Chapter 33

Advantages and disadvantages of using closed system multiuse catheters

A. Maintains PEEP, oxygenation, lowers exposure to body fluids; decreases risk of cross contamination, mat decrease cost B. Weight, airway resistance, ventilator triggering

what are some of the activities we RT's might perform while assisting with the procedure

A. Monitor the ventilator and patient. B. Assist the physician by injecting fluids through bronchoscope port, assisting with the forceps and brushes. C. Handle specimens.

High frequency jet ventilation tubes look lie standard tubes with two additional lines. what are they?

A. One line is for the high-pressure injection. B. The other can be used for humidification, liquids, and pressure monitoring.

What three types of cardiopulmonary monitoring devices are considered essential for this procedure?

A. Pulse oximeter B. Blood pressure C. ECG

name three advantages of the percutaneous technique compared with traditional surgical tracheotomy

A. Rapid B. Avoids the need for transport to the operating room C. Lower incidence of intraoperative and postoperative complications

Describe the two different strategies for removing the tube itself

A. Remove the tube during peak inspiration. B. Remove the tube as the patient coughs.

Give two disadvantages of the LMA

A. Risk of aspiration, does not protect the airway B. Only ventilates at low pressures

List five types of equipment you will want to assemble prior to extubation

A. Suction equipment B. Oxygen/aerosol equipment C. Manual resuscitator and mask D. Aerosol nebulizer and racemic epinephrine (PRN) E. Intubation equipment

State three airway emergencies

A. Tube obstruction B. Cuff leaks C. Accidental extubation

How will you determine the need for suctioning?

Assess breath sounds and look for secretions in the airway.

How long, with what FiO2, should you preoxygenate?

At least 30 to 60 seconds with 100% oxygen, either from the ventilator or a bag. If the ventilator is used, allow for washout time.

The worst complication of extubation is laryngospasm. What can you do if this persists for longer than a few seconds?

Attempt to manually ventilate the patient with the resuscitation bag and mask in the event of extended laryngospasm. If unable to ventilate, the patient should be given a neuromuscular blocking agent and reintubated.

What simple technique is used to assess tube obstructions that are not relieved by repositioning the head or deflating the cuff?

Attempting to pass a suction catheter through the tube

What is the final step of confirming the placement of a endotacheal tube?

Chest x-ray

What is the worst problem that results form inadequate humidification of the artificial airway?

Complete obstruction of the tube and asphyxiation

What is the worst problem that results from inadequate humidification of the artificial airway?

Complete obstruction of the tube and asphyxiation

What therapeutic modality is usually applied immediately after extubation.

Cool mist with oxygen as needed are applied. It is equally common to use a cannula or mask if the patient does not have any complications.

What special catheter is used to facilitate entry into the left mainstem bronchus?

Coude catheter with bent tip

what happens to cuff pressures when the tube is too small for the patients trachea?

Cuff pressures will have to be elevated—maybe excessively so—to achieve a seal.

Give examples of a specific drug and the general goal for each of the following classes of pre-medication used in bronchoscopy

DRUG CLASS EXAMPLE GOAL A. Tranquilizer Valium, Versed Decreased anxiety B. Drying agent Atropine Aid visibility, anesthesia C. Narcotic-analgesic Morphine, fentanyl Reduce pain, reflexes D. Anesthetic Lidocaine, cocaine Reduces reflexes

Describe the method for performing a cuff leak test

Deflate the cuff, and assess leaking around the tube during positive pressure ventilation. Compare the exhaled volumes, and quantify the leak. Egan's suggests 12% to 15% as a good percentage of leak for considering extubation.

Direct vizualization

Direct visualization: Visualize the larynx with a laryngoscope. Advance the tube into the larynx with the use of Magill forceps.

What is the most common material used to secure endotracheal tubes? Tracheostomy tubes?

ET tubes are secured with tape. Tracheostomy tubes are secured with cloth ties. Commercial harnesses are available for both types of tubes.

Why is the combitube potentially useful in the field

Ease of insertion, no need to visualize or use a scope

continuous aspiration of subglottic secretions is the generic name for the Hi-low Evac tube. What is the reported benefit of subglottic suction tube?

Evac tubes are intended to reduce the incidence of VAP.

how do flexion and extension of the neck affect tube motion? what is the average distance the tube will move in cm?

Extension (head up) moves the tube up. Flexion moves the tube down. The tube may move as much as 1.9 cm in either direction.

