methods of controlling airway

8/9/2019 Methods of Controlling Airway

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D. METHODS OF CONTROLLING AIRWAY

1. TRACHEOSTOMY

- is the surgical creation of a stoma, or opening, into the

trachea through overlying skin.

PURPOSE: Tracheostomy can be performed as an emergency procedure or

as an elective procedure, depending on the indication

INDICATIONS:

y Relief of acute or chronic upper airway obstruction, such as obstructivesleep apnea, trauma, bleeding, tumor, tissue swelling infections, or

burns (chemical or inhalation)

y Access for continuous mechanical ventilation, with the inability to wean(broadly defined as greater than two weeks of ventilation)

y Promotion of pulmonary hygiene will be accessing airway for secretionremoval

y Bilateral vocal cord paralysisy Inability to protect own airway

CONTRAINDICATIONS:

Absolute:Emergent tracheostomy ( i.e., securing emergent airway) in any patientpopulation, infants and children (18 cm), high airway pressure (>45 cm), high FiO2 (80%),retrognathic mandible with a limited view of the larynx on laryngoscopy


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Tracheostomy Care

Rubbing of the trach tube and secretions can irritate the skin around thestoma. Daily care of the trach site is needed to prevent infection and skinbreakdown under the tracheostomy tube and ties. Care should be done atleast once a day; more often if needed. Children with new trachs or children

on ventilators may need trach care more often. Tracheostomy dressings areused if there is drainage from the tracheostomy site or irritation from thetube rubbing on the skin.

It may be helpful to set up a designated spot in your home for equipmentand routine tracheostomy care.

Equipment

y Sterile cotton tipped applicators (Q-tips)y Trach gauze and "unfilled" gauzey Sterile watery Hydrogen peroxide (1/2 strength with sterile water)y Trach ties and scissors (if ties are to be changed)y Two sterile cups or clean disposable paper cupsy Small blanket or towel roll

Procedure

y Wash your hands.y Explain procedure in a way appropriate for the child's age and

understanding.y Lay your child in a comfortable position on his/her back with a small

blanket or towel roll under his/her shoulders to extend the neck andallow easier visualization and trach care.

y Open Q-tips, trach gauze and regular gauze.y Cut the trach ties to appropriate length (if trach ties are to be

changed).y Pour 1/2 strength hydrogen peroxide into one cup and sterile water

into the other.y Clean the skin around the trach tube with Q-tips soaked in 1/2

strength hydrogen peroxide. Using a rolling motion, work from the


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center outward using 4 swabs, one for each quarter around the stomaand under the flange of the tube. Do not allow any liquid to get intotrach tube or stoma area under the tube. Note: Some doctorsrecommend cleaning with just soap and water in home care, usinghydrogen peroxide only to remove encrusted secretions. This isbecause daily use of hydrogen peroxide might irritate the skin of somechildren.

y Rinse the area with Q-tip soaked in sterile water.y Pat dry with gauze pad or dry Q-tips.y Change the trach ties if needed (See Changing a Tracheostomy Tube).y Check the skin under the trach ties.y Tuck pre-cut trach gauze around and under the trach tube flush to

skin. Do not cut the gauze or use gauze containing cotton because the

child may inhale small particles. Use precut tracheostomy gauze orunfilled gauze opened full length and folded into a U shape or use twogauze pads, one placed under each wing of the tube. Be sure the trachdressing does not fold over and cover the trach tube opening. Changethe dressing when moist, to prevent skin irritation. Tracheostomydressings may not be needed for older tracheostomies when the skin isin good condition and the stoma is completely healed and free fromrash or redness.

yFor tracheostomy tubes with cuffs, check with your doctor for specificcuff orders. Check cuff pressure every 4 hours (usual pressure 15 - 20mm Hg). In general, the cuff pressure should be as low as possiblewhile still maintaining an adequate seal for ventilation.

y Monitor skin for signs of infection. If the stoma area becomes red,swollen, inflamed, warm to touch or has a foul odor, call your doctor.

y Check with the doctor before applying any salves or ointments nearthe trach. If an antibiotic or antifungal ointment is ordered by the

doctor, apply the ointment lightly with a cotton swab in the directionaway from the trach stoma.y Wash your hands after trach care.


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Care of the Inner Cannula

Some older children and teens have trach tubes with an inner cannula.Some inner cannulas are disposable (DIC: Disposable Inner Cannula).These should be changed daily, discarding the old cannula. Check with yourequipment vendor regarding disposable cannulas.

For the reusable cannulas, the cannula should be cleaned 1 to 3 times a dayand more often if needed. Do not leave the inner cannula out for more than15 minutes.

