Airway Management Part II RET 2275 Respiratory Care Theory 2

Airway Clearance - Cough Deep inspiration Glottis closes Abdominal muscles contract to compress lungs Glottis is opened Lung contents are expelled Steps in a normal cough

Airway Clearance Airway obstruction Caused by: Retained secretions Cause increased airway resistance and work of breathing, hypoxemia, hypercapnia, atelectasis, infection Foreign bodies Airway edema Tumors Trauma

Airway Clearance - Suctioning Airway obstruction Retained secretions Can be removed from the airways using mechanical aspiration – Suctioning Nasotracheal Endotracheal Oral

Secretion Evacuation Devices Suction Regulator Provide a means of reducing the high negative pressures from the supply line to safe physiological levels

Secretion Evacuation Devices Suction Tubing Connects regulator to canister, and canister to suction device (yankauer, suction catheter, etc.) Suction Canisters Collection device Protects vacuum lines from infiltration of fluids

Secretion Evacuation Devices Yankauer Suction Tip AKA – Tonsillar Tip Used to remove secretions from the oropharynx (upper airway)

Secretion Evacuation Devices Suction Catheter Used to remove secretions from the lower airway

Secretion Evacuation Devices Closed Suction System Maintains PEEP and high FiO2 when suctioning a mechanically ventilated patient May reduce caregiver and patient risk of infectious disease exposure Permits the suction catheter to be used multiple times, reducing cost

Secretion Evacuation Devices Lukens Trap Commonly referred to as “sputum trap” Used to obtain sputum specimens Placed in-line between the vacuum circuit and the suction catheter Lukens trap closed after obtaining specimen

Nasotracheal Suctioning

Nasotracheal Suctioning Indications – Assessment of Need The need to maintain a patent airway and remove retained secretions or foreign material from the trachea in the presence of: Inability to clear secretions – ineffective cough Audible evidence (auscultation) of secretions in the large airways (course crackles) that persist in spite of patient best cough effort Signs of respiratory distress To obtain sputum samples in patient who are unable to expectorate

Nasotracheal Suctioning Contraindications The only absolute contraindications are epiglottitis and croup Relative Contraindications Occluded nasal passages Nasal bleeding Acute head, facial, or neck injury Coagulopathy or bleeding disorder Laryngospasm Irritiable airway Upper respiratory tract infection including croup and epiglottitis Bronchospasm

Nasotracheal Suctioning Procedure Step 1: Assess patient for indications Auscultate Course crackles Ineffective cough Step 2: Assemble and Check Equipment Suction regulator (set pressure) Adults:100 to -120; children: 80 to -100; infants: 60 to -80 Suction canister with tubing Suction catheter

Nasotracheal Suctioning Procedure Step 2: Assemble and Check Equipment (cont.) Water-soluble lubricating jelly Sterile gloves Goggles, mask, gown (standard precautions) Sterile water or saline Oxygen delivery system (resuscitator bag/mask) and oxygen source Nasopharyngeal airway Minimizes nasal trauma when repeated access is needed

Nasotracheal Suctioning Procedure Step 3: Preoxygenate and Hyperinflate the Patient Using a manual resuscitator bag/mask connected to an 100% oxygen, preoxygenate and hyperinflate the patient for at least 30 seconds prior to suctioning

Nasotracheal Suctioning Procedure Step 3: Preoxygenate and Hyperinflate the Patient Hyperinflation fills underaerated or nonaerated segments via collateral ventilation, which helps move secretions into larger airways

Nasotracheal Suctioning Procedure Step 4: Insert the Catheter Lubricate the catheter and gently insert it through the nostril, directing it toward the septum and floor of the nasal cavity (do apply negative pressure yet) If you encounter resistance, gently twist the catheter. If this does not help, remove the catheter and try inserting it through the other nostril

Nasotracheal Suctioning Procedure Step 5: Move Catheter in Lower Pharynx Have the patient assume a “sniffing” position and advance the catheter through the larynx until the patient’s coughs, or a resistance is felt much lower in the airway Apply suction, while withdrawing the catheter using a rotating motion

Nasotracheal Suctioning Procedure Step 5: Move Catheter in Lower Pharynx (cont.) Keep total suction time to less than 10 – 15 seconds After removing the catheter, clear it using the sterile water/saline If any untoward response occurs during suctioning, e.g., hypoxemia, an abrupt change in the electrocardiogram wave form, major change in heart rate or rhythm, hypotension, increased intracranial pressure, etc., immediately remove the catheter and oxygenate the patient

Nasotracheal Suctioning Equipment and Procedure Step 6: Reoxygenate and Hyperinflate the Patient Using a manual resuscitator bag/mask connected to an 100% oxygen, reoxygenate and hyperinflate the patient for at least 60 seconds Step 7: Monitor the Patient and Assess Repeat steps 3 – 7 as needed until your see improvement or observe an adverse response

Nasotracheal Suctioning Hazards and Complications Hypoxia/hypoxemia Nasal, pharyngeal, and tracheal mucosal trauma/pain To avoid this rotate catheter while withdrawing and limit the amount of negative pressure used Cardiac or respiratory arrest Cardiac arrhythmias/bradycardia Pulmonary atelectasis Avoid this by limiting amount of negative pressure , keeping duration of suctioning as short as possible, providing hyperinflation before and after the procedure Bronchoconstriction/bronchospasm

