Artificial Airways
• Endotracheal (ET) intubation
• Tube placed into the trachea via the mouth or nose past the
larynx
• Can be preformed quickly and safely at the bedside
• Indications include:
1. Upper airway obstruction
2. High risk of aspiration
3. Ineffective clearance of secretions
4. Respiratory distress
• Disadvantages: Oral Intubation
1. Difficult to place oral tube if head and neck mobility
are limited
2. Teeth can be chipped or inadvertently dislodged
during the procedure
3. Salivation is increased and swallowing is difficult
4. Often pt will obstruct by biting down on tube (use
bite block)
5. Mouth care is challenging
6. Larger tubes, as used in oral intubation are associated
with laryngeal trauma and subglottic stenosis,
particularly in smaller individuals
• Nasal ET intubation
1. Sometimes preferred b/c it is more stable and more
difficult to dislodge
2. It is placed blindly and indicated when head and neck
manipulation is risky
3. May be uncomfortable b/c it presses on septum
• Advantages: Nasal
1. No need for bite block
2. Mouth care easier than oral route
• Disadvantages:
1. Subject to kinking
2. Work to breath is greater b/c smaller diameter tube
3. Suction and secretion removal more difficult
4. Linked with increased incidence of sinus infections,
which may be source of sepsis
• ET Intubation Procedure:
 All pt being intubated need self-inflating bag-valve-
mask (BVM) attached to O2 and suction equipment
ready and available at the bedside
 Sedative-hypnotic-amnesic is used if pt is agitated,
disorientated, or combative
 Rapid onset narcotic—Fentanyl may be used
 Paralytic – succinylcholine (Anectine) may be used
 Atropine – to limit secretions
 Pulse ox is monitored during procedure
• Oral intubation-
 Place supine with head extended and neck flexed
(Sniffing position)
 Preoxygenated before procedure for 3-5 mins 100%
O2
 Each intubation attempt limited to 30 secs
 Ventilated between each unsuccessful attempt
 Cuff inflated and placement checked following
intubation
 Auscultate breath sounds observe chest movement
 SPO2 >95%
 ABG’s obtained 10-20 mins following intubation
• Nsg responsibilities:
1. Maintaining correct tube placement
• Q 2-4 hours
• Confirm exit mark on tube
• Chest wall movement and Auscultate to
confirm bilateral breath sounds
• If dislodged- RN stays with pt, maintains
airway, secures appropriate assistance to
immediately replace tube
2. Maintaining proper cuff inflation
• Cuff pressure maintained @ 20-25 mm Hg
• Measure and record p intubation & Q 8
hours using MOV technique
o Mechanically vented- place
stethoscope over trachea and inflate
cuff until no air leak is heard
 spontaneously breathing pt- inflate
cuff until no air leak heard p deep
breath or p inhalation w BMV
• Use manometer to verify cuff pressure
between 20-25
• Record cuff pressure in chart
• If adequate pressure can’t be maintained or
lg volumes or air are needed cuff could be
leaking. Needs to be changed within 24 hrs
or sooner if pt decompensate
3. Monitoring oxygenation and ventilation
4. Maintain tube patency
• Indications for suctioning
o Visible secretions in tube
o Sudden onset or resp distress
o Suspected aspiration
o Increase in peak airway pressures
o Auscultation of adventitious breath
sounds over trachea &/or bronchi
o Increase in RR, sustained coughing
o Sudden or gradual decrease in
PaO2 &/or SpO2
• Encourage pt to cough if they cant suction is
needed (10 sec or less)
5. Assessing for complications
6. Providing oral care and maintaining skin integrity
• Oral care Q 2-4 hrs and PRN
7. Fostering comfort and communication
• Pt may require—morphine, Ativan, or other
sedatives
• 2 major complications:
 Inadvertent extubation
• STAY WITH PT
 Aspiration
• SUCTION!!
• Suction posterior pharynx before deflating
cuff (in case mucous build up on cuff)
• Tracheostomy
• Through a stoma in the neck
• Perform when artificial airway is long term
• Surgical procedure
Mechanical Ventilation
• Types
1. Negative pressure Vents
• Incases the chest and pulls upward causing air to rush
in lungs
• No artificial airway required
• Expiration is passive
• Not used for acutely ill pts
2. Positive pressure Vents
• Primary method used with acutely ill pts
• Vent pushes air into lungs during inspiration
• Expiration passive
1. Volume vents
• Predetermined tidal volume is
delivered c each inspiration and
amount of pressure needed to
deliver the breath varies based on
compliance and resistance
2. Pressure vents
• Peak inspiratory pressure is
predetermined and the tidal
volume varies based on
selected pressure and
compliance and resistance
factors
• Modes of volume ventilation
o Controlled Mandatory Ventilation (CMV)
 Breaths given at a set rate
o Assisted- control Mechanical Ventilation (ACV)
 Pt can breath faster than preset but not slower
 Vigilant assessment b/c they can be hyperventilated
and hypoventilated
o Synchronized Intermittent Mandatory Ventilation (SIMV)
  Preset volume at preset frequency in synchrony c pt’s
own breath
 All breaths are the same volume (opposed to ACV)
 Only used in pts with regular, spontaneous breathing
o Pressure Support Ventilation (PSV)
 Pressure applied only during inspiration and used
with pt’s own respirations
 Pt determines length and rate
o Pressure-Controlled Inverse Ratio Ventilation (PC-IRV) Trach/ ET care and suctioning
 Requires pt to be sedated or paralyzed Tracheostomy
• Other Ventilatory Maneuvers • Indications:
o Positive End-Expiratory Pressure (PEEP) o Bypass upper airway obstruction
 Positive pressure applied during exhalation o Facilitate removal of secretions
o Continuous Positive Airway Pressure (CPAP) o Permit long-term mechanical ventilation
 Pressure delivered continuously during o Permit oral intake and speech in the pt who requires long-
spontaneously breathing term mechanical vent
o High Frequency Ventilation (HFV) • Proving Tracheostomy Care
 Small tidal volume at rapid rates in effort to recruit o Before deflation the pt should cough up any secretion if
and maintain lung volume possible and tube and mouth suctioned
o Partial Liquid Ventilation (PLV) o Cuff deflated during exhalation and pt should cough and
 Clinical trail are being preformed suction after deflation
o If tube dislodged the RN must attempt to immediately
Indicators for Mechanical Ventilation and Weaning replace it
• Spontaneous tidal volume (SV1)
o Amount of air exchanged during normal breathing at rest
o Norm: 7-9 ml/kg
• Positive expiratory pressure (PEP)
o Norm 60-85 cm H2O