Equipment

y 1/2 strength hydrogen peroxidey Sterile water or normal saliney Two clean or sterile containers (small bowl or cup)y Inner cannula brush (tracheostomy brush or sterile pipe cleaner)y Unfilled gauze pad

Procedure

y Wash your hands.y Explain procedure in a way appropriate for the child's age and

understanding.y Pour 1/2 strength hydrogen peroxide into a bowl or cup and normal

saline or sterile water into the other.y Open the gauze pady Remove the inner cannulay Place the inner cannula into 1/2 strength hydrogen peroxide. Soak it

for a few seconds and use the brush to clean secretions on the insideand outside of cannula.

y Place the cannula into normal saline or sterile water solution, soak andrinse.

y Dry off excess water with clean or sterile gauze pad.y Suction through the outer cannula if needed.y Replace inner cannula. Be sure the cannula is secure or "locked" in

place in the trach tube.y Wash your hands.


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A cuff is a soft balloon around the distal end of the tube that can be inflatedto seal the trachea for children needing ventilator support or to help preventsecretions from entering the lungs.

Avoid over inflating the tracheostomy tube cuff. The pressure of the cuffagainst the wall of the trachea can cause damage if it is too high. Two

techniques that can be used to help avoid excess pressure are the minimaloccluding volume technique and the minimal leak technique.

Suction the trach tube if needed. After suctioning the tube, suction themouth and above the trach cuff so that secretions do not go into lungswhen cuff is deflated.

Cuff Deflation Techniques

y Minimal Occluding Volume Technique: Deflate the cuff, then slowlybegin re-injectingair (or sterile water dependingon the type of tube)with a luer lock syringe. Place a stethoscope to the side of the child'sneck near the trach tube. Injectair into the pilotline until youcannolonger hear air going past the cuff. This means the airway is sealed.For children that are totally ventilation dependent, provide breathswithmanual resuscitator.

yMinimal Leak Technique: The same procedure as Minimal OccludingVolume, except thatafter the airway is sealed, slowly withdraw asmalamount (approximately 1cc), so thata slight leak is heard at the endofinspiration.

Periodic measurements of the cuff volume should be noted and anychanges reported to the doctor. A pressure manometer may be used tocheck cuff pressure on balloons filled with air. Generally, cuff pressureshould be below 25 cmH2O.


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HOW TRACHEOSTOMY IS PERFORMED

Surgical Anatomy

The superior thyroid notch, cricoid and suprasternalnotch usually can be easily palpated through the skin. The cricothyroid

space can be identified by palpating a slight indentation immediately belowthe inferior edge of the thyroid cartilage. Cricothyroid arteries traverse thesuperior aspect of this space on each side and anastomose near themidline.

The innominate artery crosses from left to right anterior to the trachea atthe superior thoracic inlet. Its pulsations can be palpated and occasionallyseen in the suprasternal notch especially in case of a high riding vessel,

representing a contraindication for a bedside percutaneous or opentracheostomy.

The isthmus of the thyroid gland lies across the 2nd to 4th tracheal ringsand must be dealt with in any procedure at or around the upper trachea.

Preparation for Tracheostomy

Once the decision to perform a tracheostomy has been made, the surgeon

must determine if the patient is a good candidate for the surgery and obtainwritten informed consent. In addition, the range of motion of the neckneeds to be assessed. The tracheostomy team, including the surgeons andanesthesiologists need to discuss the entire sequence and alternatives tothe procedure. All equipment must be available and functioning properly.

Equipment

Aregimented approach to preparation and performance of the procedurehas been shown to significantly reduce the incidence of procedural

complications4.

Our approach includes the following equipment and protocols:

y We routinely use Cook Blue Rhino single dilator kit andvideobronchoscopy to perform the procedure.


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y The following must be available:o An attending anesthesiologist must be present for maintenance of

airway, provision of intravenous sedation and performance ofbronchoscopy.

o An intubation roll and a cricoid hook.o Open tracheostomy set.

Technique

The technique described here is based on Seldingers principle 2. Thetechnique we use was first described and later modified by Ciaglia 3. Theuse of bronchoscopy was first introduced by Marelli et al and hassubsequently been adopted by many centers 4, 5.

Positioning

1.The patients neck is extended over a shoulder roll (unless there is acontraindication).

2.The anesthesiologist stands at the head end of the bed and underdirect laryngoscopy positions the endotracheal tube (ETT) so that thecuff is midway at the vocal cord level.

Incision

1.We routinely inject the skin with 1% lidocaine with 1:100,000epinephrine solution.

2.A horizontal or vertical incision centered on the inferior border of thecricoid cartilage may be used. We routinely use a 3-4 cm verticalincision.