If you cannot clear the obstruction, what action should you be prepared to take?

Extubation and manual ventilation by bag/mask followed by reintubation

What action should you be prepared to take if the cuff is blown?

First try to reinflate the cuff and determine if the leak is in the pilot tube and valve. Check the pressure and tube position to determine if the tube is too high in the airway (which also makes a leak). If the cuff is really blown, and the patient requires ventilation, you must prepare to reintubate.

what protective gear do you need to use when performing trach care?

Goggles and gloves (face shield/mask and gown are OK, too)

What device can be used as an alternative to heated humidifiers for short term humidification of the intubated patient?

Heat-moisture exchangers

Describe the shape of a modern tube cuff.

High residual volume, low pressure; a big, soft rectangle

List two or three of the most common problems that occur after extubation

Hoarseness, sore throat, cough, trouble swallowing

Compare tracheal malacia and tracheal stenosis in terms of cause, pathology, and treatment

INJURY CAUSE PATHOLOGY TREATMENT A. Malacia Softening of rings Collapse of trachea Resection B. Stenosis Narrowing Fibrous scarring Laser resection

laryngeal injuries associated with intubation in terms of symptoms and treatment

INJURY SYMPTOMS TREATMENT A. Glottic edema Hoarseness, stridor Racemic epinephrine, steroids B. Vocal cord inflammation Hoarseness Usually resolves quickly C. Laryngeal ulceration Hoarseness, difficulty swallowing Surgery may be needed D. Polyp/granuloma Difficulty swallowing, hoarseness, stridor If symptoms do not resolve, surgical removal is indicated. E. Vocal cord paralysis Hoarseness, stridor Tracheotomy may be needed. F. Laryngeal stenosis Stridor, hoarseness Surgical correction of tracheotomy

what is the disadvantage of using capnographyc or colorimetric analysis of carbon dioxide to assess intubation in a cardiac arrest victim?

If the patient has poor blood flow or no perfusion, the device won't be able to detect intubation.

What is recommended safe cuff pressure? what is the consequence of elevated cuff pressure

Keep the cuff pressures below the 20 to 25 mm Hg (or below 25 to 35 cm H2O) which will maintain tracheal mucosal capillary blood flow. If cuff pressure exceeds the mucosal perfusion pressure, ischemia, ulceration, and necrosis may result. If cuff pressures are too low, lung infections are more likely secondary to material above the cuff sliding past the cuff and into the lungs.

what drugs do you use to numb the airways?

Lidocaine could numb the nose; benzocaine for the throat

What effects will occur with a cuff leak when a patient is being mechanically ventilated?

Loss of delivered volume and decreased inspiratory pressures

What drugs are used to sedate a patient?

Muscle relaxing or paralyzing agents

What specialized airway is used to facilitate repeated nasal suctioning?

Nasopharyngeal airway

how long must you attempt intubation? why do you think we have a rule like this?

No more than 30 seconds; otherwise, the patient will become hypoxic.

what is the preferred route for establishing an emergency tracheal airway?

Orotracheal or oral intubation

what drugs are used for vasoconstriction/prevent bleeding?

Phenylephrine

When is a tracheotomy the preferred route of airway management?

Preferred route to overcome airway obstruction or trauma, or to best manage the airway for long-term care of patients with neuromuscular disease

a trach can be temporarily closed with a finger. A more effective solution in the long run is the Passy-Muir Valve. What do you need to do witht he cuff? How about the ventilator?

The cuff needs to be partially deflated; sometimes the tube is changed. The tidal volume can be increased to compensate.

What is a King airway

The new "comitube" replaces that device and the oral airway. It is easier to insert and ventilate the patient.

The primary indication for performing a tracheotomy?

The primary indication is the need for an artificial airway for a prolonged period of time.

State one advantage and three disadvantages of the metal rigid bronchoscope

The rigid bronchoscope has a large inside diameter that facilitates surgery and removal of foreign material and mucous plugs. It is very uncomfortable, requires an anesthesiologist in an operating room setting, and cannot be used to access smaller airways.

When should you use a video laryngoscope

The video laryngoscope lets you see directly on a screen. It is useful for difficult intubations.

once the tube is inserted, how can you quickly assess placement?

There are several methods. Listen for equal, bilateral breath sounds and observe chest motion. Listen over the stomach. Check depth of insertion. Use an EDD or colorimeter. Check with a light wand.

