Egans CH 37 Exam 1 Mechanical Ventilation

Intubation

Process of placing an artificial airway into the trachea.

Endotracheal tube (ETT)

Artificial airway tube inserted through mouth or nose into the trachea.

Orotracheal intubation

Endotracheal tube passed through the mouth on its way into the trachea.

Nasotracheal intubation

Endotracheal tube passed through the nose first.

Artificial airway

Airways placed to maintain ventilation; through mouth/nose (ETT) or through the neck (tracheostomy tubes).

Pharyngeal airway

Airway device that extends only into the pharynx.

Nasopharyngeal airway (NPA) and how to place

Nasal airway to facilitate frequent nasotracheal suctioning; minimizes nasal mucosa damage; size is nose to tip of ear lobe, NPA diameter is smaller than pts nares; bevel toward septum; lubricated; flange rests at nostril.

Oropharyngeal airway (OPA)

Oral airway used in unconscious patients to maintain patient airway by preventing tongue obstruction and may serve as a bite block for pts w/ oral tubes.

How to place an OPA

OPA sized by measuring from center of mouth to angle of jaw, or corner of the mouth to earlobe; place oral airway in mouth w/ curved end towards roof or side of mouth, when inserting device and approaches posterior pharynx rotate device 180 degrees into correct position.

Laryngeal mask airway (LMA)

Supraglottic airway for quick, temporary ventilation in difficult to intubate patients or short surgeries.

i-gel

Brand of supraglottic airway (gel-like) used as an alternative to LMA.

Double-lumen endotracheal tube

ETT with two channels enabling independent lung ventilation.

Combitube

Esophageal–tracheal tube used for difficult intubations or when ventilation or intubation cannot be achieved.

Esophageal–tracheal Combitube

A Combitube designed to function in both esophagus and trachea for airway management in difficult cases.

Mac blade

Curved laryngoscope blade commonly used in adults.

Miller blade

Straight laryngoscope blade used for infants/children.

Magill curve

Curvature used in airway instrumentation (Magill curve radius referenced in equipment).

Bevel

Slanted, angled tip of an endotracheal tube.

Murphy Eye

Side hole near the distal end of an endotracheal tube.

Pilot balloon

Inflation/deflation balloon for the ETT cuff.

Cuff

Inflatable ring on the ETT that seals the airway when inflated.

Carina

Bifurcation of the trachea into the left and right main bronchi; ETT tip should be 3–5 cm above it.

Glottis

Opening between the vocal cords.

Vocal cords

Vocal folds within the larynx; visualized during intubation.

Epiglottis

Flap that covers the glottis; displaced during laryngoscopy to visualize the airway.

Vallecula

Anatomical space used as a landmark where the laryngoscope tip is placed to visualize the glottis.

Capnography

Real-time CO2 waveform used to confirm ventilation and correct tube placement.

Capnometry

Measurement of the concentration of CO2 in exhaled air.

End-tidal CO2

CO2 level at the end of expiration; used to verify ventilation and tube position.

CO2 detector / colorimetric

Color-changing device that indicates the presence of CO2 and helps confirm ETT placement.

Securement device

Device or method (e.g., adhesive tape) used to fix the ETT in place.

Extubation

Process of removing an endotracheal tube.

Nasal cannula

Oxygen delivery device inserted into the nostrils.

Pre-oxygenation

Preoxygenating the patient with high FiO2 before induction to extend safe apnea time.

Laryngoscope

Instrument with blades (Mac or Miller) used to visualize the larynx during intubation.

Pre-oxygenate and ventilate

Preoxygenate the patient and ventilate prior to laryngoscopy to optimize oxygenation.

Steps to intubation

1. Assemble & check equipment

2. Position pt.

3. Pre-oxygenate & ventilate pt.

4. Insert laryngoscope

5. Visualize glottis

6. Displace epiglottis

7. Insert tube

8. Assess tube position

9. Stabilize tube/confirm placement (Listen for equal & bilateral breath sounds as pt. ventilated)

10. Secure ETT

Steps of extubation

1. Assemble needed equipment

2. Suction ETT tube nad pharynx above cuff

3. Oxygenate pt.

4. Remove securement device

5. Deflat cuff

6. Remove tube

7. Apply appropriate O2 & humidity therapy (O2 w/ cool mist)

8. Assess/reassess pt. (check for good air movment via auscultation, check for stridor, check pts. skin color, check pts. SpO2)

