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Endotracheal Tube Insertion

 Orotracheal insertion is technically easier, because it is done under direct visualization

 Disadvantages are increased oral secretions, decreased patient comfort, difficulty with tube
stabilization, and inability of patient to use lip movement as a communication means.
 Nasotracheal insertion may be more comfortable to the patient and is easier to stabilize.
o Disadvantages are that blind insertion is required; possible development of pressure necrosis of
the nasal airway, sinusitis, and otitis media.
 Tube types vary according to length and inner diameter, type of cuff, and number of lumens.
o Usual sizes for adults are 6.0, 7.0, 8.0, and 9.0 mm.
o Most cuffs are high volume, low pressure, with self-sealing inflation valves, or the cuff may be of
foam rubber (Fome-Cuff).
o Most tubes have a single lumen; however, dual-lumen tubes may be used to ventilate each lung
independently (see Figure 10-2).

FIGURE 10-2 (A) Endotrachial tubes: single lumen and double lumen endotracheal tube. When
the double lumen tube is used (B), two cuffs are inflated. One cuff (1) is positioned in the
trachea and the second cuff (2) in the left mainstem bronchus. After inflation, air flows through
an opening below the tracheal cuff (3) to the right lung and through an opening below the
bronchial cuff (4) to the left lung. This permits differential ventilation of both lungs, lavage of one
lung, or selective inflation of either lung during thoracic surgery. (Marshall, B. E., Longnecker, D.
E., & Fairley, H. B. [Eds.]. [1988]. Anesthesia for thoracic procedures [p. 381]. Boston: Blackwell
Scientific Publications.)

 May be contraindicated when glottis is obscured by vomitus, bleeding, foreign body, or trauma, or
cervical spine injury or deformity.

Tracheostomy Tube Insertion

 Tube types vary according to presence of inner cannula and presence and type of cuff
o Tubes with high-volume, low-pressure cuffs with self-sealing inflation valves; with or without
inner cannula
o Fenestrated tube
o Foam-filled cuffs (Fome-Cuff)
o Speaking tracheostomy tube
o Tracheal button or Passy-Muir valve
o Silver tube (rarely used)
 Vary according to length and inner diameter in millimeters. Usual sizes for an adult are 6.0, 7.0, 8.0,
and 9.0 mm.
 Tracheostomy is usually planned, either as an adjunct to therapy for respiratory dysfunction or for
longer-term airway management when ET intubation has been used for more than 14 days.
 May be done at the bedside in an emergency when other means of creating an airway have failed

Indications for Endotracheal Intubation or Tracheostomy

 Acute respiratory failure, CNS depression, neuromuscular disease, pulmonary disease, chest wall
 Upper airway obstruction (tumor, inflammation, foreign body, laryngeal spasm)
 Anticipated upper airway obstruction from edema or soft tissue swelling due to head and neck trauma,
some postoperative head and neck procedures involving the airway, facial or airway burns, decreased
level of consciousness
 Aspiration prophylaxis
 Fracture of cervical vertebrae with spinal cord injury; requiring ventilatory assistance.

Complications of Endotracheal or Tracheostomy Tubes

 Laryngeal or tracheal injury
o Sore throat, hoarse voice
o Glottic edema
o Ulceration or necrosis of tracheal mucosa
o Vocal cord ulceration, granuloma, or polyps
o Vocal cord paralysis
o Postextubation tracheal stenosis
o Tracheal dilation
o Formation of tracheal-esophageal fistula
o Formation of tracheal-arterial fistula
o Innominate artery erosion
 Pulmonary infection and sepsis
 Dependence on artificial airway.

Nursing Care for Patients with Artificial Airways

General Care Measures

 Ensure adequate ventilation and oxygenation through the use of supplemental oxygen or mechanical
ventilation as indicated.
 Assess breath sounds every 2 hours. Note evidence of ineffective secretion clearance (rhonchi,
crackles), which suggests need for suctioning.
 Provide adequate humidity when the natural humidifying pathway of the oropharynx is bypassed.
 Provide adequate suctioning of oral secretions to prevent aspiration and decrease oral microbial
 Use clean technique when inserting an oral or nasopharyngeal airway, and take it out and clean it with
hydrogen peroxide and rinse with water at least every 8 hours.
 Perform frequent oral care with soft toothbrush or swabs and antiseptic mouthwash or hydrogen
peroxide diluted with water. Frequent oral care will aid in prevention of ventilator-associated
 Ensure that aseptic technique is maintained when inserting an ET or tracheostomy tube. The artificial
airway bypasses the upper airway, and the lower airways are sterile below the level of the vocal cords.
 Elevate the patient to a semi-Fowler's or sitting position, when possible; these positions result in
improved lung compliance. The patient's position, however, should be changed at least every 2 hours
to ensure ventilation of all lung segments and prevent secretion stagnation and atelectasis. Position
changes are also necessary to avoid skin breakdown.
 If an oral or nasopharyngeal airway is used, turn the patient's head to the side to reduce the risk of
aspiration (because there is no cuff to seal off the lower airway).

