Class #16: Airway Management/Suctioning, Infection Control

Why is airway management important?

Airway management:

→ RTs aim to OPTIMIZE patient ventilation and gas exchange

-Adequate ventilation and gas exchange are impossible without a PATENT AIRWAY

-RTs often assume responsibility for AIRWAY MANAGEMENT

What broad areas of airway care must RTs develop skills in?

Three Broad Areas of Airway Care:

1) Must be proficient in AIRWAY CLEARANCE TECHNIQUES

-Including methods designed to ensure the patency of the patient's natural or artificial airway

2) Must be able to INSERT and MAINTAIN artificial airways designed to support those whose own natural airways are inadequate

3) Must be able to assist physicians in PERFORMING SPECIAL PROCEDURES related to airway management

What is airway clearance?

Airway Clearance:

→ Therapies and/or procedures designed to MOBILIZE and REMOVE secretions

-Suctioning!!!

What is the goal of airway clearance?

The goal of airway clearance:

→ To ensure PATENCY of airways, natural or artificial

-Patency: "The quality or state of being OPEN or UNOBSTRUCTED

-Artificial airway: endotracheal tube, tracheostomy tube

What can cause an obstruction of the airways?

The airways can be obstructed from:

→ Retained secretions (ex: Edema)

→ Foreign bodies (ex: Tumors)

→ Structural changes (ex: Trauma)

-These can cause:

∙HYPOXEMIA, hypercapnia, atelectasis, increased WOB, or INFECTION

Why do patients have difficulty clearing secretions from their airway?

Patients can have difficulty clearing secretions from their airway because of:

→ THICKNESS

-Inadequate humidity, inadequate hydration, disease process

→ VOLUME/AMOUNT

-Disease process

→ INABILITY to generate an effective cough

-Muscle weakness, altered mental status, artificial airway, age

What is suctioning?

Suctioning:

→ REMOVING retained secretions or other semifluid liquids from the airway

→ Application of NEGATIVE PRESSURE (vacuum) to the airways through a collection tube

What are the suctioning adjuncts?

Suctioning adjuncts:

→ Mechanical insufflation-exsufflation therapy (Cough Assist)

→ Chest physiotherapy (CPT)

→ POSITIVE EXPIRATORY PRESSURE THERAPY (PEP)

-All have the goal of moving secretions to larger central airways for removal by suction or effective cough

What can you suction?

Can suction:

1) OROPHARYNX

-Use Yankauer

2) TRACHEA and MAINSTEM BRONCHI

-Use flexible suction catheter

-If no artificial airway, access

-If have artifical airway = ENDOTRACHEAL SUCTION

3) BEYOND MAINSTEM BRONCHI

How do you know what sized catheter to use?

Catheter size:

-Most are 22 inches long

*Multiply the trach size by 2 and subtract 2

What are the types of Nasotracheal/endotracheal suction?

Types of Nasotracheal/endotracheal suction:

1) OPEN suction

2) CLOSED suction

3) DEEP suction

4) SHALLOW suction

What is open suction?

Open suction:

→ Requires STERILE technique and DISCONNECTION from ventilator

-Typically reserved for patients on trach collar on HME

What is a closed suction?

Closed suction:

→ Closed, sterile suction catheter attached to the ventilator circuit that is advanced into the endotracheal airway

-Does NOT require disconnection from ventilator

What is a deep suction?

Deep Suction:

→ Insert catheter until RESISTANCE is met, withdraw 1 cm before applying suction

What is a shallow suction?

Shallow suction:

→ Advance catheter to predetermined depth (LENGTH of airway + ADAPTOR)

-More frequently used in infants and children, less risk of complications

What are the indications for Nasotracheal/endotracheal suction?

Indications for Nasotracheal/endotracheal suction:

→ Need to MAINTAIN PATENCY and integrity of the artificial airway

→ Need to REMOVE ACCUMULATED SECRETIONS

-Evidenced by:

∙ Wet/coarse crackles

∙ Decreased SPO2/PaO2

∙ Visible secretions in the airway

∙ Inability of the patient to generate an effective cough

→ Need to obtain a SPUTUM SPECIMEN to rule out or identify the organism or sputum cytology

What are the hazards of Nasotracheal/endotracheal suction?

Hazards of Nasotracheal/endotracheal suction:

1) ATELECTASIS

2) HYPOXIA or HYPOXEMIA

3) TISSUE TRAUMA to the tracheal or bronchial mucosa

4) Increased INTRACRANIAL PRESSURE (ICP)

5) BACTERIAL COLONIZATION of the lower airway

-Use sterile technique

6) Bronchoconstriction or bronchospasm

7) Hypertension (from stress or anxiety)

8) Cardiac arrhythmias

9) TACHYCARDIA may occur due to agitation and/or hypoxemia

How can suctioning cause atelectasis?

Suctioning can cause atelectasis:

-From removing too much air from the lungs in short period of time

-Avoid or minimize

1) limit the amount of negative pressure used

2) keeping the duration of suctioning as short as possible

3) Using the appropriate size suction catheter

How can suctioning cause hypoxia or hypoxemia?