Why are minimum leak and minimum occluding volume no longer recommended?

They increase the risk of silent aspiration.

What kind of patients might need to remain intubated even after the ventilator is removed?

Those with poor airway control or excessive secretions

describe two common trouble shooting procedures used when the laryngoscope does not light up properly.

Tighten the bulb. Check batteries. Replace the bulb.

Why is suction equipment needed for intubation?

To clear vomit or secretions so you can visualize the vocal cords

Describe the tracheoesophageal fistula in terms of cause, complication, and treatment

Tracheoesophageal fistula is caused by tracheal erosion from cuffs, esophageal erosion from NG tubes, malnutrition, or poor surgical technique. Aspiration may occur. Treatment involves surgical closure of the opening.

compare the location of placement in percutaneous and traditional surgical tracheotomy

Traditional surgical tracheotomy places the tube in the neck over the second or third tracheal ring. Percutaneous trach tubes are placed between the cricoid cartilage and the first ring, or between the first and second tracheal rings.

What type of lung disease requires the use of a double lumen ET tube?

Unilateral lung disease

Oral feeding should be withheld for how long following extubation? Why?

Up to 24 hours (at least 4 hours) to avoid the risk of aspiration; ice chips can be given fairly quickly in some patients

what other actions must be taken before making any attempt to intubate??

Ventilate and preoxygenate the patient

how is a catheter prepared to prevent trauma during this procedure

Water-soluble lubricant

People with endotracheal tubes cant talk, and they shouldn't. what device is used to help with communication?

Writing boards

You will need to suction which two places before extubating?

You need to suction the endotracheal tube and then the pharynx above the cuff.

prior to insertion how should the RT rest the tube?

check the cuff for leaks

Also called Carlen's or endobronchial tubes. what is the name of the special type of ventilation used with this tube?

independent lung ventilation (ILV)

What will decrease the risk of damage to the trachea from the endotracheal tube cuff?

maintaining cuff pressures of 25 cm H2O and utilizing high volume low pressure cuff

What device do you need to include when you want to collect a sputum specimen during suctioning?

"Sputum trap" is its common name; it's also called a "specimen container."

The diameter of the suction catheter for an adult should be no longer than...

1/2 the inner diameter of the ET tube

What size suction catheter is suggested using the RULE OF THUMB found in Egan's?

14 French

After suctioning you will need to check the cuff pressure. what is a safe cuff pressure?

20 to 25 mm Hg or 25 to 30 cm H2O

What temperature range must be maintained in a heated humidification system provide adequate impaired moisture?

32° to 35º C

what vacuum, pressure should be set prior to suctioning

80 to 100 mm Hg- infant 100 to 120 mm Hg- child 120 to 150 mm Hg- adult

How is food coloring used to treat for aspiration?

A methylene blue test is performed by adding methylene blue to the patient's tube feedings, or by adding it to some type of food (the book says water, but it is common to see something cold and thick like sherbet being used) and having the patient swallow a small amount. Next, the airway is suctioned. If you observe blue dye in the secretions, you know that the patient has aspirated. This practice is controversial, and some facilities no longer use it. Any food coloring could work.

What are clues and what are immediate and corrective actions taken when dealing with tracheoiminate fistula?

A pulsating tracheostomy tube may be the only clue. Once hemorrhage begins, hyperinflation of the cuff may help, but surgery is needed. Only 25% of these patients will survive.

Describe three techniques that can be used to decrease the risk of infection.

A. Adhering to sterile technique with suctioning B. Using aseptic or sterile equipment C. Handwashing

Name four types of practitioners who most common perform endotracheal intubation

A. Anesthesiologist, emergency department doctor, or pulmonary specialist B. Respiratory therapist C. Paramedic D. Registered nurse (usually nurse anesthetist)

Describe the eight basic steps of tracheostomy care

A. Assemble and check equipment. B. Explain the procedure to the patient. C. Perform endotracheal suctioning. D. Clean the inner cannula or dispose of it. E. Clean the stoma and change the dressing. F. Change the ties or Velcro holder. G. Replace the inner cannula. H. Assess the patient.

Name the 9 methods for bedside assessment of the correct tube positioning.