Describe unplanned extubation

Assess pt. readiness for extubation, OG problem no longer present, quantity & thickness of secretions, upper airway patency, presence of intact gag reflex, ability to clear airway secretions

Equipment for intubation

ETT (stylet, 10 mL syringe, securement device), check cuff is not broken, place stylet inside ETT & full 10 mL syringe on pilot balloon

Bag/mask w/ O2 source

Laryngoscope (Mac for adults, Miller for infants/children)

Suction on & working

CO2 detector or capnography

Vent for after intubation

Sometimes OP airway & bougie

Equipment for extubation

Nasal Cannula

O2 source

Towel

Pulse ox & HR monitor

Suction inline & yankauer

Ambu-bag/mask

Re-intubation supplies on standby if previously diff. intubation

Racemic epinephrine, if known hx of laryngeal spasm (w/ nebulizer)

Suctioning

Application of negative pressure to airways through a collecting tube.

Upper airway suctioning

Suctioning of the oropharynx (upper airway).

Lower airway suctioning

Suctioning of the trachea and bronchi (airways below the larynx).

Tracheal suctioning through the mouth

Suctioning into the trachea via the mouth; should be avoided due to gagging/reflex irritation.

Coude tip catheter

Suction catheter with a bent tip to facilitate entry, and suction left mainstem bronchus.

Open endotracheal suctioning

Sterile technique with disconnection from the ventilator; one-time-use catheter, must maintain sterile technique.

Closed endotracheal suctioning

Sterile, closed, in-line suction catheter attached to the ventilator circuit; allows reuse and no disconnection from ventilator and therefore O2.

In-line suction catheter

A suction catheter designed to stay in the circuit during suctioning.

Ballard suction catheter

A commonly used closed suction catheter platform.

What is step 1 of Endotracheal Suctioning?

Check the patient for indications for suctioning

When the patient cannot clear secretions (e.g., unconscious, sedated, paralyzed, intubated, trach); indicated by poor airway clearance and abnormal breath sounds.

Relative contraindication for endotracheal suctioning?

High intracranial pressure

There are no absolute contraindications; high ICP is a relative consideration.

Abnormal breath sounds indicating suction

Coarse crackles, rhonchi, or crackles suggesting need for suctioning.

Cough reflex as indicator

A need for suctioning is suggested when the patient should cough but cannot.

What is step 2 of Endotracheal Suctioning?

Assemble and check equipment

Catheter size formula (ID × 3)/2

Estimate proper suction catheter size in French; choose size equal to or smaller than (ID × 3)/2.

Example: 8.0 ETT → 12 Fr catheter

For ID 8.0, catheter size = (8 × 3)/2 = 12 Fr.

What is step 3 of Endotracheal Suctioning?

Hyperoxygenation

Give 100% oxygen before suctioning (30–60 seconds; neonates get 10% more).

Total suction time

Keep suctioning passage time to less than 15 seconds per pass.

Suction pressures (adult)

120–150 mm Hg for adults.

Suction pressures (child)

100–120 mm Hg for children.

Suction pressures (infant)

80–100 mm Hg for infants.

What is step 4 of Endotracheal Suctioning?

Insert catheter

Introduce the suction catheter into the endotracheal tube as part of the procedure.

What is step 5 of Endotracheal Suctioning?

Apply suction / clear catheter

Activate suction while withdrawing to collect secretions; clear catheter as needed.

<15 seconds total suction time

What is step 6 of Endotracheal Suctioning?

Re-oxygenation after the suctioning episode.

What is step 7 of Endotracheal Suctioning?

Monitor patient and assess outcomes

Repeat steps (3–7) as needed.

Tracheostomy suctioning

Similar to endotracheal suctioning but with a shorter, sometimes deeper, catheter; avoid deep suction with an open catheter use the tip of the tracheostomy tube.

Sniffing position

Position used to facilitate nasotracheal suctioning; head position aids catheter passage.

Nasotracheal suctioning

Suctioning through the nose into the trachea for patients with secretions but no artificial airway.

May cause gagging or regurgitation; avoid after meals

Sputum sampling

Collection of sputum to identify airway organisms; use sterile technique.

Lukens trap

Sterile collection device used to collect sputum without contaminating the sample.

