1. Airway Management Part II
RET 2275
Respiratory Care Theory 2

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

3. 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

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

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

6. 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

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

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

9. 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

10. 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

11. Nasotracheal Suctioning

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

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

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

25. 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)

26. Endotracheal Suctioning

27. Endotracheal Suctioning
Equipment

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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)

35. 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

36. 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

37. 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

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

39. 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

40. 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)