Mechanical Ventilation and Intubation
This type of respiratory support is used in patients with ARDS as well as other disorders. Patients who require intubation and mechanical ventilation are unable to appropriately complete gas exchange necessary to maintain life. This patient has failed attempts to support ventilation and gas exchange with supplemental oxygen. This is likely a short-term situation for patients who have had surgery with general anesthesia, or given sedatives. Patients with traumatic brain injury, chronic lung disease, or end-stage neuromuscular diseases may require long-term respiratory support (Ignatavicius et al., 2018; Wilkinson et al., 2016).
The nurse should determine if the patient has an advance directive as these often contain parameters for the implementation of mechanical ventilation. In some cases, patients or families may decide to suspend the advance directive and implement mechanical ventilation. The process should be explained to the patient and their family, and any questions they have should be discussed. In life-threatening situations, the educational component might come after the intubation and ventilation process has begun (Ignatavicius et al., 2018; Wilkinson et al., 2016).
Prior to intubation and mechanical ventilation, the nurse should perform a full assessment of the respiratory system including rate, depth, and rhythm as well as auscultation of lung sounds, assessment for skin pallor and/or cyanosis, and pulse oximetry. An oral assessment should be completed for any open wounds, evidence of candidiasis or other possible infections, and any bleeding or abnormal odor. The nurse should continue to complete a full physical assessment if time allows prior to the intubation and implementation of mechanical ventilation. If time does not allow, the nurse can complete the remainder of the full assessment following the procedure. The nurse should carefully document their assessment findings. The provider will likely order arterial blood gases and other diagnostic studies, and the nurse should alert the team of the results when available (Ignatavicius et al., 2018; Wilkinson et al., 2016).
If a patient requires mechanical ventilation, they will need an artificial airway. The selection of an airway depends on multiple factors, including whether the need is short-term or long-term. If the patient requires short-term ventilation, the artificial airway can be provided by an ETT, but long-term ventilation (longer than 14 days) will likely require the placement of a tracheostomy tube. Utilization of an ETT for more than 14 days puts the patient at risk for damage to the vocal cords and trachea (Ignatavicius et al., 2018; Wilkinson et al., 2016).
Placement of an artificial airway not only allows for ventilation and suctioning if needed, but also helps stabilize the airway. ETTs are inserted through the nose or mouth into the trachea (see Figure 5 below). Anesthesia providers and respiratory therapists usually perform intubations. Each patient will require a different size of tube based on their size, but an average size adult will use from a 7 to 9 mm ETT with pediatric and neonates requiring much smaller tubes. The tube may be inserted quickly under emergency conditions, or in a more controlled situation in a patient who is slowly getting worse (Ignatavicius et al., 2018; Wilkinson et al., 2016).
As the tube is being placed, nursing is responsible for monitoring the patient for any changes in vital signs or increasing signs of hypoxia or cardiac dysrhythmias. The nurse should also monitor time lapse during the insertion procedure, with a goal of 15-30 seconds for insertion of the tube. If the intubation lasts longer than 30 seconds, the patient must be ventilated with a manual resuscitation bag and supplemental oxygen to prevent further injury or damage. The patient must continue to receive oxygen to prevent hypoxia, and potential cardiac arrest. If necessary, the patient may need to be suctioned. If inserted correctly, the tip of the tube should be positioned approximately 2 cm above the tracheal carina (internal ridge at the bifurcation of the right and left bronchi). Once the ETT has been placed, an x-ray is taken to confirm the correct placement. The ETT has radiopaque lines that can be seen on x-ray and allow the provider to establish placement, and act as a guide for identifying the depth of the tube. The tube’s depth markings are assessed frequently to make sure the correct tube placement is maintained at the nares or mouth (Ignatavicius et al., 2018; Wilkinson et al., 2016).
Once the placement is confirmed, the ETT needs to be sealed by inflating the cuff with air. When the cuff is inflated, the patient will not be able to talk; therefore, a different form of communication will be necessary. At this time, the ETT will need to be stabilized by two persons. The tube should be marked at the nares or the incisors where the tube touches. It is best to use a manufactured device to hold the tube in place. One person holds the patient’s head as well as the ETT at the entry point while the other secures the tube into the device. Both nurses should verify that the tube has remained in the correct position and that the tube device is secure (Ignatavicius et al., 2018; Wilkinson et al., 2016).
At this time, the nurse should assess the patient for symmetry: equal breath sounds in both lungs as well as bilateral chest rise and fall. Documentation indicating the lung sounds and the level of the tube should then be completed if the patient is stable. Nursing should also make sure the patient is comfortable, with all needs met as well as a call light available. Essential nursing care requires continuous monitoring of vital signs, ETT positioning, and frequent respiratory assessments (Ignatavicius et al., 2018; Wilkinson et al., 2016).
