Res 104 Exam 2

Whats the prefered route for placing tracheal airway in emergency

Orotracheal Intubation

Who can intubate Orotracheal

Trained MD,RT,Paramedic

What does artifical airway do

Relieve upper airway obstruction

Allow susctoning

Protects the airway

Allow mechinical Vent

What causes more resistance in artificial airway

artifical tube

short tube

curvy tube

ET tube size for male

8.0-9.0 mm inner dimater

21-23 cm size length

ET tube size in female

7.5-8 mm inner dimater

19-21 length

Equipment needed for intubation

3 sizes of tube

gloves'

suction

AMBU Bag

EZ cap O2 detector

oral airway

larangscope

mac and miller blade

stylet

syringe

tube holder

steps for intubation

gather equipment

position pt

preoxgynate pt

insert laryngoscope

visulaie the glottis

displace the epiglottis

insert tube

assess tube position

stablize tube and confirm placement

gather equipment detail

set up susction

laryngoscope blade

get 3 tubes

test cuff

add stylet

position the patient detail

align the mouth, pharynx, larynx

extensins

towels

sniffer position

preoxgyenate the pt detail

pt is already in distress or apneic

ventilate and oxgynate with AMBU 100% O2

15-30 attempts

if faild bag them for couple minutes and try again

Insert the laryngoscope detail

use left hand to hold the scope and right hand tube

advance blade till you see epiglottis

insert on right side and move tounge to left

Visual the glottis

see epiglottis and glottic opening

displace the epiglottis

maclntosh blade-into the vallecula

miller blade- directly lift epiglottis

avoid levreing scope against teeth lift up and forward

insert the tube detail

once you displace the epiglottis and see the glottic opening, you’ll see the vocal cord

insert the tube through glottis and past the vocal cords

hold on to the tube untill it is secured

inflate cuff ( cuff protects the lower airway from aspiration and allows ventilation)

assess tube position detail

1-1.5 inches above the carina

first listen to bilateral breath sounds while bagging

observe equal chest expansion

things that could go wrong with intubation

right mainstem intubation

left mainstem intubation

esophageal intubation

if its not in the correct place deflate the cuff and pull tube back or advance it or pull out and try again

Depth of tube 19-21cm female

21-23 cm male

things you use to make sure its in the right place

esophageal detection EDD

light wand stylet with light see through skin

capnometry mesured CO2

easycap chagnge color when detect CO2

Chest Xray standard gold standard

fiberoptic bronchoscope

stablize the tube and confirm placement detail

secure tube with tapr or ETT placement

Complications of intubation

Esophageal intubation

Right or mainstem intubation

Trauma to oral cavity

Kinked tube

Vomit or aspiration

Hypoxemia and hypercapnia

Bradycardia

Cardiac arrest

Which intubation is more difficult Nasal or Oral

Nasal intubation

when is nasotrach is choice

pt with head, neck, facial injuries

2 ways of nasal intubation

blind and direct insertion

most common complicatin for nasal intubation

bleeding

equipment for nasal intubation

magill forceps

lube

insert bevel towards nasal septum

depth for nasal intubation

26-29 cm

blind nasal intubation

supine or sitting position

insert through nose

listen to breath sounds

3 emergency situation troubleshooting

Tube obstruction

Cuff Leak

Accidental Extubation

signs of airway emergency

respiratory distress, change in b/s, air movement heard through mouth

supplies need replacement airway, AMBU w mask, 4×4 gauze pads

Most common causes of airway emergencies

Obstruction- kinking or biting, muscus plug, trach getting pushed in skin

What to do first if the patient is unstable

Oxygenate with mask

Partial airway obstruction

On the vent increased peaked flow and decreased tidal volume

Decreased b/s and decreased airflow through the tube

Complete obstruction

Severe respiratory distress

Absent b/s

No airflow thought the tube

What to do if tube is jammed against the trach wall

Check the inner cannula

Reposition pt head and neck

Deflate the cuff

Suction catheter if it can’t go far it’s a mucus plug

If there’s a mucus plug

Remove the inner cannula clean it or replace it

If you have tried reposition head, tried suctioning AMBU, deflate the cuff and remove the inner cannula and it dosen’t work the you have to extubate the pt