Placement of Introducer Needle

1.A minimal dissection is performed onto the pretracheal tissue in orderto push the thyroid isthmus downward.

2.The larynx is stabilized and pulled cephalad with the operators lefthand.

3.A bronchoscopy is then performed and the light reflex is used to selectthe best site for the introducer needle.


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4.Placing the needle at the inferior edge of the light reflex, the tip of theneedle is directed caudad into the tracheal lumen avoiding theposterior tracheal wall at all cost.

Placement of the Tracheostomy Tube

1.A tracheostomy tube is loaded onto the dilator- Females: a size 6 cuffed Shiley tracheostomy tube is loaded on to the26 FR dilator

- Males: a size 8 cuffed Shiley tracheostomy tube is loaded on to the28 FR dilator

2.The dilator is then loaded on the safety ridge of the stylet and placedinto the tracheal lumen under direct visualization.

Confirmation of Placement

The bronchoscope is withdrawn from the ETT and introduced via thetracheostomy tube. The placement is confirmed by visualizing the carina.

Securing the Tube

We routinely secure the tube with 2 sutures of 2-0 nylon on each side of

the flange. In addition, a tracheostomy tape is used to hold the tube inplace. A flexible extension tube is used to connect the tube to the ventilatorcircuit to avoid undue movement of the tube in the immediate postoperativeperiod.

Postoperative Consideration

A chest X-ray is not routinely required as long as the entire procedure wasdone under direct visualization and there were no adverse eventsintraoperatively6. The postoperative care is same as for the open procedure.

The tract between the skin and the tracheal lumen takes a little longer (10-14 days) to mature as there is no formal layer by layer dissection involved.We, therefore, perform the first tube change on Day 10-12 postoperatively.


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Types of Tracheostomy Tubes

A tracheostomy (trach) tube is a curved tube that is inserted into atracheostomy stoma (the hole made in the neck and windpipe (Trachea)).There are different types of tracheostomy tubes that vary in certain featuresfor different purposes. These are manufactured by different companies.However, a specific type of tracheostomy tube will be the same no matterwhich company manufactures them.

A commonly used tracheostomy tube consists of three parts: outer cannulawith flange (neck plate), inner cannula, and an obturator. The outercannula is the outer tube that holds the tracheostomy open. A neck plateextends from the sides of the outer tube and has holes to attach cloth tiesor velcro strap around the neck. The inner cannula fits inside the outer

cannula. It has a lock to keep it from being coughed out, and it is removedfor cleaning. The obturator is used to insert a tracheostomy tube. It fitsinside the tube to provide a smooth surface that guides the tracheostomytube when it is being inserted.

There are different types of tracheostomy tubes available and the patientshould be given the tube that best suits his/her needs. The frequency ofthese tube changes will depend on the type of tube and may possibly alter

during the winter or summer months. Practitioners should refer to specialistpractitioners and/or the manufacturers for advice.


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Types of Tracheostomy Tubes

Tube Indication Recommendations

CuffedTube with Disposable Inner Cannula

Used to obtain a closed

circuit for ventilation

Cuff should be inflated whenusing with ventilators.

Cuff should be inflated justenough to allow minimal airleak.

Cuff should be deflated if patient

uses a speaking valve.Cuff pressure should be checkedtwice a day.

Inner cannula is disposable.

Cuffed Tube with Reusable Inner Cannula

Used to obtain a closed

circuit for ventilation

Cuff should be inflated whenusing with ventilators.

Cuff should be inflated justenough to allow minimal airleak.

Cuff should be deflated if patientuses a speaking valve.

Cuff pressure should be checkedtwice a day.

Inner cannula is not disposable.You can reuse it after cleaning itthoroughly.


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Cuffless Tube with Disposable Inner Cannula

Used for patients with

tracheal problems

Used for patients who areready for decannulation

Save the decannulation plug ifthe patient is close to gettingdecannulated.

Patient may be able to eat andmay be able to talk without aspeaking valve.

Inner cannula is disposable

Cuffed Tube with Reusable Inner Cannula

Used for patients withtracheal problems

Used for patients who areready for decannulation

Save the decannulation plug ifthe patient is close to gettingdecannulated.

Patient may be able to eat andmay be able to speak without aspeaking valve.

Inner cannula is not disposable.You can reuse it after cleaning it

thoroughly.

Fenestrated Cuffed Tracheostomy Tube

Used for patients who are

on the ventilator but arenot able to tolerate a

speaking valve to speak

There is a high risk forgranuloma formation at the siteof the fenestration (hole).

There is a higher risk foraspirating secretions.

It may be difficult to ventilatethe patient adequately.