If the provider determines that the need for mechanical ventilation will be long-term, then the patient will require a tracheostomy (see Figure 6 below). Education should be provided to the patient regarding the placement procedure, advantages, and disadvantages before the procedure and obtaining the consent. If this is an emergency, the provider will briefly explain the process but may not have time to go into detail. The patient will have routine preoperative care, and then anesthesia will insert an ETT. The surgeon will make a tracheotomy incision and then create the stoma or opening into the trachea, which is referred to as the tracheostomy. Anesthesia will remove the ETT once the trachea is open, which allows for the placement of the tracheostomy tube. The tube will need to be secured with sutures and either tracheostomy ties or another type of securement device. As with an ETT, the patient will need to have a chest x-ray to confirm exact placement (Ignatavicius et al., 2018; Wilkinson et al., 2016).
Nursing postoperative care includes assessing for, and maintaining a patent airway, monitoring vital signs, observing for signs of bleeding, and completing respiratory assessments frequently. In a patient with a new tracheostomy, minor bleeding will likely occur, but heavier bleeding should be reported to the provider. Nursing will want to assess the tracheostomy tube to ensure proper positioning and patency are maintained. The nurse may need to suction the cannula or provide tracheostomy care frequently at first. Respiratory therapy and nursing may work in collaboration to provide care such as oxygen therapy, assisting the patient to cough and deep breath, and nebulizer treatments if required. Any change in respiratory status, secretions, or vital signs must be documented and reported to the provider immediately to identify postoperative complications early (Ignatavicius et al., 2018; Wilkinson et al., 2016).
Another concern in the postoperative period is an infection of the surgical site. Sterile technique should always be utilized during the postoperative period for tracheostomy care and suctioning to reduce the risk of infection. As nursing is providing care, it is imperative to assess for signs of infection, which could include swelling, inflammation, or excessive/purulent drainage coming from around, or in the tracheostomy. The patient may also be febrile or have other changes in other their vital signs. Prior to or during tracheostomy care, the patient may complain of pain, or burning at the site, which should be assessed. A split gauze dressing specifically made for stoma sites should be applied after inspecting the site. It is not recommended to use standard 4×4 gauze and cut it to fit as the small fibers or threads can enter the open surgical site and lead to infection. It is important to change the dressing as needed when it becomes soiled with blood or drainage to prevent the moist dressing from becoming a receptacle for infection (Ignatavicius et al., 2018; Wilkinson et al., 2016).
Nursing should be familiar with the various types of tracheostomy tubes that are utilized currently in their facility. Tracheostomy tubes vary in physical design and the type of material that is utilized, which is usually plastic or metal. Some tubes may have a cuff and can be single or double lumen. The provider decides on the type of tube to use based on the client’s needs. A patient who will be on a mechanical ventilator or has dysphagia will most likely have a cuffed tube. If a patient can perform self-care, the best option is a tracheostomy tube that has an inner cannula. This type of tube allows the patient to remove the inner cannula for cleaning and is easier to maintain patency. If the tracheostomy tube has an inner cannula, this should be changed regularly per the institution’s protocols and procedures (Ignatavicius et al., 2018; Wilkinson et al., 2016).
There should always be a new tracheostomy set and insertion kit at the patient’s bedside that is the same brand, type, and size (or one size smaller). Nurses working with new tracheostomy patients should be prepared to change or replace the outer cannula if indicated (i.e., the tube becomes plugged and the nurse is unable to suction it out or the tube becomes dislodged). To replace a tracheostomy tube, the nurse should position the head by extending the neck and secure the airway by using a clamp to hold back any tissue. Make sure to place the obturator into the new tracheostomy tube and check the cuff for leaks. If the old tracheostomy tube is still in place, remove any ties/sutures, deflate the cuff, and gently remove the tube. Insert the new tube into the patient’s trachea quickly with the curve pointing down. Once the tracheostomy tube is in the trachea, remove the obturator and secure the tube. Inflate the cuff and ventilate the patient if needed. Once the tube is secured and the patient is settled, the nurse should assess for any signs of bleeding or trauma to the site and complete a full respiratory assessment. If the nurse is unable to replace the tube, they should maintain the airway and breathing with rescue methods and notify the provider and respiratory therapy for assistance. Nursing may also need to activate the emergency system within your facility for additional support (Ignatavicius et al., 2018; Wilkinson et al., 2016).