A. Ausculate chest and abdomen B. Observe chest movement C. Tube length at teeth D. Esophageal detection device E. Light wand F. Capnometry G. Colorimetry H. Fiberoptic laryngoscope or bronchoscope I. Video laryngoscope

State at least four reasons why tracheal airways always increases the risk infection

A. Bypass upper airway filtration B. Increase aspiration from the pharynx C. Contaminated equipment or solutions D. Impaired mucociliary clearance in trachea

when would you use nasotracheal intuabtion over oral intubation?

A. Cervical spine injuries B. Maxillofacial injuries

Give three advantages of the LMA

A. Easy to insert B. No special equipment C. Avoids trauma

name 2 anatomic landmarks to be visualized prior to intubation.

A. Epiglottis B. Glottis, arytenoid

Name the three most common tracheal lessions

A. Granulomas B. Tracheomalacia C. Tracheal stenosis

give 4 reasons why a tube may become obstructed.

A. Kinking or biting on the tube (if the patient has an oral ETT in place) B. Herniation of the cuff over the tube tip C. Jamming of the tube orifice against the tracheal wall D. Mucus plugging

What would RT's nebulize prior to the procedure on a nonintubated patient?

A. Lidocaine B. Albuterol if wheezing

What indicated edema in the upper airways

Stridor

A common complication of extubation is glottic edema. How will you recognize and treat this problem?

Stridor indicates glottic edema. Racemic epinephrine can be given to reduce the swelling. Reintubation may be needed.

State the tree methods for weaning form a tracheotomy tube. Give one advantage and one disadvantage for each technique.

TECHNIQUE ADVANTAGE DISADVANTAGE A. Fenestrated tubes Easy to suction, ventilate Malposition, granuloma B. Progressively smaller tube Stoma healing, gradual Impairs cough, obstructs easily C. Tracheostomy button Low resistance, suction No cuff

What is a talking trach? what are some of the problems with these gadgets?

Talking tracheostomy tubes allow a flow of oxygen or air to be directed above the cuff and through the vocal cords, which allows the patient to talk. These are bulky and difficult to use.

describe the sequence for removing an ET during the tracheotomy procedure

The ET tube should remain in place until just prior to inserting the tracheostomy tube. As you insert the trach, the cuff of the ET is deflated, and it is removed more or less at the same time as the trach is pushed into place.

compare the Miller and Macintosh laryngoscope blades during the intubation procedure

The MacIntosh blade fits into the vallecula (at the base of the tongue) and lifts the epiglottis indirectly. The Miller blade slips under the epiglottis and directly lifts the epiglottis out of the way to allow visualization of the glottis. The Miller is more commonly used in pediatric patients, because their epiglottis is not as rigid as an adult's and must be lifted out of the way.

How are tube sizes selected for adults? How does size differ for men and women?

Similarly by size, but women usually get smaller tubes than men. No. 8 is the standard size for adults. Small women may get 6.5 to 7.5, whereas larger men may be intubated with a No. 9. The largest tube is best for low resistance and

Blind insertion

Blind: Insert the tube through the nose in an upright patient, listening through the tube for breath sounds. Advance the tube on inspiration because the airway opening will be at its widest.

How are tubes sized for selected infants?

By weight

How should you position a patient for nasotracheal suctioning>

Sitting up, sniffing position

how is the head positioned to align the mouth, pharynx, and larynx?

Sniffing position and rolled towel under the head

Why do you need to be careful when you're putting a device in someones mouth?

Reference: Page 733, Gagging and vomiting may occur; also bradycardia and oral trauma.

Oral suctioning alone is usually accomplished with a rigid plastic tube called a tonsil tip. Whats the other common name for this device

Reference: Page 733, Yankauer suction

Complications, causes, and prevention of: Hypoxemia, Cardiac arryhmia, Hypotension, Atelectasis, Mucosal trauma, and Increased ICP::

Reference: Pages 737-738 COMPLICATION CAUSE PREVENTION A. Hypoxemia:Removes O2 from the lungs Preoxygenate with 100% oxygen B. Cardiac arrhythmia:Hypoxia, vagal stimulation, Pre- and post-oxygenation on 100% C. Hypotension:Cough, vagal stimulation, Topical anesthetic D. Atelectasis: Suction, Hyperinflation before and after procedure E. Mucosal trauma:Vacuum, technique,Use appropriate suction pressure technique F. Increased ICP: Cough, Topical anesthetic

What additional troubleshooting step can often be performed on patients with tracheostomies?

Remove the inner cannula and check to see if it is plugged

What is the most common cause of airway obstruction in the critically ill patient?

Retained secretions