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Fenestrated Cuffless Tracheostomy Tube

Used for patients who have

difficulty using a speaking

valve

There is a high risk forgranuloma formation at the siteof the fenestration (hole).

Metal Tracheostomy Tube

Not used as frequently

anymore. Many of the

patients who received a

tracheostomy years ago still

choose to continue usingthe metal tracheostomy

tubes.

Patients cannot get a MRI.

One needs to notify the security

personnel at the airport prior tometal detection screening.

Complications and Risks of Tracheostomy

As with any surgery, there are some risks associated with tracheotomies.However, serious infections are rare.

Early Complications that may arise during the tracheostomy procedure orsoon thereafter include:

y Bleedingy Air trapped around the lungs (pneumothorax)y Air trapped in the deeper layers of the chest(pneumomediastinum)y Air trapped underneath the skin around the tracheostomy

(subcutaneous emphysema)y Damage to the swallowing tube (esophagus)y Injury to the nerve that moves the vocal cords (recurrent laryngeal

nerve)


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y Tracheostomy tube can be blocked by blood clots, mucus or pressureof the airway walls. Blockages can be prevented by suctioning,humidifying the air, and selecting the appropriate tracheostomy tube.

Many of these early complications can be avoided or dealt withappropriately with our experienced surgeons in a hospital setting.

Over time, other complications may arise from the surgery.

Later Complications that may occur while the tracheostomy tube is inplace include:

y Accidental removal of the tracheostomy tube (accidentadecannulation)

y Infection in the trachea and around the tracheostomy tubey Windpipe itself may become damaged for a number of reasons,

including pressure from the tube; bacteria that cause infections andform scar tissue; or friction from a tube that moves too much

These complications can usually be prevented or quickly dealt with if thecaregiver has proper knowledge of how to care for the tracheostomy site.

Delayed Complications that may result after longer-term presence of a

tracheostomy include:

y Thinning (erosion) of the trachea from the tube rubbing against it(tracheomalacia)

y Development of a small connection from the trachea (windpipe) to theesophagus (swallowing tube) which is called a tracheo-esophagealfistula

y Development of bumps (granulation tissue) that may need to besurgically removed before decannulation (removal of trach tube) canoccur

y Narrowing or collapse of the airway above the site of thetracheostomy, possibly requiring an additional surgical procedure torepair it

y Once the tracheostomy tube is removed, the opening may not close onits own. Tubes remaining in place for 16 weeks or longer are more atrisk for needing surgical closure


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A clean tracheostomy site, good tracheostomy tube care and regularexamination of the airway by an otolaryngologist should minimize theoccurrence of any of these complications.

High-risk groups

The risks associated with tracheostomies are higher in the following groupsof patients:

y children, especially newborns and infantsy smokersy alcohol abusersy diabeticsy immunocompromised patientsy persons with chronic diseases or respiratory infectionsy persons taking steroids or cortisone


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WEANING, REMOVAL, and RESCUE BREATHING

1. WEANING FROM A TRACHEOSTOMY TUBE

Clients can be weaned by mechanical ventilation if they can clear their

secretions by mouth with an adequate cuff, maintain oxygenation, and have

a functional upper airway without obstruction.

A tracheostomy tube is usually plugged by inserting a tracheostomy plug

(decannulation stopper) into the opening of the outer cannula if the tube as

a tight to shaft cuff, penetration, or no cuff. This closes off the

tracheostomy allowing air to flow and respiration to occur normally through

the nose and mouth.

2. REMOVING A TRACHEOSTOMY TUBE

A tracheostomy tube is removed after resumption of normal respiration as

indicated by the clients ability to breathe comfortably with the

tracheostomy plug, to cough and expectorate secretions, and to maintain

normal ABG values or oxygen saturation. Gradually increase the length of

plugging sessions until the client is comfortable and confident with the tube

plug continuously for at least 24 hours.After removal, place petroleum gauze pad covered by a sterile dressing over

the stoma. Providing an occlusive dressing minimizes air leak during the

stoma healing process. Clean the skin around the stoma, remove mucus

with hydrogen peroxide, rinse the area with normal saline, and apply a

fresh dry dressing over healing stoma. Document the condition of the stoma

and the surrounding skin. Notify if it appears to be irritated or infected.

After decannulation, ongoing assessment of respiratory function is

necessary. Some complications of tracheostomy, such as tracheostenosis,

can appear months after tracheostomy tube removal.


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3. PERFORMING RESCUE BREATHING

Emergency rescue breathing in the bag-to-neck mode may be necessary if

a client who has a tracheostomy or laryngectomy experiences respiratory

depression or respiratory arrest.

