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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