Artificial Airways

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ARTIFICIAL AIRWAYS: are inserted to maintain patent air passage for clients whose airway has become obstructed or may become obstructed. A. Endotracheal tubes: are most commonly inserted for clients who have had general anesthetics or for those in emergency situations where mechanical ventilation is required. B. Tracheostomy: is an opening into the trachea through the neck. The tube is usually inserted through this opening and an artificial airway is created. o PURPOSES: ~ To maintain patent airway. ~ Indicated to the following: -Acute respiratory failure, CNS depression, neuromuscular disease, pulmonary disease, chest wall injury -Upper airway obstruction (tumor, inflammation, foreign body, laryngeal spasm) -Anticipated upper airway obstruction from edema or soft tissue swelling due to head and neck trauma, some postoperative head and neck procedures involving the airway, facial or airway burns, decreased level of consciousness -Aspiration prophylaxis -Fracture of cervical vertebrae with spinal cord injury; requiring ventilatory assistance.

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PRECAUTIONS & SPECIAL CONSIDERATIONS: o Watch out for redness and irritation of the nasal and oral mucosa. o Recognize that patient is usually apprehensive, particularly about choking, inability to communicate verbally, inability to remove secretions, uncomfortable suctioning, difficulty in breathing, or mechanical failure. Ensure adequate ventilation and oxygenation through the use of supplemental oxygen or mechanical ventilation as indicated. Assess breath sounds every 2 hours. Note evidence of ineffective secretion clearance (rhonchi, crackles), which suggests need for suctioning. Provide adequate suctioning of oral secretions to prevent aspiration and decrease oral microbial colonization. Perform frequent oral care with soft toothbrush or swabs and antiseptic mouthwash or hydrogen peroxide diluted with water. Frequent oral care will aid in prevention of ventilator-associated pneumonia. Ensure that aseptic technique is maintained when inserting an ET or tracheostomy tube. The artificial airway bypasses the upper airway, and the lower airways are sterile below the level of the vocal cords. Elevate the patient to a semi-Fowler's or sitting position, when possible; these positions result in improved lung compliance. The patient's position, however, should be changed at least every 2 hours to ensure ventilation of all lung segments and prevent secretion stagnation and atelectasis. Position changes are also necessary to avoid skin breakdown.

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(Nutritional considerations): o Recognize that an ET tube holds the epiglottis open. Therefore, only the inflated cuff prevents the aspiration of oropharyngeal contents into the lungs. The patient must not

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receive oral feeding. Administer enteral tube feedings or parenteral feedings as ordered. Administer oral feedings to a conscious patient with a tracheostomy, usually with the cuff inflated. The inflated cuff prevents aspiration of food contents into the lungs, but causes the tracheal wall to bulge into the esophageal lumen, and may make swallowing more difficult. Patients who are not on mechanical ventilation and are awake, alert, and able to protect the airway are candidates for eating with the cuff deflated. To assess ability to protect the airway, sit the patient upright and feed the patient colored gelatin or juice. If color from gelatin can be suctioned from the tracheostomy tube, aspiration is occurring, and the cuff must be inflated during feeding and for 1 hour afterward with head of bed elevated. Patients should receive thickened rather than regular liquids; this will assist in effective swallowing.

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EQUIPMENT: Endotracheal Intubation Laryngoscope with curved or straight blade and working light source (check batteries and bulb regularly) Endotracheal (ET) tube with low-pressure cuff and adapter to connect tube to ventilator or resuscitation bag Stylet to guide the endotracheal tube Oral airway (assorted sizes) or bite block to keep patient from biting into and occluding the ET tube Adhesive tape or tube fixation system Sterile anesthetic lubricant jelly (water-soluble) 10-mL syringe Suction source Suction catheter and tonsil suction Resuscitation bag and mask connected to oxygen source Sterile towel Gloves Face shield End tidal CO2 detector

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EQUIPMENT: Assisting with Tracheostomy Insertion

Tracheostomy tube (sizes 6-9 mm for most adults) Sterile instruments: hemostat, scalpel and blade, forceps, suture material, scissors Sterile gown and drapes, gloves Cap and face shield Antiseptic prep solution Gauze pads Shave prep kit Sedation Local anesthetic and syringe Resuscitation bag and mask with oxygen source Suction source and catheters Syringe for cuff inflation Respiratory support available for post-tracheostomy (mechanical ventilation, tracheal oxygen mask, CPAP, T-piece)