A tracheostomy cuff is an internal balloon that wraps around the outside of the tracheostomy tube. When it is inflated, the cuff puts pressure on the trachea and creates a seal around the cannula, and airflow is contained in the tracheostomy tube. There is an external balloon often referred to as the pilot balloon. A syringe of air is attached to a valve at the end of the pilot balloon, which allows air to be injected into the balloon, flow through the thin tube, and into the internal cuff. This inflates the cuff and the pilot balloon simultaneously, allowing healthcare workers to visualize and palpate the external balloon to monitor for cuff inflation. When assessing the air in the pilot balloon, the nurse must recognize that air in the pilot balloon indicates air is present in the internal cuff, but it does not indicate the amount of air present in the cuff (Ignatavicius et al., 2018; Wilkinson et al., 2016).
There are also fenestrated tracheostomy tubes. When the inner cannula is in place, this closes the fenestration and is recognized as a double lumen. If the patient is attempting to speak or cough, the inner cannula can be removed, the cuff deflated, and a stopper-like device can be attached. Because the inner cannula is gone, this allows air to come in through the fenestrated part of the tube, which helps the patient to cough and speak. Some patients adapt to this quickly while others become anxious, and have trouble breathing. If a patient has trouble when the stopper is applied, the nurse should assess whether the type, size, or placement needs to be adjusted. Fenestrated tubes come with cuffs or can be cuffless. It is imperative to deflate the cuff before applying the stopper to ensure the patient has a patent airway (Ignatavicius et al., 2018; Wilkinson et al., 2016).
When caring for a patient with a tracheostomy tube, consideration must be given to the potential complications. A cuffed tracheostomy tube puts pressure on the lining of the trachea, which can cause impaired tissue integrity. To prevent damage, the pressure exerted should range between 14 and not exceed 20 mmHg or between 20 and 30 cm of water. The recommendation is to use less than 25 cm of water for the best outcomes, unless there are special circumstances and it is indicated by the provider or respiratory therapy (Ignatavicius et al., 2018; Wilkinson et al., 2016).
There are two ways to measure the cuff pressure, and best practice suggests that cuff pressure should be checked at least once per shift, or at least every eight hours at home. This may be done more frequently in a newly established tracheostomy. The nurse can check the cuff pressure with the minimal leak technique, or a pressure cuff inflator. The minimal leak technique can be used anytime, but it is convenient to complete after tracheostomy suction and care are completed. Using a 10 ml syringe attached to the valve on the pilot balloon, start to withdraw the air while auscultating with a stethoscope on the patient’s neck near the tracheostomy site. The nurse should hear a pronounced rush of air as the pilot balloon deflates. The sound of rushing air is the seal between the internal cuff and the trachea being broken. The nurse re-inflates the pilot balloon while listening for the air going into the cuff. When air is no longer auscultated, this will indicate the seal is again in place. The nurse should withdraw 1 ml of air to decrease the risk of over-inflation. The cuff pressure can also be measured with a pressure cuff inflator or pressure manometer. The manometer is attached to the pilot tube and the pressure is read on the gauge. If the pressure is too high or too low, it can be adjusted by inflating or deflating with the manometer (Ignatavicius et al., 2018).
Nursing care of a tracheostomy patient should also focus on monitoring and maintaining adequate nutrition, hydration, and oxygen levels. The nurse should ensure the secured and stable positioning of the tube and limit suction to the amount that is needed to keep the patient’s airway patent. Warmed humidity can help keep secretions thinner and add moisture to the tissue (Ignatavicius et al., 2018; Wilkinson et al., 2016).
Tracheostomy patients require suctioning to decrease secretions in the cannula, and to keep the tube patent. Nursing needs to monitor the patient closely for the need to suction with each interaction. The patient should also notify the nurse if they feel the need to be suctioned and are able to communicate. All staff should be responsible for monitoring patients that have artificial airways and mechanical ventilators. Some signs that a patient needs to be suctioned are:
- obvious secretions coming from the tube,
- increasing shortness of breath,
- wheezing, or other adventitious breath sounds,
- increasing respiratory effort,
- decreased oxygen saturation,
- increased respiratory and heart rate, and/or
- appearing restless or agitated.
Suctioning should remove the secretions from the tube, decrease the respiratory and heart rate to an appropriate rate, increase oxygen saturation, improve lung sounds, and cause the patient to feel better (Ignatavicius et al., 2018; Wilkinson et al., 2016).
An assessment should be completed prior to suctioning and should include auscultation of lung sounds, oxygen saturation, respiratory and heart rate, presence of secretions, and distress of the patient. If the patient is on mechanical ventilation, PIP should be assessed prior to suctioning. Suctioning can be painful, especially deep suction, and should be done as quickly and efficiently as possible. Emotional support should be provided to the patient in addition to good communication to explain what is going to be done and when it will be done (Ignatavicius et al., 2018; Wilkinson et al., 2016).
