Critical Care Techniques Day 7

Front 1

Assignment 7

Back 1

Egan chapter 36 page 768 to 788

Front 2

Airway trauma assocciate with tracheal tubes

Back 2

Tracheal lesions

:granulomas

:tracheomalacia

:tracheal stenosis

:tracheosophageal fistula

:tracheo inominate artery erosion

Front 3

Airway trauma associated with tracheal tubes

Back 3

Treatment

:depends on severity, especially length and circumference of damage

:Laser therapy may be useful for small lesions

:Resection and end to end anastomosis(tying to tubes together) may be indicated when damage involves less than three tracheal rings

:Staged repair and stents may be required for more involved damages

Prevention

:Tube movement is primary cause of injury

:sedation can help avoid self extubation

:nasotracheal tubes are easier to stabilize

:swivel adapter can reduce tube traction

:Selection of correct airway size is important

:Maintain pressure of 25 to 36 cm H2O to reduce tracheal wall injury

Front 4

Airway trauma associated with tracheal tubes

Back 4

Alternative cuff designs

:Lans tub incorporates external pressure regulating valve and control reservoir

::Designed to limit cuff pressure between 16 and 18 mm Hg

:Foam cuff designed to seal trachea with atmospheric pressure in cuff

::Not commonly used except in patients who have already developed tracheal injury

Alternative cuff designs continued

:Tight to shaft cuff

::Low volume, high pressure cuff design

::That maximizes airflow around cuff when deflated

::Can only be inflated with sterile water not air since it is made of porous silicone material

Front 5

Speaking valve

Back 5

cuff must be deflated so you can get air in around the tube

:one way valve that fit over trach and allows inspiration through trach but not expiration

:Air is directed up through vocal cords enabling patient to speak. Cuff must be deflated

::Often referred to as a passy muir valve

:Air is directed up through vocal cors enabling patient to speak. Cuff must be deflated

Front 6

Tracheostomy tubes

Back 6

RT responsibilities

:maintenance of patent airway

:provide humidification and hydration

:Suction PRN

:infection prevention

:Maintain tube in correct alignment

:regular trach care (RN or RT) per hospital policy

Front 7

Tracheostomy care

Back 7

Equipment:

:Trach dressing kit with sterile gloves

:2 pair clean gloves

:Suction kit with catheter and sterile gloves

:10 ml syringe

:Oxygen source and suction source

:Manual resuscitator

Front 8

Troubleshooting airway emergencies

Back 8

Tube obstruction

:kinking or biting tube

::Obstruction is reversed by moving patients head and neck or respositioning tube

:Herniation of cuff over tip

::Deflate cuff

::If deflating cuff failrs to overcome obstruction, try to pass suction catheter through tube

Front 9

Troubleshooting airway emergencie

Back 9

Obstruction of tube orifice against tracheal walll

:Mucus plugging

::Suction tube if instillation of sterile normal saline is not necessary

Cuff Leads

:primarily problem for patients receiving mechanical ventilation

:will cause reduced delivery of tidal volume

:If pilot valve is leaking, tube needs to be changed as soon as possible

::Pilot valve repair kit offers safe and effective alternative by permitting insertion of replacement valve into pilot tubing

Cuff Leaks

:Ruptured cuff requires extubation and reintubation or using endotracheal tube exhanger

::ETT tube exchanger is a semi rigid guide like a bousgie, over which damaged tube can be removed and new tube inserted

Front 10

Troubleshooting airway emergencies

Back 10

Spare trach

:Same sized taped above the bed in case the tube gets obstructed, pulled out etc

:Manual resuscitator with ped mask is good if available

Front 11

Troubleshooting airway emergencies

Back 11

Accidental extubation

:partial displacement of airway out of trachea can be detected by:

::decreased breath sounds

::Decreased airflow through tube

::Decreased ability to pass catheter past end of tube

Front 12

Troubleshooting airway emergencies

Back 12

Accidental extubation

:With positive pressure ventilation, airflow through mouth and nose or into stomach may be heard

::Completely remove tube and provide ventilatory support by manual resuscitator and mask as needed

::Until patient can be reintubated or trachesotomy tube reinserted

Front 13

Decannulation

Back 13

Removal of tracheostomy tube

Weaning process

:Fenestrated tube

::Double cannulated tube that has opening in posterior wall of outer cannula ablove cuff

:Progressively smaller tubes

:Tracheotomy buttons

Front 14

Alternative airway devices

Back 14

Laryngeal mask airway (LMA)