Suctioning can cause hypoxia or hypoxemia:

-Avoid or minimize by pre-oxygenating/hyper-oxygenating your patient

*100% FiO2 for 30-60 seconds

How can suctioning cause hypotension?

Suctioning can cause hypotension:

-From severe coughing that decreases venous return, stop suctioning, administer O2, provide ventilation, notify the physician and nurse

How can suctioning cause cardiac arrhythmias?

Suctioning can cause cardiac arrhythmias:

-From hypoxemia and/or stimulation of the vagal nerve (bronchospasm)

-Stop suctioning, administer O2, provide ventilation, notify physician and nurse

What is a Health-associated infection (HAI)?

Health-associated infection (HAI):

→ Infections that develop in a patient during the course of medical treatment

-Nosocomial infections

How are HAIs decreased?

Efforts to DECREASE HAIs are organized and coordinated by a hospital system's Infection Prevention (IP) program

-Protecting patients and health care professionals against infections requires strict adherence to infection control procedures

What does infection control aim to do?

INFECTION CONTROL procedures aim to ELIMINATE the SOURCES of infectious agents, CREATE BARRIERS to their transmission, and monitor and evaluate the effectiveness of control

What is the spread of infection?

Spread of infection:

Source of infectious agent → Mode of transmission → Susceptible host

What are the sources of infection?

Sources of infection:

→ Humans

-Patients, Personnel, Visitors

→ Inanimate objects

-Equipment, Linens, Medications (IV solutions)

What are susceptible hosts?

Susceptible hosts:

→ Poorly controlled/managed chronic disease

→ Immunodeficiency (CA, Chemotherapy)

→ Extremes of age

→ Surgical incisions

→ Indwelling catheters, endotracheal tubes

→ Pain

→ Anesthesia, narcotics, sedatives

What are the modes of transmission?

Modes of transmission:

1) Contact

2) Droplet

3) Airborne

What is the contact transmission?

Contact transmission:

1) Direct

-HCW with "cold" does not properly wash hands and transmits virus to patient

2) Indirect

-Transfer of a pathogen through a contaminated INTERMEDIATE object or person

-Equipment not adequately cleaned or sterilized between uses

-HCW touches contaminated patient, does not properly wash hands, touches another patient

What is the droplet transmission?

Droplet transmission:

→ Respiratory droplets are generated when an infected individual discharges large contaminated liquid droplets into the air by:

- COUGHING, SNEEZING, or TALKING

→ Respiratory droplets are also generated during procedures such as:

-SUCTIONING, BRONCHOSCOPY, and COUGH INDUCTION

→ Transmission occurs when infectious droplets are propelled (usually 3-6 ft through the air) and are deposited on another person's mouth or nose, or surface they then touch

What is an airborne transmission?

Airborne transmission:

→ Airborne transmission occurs via the spread of airborne droplet nuclei

→ These are small particles (< 5 μm) of EVAPORATED DROPLETS containing infectious microorganisms that can remain suspended in air for long periods

→ Microorganisms carried in this manner may be dispersed widely by air currents because of their small size and inhaled by susceptible hosts over a longer distance from the source patient compared with droplet transmission

-Ex: TB, chicken pox, measles

How do you eliminate the source?

Eliminating the source:

→ Recommended practices for cleaning and disinfecting noncritical surfaces in patient care areas should be followed

-Equipment processing involves:

∙CLEANING

∙DISINFECTION

∙STERILIZATION

What is disinfection and sterilization?

Disinfection and sterilization:

1) Bactericidal (Kill bacteria)

2) Bacteriostatic (Inhibit growth)

3) Virucidal

4) Sporacidal

What are the common disinfectants?

Common disinfectants:

→ Alcohol

→ Chlorine and chlorine products (orange wipes)

→ Phenolics

→ Quaternary ammonium compounds (purple wipes)

→ Hydrogen Peroxide

What is sterilization?

Sterilization:

→ Physical methods include various forms of heat (steam- called AUTOCLAVING) and ionizing radiation

→ Chemical methods include:

-Low temperature sterilization technologies such as ETHYLENE OXIDE (EtO) gas

How do you interrupt transmission?

Interrupt transmission:

1) Standard/universal precautions

2) Transmission-based precautions

What are the Standard/Universal Precautions?

Standard/Universal Precautions:

→ To be applied to the care of ALL patients in ALL health care settings ALL the time

→ Application of standard precautions on a routine basis is recognition that ALL blood, body fluids, secretions, and excretions may contain transmissible infectious agents

→ To mitigate against this risk, a health care worker should employ PERSONAL PROTECTIVE EQUIPMENT (PPE)

-Various barriers and respirators used alone or in combination to protect mucous membranes, skin, and clothing from contact with infectious agents

What are transmission-based precautions?

Transmission-based precautions:

→ ***In addition to SP/UP

→ For patients who are known or suspected to be infected with pathogens that require additional control measures to prevent transmission

What are nosocomial infections?

Nosocomial infections:

→ AKA Hospital-acquired infections

→ Infections acquired DURING THE COURSE OF TREATMENT

-Upon admission, the patient did not have this infection, but they developed while they were under our care

-A significant source of MORTALITY

-Medicare/Medicaid, private insurance NOT PAYING