Nutritional Considerations

 Consciousness is usually impaired in the patient with an oropharyngeal airway, so oral feeding is
 To enhance comfort, remove a nasopharyngeal airway in the conscious patient during mealtime.
 Recognize that an ET tube holds the epiglottis open. Therefore, only the inflated cuff prevents the
aspiration of oropharyngeal contents into the lungs. The patient must not receive oral feeding.
Administer enteral tube feedings or parenteral feedings as ordered.
 Administer oral feedings to a conscious patient with a tracheostomy, usually with the cuff inflated. The
inflated cuff prevents aspiration of food contents into the lungs, but causes the tracheal wall to bulge
into the esophageal lumen, and may make swallowing more difficult. Patients who are not on
mechanical ventilation and are awake, alert, and able to protect the airway are candidates for eating
with the cuff deflated.
 To assess ability to protect the airway, sit the patient upright and feed the patient colored gelatin or
juice. If color from gelatin can be suctioned from the tracheostomy tube, aspiration is occurring, and the
cuff must be inflated during feeding and for 1 hour afterward with head of bed elevated.
 Patients should receive thickened rather than regular liquids; this will assist in effective swallowing.
Endotracheal Intubation

 Laryngoscope with curved or straight blade and working light source (check batteries and bulb
 Endotracheal (ET) tube with low-pressure cuff and adapter to connect tube to ventilator or resuscitation
 Stylet to guide the endotracheal tube
 Oral airway (assorted sizes) or bite block to keep patient from biting into and occluding the ET tube
 Adhesive tape or tube fixation system
 Sterile anesthetic lubricant jelly (water-soluble)
 10-mL syringe
 Suction source
 Suction catheter and tonsil suction
 Resuscitation bag and mask connected to oxygen source
 Sterile towel
 Gloves
 Face shield
 End tidal CO2 detector

Nursing Action Rationale
Preparatory phase
1. Assess the patient's heart rate, level of 1. Provides a baseline to estimate the patient's tolerance
consciousness, and respiratory status. of the procedure.
Performance phase
1. Remove the patient's dental bridgework and 1. May interfere with insertion. Will not be able to remove
plates. easily from the patient once intubated.
2. Remove the headboard from the bed (optional). 2. To provide room to stand behind patient's head.
3. Prepare equipment. 3.
a. Ensure function of resuscitation bag with a.The patient may require ventilatory assistance during
mask and suction. procedure. Suction should be functional because
gagging and emesis may occur during procedure.
b. Assemble the laryngoscope. Make sure the
light bulb is tightly attached and functional.
c. Select an ET tube of the appropriate size (6-9
mm for the average adult).
d. Place the ET tube on a sterile towel. d.Although the tube will pass through the contaminated
mouth or nose, the airway below the vocal cords is
sterile, and efforts must be made to prevent iatrogenic
contamination of the distal end of the tube and cuff.
The proximal end of the tube may be handled
because it will reside in the upper airway.
e. Inflate the cuff to make sure it assumes a e.Malfunction of the cuff must be determined before
symmetrical shape and holds volume without tube placement occurs.
leakage. Then deflate maximally.
f. Lubricate the distal end of the tube liberally f. Aids in insertion.
with the sterile anesthetic water-soluble jelly.
g. Insert the stylet into the tube (if oral intubation g.Stiffens the soft tube, allowing it to be more easily
is planned). Nasal intubation does not employ directed into the trachea.
use of the stylet.
4. Aspirate the stomach contents if a nasogastric 4. To reduce risk of aspiration.
tube is in place.
5. If time allows, inform the patient of the
impending inability to talk and discuss
alternative means of communication.
6. If the patient is confused, it may be necessary to 6. Restraint of the confused patient may be necessary to
apply soft wrist restraints. promote patient safety and maintain sterile technique.
7. Put on gloves and face shield. 7. Prevents contact with patient's oral secretions.
8. During oral intubation if cervical spine is not 8. Upper airway is open maximally in this position.
injured, place patient's head in a
“sniffing― position (extended at the
junction of the neck and thorax and flexed at the
junction of the spine and skull).
9. Spray the back of the patient's throat with 9. Will decrease gagging.
anesthetic spray.
10 Ventilate and oxygenate the patient with the 10.Preoxygenation decreases the likelihood of cardiac
resuscitation bag and mask before intubation. dysrhythmias or respiratory distress secondary to
11.Hold the handle of the laryngoscope in the left 11.Leverage is improved by crossing the thumb and index
hand and hold the patient's mouth open with the fingers when opening the patient's mouth (scissor-twist
right hand by placing crossed fingers on the technique).
12.Insert the curved blade of the laryngoscope 12.Rolling the lip away from teeth prevents injury by being
along the right side of the tongue, push the caught between the teeth and the blade.
tongue to the left, and use right thumb and index
finger to pull patient's lower lip away from lower
13.Lift the laryngoscope forward (toward ceiling) to 13.Do not use teeth as a fulcrum; this could lead to dental
expose the epiglottis. damage.
14.Lift the laryngoscope upward and forward at a 14.This stretches the hypoepiglottis ligament, folding the
45-degree angle to expose the glottis and epiglottis upward and exposing the glottis.
visualize vocal cords.
15.As the epiglottis is lifted forward (toward ceiling), 15.Do not use the wrist. Use the shoulder and arm to lift
the vertical opening of the larynx between the the epiglottis.
vocal cords will come into view (see
accompanying figure).

