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Course: Medical Surgical Nursing

Topic: Airway Management Part I

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Module Goals

Learners will be able to

Describe the indication for and management of endotracheal intubation.
Describe the nurse’s role in endotracheal intubation.
Describe the indication for and management of tracheostomy.
Describe the nurse’s role in tracheostomy.

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Endotracheal Intubation

An emergent resuscitative procedure.

Purpose: To secure a client’s airway to provide oxygenation and ventilation.

Indication:

Prior to general anesthesia
Respiratory failure or respiratory arrest

Ernstmeyer & Christman, 2021

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Endotracheal Intubation (Continued)

Ernstmeyer & Christman, 2021

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Endotracheal Intubation: Indications

Poor respiratory drive
Questionable airway patency
Hypoxia, Hypercarbia
In trauma, a Glasgow Coma Scale of 8 or less

Indications are evaluated by:

Mental status
Conditions that may compromise the airway
Level of consciousness
Respiratory rate
Respiratory acidosis, and level of oxygenation

Alvarado & Panakos, 2022

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Endotracheal Intubation: Equipment

Preparation:

Intravenous access
Hemodynamic monitoring
Stethoscope
Pulse oximeter
End-tidal carbon dioxide (EtCO2) monitor
Suction catheter attached to continuous suction
Cardiac arrest cart with resuscitation medications
Rapid sequence intubation medications (paralytic, sedative, and/or dissociative agent)
Defibrillator

Alvarado & Panakos, 2022

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Endotracheal Intubation: Equipment (Continued)

Pre-oxygenation

Nasal cannula or high-flow nasal cannula (HFNC)
Bag-valve mask with masks of various sizes
Positive end-expiratory pressure (PEEP) valve
Oral and nasal airways of various sizes
Non-rebreather mask
Supplemental oxygen

Alvarado & Panakos, 2022

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Endotracheal Intubation: Equipment (Continued)

Direct Laryngoscopy:

Laryngoscope handle with batteries
Laryngoscope blades of various sizes and shapes
Endotracheal tubes of various sizes
Malleable stylet
10cc syringe
Tape

Video Laryngoscopy

Video laryngoscope connected to a power source
Rigid or malleable stylet
See video: https://www.youtube.com/watch?v=QSIWSPM9_f8

Alvarado & Panakos, 2022

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Endotracheal Intubation: Equipment (Continued)

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Endotracheal Intubation:

Preparation and Evaluation

Conduct Airway Evaluation:

A history of intubation, any difficult intubations

Commonly used mnemonic is “LEMON.”

Look externally for signs of trauma, facial hair, neck masses, large tongue, or dentures
Evaluate the 3-3-2 rule
Mallampati class greater than or equal to 3
Obstruction or obesity
Neck mobility and any restriction of

Alvarado & Panakos, 2022

Contact info: info@nursesinternational.org

The first step in preparation is to perform an airway evaluation

Evaluation of the external anatomy may be predictive of a difficult airway
Clients with restricted cervical motion, obesity, and facial or neck trauma may present as difficult airways, and providers should anticipate alternative modes of intubation in these situations
Evaluate 3-3-2 rule:

Less than three fingers between the incisors, three fingers between the hyoid bone and the mental protuberance, and two fingers between the hyoid bone and the thyroid cartilage (Adam’s Apple) may be representative of a difficult airway.

“Mallampati” class greater than or equal to 3 is predictive of difficult intubation

“Obstruction” or obesity may restrict visualization of the vocal cords

“Neck” mobility and any restriction of it can contribute to difficulty passing the endotracheal tube

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Endotracheal Intubation: Positioning

The ‘sniffing position’

Procedure:

Elevate the client’s head
Extend the head at the neck
Align the ears horizontally with the sternal notch

In obese clients, rolls may be utilized to elevate the head until the external auditory meatus aligns with the sternal notch.

Alvarado & Panakos, 2022

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Endotracheal Intubation: Tube Size

Women: 7.0

Men: 8.0

A Bronchoscopy requires at least a 7.5 or 8.0 tube
For children, select tube size using the equations:

Size = [(Age/4) + 4] for uncuffed tubes
Size = [(Age/4) + 3.5] for cuffed tubes (preferred for the pediatric population)

Alvarado & Panakos, 2022

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Endotracheal Intubation: Preoxygenation

A high (FiO2) before the administration of sedative and paralytic medications.

