Comprehensive Study Guide for Artificial Airways: Adult Nursing and Lab Skills

Anatomical Fundamentals for Artificial Airways

• Anatomy and Positioning During Insertion:

  • When performing oral procedures, the tube passes the trachea and reaches the carina, which is a spot of anatomical resistance located where the trachea bifurcates.
  • Carina Resistance: If resistance is felt a couple of inches into insertion, the practitioner must stop pushing to avoid trauma to the carina.
  • Bronchi Symmetry: The right main bronchus is shorter and easier for a tube (especially an endotracheal tube) to enter accidentally. This necessitates assessing for symmetry in breath sounds.
  • Assessment Requirements: Practitioners must auscultate all three lobes (upper, middle, and lower) on both sides. Hearing airflow only in the right lung indicates the tube has been inserted too far.

• Artificial Airway Types and Adult Focus:

  • The primary focus of this instruction is on adult patients; sizes and techniques may differ in pediatric clinical settings.
  • Home care settings for procedures like straight catheterization use clean technique because home sinks typically lack pathogens like Legionella, whereas hospital settings require stricter protocols.

Oropharyngeal Airways (OPA)

• User Criteria:

  • Used only for unconscious patients.
  • Requires the absence of a gag reflex. If a patient begins to regain consciousness or a gag reflex, the OPA must be removed immediately to prevent vomiting and aspiration into the lungs.

• Sizing and Identification:

  • Sizes are often color-coded: Yellow is a size $9$, and Green is a size $8$.
  • To size correctly, measure from the level of the patient's incisors (front teeth) to the angle of the jawbone.

• Insertion Technique (The "Invert, Insert, Rotate, and Locate" Method):

  • 1. Invert: Turn the OPA upside down (curve facing up).
  • 2. Insert: Insert it into the mouth against the hard palate.
  • 3. Rotate: Rotate the device $180^{\circ}$ so the curve follows the anatomical shape of the tongue.
  • 4. Locate: Ensure it is seated nicely in the oropharynx, pushing the tongue down to prevent airway blockage.

• Safety and Maintenance:

  • OPAs are for short-term use only (typically less than an hour, such as during a rapid response or until Narcan takes effect).
  • Nurses must monitor the lips for skin breakdown caused by pressure from the device flange.
  • The OPA is hollow, allowing for suctioning through the device.

Nasopharyngeal Airways (NPA) / Nasal Trumpets

• User Criteria:

  • Used for semi-conscious patients who still have a gag reflex.
  • Often used when frequent nasal suctioning is required to reduce trauma and make the process less invasive for the patient and family.

• Sizing and Preparation:

  • Size is determined by the patient's anatomy and the size of the nares.
  • Average sizes: Size $7$ for an average male; Size $6$ for an average female.
  • Measurement: From the tip of the nose to the earlobe.
  • Preparation: Requires lubrication (unlike the OPA). Ensure lubricant does not obscure the open ends of the airway.

• Insertion Technique:

  • Insert with the bevel (slanted edge) facing the septum (midline).
  • Push vertically down into the largest nostril, allowing it to follow the anatomical curve into the nasopharynx.
  • If a strong gag reflex is triggered, pull the tube back approximately one inch or use a shorter tube.
  • Devices may include a washer or a safety pin to prevent the tube from migrating too far into the nostril.

Endotracheal (ET) Tubes and Intubation

• Purpose and Placement:

  • Used for mechanical ventilation or Ambu bag ventilation.
  • Placed by specialized providers (Anesthesia, NP, or Respiratory Therapy), not standard nurses.
  • Can be inserted orally or nasally.

• The Cuff Function:

  • The cuff is inflated with air (typically $15\,ml$ via a side port) using a syringe.
  • Purpose: To prevent air leakage during mechanical ventilation. It is not an anchor and does not secure the tube in place; the tube must be secured at the mouth using adhesive devices or twill ties.
  • Nurses must shift the tube from side to side Every $4\,hours$ to prevent skin breakdown on the lips.

• Placement Verification:

  • CO2 Monitor: A colorimetric device is applied to the end of the tube. Yellow indicates good gas exchange; purple indicates inadequate exchange/wrong placement.
  • Auscultation: Listen over the lung apices, axillae, and stomach.
  • Chest X-Ray: Best practice is to obtain a chest X-ray daily for ventilated patients to ensure the tube remains in the correct position.

• Step-by-Step Intubation Process (Video Transcript):

  • 1. Check equipment: Ensure laryngoscope light works and the cuff inflates/deflates.
  • 2. Pre-oxygenate: Use a bag and mask for up to one minute.
  • 3. Positioning: The patient's head should be in the "sniffing the morning air" position.
  • 4. Laryngoscopy: Hold the laryngoscope in the left hand. Insert the blade into the right side of the mouth, displacing the tongue to the left. Advance tip to the vallecula.
  • 5. Visualization: Lift upward at a $45^{\circ}$ angle to display vocal cords and the laryngeal opening.
  • 6. Insertion: Insert the ET tube between the cords until the cuff passes through them. Markings at the incisors should be between $21\,cm$ and $24\,cm$ in an average adult.

Tracheostomy (Trach): Surgical Considerations and Duration

• Definitions:

  • Tracheotomy: The surgical procedure of creating the opening (stoma).
  • Tracheostomy: The actual plastic appliance inserted into the stoma.

• Timing and Vulnerability:

  • Long-term Use: Often considered if mechanical ventilation is required for $21$ days or more.
  • The First 7 Days: This is the "fresh trach" period. The site is most vulnerable, inflamed, and can close rapidly if the device is dislodged. If a trach comes out within the first seven days, it is a Code Blue emergency.
  • Healing: After seven days, the inflammatory response decreases and the stoma begins to establish.