If the assessment indicates the need for suction, the nurse begins with handwashing and donning personal protective equipment (PPE) as warranted by the situation. This may include sterile gloves, protective eyewear, as well as other PPE. When performing tracheostomy suction, there are various opinions about using a sterile technique, modified sterile technique, or clean technique based on the client scenario. In most facilities, sterile technique is utilized for patients that have a new tracheostomy or are highly susceptible to infection. Modified sterile technique is frequently used for patients that have an established tracheostomy with normal risk for infection, and no history of complications with their tracheostomy. With this technique, the nurse still uses a sterile suction catheter and supplies but could use clean gloves instead of sterile. This is becoming a more widely used method for suction. The final technique is a clean technique that is more prevalent for patients and families providing care in their own homes. This technique utilizes clean gloves and clean supplies. If the patient is doing their own suction and care, some argue that there is no need for the use of gloves. This final technique has limited situations for valid use. If a nurse is performing suction in a home, they should wear clean or sterile gloves to prevent infection in both the client and themselves (Ignatavicius et al., 2018).
A suction kit, or necessary supplies based on the technique that will be used should be at the patient’s bedside. For a normal-sized adult with a standard tracheostomy, a 12-14 French suction catheter should be used. The suction catheter should not be larger than half the size of the lumen of the tracheostomy tube. Using a suction catheter that is too large can cause damage and decrease the oxygen level. As the nurse is preparing their supplies, they should explain to the patient what will be done, and what they might experience. Test the suction tubing for the appropriate level of suction. Occluding the suction tubing, if functioning and set properly, should cause the pressure gauge to increase to between 80 to 120 mmHg. The sterile field and supplies from the suction kit should be set up and easily accessible. In some patients, hyperventilation with or without supplemental oxygen may be required prior to suctioning, and some may need additional ventilation immediately following the suctioning. If indicated, the patient should be hyperventilated prior to suctioning with three to four inhalations using a manual resuscitation bag. If hyperventilation is not necessary, the nurse should ask the patient to take three or four deep breaths prior to suctioning. Monitor the patient’s oxygen saturation level, heart rate, and level of distress while suctioning (Ignatavicius et al., 2018; Wilkinson et al., 2016).
With sterile gloves on and with the sterile suction catheter, the nurse will access the tracheostomy tube by inserting the catheter into the tube until feeling resistance. While inserting the catheter, it is essential not to apply any suction as this could cause damage to the mucosa. The nurse should then pull the suction catheter back approximately 0.5 in and apply the suction. Suction should be applied continuously as the catheter is gently rotated and withdrawn. It will take a while after suctioning for the patient to settle as suctioning temporarily decreases available oxygen and, therefore, the saturation rate. For this reason, the nurse should suction tracheostomy patients thoroughly but quickly and not more often than is necessary. Suctioning should take no more than 10 to 15 seconds. The patient may need hyperoxygenation again until the pulse and oxygen saturations reach the patient’s baseline. This process may need to be repeated up to three times total. Suctioning can irritate the mucosal lining of the trachea, which can produce more secretions, so limiting suction attempts is recommended unless patency is a concern. If necessary, the nurse should suction the mouth and provide oral care at this time as well. As with all patient care, the nurse should conclude by removing the gloves and completing hand hygiene. The nurse should also complete an evaluation of how the patient tolerated the procedure and the outcome and document accordingly in the patient’s medical record (Ignatavicius et al., 2018; Wilkinson et al., 2016).
In addition to regular suctioning, tracheostomy patients require routine care for their stoma and tube apparatus. Depending on the type of device that is used to secure the tracheostomy tube, this will also need to be changed at intervals or as it becomes soiled. The nurse should gather a tracheostomy tube care kit and other supplies prior to getting started with tracheostomy care. Arrange the supplies and set up the sterile field after completing hand hygiene and explaining the procedure to the patient. Don the appropriate PPE other than gloves, which are typically contained in the kit. The old tracheostomy dressing and any secretions that are present should be removed. If present, remove the inner cannula and replace it if disposable. If not disposable, the cannula should be cleaned with half-strength peroxide on the inside and outside and rinsed with sterile saline. The stoma and faceplate should be cleaned and rinsed using sterile cotton swabs and half-strength peroxide. While cleaning the stoma, the nurse should assess for any swelling, erythema, odor, or drainage. The skin should be rinsed well and dried. The ties or device securing the tracheostomy tube should be checked. If soiled or wet, it should be changed. Make sure to attach and secure the new ties or device before removing the old ones. Only one finger should be able to fit between the securing device and the patient’s neck. The nurse should complete hand hygiene and evaluate the patient, making sure all needs have been met. Complete all documentation of the tracheostomy care and relevant information (Ignatavicius et al., 2018; Wilkinson et al., 2016).