If a tracheostomy tube is in place, provide ventilation by attaching a manua

self-inflating bag to the standard 15mm adapter in the inner cannula. If the

tracheostomy tube is cuffed, inflate the cuff if it impedes ventilation,

immediately deflate cuff and attempt to compensate for volume loss by

compressing the bag more forcefully or quickly.


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2. ENDOTRACHEAL INTUBATION

Definition

Endotracheal intubation is the placement of a tube into thetrachea (windpipe) in order to maintain an open airway in patients

who are unconscious or unable to breathe on their own. Oxygen,anesthetics, or other gaseous medications can be deliveredthrough the tube.

Purpose

Specifically, endotracheal intubation is used for the following conditions:

y respiratory arresty respiratory failurey airway obstructiony need for prolonged ventilatory supporty Class III or IV hemorrhage with poor perfusiony severe flail chest or pulmonary contusiony multiple trauma, head injury and abnormal mental statusy inhalation injury with erythema/edema of the vocal cordsy protection from aspiration

Description

To begin the procedure, an anesthesiologist opens the patient's mouth byseparating the lips and pulling on the upper jaw with the index finger.Holding a laryngoscope in the left hand, he or she inserts it into the mouthof the patient with the blade directed to the right tonsil. Once the righttonsil is reached, the laryngoscope is swept to the midline, keeping the

tongue on the left to bring the epiglottis into view. The laryngoscope bladeis then advanced until it reaches the angle between the base of the tongueand the epiglottis. Next, the laryngoscope is lifted upwards towards thechest and away from the nose to bring the vocal cords into view. Often anassistant has to press on the trachea to provide a direct view of the larynx.The anesthesiologist then takes the endotracheal tube, made of flexibleplastic, in the right hand and starts inserting it through the mouth opening.The tube is inserted through the cords to the point that the cuff rests just


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below the cords. Finally, the cuff is inflated to provide a minimal leak whenthe bag is squeezed. Using a stethoscope, the anesthesiologist listens forbreathing sounds to ensure correct placement of the tube.

Preparation

For endotracheal intubation, the patient is placed on the operating tablelying on the back with a pillow under the head. The anesthesiologist wearsgloves, a gown and goggles. General anesthesia is administered to thepatient before starting intubation.

Risks

The anesthesiologist should evaluate and follow the patient for potentialcomplications that may include edema; bleeding; tracheal and esophageaperforation; pneumothorax (collapsed lung); and aspiration. The patientshould be advised of the potential signs and symptoms associated with life-threatening complications of airway problems. These signs and symptomsinclude but are not limited to sore throat, pain or swelling of the face andneck, chest pain, subcutaneous emphysema, and difficulty swallowing.

Normal Results

The endotracheal tube inserted during the procedure maintains an openpassage through the upper airway and allows air to pass freely to and fromthe lungs in order to ventilate them.


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MECHANICAL VENTILATION

Definition

Mechanical ventilation is the use of a mechanical device (machine) to inflateand deflate the lungs.

Purpose

Mechanical ventilation provides the force needed to deliver air to the lungsin a patient whose own ventilatory abilities are diminished or lost.

Description

Breathing requires the movement of air into and out of the lungs. This is

normally accomplished by the diaphragm and chest muscles. A variety ofmedical conditions can impair the ability of these muscles to accomplish thistask, including:

y muscular dystrophiesy motor neuron disease, including ALSy damage to the brain's respiratory centersy polioy myasthenia gravisy myopathies affecting the respiratory musclesy scoliosis

Mechanical ventilation may also be used when the airway is obstructed,especially at night in sleep apnea.

Mechanical ventilation may be required only at night, during limited daytimehours, or around the clock, depending on the patient's condition. Some

patients require mechanical ventilation only for a short period, duringrecovery from traumatic nerve injury, for instance. Others require itchronically, and may increase the number of hours required over time astheir disease progresses.

Mechanical ventilation is not synonymous with the use of an oxygen tank.Supplemental oxygen is used in patients whose gas exchange capacity hasdiminished, either through lung damage or obstruction of a major airway.


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For these patients, the muscles that deliver air work well, but too littleoxygen can be exchanged in the remaining lung, and so a higherconcentration is supplied with each breath. By the same token, manypatients who require mechanical ventilation do not need supplementaoxygen. Their gas exchange capacity is normal, but they cannot adequatelymove air into and out of the lungs. In fact, excess oxygen may bedangerous, since it can suppress the normal increased respiration responseto excess carbon dioxide in the lungs.

