterile suctioning catheter to the connecting tube (for mouth).

6. Insert the suction catheter into the mouth smoothly and with closing catheter.

7. Rinse suction catheter by placing it in a container of solution (sterile normal saline) to clean inside the catheter for both (nose mouth).

After suctioning:

1. Turn back the pressure of aspiration to zero mm.Hg.

2. Dispose the equipments.

3. Assist patient to comfortable position.

4. Wash hands.

Documents the following information on the patient's record:

1. Frequency of suctioning.

2. Amount, color, consistency, odor of Secretions.

3. Patient's tolerance to suctioning.

4. Any complications and nursing actions taken.

Endotracheal intubation

Definition

Endotracheal intubation is the placement of a tube into the trachea (windpipe) in order to maintain an open airway in patients who are unconscious or unable to breathe on their own. Oxygen, anesthetics, or other gaseous medications can be delivered through the tube.

Purpose:-

Endotrecheal intubation is used for the following condition:

respiratory arrest

respiratory failure

airway obstruction

need for prolonged ventilatory support

Class III or IV hemorrhage with poor perfusion

severe flail chest or pulmonary contusion

multiple trauma, head injury and abnormal mental status

inhalation injury with erythema/edema of the vocal cords

protection from aspiration

Types of endotracheal tube:-

1) Orotracheal tube a tube that is inserted in the trachea through mouth.

2) Nasotracheal tube a tube that is inserted in the trachea through nose.

Advantages of orotracheal tube:-

1. Easily inserted and used in emergency situation.

2. Easily to suction.

Disadvantages of orotracheal tube:-

1. Uncomfortable for alert and irritable patient.

2. Interfere with communication of the patient.

3. Cannot allow making good oral hygiene.

4. Cannot be easily secured in place.

Advantages of nasotracheal tube:-

1. More comfortable for the patient.

2. Can be easily secured in place.

3. Allow good oral hygiene.

4. Effective in the case of mouth surgery e.g. tonsillectomy.

Disadvantages of nasotracheal tube:-

1. More difficult for insertion.

2. Bleeding during insertion and removal.

3. Difficult for suction.

4. Cannot be used in patient with nasal obstruction or sinusitis.

5. Nasal bacterial are introduced into trachea

Procedure of endotracheal tube

Equipment

NOTE: check beforehand to make sure everything works

Patient positioning equipment

. Bed or procedure table that can be raised and lowered

. Pillows or blankets that can be rolled and placed under patient for optimal positioning (discussed below)

Monitoring equipment

. Pulse oximeter

. Blood pressure gauge

. Cardiac monitor

Oxygenation equipment

. Oxygen source and tubing

. Face mask

. Anesthesia bag or self-inflating ambu-bag

. Suction catheter with Yankauer tip

Premedication and induction equipment

. Intravenous access

. Premedication agents (discussed below)

. Induction agents (discussed below)

. Paralytic agents (discussed below)

Intubation equipment

. Laryngoscope handle and blades of different sizes and shapes (remember to check light bulb on each blade):

. Curved blades (e.g. Macintosh blades)

. Straight blades (e.g. Miller or Wisconsin blades)

Endotracheal tubes

. Have several different sizes available

. Remember to check cuff for leaks

Means of securing tube in place

. Commercial products specifically designed for this purpose are recommended

. Alternatives include tape or ties

Equipment for verifying tube position after placement

Stethoscope.

Carbon dioxide detector or end-tidal CO2 monitor.

Esophageal syringe or bulb syringe.

Chest x-ray to verify position is also required.

Checklist for endotracheal intubation

Procedure

Done

partial done

Not done

A: wash hands.

B: prepare equipment.

C: prepare the patient.

1-The patient is given nothing per mouth (N.P.O) ((to avoid aspiration)).

2-Explain the procedure to the patient to gain his co-operation ((to decrease anxiety)).

3-Assess patients color and ventilator status.

4-Positioning:

The patient is placed in supine position and the head board is removed from the bed ((to open the air way))

Ahead tilt chin lift technique is used ((to open air way from the mouth to the glottis))

5-Administer sedative, paralytic agent or topical anesthesia as ordered ((to depress gag reflex and reduce discomfort)).

6-Give pre-medication as ordered as ((Atropine to decrease salivation and bronchial secretion and correct Brady- cardia)), or give ((morvine or valium which given to agitated patient

7- Maintenance for air way and hyper oxygenation.

8-Lubricate tube with K-Y gel ((to facilitate insertion)).

9- Wear sterile gloves.

11-The tongue should be swept to one side and be careful not rock the laryngoscope on patient's teeth ((to avoid teeth fracture))

12-Visualize the vocal cords and larynx.

13- Place the E.T.T through the cord.

14- Attempt ventilation through the E.T.T ((To test the tube place)).

15- Check for correct position of the tube.

16- Continue ventilation while inflating cuff in the tube is incorrect place.

17- Secure the tube.

.

INAYA COLLAGE

Steps

Done

partial Done

not Done

1. Size the airway by measuring from the patients earlobe to the corner of the mouth.

2. Open the patients mouth with the cross-finger technique.

3. Hold the airway upside down with your other hand.

4. Insert the airway with the tip facing the roof of the mouth.

5. Rotate the airway 180.

6. Insert the airway until the flange rests on the patients lips and teeth.

7. In this position, the airway will hold the tongue forward.

Remove oropharyngal:

Remove immediately if patient starts to gag reflex.

Extract using a downward and outward motion from mouth.

Insertion an oral airway (oropharyngal)

INAYA COLLAGE

Inserting a Nasal Airway (NASOPHARYNGEAL)

NAME OF STUDENT: ID NUMBERDATE

Steps

Done

Partial Done

Not Done

Do not use if:

Evidence of clear fluid issuing from ear or nose

Severe facial trauma

1.

1. Measure nasopharyngeal airway from the tip of the patients nose.

2. To the tip of earlobe on same side of the patients face.

3. The diameter of the airway should be about the same as the diameter of the patients little finger

4. Lubricate the outside of the airway with water-based lubricant before insertion.

5. Insert airway is facing toward the base of the nostril

6. insert airway posterior, avoiding an upward angle

Advance airway until flange rests against patients nostril.

7. Do not forc