Artificial Airways

NUCLEUS MEDICAL ART, VISUALS UNLIMITED/SPL - ARTIFICIAL AIRWAYS

Introduction

  • Prof. Dougherty NP IV discusses artificial airways in medical practice.

Artificial Airways

  • Function of Artificial Airways: Help maintain a patent airway.

  • Types of Artificial Airways:

    • Nasopharyngeal airway: Inserted through the nose to the pharynx.

    • Oropharyngeal airway: Inserted through the mouth to the pharynx.

    • Endotracheal tube (ET tube): Inserted into the trachea.

    • Nasotracheal tube: Tube inserted through the nose into the trachea.

    • Tracheostomy: Surgical creation of a stoma (opening) in the trachea.

Noninvasive Ventilation (NIV)

  • Common Modes:

    • Continuous Positive Airway Pressure (CPAP): Continuous pressure during both inspiration and expiration.

    • Bi-level Positive Airway Pressure (Bi-PAP): Two levels of pressure support: inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP).

  • Contraindications: Not recommended for acute myocardial infarction (MI) or gastrointestinal (GI) bleeding patients.

  • Ideal Patients: Patients needing higher levels of ventilatory support but not mechanical ventilation (e.g. Chronic Obstructive Pulmonary Disease [COPD], Heart Failure [HF]).

  • Usage: Utilizes a nasal or full-face mask instead of an ET tube.

CPAP Details

  • Functions:

    • Restores functional residual capacity (FRC).

    • Provides one level of pressure throughout the respiratory cycle.

    • Commonly used for patients with obstructive sleep apnea.

Bi-PAP Details

  • Features:

    • Provides two levels of positive airway pressure:

    • IPAP: Higher pressure during inhalation, aiding CO2 removal.

    • EPAP: Maintains alveoli open at the end of expiration.

  • Patient Requirements: Must be awake, alert, able to breathe spontaneously, and tolerate face mask use.

  • Applications: Often used in COPD patients and following extubation.

Nursing Management for Noninvasive Ventilation

  • Assessment Needs:

    • Constant assessment of patient status including level of consciousness (LOC), hemodynamic stability, and work of breathing (WOB).

  • Care Considerations:

    • Mouth, nares, and eye care for skin protection against breakdown and ulceration.

    • Any redness constitutes a Stage I pressure injury (PI).

    • Alternate mask duration to alleviate pressure and utilize different masks based on fit.

    • Collaborate with respiratory therapy (RT).

Mechanical Ventilation (Invasive Ventilation)

  • Definition: Use of a ventilator to deliver oxygen to lungs, a supportive measure rather than curative.

  • Purpose:

    • Supports patients temporarily until they regain the ability to breathe independently.

    • Can serve as a bridge to long-term mechanical ventilation or as a decision point to stop support.

Indications for Mechanical Ventilation

  • Situations Necessitating Mechanical Ventilation:

    • Acute respiratory failure (ARF).

    • Apnea or inability to protect airway.

    • Severe hypoxia or hypercarbia.

    • Respiratory muscle fatigue.

    • Other causes: hemorrhage, trauma, neuromuscular problems, drug overdose, burns, or shock.

  • Pre-Planning: Patients with chronic lung disease should discuss potential need for mechanical ventilation before emergencies arise.

Ethical Considerations in Mechanical Ventilation

  • End-of-life considerations: Importance of documenting treatment wishes in advance directives.

  • Communication: Engage families and caregivers to discuss mechanical ventilation decisions.

  • Ethics Committee: Resource for dealing with disagreements in treatment decisions.

Mechanical Ventilation Techniques

Positive Pressure Ventilation (PPV)

  • Usage: Primarily in acutely ill patients.

  • Mechanism:

    • Air is pushed into the lungs under positive pressure during inhalation, causing increased intrathoracic pressure (opposite of normal).

    • Expiration is passive.

    • Can be by volume or pressure ventilation.

Types of Mechanical Breaths

  1. Volume Ventilation:

    • Delivers a preset tidal volume (VT) per breath; pressure varies based on lung resistance.

  2. Pressure Ventilation:

    • Delivers breath based on set peak inspiratory pressure (PIP), with the volume varying according to pressure and lung compliance factors.

Endotracheal (ET) Intubation Procedure

Preparation Steps

  • Consent: Required unless in emergency situations.