Mechanical ventilation systems come in a variety of forms. Almost alsystems use a machine called a ventilator that pushes air through a tube fordelivery to the patient's airways. The air may be delivered through a nasalor face mask, or through an opening in the trachea (windpipe), called atracheostomy. Much rarer are systems that rhythmically change the

pressure around a patient's chest when the pressure is low, air flows intothe lungs, and when it increases, air flows out.

Ventilators

Ventilators can either deliver a set volume with each cycle, or can be set toa specific pressure regimen. Both are in common use. Volume ventilatorsettings are adjustable for total volume delivered, timing of delivery, and

whether the delivery is mandatory or determined by the patient's initialinspiratory effort.

Pressure ventilators deliver one of two major pressure regimens.Continuous positive airway pressure (CPAP) delivers a steady pressure ofair, which assists the patient's inspiration (breathing in) and resistsexpiration (breathing out). The pressure of CPAP is not sufficient tocompletely inflate the lungs; instead its purpose is to maintain an open

airway, and for this reason it is used in sleep apnea, in which a patient'sairway closes frequently during sleep.

Bilevel positive airway pressure (BiPAP) delivers a higher pressure oninspiration, helping the patient obtain a full breath, and a low pressure onexpiration, allowing the patient to exhale easily. BiPAP is a common choicefor neuromuscular disease.


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The choice of ventilator type is partly determined by the knowledge andpreferences of the treating physician. Settings are adjusted to maintainpatient comfort and appropriate levels of oxygen and carbon dioxide in theblood.

MasksVs. Tracheostomy

Delivery of air from a ventilator may be either through a mask firmly held tothe face, or through a tube inserted into the trachea toward the bottom ofthe throat. A mask interface is called noninvasive ventilation, while atracheostomy tube is called invasive ventilation.

Until the mid-1990s, invasive ventilation was the option used by virtually allpatients requiring long-term mechanical ventilation. For some patients,

tracheostomy continues to be a preferred option. It is commonly used when24-hour ventilation assistance is required, and may be preferred by patientswho find masks uncomfortable or unsightly. Some patients feel ventilationthrough a "trach tube" is more reassuring. Tracheostomy is also thepreferred option for most patients with swallowing difficulties. The potentialto choke and suffocate on improperly swallowed food is avoided with atracheostomy.

Tracheostomies may require more frequent suctioning of airway secretions,produced in response to the presence of the tube and the inflatable cuffthat some patients require to hold it in place. The risk of infection is higher,and air must be carefully humidified and cleaned, since these functions arenot being served by the nasal passages. Tracheostomies do not preventspeech, despite misinformation to the contrary that even some doctorsbelieve. Speech requires passage of air around the trach tube, which canoccur either with an uncuffed tube, or with the presence of a special valve

that allows air passage past the cuff.Noninvasive interfaces come in a variety of forms. A simple mouthpiece maybe used, which a patient bites down on to seal the lips around the tube asthe pressure cycle delivers a breath. Most masks are individually fitted tothe patient's face, and held in place with straps. A tight fit is essential, sincethe pressure must be delivered to the patient's lungs, and not be allowed toblow out the sides of the mask. Masks may be used around the clock. Nasa


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masks do not prevent speech, though the tone may change. Oral or full-face masks do interfere with speech, and are typically used at night orintermittently throughout the day, for patients who do not need continuousventilation assistance.

Other Alternatives

The iron lung was an early mechanical ventilation device, and is still in usein some hospitals. The patient's head remains outside of it, while theinterior depressurizes. This allows air to push in to the lungs. Repressurizingdeflates the lungs again.

A device that works on the same principle is the chest shell (something likea turtle's shell swung around to the front). The pneumobelt applies pressure

to deflate, and relaxes it to allow inflation. A rocking bed is used fornighttime ventilation. Tilting the head of the bed down deflates the lungs byallowing the abdominal contents to press against the diaphragm. Reversingthe angle reverses the process, allowing inflation.

Preparation

Patients with diseases in which mechanical ventilation may be required areadvised to learn as much as possible about treatment options before theybecome necessary. In particular, it is important to learn about and makedecisions about invasive vs. noninvasive ventilation before the time comes.Many patients who begin ventilation with emergency tracheostomy have adifficult time switching to noninvasive ventilation later on (though it iscertainly possible).

It is often a good idea to try out different masks and other interfaces beforetheir need arises, and to have these fitted in preparation for a plannedtransition to the ventilator. Patients can find support groups and othersources of information to learn more about the options and the features ofeach means of ventilation. Patients may have to help educate their doctorsif they are not familiar with noninvasive options.


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Patients with neuromuscular disease may have as much or more need for adeep cough as they do for ventilatory assistance, and many patients whoundergo emergency tracheostomy do so because their airways havebecome clogged with mucus build up. Physical therapy cough assistanceand a cough assist device are important options for full respiratory health.