Sterile technique needs maintained when touching connection points on sterile Lukens trap

Securing the airway

ETT holders (ICU), tape (OR), commercial stabilizers, or cloth ties for tracheostomy to secure the airway.

How is proper placement of an ET or Tracheostomy tube confirmed?

Chest X-ray confirmation

Carina distance (ETT tip)

ETT tip should be 3–5 cm above the carina in adults, or between the second and fourth tracheal rings

Humidification

Artificial tracheal airways bypass upper airway humidification, filtration, and heating; device choice based on needs, assessment of airway, and volume and thickness of secretions/history of mucous plugging or tube occlusions of the pt.

Nosocomial infections

Pts. w/ ETT/Tracheal airways are susceptible to bacterial colonization and infection of lower respiratory tract

Risk of lower respiratory infection; emphasize hand hygiene and sterile technique during suctioning, and only aseptically clean/sterile respiratory equipment used for each pt.

Tube obstruction

Blockage of the airway tube; fix by repositioning head/neck or tube; suction as needed.

Kinking or biting tube

Tube obstruction from bending or biting; fixed by moving the pt’s head and neck or repositioning the tube.

Cuff herniation

Cuff protrudes over the tube tip; deflate cuff and/or pass suction catheter through tube if deflating cuff fails; reassess.

Mucus plugging

Obstruction due to mucus; clear with suction if instillation of sterile normal saline is not necessary.

Cuff leaks

Primary problem for pts receiving mechanical ventilation, causing reduction delivery of tidal volume

Leak around the cuff due to pilot/valve issues; may require tube change or ETT exchanger.

Endotracheal tube exchanger

Semirigid guide which damaged tube can be removed and new tube inserted.

Extubation

Process of removing an oral or nasal endotracheal airway.

Decannulation

Process of removing a tracheostomy tube.

Readiness for extubation/decannulation

OG problem is not present,assessment of secretions (quantity and thickness), upper airway patency, presence of gag reflex, and ability to clear secretions before removal.

What type of endotracheal suctioning is useful on high levels of PEEP?

Closed endotracheal suctioning

How do you minimize complications and adverse responses while suctioning?

• Pre-oxygenation reduces inccidence of hypoxemia

• Limit the amount of negative pressure used

• Keep the time of suctioning duration low

• Use appropriate size suction catheter

• Avoid disconnection from ventilator

• Use sterile technique during suctioning and manually ventilate pt. to minimize bacterial colonization

• Don’t routinely instill sterile normal saline into artificial airway prior to suctioning unless needed to mobilize thick secretions

What do you do if secretions are thick and difficult to suction?

1. Ensure suction pressure in right range

2. Increase to maximum size suction catheter (not going over)

3. Increase suction pressure (not exceeding range)

4. Increase suction time

5. May also need to check canister of sputum, if too full will not suction properly

What is this picture of nasotracheal suctioning showing?

Sniffing position

What is this picture of sputum sampline showing?

Lukens trap

What type of tubes are these on the chest x-ray?

Left: Tracheostomy tube

Right: Endotracheal tube

Translaryngeal intubation

Endotracheal intubation passed through the larynx for airway ventilation (oral or nasal route); reevaluated daily with consideration of duration and potential transition to tracheostomy.

Extubation

Removal of the endotracheal tube; often planned within days of intubation; if extubation is unlikely, consider tracheostomy.

Tracheostomy

Surgical opening in the neck to access the trachea

Tracheotomy

Procedure of establishing access to trachea via neck incision, can be traditional surgical or percutaneous dilational, procedure best performed by physician/surgeon in surgical setting after pts airway is stabilized, tube selection depends on patient age, size, weight, and airway anatomy.

Tracheostomy tube

Tube placed via a tracheostomy to maintain airway; includes components such as outer cannula, flange, inner cannula, cuff, connectors, obturator, rounded tip, inflation tube, pilot balloon, & one way valve.

Outer cannula

The main, immovable tube that stays in the trachea to maintain the airway.

Inner cannula

Removable lumen inside the outer cannula; can be disposable or reusable and is cleaned/replaced as needed.

Cuff

Inflatable balloon on the tracheostomy tube used to seal the airway and secure ventilation.

Pilot balloon

Small balloon connected to the cuff used to monitor and adjust cuff inflation via the inflation tube.

Inflation tube

Channel connecting the pilot balloon to the cuff for cuff inflation and pressure monitoring.