Bag first, lavage with saline and suction

After extubating

Use AMBU to oxygenate/ventilate

If ETT reintubate

If fresh trach stoma will close if so bag with AMBU

what will happen if theres a cuff leak

losing volume pt will get less O2 and may hear air mvement through the mouth

What to look at when theres a cuff leak

Cuff

pilot ballon with one way valve

pilot tube or cuff filling tube

what can cause a small leak in the cuff

how to prevent it?

decreased cuff pressure overtime

check pressure every shift

what will cause a larger leak

how to fix

what till you hear

blowen cuff if theres a tear in the cuff

reintubate with new tube

hear and feel airflow gurgling through mouth

how to troubleshoot cuff leak

try and inflate the cuff

if theres a leak fix it with repair kit

marking for male oral

21-23 cm

marking for female oral

19-21

marking for nasal

26-28

What will you hear when the tube is partially out

decreased b/s, decreased airflow

airflow from around the mouth and decreased delivered volume

how to fix partial extubation

sometimes deflate cuff, advance the tube, reinflate, secure tube, assess the patient

other times you have to extubate and reintubate

xygnate and ventilate while reintubating

cuff pressure range

20-30 cmH20

What is extubation

Remvoing an artifical airway

when do you extubate

when the reason for intubation has been resolved

What do you do before extubating

weaning parameters, look at vital signs, overall pt status, cuff leak test

step 1 extubation get equipment

Suction, O2, syringe, towel, AMBU bag mask, neb, racemic epi and intubation equip

step 2 extubation suction the ett and pharynx above the cuff

to prevent aspiratin suction the cuff before and after deflating

suction the tube, mouth, above the cuff

step 3 oxgynate the pt after suctioning

suctioning can cause hypxemia because you sucked it all out

oxgynate for 1-2 minutes

undo tape

step 4 extubation deflate cuff

deflate the cuff

step 5 extubation remve the tube

you make pt take a large breath and remove at the peak inspiration, or have them cough and pull out tube when they cough

Step 6 extubation O2 therapy and humidity

Continue the O2 that they were on before extubation

Cool aerosol mask

Suction cough speak

Step 7 extubation assess the patient

Check b/s, air movement, HR, RR, SpO2, color

Encourage cough

Major complication of extubation

Laryngospasm

If persist AMBU and give neuromuscular blocking med and reintubate

Common complications of extubation

Stridor/decreased air movement due to upper airways edema (treated with racemic epi)

Pt will sound hoarse for a while

Glottic edema

Aspiration (prevent by increasing head of bed and suctioning)

Only feed ice chips or sips of water after 24 hours extubation

Tracheostomy removal known as

Decannulation(trach removal)

What to do before decannulation

Weaning process

Cautions to take before decannulation

assess pt strength of cough

must be able to handle secretions and not aspirate (do cookie test)

look for infection

after decannulatin when does stoma close

in couple weeks

also check for vocal cord respnse

weaning process things you could use

fenestrated tube

try smaller tubes

trach button

uncuffed tubes

spontaneous breathing trials

with the fenestrated trach tube is the cuff inflated or deflated

deflated

info on fenestrated trach tube

double cannulated

opening in posterior wall of outter cannula

to open fenestration remove inner cannula

deflate cuff so the airflow can get from upper airway

to suction remove plug

to put back on vent put in inner cannula and inflate cuff

can be accidently positioned against wall of larynx

smaller tube detail

go smaller and smaller tubes

it increases RAW(resistance)

Trach buttons detail

it maintains stoma and allows weaning

fits in the trach

can talk with it

can suction with it

dosent increase RAW

What does increased secretions do to the Resistance, WOB?