Normal Results

Mechanical ventilation is a life saver, and provides comfort and confidenceto patients who require it. Proper ventilation restores levels of oxygen andcarbon dioxide in the blood, improving sleep at night and increasing theability to engage in activities during the day. When combined with properrespiratory hygiene, it can prolong life considerably. Patients withprogressive diseases such as ALS may wish to consider end-of-life decisions

before commencing mechanical ventilation, or before the ability tocommunicate is lost.

TRIGGERING MECHANISMS

Three basis of triggering mechanisms:

1. Time-triggered- used to manage clients who cannot breathe on theirown.

2. Negative pressure inhalation- this is triggered by the initial negativepressure that begins inspiration. As soon as the client initiates breath, theventilator is triggered to produce inhalation.

3. Flow-triggered inhalation- occurs when the client can initiate a breath.The ventilator completes the breath by sensing the flow of air into thechest.

4. Volume-triggered ventilation- occurs when the ventilator completesthebreath to maximize inhaled gas volumes.


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Chest Tubes

A chest tube (chest drain or tube thoracostomy) is a flexible plastic tube that is

inserted through the side of the chest into the pleural space. It is used to remove

air (pneumothorax) or fluid (pleural effusion, blood, chyle), or pus (empyema)

from the intrathoracic space.

Types:

y One-bottle system: water seal and collection of drainage occurs in the samebottle. Used for simple pneumothorax

y Two-bottle system: water seal and collection of drainage are in separatebottles.

- 1st

bottle: directly attached to the patient, serves as the collectioncontainer for fluid

- 2nd

bottle: serves as the water seal container, as in the one-bottle

system

y Three-bottle system- collection chamber: where the chest tube from the patient connectsto the system. Drainage from the tube drains into and collects in a

series of calibrated columns in this chamber

- water-seal chamber: this chamber provides a water-seal, which

establishes 2cm of water pressure

- suction chamber: controlled to provide (-) pressure to the chest. The

chamber is filled with various levels of water to achieve the desired

level of suction

Purpose:

Chest tube insertions are usually performed as an emergency procedure. Chest

tubes are used to treat conditions that can cause the lung to collapse, which

occurs because blood or air in the pleural space can hamper the ability of a patient

to breathe.


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Size of Chest Tube:

Newborn: 12-14 Fr

Child: 18 Fr

Adult or Teen Female: 28 Fr

Adult or Teen Male: 28-32Fr

Indications:

1. Pneumothorax: accumulation of air in the pleural space

2. Pleural Effusion: accumulation of fluid in the pleural space

y Chylothorax: a collection of lymphatic fluid in the pleural space

y Empyema: a pyogenic infection in the pleural spacey Hemothorax: accumulation of blood in the pleural spacey Hydrothorax: accumulation of serous fluid in the pleural space

Contraindication:

Contraindications to chest tube placement include refractory coagulopathy, lack of

cooperation by the patient, and diaphragmatic hernia. Additional contraindications

include scarring in the pleural space (adhesions)

Complications:

Major complications are hemorrhage, infection, and reexpansion pulmonaryedema. Chest tube clogging can also be a major complication if it occurs in the

setting of bleeding or the production of significant air or fluid. When chest tube

clogging occurs in this setting, a patient can suffer from pericardial tamponade,

tension pneumothorax, or in the setting of infection, an empyema. All of these can

lead to prolonged hospitilization and even death.

Nursing Management:


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y Check the tube connection periodically. Tape if necessary.y Make sure the tube (water seal chamber) is immersed 2.5 cm deep into

the water.

y Monitor bubbling in suction control which indicated proper function.y Check for fluctuations in water-sealed chamber with respirations.y Mark the original fluid level with tape on the outside.y Make sure that the tubings does not loop or interfere with the movement

of the patient.

y Notify doctor if unable to clear clots form tubing.y Perform ROM of the arm in the affected.y If drainage slows or stops, gently milk chest tube (or strip as last resort).

Suctioning

Aspirating secretions through a catheter connected to a suction machine or wall

suction outlet.

Purpose:

y To remove secretions that obstruct the airwayy To facilitate ventilationy To obtain secretions for diagnostic purposesy To prevent infection that may result from accumulated secretions

Indications:

Noisy, rattling breathing sounds

Secretions (mucus) visible and filling opening of tracheostomy

Signs of respiratory distress: difficulty breathing, agitation, paleness, excessive

coughing, cyanosis

(blueness), nasal flaring, retracting.

