Adequate ventilation is dependent on free movement of air through the upper and lower airways. In many disorders, the air-way becomes narrowed or blocked as a result of disease, bron-choconstriction (narrowing of airway by contraction of muscle fibers), a foreign body, or secretions. Maintaining a patent (open) airway is achieved through meticulous airway management, whether in an emergency situation such as airway obstruction or in long-term management, as in caring for a patient with an endotracheal or a tracheostomy tube.
Upper airway obstruction has a variety of causes. Acute upper air-way obstruction may be caused by food particles, vomitus, blood clots, or any other particle that enters and obstructs the larynx or trachea. It also may occur from enlargement of tissue in the wall of the airway, as in epiglottitis, laryngeal edema, laryngeal carci-noma, or peritonsillar abscess, or from thick secretions. Pressure on the walls of the airway, as occurs in retrosternal goiter, en-larged mediastinal lymph nodes, hematoma around the upper airway, and thoracic aneurysm, also may result in upper airway obstruction.
The patient with an altered level of consciousness from any cause is at risk for upper airway obstruction because of loss of the protective reflexes (cough and swallowing) and the tone of the pharyngeal muscles, causing the tongue to fall back and block the airway.
The nurse makes the following rapid observations to assess for signs and symptoms of upper airway obstruction:
1. Inspection—Is the patient conscious? Is there any inspira-tory effort? Does the chest rise symmetrically? Is there use or retraction of accessory muscles? What is the skin color? Are there any obvious signs of deformity or obstruction (trauma, food, teeth, vomitus)? Is the trachea midline?
2. Palpation—Do both sides of the chest rise equally with in-spiration? Are there any specific areas of tenderness, frac-ture, or subcutaneous emphysema (crepitus)?
3. Auscultation—Is there any audible air movement, stridor (inspiratory sound), or wheezing (expiratory sound)? Are breath sounds present bilaterally in all lobes?
As soon as an upper airway obstruction is identified, the nurse takes emergency measures (Chart 25-6).
Endotracheal intubation involves passing an endotracheal tubethrough the mouth or nose into the trachea (Fig. 25-5). Intuba-tion provides a patent airway when the patient is having respira-tory distress that cannot be treated with simpler methods. It is the method of choice in emergency care. Endotracheal intubation is a means of providing an airway for patients who cannot maintain an adequate airway on their own (eg, comatose patients or patients with upper airway obstruction), for mechanical ventilation, and for suctioning secretions from the pulmonary tree.
An endotracheal tube usually is passed with the aid of a laryn-goscope by specifically trained medical, nursing, or respiratory therapy personnel. Once the tube is in-serted, a cuff around the tube is inflated to prevent air from leaking around the outer part of the tube, to minimize the possibility of subsequent aspiration, and to prevent movement of the tube.
Nurses should be aware that complications could occur from pressure in the cuff on the tracheal wall. Cuff pressures should be checked with a calibrated aneroid manometer device every 8 to 12 hours to maintain cuff pressure between 20 and 25 mm Hg. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis, while low cuff pressure can increase the risk of aspiration pneumonia. Routine deflation of the cuff is not recommended due to the increased risk of aspiration and hypoxia. The cuff is de-flated prior to removing the endotracheal tube (St. John, 1999b).
Tracheobronchial secretions are suctioned through the tube. Warmed, humidified oxygen should always be introduced through the tube, whether the patient is breathing spontaneously or is re-ceiving ventilatory support. Endotracheal intubation may be used for no more than 3 weeks, by which time a tracheostomy must be considered to decrease irritation of and trauma to the tracheal lin-ing, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing. Chart 25-7 discusses the nursing care of the patient with an en-dotracheal tube.
There are several disadvantages of endotracheal and trache-ostomy tubes. First, the tube causes discomfort. In addition, the cough reflex is depressed because closure of the glottis is hindered. Secretions tend to become thicker because the warming and hu-midifying effect of the upper respiratory tract has been bypassed. The swallowing reflexes, composed of the glottic, pharyngeal, and laryngeal reflexes, are depressed because of prolonged disuse and the mechanical trauma of the endotracheal or tracheostomy tube, which puts the patient at increased risk for aspiration. In addi-tion, ulceration and stricture of the larynx or trachea may de-velop. Of great concern to the patient is the inability to talk and to communicate needs.
Unintentional or premature removal of the tube is a potentially life-threatening complication of endotracheal intubation. Removal of the tube is a frequent problem in intensive care units and occurs mainly during nursing care or by the patient. It is important for nurses to instruct patients and family members about the purpose of the tube and the dangers of removing it. Baseline and ongoing assessment of the patient and equipment ensures effective care. Providing comfort measures, including opioid analgesia and seda-tion, can improve the patient’s tolerance of the endotracheal tube.