More secretions means more traffic to get through so it causes more resistance and increased WOB

low O2 cause hypoxemia, hypercapnia, atelectasis, infection

When do you usually suction a patient

When the secretions are too thick or when the patient can’t cough it up

What do you use to suction the upper airway(oropharynx)

yankeur suction(rigid tonsillar)

When do you need to suction the upper airway(oropharynx)

When you can hear secretions

See secretion in vomit or oral cavity

Hazards of suction the upper airway(oropharynx)

Damage teeth, gag/vomit or bite

What do you use to suction the lower airway( trachea and bronchil)

Flexible catheter:

down the nose(nasotrach suction)

Through artificial airway (ET suction, trach suction)

When do you ET suction

rhonchi, increased tactile fremitus, weak cough, retained secretions, increased PIP( peak inspiration pressure), visible secretion in airway, suspected aspiration, need sputum sample

To maintain patent(clear) airway

Even if the b/s is clean pass the catheter to make sure the tip isn’t plugged

Hazards of ET suction

Hypoxia/hypoxemia

Trauma

Cardiac/respiratory arrest

Cardiac dysrythmia

Atelectasis

Bronchoconstriction

Bleeding

Elevated ICP

BP change

Infection

What do you monitor while ET suction

Breath sounds

HR

RR

BO

SpO2

EKG

Sputum

Steps for ET suctioning

Introduce, assess, equipment(suction catheter, sterile gloves, protection equipment, water/saline, basin(tub), O2

At what pressure do you suction

120-150 adults

100-120 children

80-100 infants

Why do catheters have the side port

To decrease the mucosal damage to the trach

Where should the catheter reach to?

The mainstream bronchi(average 22in long)

French size based on external diameter

Course-tip catheter

Angled tip allows to enter right or left bronchi

After insertion rotate tip to get to desired bronchi

Whistle tip catheter

Eye hole on side

It if comes in contact with trach wall eye should absorb the vacuum

What size catheter do you use compare to the tube

Catheter with a outer diameter that is no more then ½ the inner diameter of trach tube

If the tube is too big it will obstruct the airway and cause atelectasis and hypoxemia

How do you calculate what catheter size you need compared to the inner diameter

Inner dimeter x 1.5

8mm x 1.5 = 12 French

Close suction

Change every 24-48 hours

Pt don’t have to be disconnected to the vent (less risk of hypoemia)

Cost effective

Less risk of infection

Still preoxg with 100%

Saline debate

Some say adding saline cause pneumonia

Some say it’s good for thick secretions

Preoxgynate pt for how long

1 minute

If on vent 3 minutes

Inserting catheter

Advance catheter untill feel resistant or pt cough and pull up a few cm and suction on the way out

Applying suction

Intermittent suctioning while withdrawing catheter and rotating

Don’t suction more then 15 seconds

After clean with steral water

Repxgynate pt after suction to avoid

Hypoxemia

Monitor and assess pt after suction

HR,RR BP SpO2 EKG color

Repeat untill improvemnt

If adverse reaction stop remove catheter increase FiO2 and ventilate

Monitor/ assess before and after

Chart the amount, consistence, color, odor

Minimizing complications

Preoxgynate

Watch our from the vagal nerve could cause dysthymia

If anything goes wrong stop and oxygenate

Atelectasis caused by too much air sucked out (to prevent only 15 seconds pressure under 200

Mucosal trauma (catheter hits the trach wall while auctioning (prevent limit pressure and rotate cuff)

Nasotracheal suction equipment

Similar to ET

needs lube and maybe a nasal trumpet to decrease mucosal damage

How to suction nasotrachea how to insert it

after hyperoxgynating

lubricate catheter insert bevel towards the sputum

pt should be sitting up or netural head position

Nasotracheal suction contraindication

nasal bleeding, facial/neck injury, upper respiratory infection

basal skull fracture (MAJOR)

hazards of Nasotracheal suction

same as ET plus

nasal bleeding

contamination of lungs with bacteria from upper airway

gagging/vomit

what is bronchoscopy

insertion of an instrument to visualize the bronchi

types of bromchosope

rigid

flexible

why is bronchoscopy done

to inspect the airway, remove objectin airway and to collect sample