Nasotracheal Suctioning Hazards and Complications (cont.) Infection (patient and/or caregiver) Mucosal hemorrhage Elevated intracranial pressure Uncontrolled coughing/laryngospasm Hyper/hypotension Gagging/vomiting

Nasotracheal Suctioning Assessment of Outcome Effectiveness should be reflected by removal of secretions Effectiveness should be reflected by improved breath sounds

Nasotracheal Suctioning Monitoring The following should be monitored before, during, and after the procedure: Breath sounds SpO2 Respiratory rate and pattern Pulse rate, BP, ECG (if available) Sputum (color, volume, consistency, odor) Presence of bleeding (evidence of trauma) ICP (if indicated and available)

Endotracheal Suctioning

Endotracheal Suctioning Equipment

Endotracheal Suctioning Indications – Assessment of Need The need to maintain a patent airway and remove retained secretions Audible evidence (auscultation) of secretions in the large airways (course crackles) Clinically apparent work of breathing Increased peak inspiratory pressures on volume-controlled ventilation; decreased VT on pressure control ventilation To obtain sputum samples for microbiological or cytologic examination Should be a routine part of a patient/ventilator check

Endotracheal Suctioning Contraindications When indicated, there is no absolute contrindication to endotracheal suctioning because abstaining from suctioning in order to avoid possible adverse reaction may, in fact be lethal

Endotracheal Suctioning Procedure Step 1: Assess patient for indications Auscultate Course crackles Ineffective cough Step 2: Assemble and Check Equipment Suction regulator (set pressure) Adults:100 to -120 Children: 80 to -100 Infants: 60 to -80

Endotracheal Suctioning Procedure Step 2: Assemble and Check Equipment (cont.) Suction canister with tubing Suction catheter OD must be less than ½ of ID of ET tube Example: 8.0 mm ID tube 8 X 2 = 16 next smallest size is 14 French

Endotracheal Suctioning Procedure Step 2: Assemble and Check Equipment (cont.) Sterile gloves Goggles, mask, gown (standard precautions) Sterile water or saline Oxygen delivery system (resuscitator bag/mask, ventilator) and oxygen source

Endotracheal Suctioning Procedure Step 3: Preoxygenate and Hyperinflate the Patient Using a manual resuscitator bag/mask connected to an 100% oxygen, preoxygenate and hyperinflate the patient for at least 30 seconds If the patient is on a ventilator, adjust the FiO2 to 100% and use machine breaths to hyperinflate the patient Step 4: Insert the Catheter Insert the catheter carefully until it can go no farther Do not contaminate the catheter by touching it to the outside of the ET tube or any other surface Withdraw the catheter a few centimeters before applying suction

Endotracheal Suctioning Procedure Step 5: Apply Suction / Clear Catheter Apply suction, while withdrawing the catheter using a rotating motion Keep total suction time to less than 10 – 15 seconds After removing the catheter, clear it using the sterile water/saline Closed suction catheter systems have an adapter for saline vials to be placed inline with device (the catheter is cleared by squeezing the saline vial and applying suction at the same time)

Endotracheal Suctioning Procedure If any untoward response occurs during suctioning, e.g., hypoxemia, an abrupt change in the electrocardiogram wave form, major change in heart rate or rhythm, hypotension, increased intracranial pressure, etc., immediately remove the catheter and oxygenate the patient

Endotracheal Suctioning Equipment and Procedure Step 6: Reoxygenate and Hyperinflate the Patient Using a manual resuscitator bag/mask connected to an 100% oxygen, reoxygenate and hyperinflate the patient for at least 60 seconds If the patient is on a ventilator, adjust the FiO2 to 100% and use machine breaths to hyperinflate the patient Step 7: Monitor the Patient and Assess Outcomes Repeat steps 3 – 7 as needed until your see improvement or observe an adverse response

Endotracheal Suctioning Hazards and Complications Hypoxia/hypoxemia Tracheal or bronchial mucosal trauma To avoid this rotate catheter while withdrawing and limit the amount of negative pressure used Cardiac or respiratory arrest Cardiac arrhythmias Pulmonary atelectasis Avoid this by limiting amount of negative pressure , keeping duration of suctioning as short as possible, providing hyperinflation before and after the procedure

Endotracheal Suctioning Hazards and Complications (cont.) Bronchoconstriction/bronchospasm Infection (patient and/or caregiver) Mucosal hemorrhage Elevated intracranial pressure Hyper/hypotension

Endotracheal Suctioning Assessment of Outcome Removal of pulmonary secretions Improvement in breath sounds Decreased peak inspiratory pressures on volume control ventilation Increased VT on pressure control ventilation Decreased airway resistance Improvement in ABG values or SpO2

Endotracheal Suctioning Monitoring The following should be monitored before, during, and after the procedure: Breath sounds SpO2 Respiratory rate and pattern Pulse rate, BP, ECG Sputum (color, volume, consistency, odor) Ventilation parameters ICP (if indicated and available)