To prevent tube removal by the patient, the nurse can use the following strategies: explain to the patient and family the purpose of the tube, distract the patient through one-to-one interaction with the nurse and family or with television, and maintain com-fort measures. As a last resort, soft wrist restraints may be used, according to agency policy.
Studies have shown that the most effective way to prevent tube removal by the patient is through the use of soft wrist restraints (Happ, 2000). However, discretion and caution must always be used before applying any restraint. If the patient cannot move the arms and hands to the endotracheal tube, restraints would not be needed. If the patient is alert, oriented, able to follow directions, and cooperative to the point that it is highly unlikely that he or she will remove the endotracheal tube, restraints are not needed. On the other hand, if the nurse determines there is a risk that the patient may try to remove the tube, soft wrist restraints are appropriate with a physician’s order (check agency policy). Close monitoring of the patient remains essential to ensure safety and prevent harm.
A tracheotomy is a surgical procedure in which an opening is made into the trachea. The indwelling tube inserted into the tra-chea is called a tracheostomy tube. A tracheostomy may be either temporary or permanent.
A tracheostomy is used to bypass an upper airway obstruction, to allow removal of tracheobronchial secretions, to permit the long-term use of mechanical ventilation, to prevent aspiration of oral or gastric secretions in the unconscious or paralyzed patient (by closing off the trachea from the esophagus), and to replace an endotracheal tube. There are many disease processes and emer-gency conditions that make a tracheostomy necessary.
The surgical procedure is usually performed in the operating room or in an intensive care unit, where the patient’s ventilation can be well controlled and optimal aseptic technique can be maintained.A surgical opening is made in the second and third tracheal rings. After the trachea is exposed, a cuffed tracheostomy tube of an ap-propriate size is inserted. The cuff is an inflatable attachment to the tracheostomy tube that is designed to occlude the space be-tween the trachea walls and the tube to permit effective me-chanical ventilation and to minimize the risk of aspiration.
The tracheostomy tube is held in place by tapes fastened around the patient’s neck. Usually a square of sterile gauze is placed between the tube and the skin to absorb drainage and pre-vent infection.
Complications may occur early or late in the course of tra-cheostomy tube management. They may even occur years after the tube has been removed. Early complications include bleed-ing, pneumothorax, air embolism, aspiration, subcutaneous or mediastinal emphysema, recurrent laryngeal nerve damage, and posterior tracheal wall penetration. Long-term complications in-clude airway obstruction from accumulation of secretions or pro-trusion of the cuff over the opening of the tube, infection, rupture of the innominate artery, dysphagia, tracheoesophageal fistula, tracheal dilation, and tracheal ischemia and necrosis. Tracheal stenosis may develop after the tube is removed. Chart 25-8 out-lines measures nurses can take to prevent complications.
The patient requires continuous monitoring and assessment. The newly made opening must be kept patent by proper suctioning of secretions. After the vital signs are stable, the patient is placed in a semi-Fowler’s position to facilitate ventilation, promote drainage, minimize edema, and prevent strain on the suture lines. Analgesia and sedative agents must be administered with caution because of the risk of suppressing the cough reflex.
Major objectives of nursing care are to alleviate the patient’s apprehension and to provide an effective means of communication.
The nurse keeps paper and pencil or a Magic Slate and the call light within the patient’s reach to ensure a means of commu-nication. The care of the patient with a tracheostomy tube is summarized in Chart 25-9.
When a tracheostomy or endotracheal tube is in place, it is usu-ally necessary to suction the patient’s secretions because of the de-creased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are obviously present. Unnecessary suction-ing can initiate bronchospasm and cause mechanical trauma to the tracheal mucosa.
All equipment that comes into direct contact with the pa-tient’s lower airway must be sterile to prevent overwhelming pul-monary and systemic infections. The procedure for suctioning a tracheostomy is presented in Chart 25-10. In mechanically ven-tilated patients, an in-line suction catheter may be used to allow rapid suction when needed and to minimize cross-contamination of airborne pathogens. An in-line suction device allows the pa-tient to be suctioned without being disconnected from the venti-lator circuit.
As a general rule, the cuff on an endotracheal or tracheostomy tube should be inflated. The pressure within the cuff should be the lowest possible that allows delivery of adequate tidal volumes and prevents pulmonary aspiration. Usually the pressure is main-tained at less than 25 cm H2O to prevent injury and at more than 20 cm H2O to prevent aspiration. Cuff pressure must be moni-tored at least every 8 hours by attaching a hand-held pressure gauge to the pilot balloon of the tube or by using the minimal leak volume or minimal occlusion volume technique. With long-term intubation, higher pressures may be needed to maintain an adequate seal.
Teaching Patients Self-Care. If the patient is at home with a tra-cheostomy, the nurse instructs the patient and family about its daily care as well as measures to take in an emergency. The nurse also makes sure the patient and family are aware of community contacts for education and support needs. It is important for the nurse to teach the patient and family strategies to prevent infec-tion when performing tracheostomy care (McConnell, 2000).
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