Endotracheal intubation. (A) The primary glottic landmarks for tracheal intubation as visualized with
proper placement of the laryngoscope. (B) Positioning the endotracheal tube.
16.Once the vocal cords are visualized, insert the 16.Make sure you do not insert the tube into the
tube into the right corner of the mouth and pass esophagus; the esophageal mucosa is pink and the
the tube while keeping vocal cords in constant opening is horizontal rather than vertical.
17.Gently push the tube through the triangular 17.If the vocal cords are in spasm (closed), wait a few
space formed by the vocal cords and back wall seconds before passing tube.
of trachea.
18.Stop insertion just after the tube cuff has 18.Advancing the tube further may lead to its entry into a
disappeared from view beyond the cords. mainstem bronchus (usually the right bronchus) causing
collapse of the unventilated lung
19.Withdraw laryngoscope while holding ET tube in
place. Disassemble mask from resuscitation
bag, attach bag to ET tube, and ventilate the
20.Inflate the cuff with the minimal amount of air 20.Listen over the cuff area with a stethoscope. Occlusion
required to occlude the trachea. occurs when no air leak is heard during ventilator
inspiration or compression of the resuscitation bag.
21.Insert a bite block if necessary. 21.This keeps the patient from biting down on the tube and
obstructing the airway.
22.Ascertain expansion of both sides of the chest 22.Observation and auscultation help in determining that
by observation and auscultation of breath tube remains in position and has not slipped into the
sounds. right mainstem bronchus.
23.Record distance from proximal end of tube to 23.This will allow for detection of any later change in tube
the point where the tube reaches the teeth. position.
24.Secure the tube to the patient's face with 24.The tube must be fixed securely to ensure that it will not
adhesive tape or apply a commercially available be dislodged. Dislodgement of a tube with an inflated
endotracheal tube stabilization device. cuff may result in damage to the vocal cords.
25.Obtain a chest X-ray to verify tube position.
26.Document and monitor tube distance from lips 26 Assures correct placement of the tube.
to end of ET tube.
Follow-up phase
1. Record tube type and size, cuff pressure, and 1. ABGs may be prescribed to ensure adequacy of
patient tolerance of the procedure. Auscultate ventilation and oxygenation. Tube displacement may
breath sounds every 2 hours or if signs and result in extubation (cuff above vocal cords), tube
symptoms of respiratory distress occur. Assess touching carina (causing paroxysmal coughing), or
ABGs after intubation if requested by the health intubation of a mainstem bronchus (resulting in collapse
care provider. of the unventilated lung).
2. Measure cuff pressure with manometer; adjust 2. The tube may be advanced or removed several
pressure. Make adjustment in tube placement centimeters for proper placement based on the chest X-
on the basis of the chest X-ray results. ray results.
Consider the patient's nutritional needs early in process of intubation so nutritional status does not decline
further. It is difficult to wean patients who have compromised nutritional status.
Cuff Maintenance

 ET tube cuffs should be inflated continuously and deflated only during intubation, extubation, and tube

 Tracheostomy tube cuffs also should be inflated continuously in patients on mechanical ventilation or
continuous positive airway pressure (CPAP).
 Tracheostomized patients who are breathing spontaneously may have the cuff inflated continuously (in
the patient with decreased level of consciousness without ability to fully protect airway), deflated
continuously, or inflated only for feeding if the patient is at risk of aspiration.
 Monitor cuff pressure every 4 hours