• Surgical Insertion:

  • Done in the Operating Room. The incision is made right below the thyroid; accidental damage to the thyroid must be avoided.
  • Vocal cords are bypassed, meaning patients cannot speak initially. They may require communication boards or laptops.

Critical Components of Tracheostomy Care

• Types of Trach Tubes and Brands:

  • Shiley: A common brand. Some have disposable inner cannulas (clips on the sides), and some have reusable ones (two dots on the plate that must be rotated to line up).
  • Portex: Some have rings and are used for extra-long applications, such as for obese patients ($600\,lbs+$).
  • Metal Trach: Used for very long-term/chronic care (e.g., motorcyclist accidents or quadriplegics). These are cleaned and reinserted using a clean (not sterile) procedure.

• The Cuff in Tracheostomies:

  • While used for mechanical ventilation, the cuff is also inflated during mealtimes to prevent aspiration.
  • Nursing Alert: The cuff must be deflated after the meal. Constant inflation causes pressure on soft tissue, leading to tissue necrosis.

• The Obturator:

  • A rounded-tip guide used during insertion to prevent hard edges from traumatizing the tissue.
  • It must be at the bedside at all times but removed immediately after insertion because it occludes the airflow.

Essential Bedside Safety Equipment

Every tracheostomy patient must have the following at the bedside:

1. Suction Setup: Tested and ready to go (don't leave it in pieces).
2. Two Spare Trach Tubes: One of the same size and one one size smaller (in case of inflammation-related closure).
3. Obturators: Located inside the spare trach kits.
4. Humidified Oxygen: A "mist collar" should be available. Trachs bypass the natural humidification of the nose, and dry air causes secretions to occlude the airway.
5. Steile Saline: For cleaning and testing suction.

Suctioning Procedures and Equipment

• Catheter Types:

  • Yankauer: Hard plastic for oral/tonsillar suctioning only. Never used in an artificial airway.
  • Whistle Tip/Open Tipped: Flexible catheters for ET or trach suctioning. These have a portal that the nurse covers with a thumb to apply suction.
  • Closed Suctioning (Inline): A catheter encased in plastic, connected directly to the ventilator. This allows for frequent suctioning without opening the system, though the extra weight can be problematic for fresh trachs.

• Suctioning Technique:

  • Hyperoxygenation: Increase oxygen flow to $10 – 12\,L/min$ before suctioning.
  • Insertion: Do NOT apply suction while going down. Insert until resistance is felt or the patient gags/coughs.
  • Suction Application: Apply suction only while withdrawing. Use a rotating motion.
  • Duration: The entire process (insert and withdraw) should take less than $15\,seconds$; however, actual suction application should ideally be closer to $5 – 10\,seconds$ because the nurse is occluding the airway.

• Numerical Standard Settings:

  • Suction Pressure: Continuous wall suction between $100\,mmHg$ and $150\,mmHg$ (Goal: $120 – 140\,mmHg$).
  • Oxygen Flow: $10\,L/min$ to $12\,L/min$.

Tracheostomy Complications and Nursing Management

• Infection Risks:

  • Loss of nasal cilia and natural filters increases the risk of constant pulmonary infections and pneumonia.
  • Secretions: Normal secretions are clear or slightly yellow. Green or brown indicates infection. Pink-tinged or red secretions are common in the first seven days due to inflammation/trauma.
  • Odor: Any foul odor indicates infection.

• Skin Integrity:

  • Monitor the neck for maceration caused by wet or soiled Velcro ties. If a tie is soiled, it must be changed using two people (one to hold the plate, one to change the tie).
  • The second the tie is unhooked, a cough could cause true dislodgment.

• Dislodgment Emergency:

  • If a trach comes out, use the obturator to keep the stoma open. Do not let go of the device or let it fall further into the hole.
  • Fresh trachs (less than $24\,hours$ old) can close within seconds without a placeholder.

• Behavioral Indicators of Distress:

  • Restlessness, increased heart rate, increased blood pressure, and increased respiratory rate are early signs of airway obstruction.
  • Cyanosis is a VERY late sign and represents an emergency.
  • Rhonchi: Sounds like snoring in the main bronchi, indicating mucus buildup.

Specific Product Examples and Identification

• Case Study: Christopher Reeve: Played Superman; had a high $C2$ break and required a permanent tracheostomy for mechanical ventilation.
• Identification: The plate of the trach tube indicates its size (e.g., ID $7$, ID $8.5$). ID stands for "Internal Diameter."
• Metal Trachs: Often found in the VA, home care, or long-term rehab. These can range up to size $12$. Cleaning is a clean, non-sterile procedure.

Questions & Discussion

• Q: Are CO2 monitor colors universal?

  • A: While not necessarily universal across every manufacturer, the standard is that yellow is "good" (detecting gas exchange) and purple indicates a problem.

• Q: Does the patient have a gag reflex with an NPA?

  • A: Yes, because they are semi-conscious. If the device triggers a solid gag, it must be pulled back one inch.

• Q: Can you use a pen to create an emergency airway like on TV shows?

  • A: Breathing through a pen is effectively impossible and can cause massive thyroid damage or trauma. True emergency tracheotomies should avoid the thyroid.

• Q: What is decannulation?

  • A: This is the process of removing the tracheostomy tube once the patient no longer needs it. It is often a source of great joy but also fear for the patient.

• Q: What happens to the stoma after decannulation?

  • A: If the stoma was long-term (like a piercing), it might stay open. Patients often learn to plug it with a finger to speak. Some may opt for plastic surgery later to close it, though this carries risks if they ever need a trach again.

• Q: What are the suction pressure and O2 settings for the test?

  • A: Set oxygen at $10 – 12\,L/min$ and continuous wall suction between $100 – 150\,mmHg$ (specifically aim for $120 – 140\,mmHg$).