No air moving through tracheostomy (listen for sounds)

Before eating or drinking if congested

After respiratory treatments (inhalation therapy, assisted breathing with a self-inflating manual

resuscitator), chest percussion and drainage


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Contraindications:

y Severe coagulopathy and/or unexplained haemoptysisy Laryngospasmy Acute neck, facial or head injuryy Severe bronchospasmy Loose teeth or crownsy Intact gag reflex

Procedure:

1. Prepare patient by giving analgesiaif required, reassurance and

information.

Minimizes patient discomfort,thereby

maximizing effectiveness of theprocedure.

2. Ensure informed consent is given

where able as per trust policy.

3. Put on non-sterile gloves and

apron,

and eye protection/mask if indicated.

Minimizes risk of cross infection

to patient or

operator.

4. Check correct functioning of

vacuumsource and set negative pressure to

no greater than 20kPa / 150mmHg

Minimizes the risk of mechanical

trauma.Note that increased pressures

does not

facilitate better removal of

secretions.

5. Where possible, position the

patientto open the airway.

Minimizes the risk of

misdirection into theoesophagus.

6. Maximally pre-oxygenate for atleast

30 seconds, unless there is a

contraindication to an increased

FiO2.

Minimizes the risk of hypoxia /hypoxaemia

and cardiac dysrhythmias.

7a. Orotracheal suction:

Insert oropharyngeal airway.

Provides a patent route for

passage of the

suction catheter.


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7b. Nasotracheal suction:

Insert nasopharyngeal airway, if

repeated nasotracheal suction is

anticipated.

Provides a more comfortable

route for

repeated passage of the suction

catheter.

8. Open suction catheter packaging.

Connect suction catheter tubing,

ensuring that catheter remains insterile pack. Put sterile glove on

dominant hand and use that hand to

withdraw catheter from pack.

Minimizes risk of cross infectionto patient or

operator.

9. Insert suction catheter via

oropharyngeal airway,nasopharyngeal airway, or nostril. If

using a nasopharyngeal airway or

nostril, a small amount of sterilelubricating gel facilitates passage.

Aim to time insertion with the

patients inspiratory cycle. Proceed

gently in order to ascertain the

correct route. Do not apply suctionduring insertion.

Minimizes mechanical trauma

and patientdiscomfort.

10. Continue to insert catheter until a

resistance is felt or a cough elicited.Withdraw by 1cm before applyingsuction to ensure tip of catheter is

not abutting the carina.

Minimises the risk of mechanical

trauma.

11. Remove catheter if misdirectioninto

the oesophagus is suspected (e.g.

gagging, absence of cough,aspiration of gastric contents).

Maximizes effectiveness ofprocedure and

minimizes risk of aspiration.

12. Apply suction continuously

throughout catheter removal.Withdraw catheter smoothly (without

rotation). Ensure that this period of

suction application does not exceed15 seconds. The catheter must be

withdrawn cleanly and not reinserted

Minimizes adverse effects /

hazardsassociated with suction, e.g.

hypoxia /

hypoxaemia, cardiacdysrhythmias, blood

pressure fluctuations, pain,


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during withdrawal. apnoea,

atelectasis, raised intracerebral

pressure etc.

13. Monitor patients condition

duringand following treatment, e.g. color,

breathing pattern, respiratory rate,heart rate, secretions, evidence of

trauma, distress, cough, SaO2.

Seek help in the event of patient

deterioration.

Ensures patient safety and

assessesimprovement in patient

condition.

14. Repeat procedure if appropriateusing new sterile glove and catheter.

Maximizes effectiveness ofprocedure and

minimizes risk of cross infection.

15. After the final episode of suction,remove oropharyngeal airway,

provided the patient is maintaining a

safe airway and discard. If a nasalairway is used, this stays in situ.

Ensures patient safety andcomfort.

16. Where possible encourage deep

breathing.

Minimize atelectasis.

17. Once treatment is completed,

rinsesuction connector tubing using asmall amount of water decanted

from the bottle into a container.

Ensure opening date and time has

been marked on bottled water in

order that it may be discarded after

24 hours.

Maintain safe, clean

environment.

18. Wash hands.

Discard any disposable items in

clinical waste bins and changesuction bottle if necessary.

Maintain safe, clean

environment.

19. Reassess patient and report any

adverse effects or changes inpatients overall condition to senior

nursing and/or medical personnel.

Patient safety.


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20. Document procedure, effects and

response as per documentation

policies

Allows ongoing assessment and

evaluation of

patients condition.

Complications:

y Hypoxia/hypoxemiay Tissue trauma to the tracheal and bronchial mucosay Cardiac arresty Respiratory arresty Cardiac dysrhythmiasy Pulmonary atelectasisy B

ronchoconstriction/bronchospasmy Infectiony Hypertension and hypotension

methods of controlling airway

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