:consists of short tube and small mask that is inserted deep into oropharynx

:Open surface of mask faces laryngeal opening

:Ventilation is directed to lungs

Artificial airways (EOA) Esophageal obturator airway

:Designed to faciliate blind intubation quickly and effectively

EOA

: is positioned into the esophagus, the distal cuff is inflated with the syringe

:esophagus is sealed, air cannot enter the stomach. it is diverted into the trachea

Includes mask, syringe and airway tube with check valve

Front 15

Indications for various EOA type devices

Back 15

Emergency responders not trained in endotracheal intubation

Attempted endotracheal intubation has not been successful

Patient is apneic, without reflexes and unconscious

Front 16

Contraindications

Back 16

Endotracheal intubation can be performed

Patient is responsive with gag reflex

EOA would be in place less than 1 to 2 hours until they are intubated

Patient is known to have:

:Esophageal trauma

:pathology

:Ingested corrosive substance

Front 17

Alternative airway devices

Back 17

Laryngeal mask airway (MLA)

:LMAs range in sizes from size 5 for aduluts to size 1 for infants

:DIsadvantages

::Cannot be used in conscious or semi comatose patients due to stimulation of gag reflex

::If ventilation pressure greater than 20 cm H2O is needed, gastric distention may occur

Front 18

Artifiicial airways LMA

Back 18

LMA laryngeal mask airway used by anesthesiologist

:Cuff seals the larynx when inflated, does not absolutely protect against aspiration

:usually used for simple surgery

:Or can not intubate patient

Double lumen airway

:also called combitute

:Inserted blindly through oropharynx into R mainstem bronchus

:Has two external openings, two 15 mm adapters, two lumens and 2 cuffs

:One cuff seals the oropharynx and second seals the right mainstem bronchus

:Combitube

::A double lumen tube

::Patient can be ventilated via esophagus or trachea

Front 19

Artificial airways combitube

Back 19

Advantages

:all of the same as tracheal airway

:for independent lung ventilation

Front 20

Bronchoscopy

Back 20

Insertion of visualization instrument endoscope into bronchi

Purpose

:Inspect airways

:Collect samples

:Remove foreign objects

:place devices into airway

There is diagnostic (75% of them) or therapeutic

Two different bronchoscopic techniques

:Rigid tube bronchoscopy

:Flexible bronchoscopy

Front 21

Rigid tube bronchoscopy

Back 21

Open metal tube with distal light source

Port for attaching oxygen or ventilating equipment

Used most often by otorhinolaryngologist and thoracic surgeons

Disadvantages

:very uncomfortable for conscious patients

:Usually requires assistance of anesthesiologist and use of operating room

:cannot assess smaller airways

Front 22

Bronchoscopy

Back 22

Flexible fiberoptic bronchoscopy

:gained popularity because it allows access to small airways

:typical scope has three Channels

::light transmission channel

::visualization channel

::multipurpose open channel

:::Used to give O2 take tissue samples and suction

Front 23

Bronchoscopy

Back 23

Premedication

:Sedatives reduce anxiety

:Anticholinergic agent dry patients airway

:narcotic analgesics may also be given to reduce pain

Equipment preparation

:RTs are often responsible for preparing equipment

:thoroughly checking for function, tight connections and integrity

Front 24

Bronchoscopy

Back 24

Airway preparation

:Goal is to prevent bleeding, coughing, gagging, pain

:Topical vasoconstrictors

::racemic epi or

::lidocaine may be used to prevent bleeding

:Airway anesthesia (lidocaine) is achieved by topical anesthetics or nerve block

Front 25

Bronchoscopy

Back 25

Monitoring

:RTs have active role in monitoring

::SpO2, EKG, vital signs

Complications

:hypoxemia

::Minimized by providing oxygen before and after procedure

:Hemodynamic changes,

::Heart rate, BP, and cardiac output vary depending on technique and medications used

Front 26

Complications

Back 26

Bronchoscopy complications

:Bronchospasm

::Premediccate with bronchodilators

::Fentanyl are better for asthma patients

:RT should be present during procedure

::Adjust ventilator

::monitor SpO2

::exhaled volumes

Front 27

Tracheostomy

Back 27

Artifiial airway position in trachea

More complicated then ETT intubation!

Percutaneous tracheostomy insertion

Front 28

Trachesotomy

Back 28

Insertion of a trach tube in place of a ETT, 2nd, 3rd, 4th cartilage below cricoid

Advantages

:pt has ability to talk

:less gag reflex

:easy to SX

:easy oral care

Front 29

Cricothyrodomy kit

Back 29

Its an emergency procedure, into the cricothyroid cartilage for ventilation