  • Patient Teaching: Explain necessity, procedures, and alternate communication needs post-intubation.

  • Equipment Requirements:

    • Self-inflating bag-valve-mask (BVM) attached to oxygen.

    • Suctioning equipment at bedside.

    • IV access in place.

Procedure Steps

  • Pre-Intubation:

    • Pre-medicate as needed.

    • Positioning: Sniff position (supine, neck flexed, head extended).

    • Preoxygenate using BVM with 100% O2 for 2 minutes.

  • Intubation Technique:

    • Limit attempts to under 30 seconds while ventilating in between attempts.

  • Rapid Sequence Intubation (RSI):

    • Simultaneous administration of sedatives and paralytics to induce unconsciousness and minimize aspiration risk.

  • End Tidal CO2 Detection:

    • Use of an EtCO2 detector to confirm tube placement via exhaled CO2.

Assessment After Intubation

  • Actions:

    • Connect to ventilator; secure tube; assess need for suctioning; monitor SpO2.

    • Confirm placement: auscultation for bilateral lung sounds and checking epigastric air sounds.

  • Cuff Inflation:

    • Importance of sealing ET tube in the trachea; prevents gas escape and aspiration.

Tube Monitoring

Proper Cuff Inflation

  • Function: Seals ET tube, preventing gas escape and potential aspiration. Inflated with air.

Indications of Displaced ET Tube

  • Requires immediate attention as it poses significant airway risks.

  • Symptoms: hypoxemia, potential pneumothorax, risk of respiratory or cardiac arrest.

Evaluation and Monitoring

  • Use of Suctioning:

    • Suction indications include visible secretions, increased respiratory rate, decreased SpO2, or auscultated adventitious sounds.

  • Hourly Assessments: Monitor suction need, with attention to sputum characteristics.

Complications of Suctioning

  • Potential Risks:

    • Hypoxemia, bronchospasm, increased intracranial pressure, mucosal damage, and bleeding.

  • Management: Pre-oxygenate and time suction passes to minimize discomfort.

Ventilator Management

Alarm Systems

  • Use and Importance:

    • All ventilator alarms must be on to ensure patient safety against potential complications.

    • Potential issues: asynchrony, disconnection, or malfunction.

Alarm Fatigue

  • Risks: Sensory overload; delayed response to alarms can lead to adverse events.

  • Management: Customize alarm settings to reduce fatigue where possible.

Ventilation Complications

  • Definitions:

    • Risks of disconnection, malfunction, or need for manual ventilation preparation in emergencies.

Sedation and Analgesia

  • Assessing Distress: Identify the cause of discomfort and utilize pain, sedation, or delirium scales to evaluate.

  • Education Required: Emphasize awareness of patient experiences even during sedation.

Nutritional Considerations

  • Administration Methods: Continuous feeding via NG or OG versus parenteral nutrition (PN); enteral nutrition (EN) preserves gut function.

  • Prophylaxis: Address potential for gastrointestinal (GI) bleeding and venous thromboembolism (VTE).

  • Early Mobility: Encouraged for patients, utilizing collaboration with PT/OT.

Psychosocial Factors

  • Attention to Anxiety: Address feelings of helplessness and promote patient safety.

  • Communication Support: Enhance methods for patients having difficulty communicating due to intubation or sedation.

  • Bundle Approach to Prevent Delirium: Include interventions involving awareness, mobility, and family engagement.

Extubation Process

Criteria for Extubation

  • Assessments: Muscle strength, cough ability, minimal secretion presence, set up an alternative oxygen delivery system, hyperoxygenate, and suction prior to extubation.

Procedure

  • Execution: Deflate cuff, remove tube in a smooth motion, and encourage deep breaths as needed.

  • Post-Extubation Monitoring: Check vital signs and respiratory status for at least 2–3 hours.

Signs of Complications Post-Extubation

  • Indicators: Decreased SpO2, tachypnea/bradypnea, tachycardia, reduced consciousness levels, or impaired gas exchange.

  • Preparation: Be ready for potential reintubation or noninvasive ventilation trials.

Conclusion

  • Comprehensive Approach: It is critical to maintain vigilance in patient monitoring, support ventilation, and collaborate interprofessionally throughout the process of airway management and mechanical ventilation. This includes addressing the physical, psychological, and nutritional needs of patients on ventilation.