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COMPLICATIONS OF ENDOTRACHEAL AND TRACHEOSTOMY TUBES:

Laryngeal or tracheal injury

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Sore throat, hoarse voice Glottic edema Ulceration or necrosis of tracheal mucosa Vocal cord ulceration, granuloma, or polyps Vocal cord paralysis Postextubation tracheal stenosis Tracheal dilation Formation of tracheal-esophageal fistula Formation of tracheal-arterial fistula Innominate artery erosion

Pulmonary infection and sepsis Dependence on artificial airway

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POSSIBLE NURSING DIAGNOSIS: Risk for infection Risk for injury(trauma) Risk for aspiration Risk for activity intolerance Impaired bed mobility Impaired social interaction Ineffective breathing pattern Disturbed body image

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TEACHINGS : Client, Community, and Home care Explain the function of the equipment carefully. Inform patient and family that speaking will not be possible while the tube is in place, unless using a tracheostomy tube with a deflated cuff, a fenestrated tube, a Passy-Muir speaking valve, or a speaking tracheostomy tube. o A Passey Muir valve is a speaking valve that fits over the end of the tracheostomy tube. Air that is inhaled is exhaled through the vocal cords and out through the mouth, allowing speech. Develop the best method of communication for the patient (eg, sign language, lip movement, letter boards, paper and pencil, magic slate, or coded messages). o Patients with tracheostomy tubes or nasal ET tubes may effectively use orally operated electrolarynx devices. o Devise a means for patient to get the nurse's attention when someone is not immediately available at the bedside, such as call bell, hand-operated bell, rattle. Anticipate some of patient's questions by discussing Is it permanent? Will it hurt to breathe? Will someone be with me? If appropriate, advice patient that as condition improves a tracheostomy button may be used to plug the tracheostomy site. A tracheostomy button is a rigid, closed cannula that is placed into the tracheostomy stoma after removal of a cuffed or uncuffed tracheostomy tube. When in proper position, the button does not extend into the tracheal lumen. The outer edge of the button is at the skin surface and the inner edge is at the anterior tracheal wall Community and Home Care Considerations

Teach patient and/or caregiver procedure. Patient will need to use stationary mirror to visualize tracheostomy and perform procedure. Suctioning patient in the home: whenever possible, patient and/or caregiver should be taught to perform procedure. Patient should use controlled cough and other secretion clearance techniques. Preoxygenation and hyperinflation before suctioning may not be routinely indicated for all patients cared for in the home. Preoxygenation and hyperinflation are based on patient need and clinical status. Normal saline should not be instilled unless clinically indicated (eg, to stimulate cough). Clean technique and clean examination gloves are used. At the end of suctioning, the catheter or tonsil tip should be flushed by suctioning recently boiled and cooled, or distilled, water to rinse away mucus, followed by suctioning air through the apparatus. The outer surface may be wiped with alcohol or hydrogen peroxide. The catheter and tonsil tip should be air-dried and stored in a clean, dry place. Generally, suction catheters should be discarded after 24 hours. Tonsil tips may be boiled and reused. Care of tracheostomy stoma: clean with half-strength hydrogen peroxide (diluted with sterile water), and wipe with sterile water or sterile saline. y PROCEDURE: ET INSERTION Nursing Action Rationale Preparatory phase 1. Assess the patient's heart rate, level of 1. Provides a baseline to estimate the patient's tolerance consciousness, and respiratory status. of the procedure. Performance phase 1. Remove the patient's dental bridgework 1. May interfere with insertion. Will not be able to remove and plates. easily from the patient once intubated. 2. Remove the headboard from the bed 2. To provide room to stand behind patient's head. (optional). 3. Prepare equipment. 3. a. Ensure function of resuscitation bag a. The patient may require ventilatory assistance during with mask and suction. procedure. Suction should be functional because gagging and emesis may occur during procedure. b. Assemble the laryngoscope. Make sure the light bulb is tightly attached and functional. c. Select an ET tube of the appropriate size (6-9 mm for the average adult). d. Place the ET tube on a sterile towel. d. Although the tube will pass through the contaminated mouth or nose, the airway below the vocal cords is sterile, and efforts must be made to prevent iatrogenic contamination of the distal end of the tube and cuff. The proximal end of the tube may be handled because it will reside in the upper airway. e. Inflate the cuff to make sure it assumes e. Malfunction of the