Artificial Airways

Reference: Hartshorn, Chapter 6

I. Indications for artificial airway placement

A. Upper airway obstruction

B. Profuse secretions
C. Need for mechanical ventilation (needs cuffed tube)
D. Likelihood of aspirating gastric contents, ie. decreased LOC. anesthesia, decreased
protective reflexes - gag, cough
II. Types
A. Oropharyngeal / nasopharygeal: indicated to establish a patent airway in emergency
situation and following procedures such as surgery
B. Endotracheal tubes - may be orotracheal or nasotracheal
1. nasotracheal - easier to stabilize, decreased risk of extubation, may be better
tolerated, a smaller diameter tube must be used to minimize tissue trauma
2. Orotracheal - more commonly used, larger diameter lessens airway resistance,
indicated with thick copious secretions which require larger suction catheter, low
compliance cuffs minimize trauma to tra chea/larynx
3. Insertion preparation:
a. check cuff
b. preoxygenated with 100% O2 for 1-2 minutes
c. assist physical or other qualified individual with insertion
d. assess for dysrhythmias, client tolerance,
4. Post insertion:
a. assess for correct placement: Look, listen, feel: airflow through tube
opening, symmetrical chest movement, bilateral breath sounds, STAT
chest Xray correct placement - 3 cm above the carina
b. mark/document exit point - cm at gum line
c. Secure tube (tape, velcro holder, biteblock)
C. Tracheostomy tubes: airway of choice for long term (more than 3 weeks of mechanical
ventilation, decreased anatomical deadspace, increased alveolar ventilation; allows client
to eat and with adaptations, to speak
D. Complications - ex: damage to trachea, vocal cords, self-extubation, more secretions,
III. Nursing Diagnoses / Care
A. Potential ineffective airway clearance r/t:
1. malposition / loss of airway
- esophageal intubation, intrabronchial intubation
- body movements (neck extension, flexion)
- inadequate securing, inadequate seal
Interventions:
Frequent ascultation - bilateral breath sounds
Keep airway and bag/valve/mask device at bedside
Check tape and exit line q 2 hrs
Use minimal air leak technique to prevent excess air leak around tube
 If trach - keep obturator, tracheal dilator and new trach at bedside
Secure new trach ties before removing old (2 person technique when
possible); same for replacing endotracheal tape
2. obstruction of artificial airway - tube kinking, pooling of blood and secretions,
biting of orotracheal tube by agitated client, placement against carina
Interventions:
Position head/neck to avoid flexion
support ventilator tubing with rolled towels
use bite block for orotracheal tubes
provide humidification to keep secretions thin, suction as needed
Clean and replace inner cannula of tracheostomy q 8hrs.
B. Potential for infection r/t contamination of respiratory tract
Interventions:
Use sterile technique during suctioning and trach care
Suction through mouth/nares at least q 8 hrs
Drain water in ventilator tubing into basin or trap NOT back into reservoir
Report/culture purulent drainage
Prevent aspiration or oral/gastric secretions with adequate oral suctioning proper
cuff inflation
Use of NG tube if indicated
C. Potential for injury; tissue damage r/t
- prolonged pressure on nares/lips
- prolonged/excessive endotracheal cuff pressure (damage to trachea, glottis, sub- glottal
area, larynx)
- bleeding - erosion of tube into innominate artery, note any pulsations of the tube (may
signal impending rupture), hyperinflate cuff to tamponade
Interventions:
reposition orotracheal tube q 8hrs, 1 hold and 1 reposition (deflating cuff not
necessary) and retape
Use minimal occluding volume or minimal leak techniques (inflate cuff until
inspiratory leak no longer audible; withdraw a small amt of air so slight leak is
present at peak inspiration
record measured pressure/cuff volume q 8hrs
use small size NG tubes or flexible Dobhoff feeding tubes to prevent tracheal
necrosis
IV. Nursing Interventions: Tracheal Suctioning
A. Indications
Ventilator high pressure alarm
Increased or new crackles, rhonchi, wheezing
Excessive accumulation of secretions in endotracheal or ventilator tubing
Cyanosis, esp. Circumoral
Dyspnea
marked retractions of the chest, nasal flaring, grunting
Apprehension in conjunction with any of the above
B. Potential complications / Interventions
Hypoxia - to minimize suction only 10-154 sec per time or "pass", monitor heart
rate and rhythm, BP, preoxygenate and hyperventilate before and after each pass
Cardiac dysrhythmias, cardiovascular collapse, cardiac arrest - due to hypoxia or
vagal stimulation
Atelectasis - due to catheter wedging in small bronchial tubes - to prevent use
intermittent suction only, suction on removal of catheter only, no suction on
insertion, use catheter no greater than 1/2 size of the ETT or Trach diameter
Damage to mucosal lining - minimize by avoiding jabbing motion, use rolled tip
catheter, use intermittent suction
Aspiration of stomach contents secondary to stimulation of gag reflex - keep
balloon inflated during suctioning,
Contamination - MUST USE ASEPTIC TECHNIQUE and meet universal
precautions