The goal is to slow the decline of oxyhemoglobin during apnea.

Preferred source:

A non-rebreather mask with 1-way valves that allow for delivery of close to 90% FiO2 and do not allow exhaled air to be re-inspired.

Alvarado & Panakos, 2022

Contact info: info@nursesinternational.org

Once all instruments are prepared for intubation, the patient requires pre-oxygenation to increase alveolar oxygen and decrease alveolar nitrogen tension.

Other oxygen masks without 1-way valves can provide up to 70% FiO2 with a tight seal around the patient’s face, and bag valve masks can often deliver a higher than ambient air FiO2. Positive end-expiratory pressure (PEEP) using continuous positive airway pressure (CPAP) or non-invasive bilevel positive airway pressure (BiPAP) may be used in patients with pulmonary shunt pathologies as methods of pre-oxygenation. Patients with underlying conditions causing alveoli to be perfused but not ventilated may benefit from increased PEEP using these mechanisms. Pre-oxygenation should last 3 minutes and achieve end-tidal oxygenation (EtO2) greater than 90%.

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Endotracheal Intubation: Medication

Patients are premedicated with various medications to facilitate ease of intubation.

The nurse should be familiar with these medications, their actions, and side effects.

Alvarado & Panakos, 2022

Contact info: info@nursesinternational.org

Rapid sequence intubation (RSI) is often the method used by most physicians in emergency settings as it has been shown to improve the likelihood of first-pass success and minimize aspiration.

RSI is accomplished by using medications that have a quick onset and short duration of action. Administration of these medications within a short period (e.g., <30 seconds) minimizes apnea time. The components of RSI include a sedative along with a paralytic agent. Delayed sequence intubation (DSI) is an alternative method used in patients in which adequate pre-oxygenation is not possible due to combativeness and/or altered mental status.

Ketamine (ketamine hydrochloride) has been approved for general anesthesia either alone or in combination with other medications. It is a superb drug for use in short-term medical procedures that do not require skeletal muscle relaxation, and it has approval for the induction of general anesthesia as a pre-anesthetic to other general anesthetic agents.

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Confirmation of Endotracheal Tube (ETT) Placement

Tracheal ultrasonographic (USG): intubation under direct visualization.
Inspection of chest wall movements
Auscultation of bilateral breath sounds
Capnography: monitoring of end‑tidal carbon dioxide (EtCO2)
Use of negative pressure devices
Fiberoptic bronchoscopy
Sonomatic confirmation of tracheal intubation (SCOTI) device
Chest X‑ray

Sethi et al., 2019

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USG is a rapid technique for identification of ETT placement. Real‑time visualization of tracheal tube with USG transducer placed over the trachea during intubation can be used for confirmation of ETT placement in the airway before initiating ventilation. This is very useful in trauma victims, pregnancy and patients at high risk for aspiration.

Among all, capnography is considered the gold standard. Although, it may not be reliable under certain conditions, such as:

endobronchial intubation
poor circulatory perfusion as in cardiac arrest
severe hypotension
pulmonary embolism
severe bronchospasm
poor pulmonary reserve like pleural effusion
pneumothorax and pulmonary malignancy

Prior bag‑mask ventilation leading to gastric insufflation, antacid consumption or ingestion of carbonated beverages also may lead to false positive results with capnography. The American College of Emergency Physicians 2005 guidelines recommend that some additional method of confirmation must be performed after placement and before securing the ETT (Sethi et al., 2019).

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Critical Thinking Question

The nurse educator is teaching a lesson on endotracheal intubation.

Which of the following statements about capnography is correct?

Avoid consuming carbonated beverages prior to intubation
It is considered the goal standard for ETT confirmation
It might not be reliable in severe hypertension
It is the preferred method for clients with cardiac arrest

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Endotracheal Intubation: Contraindications

Severe airway trauma
Severe cervical spine injury requires complete immobilization
Facial trauma
Head trauma concerning basilar skull fracture
Active epistaxis

Ahmed & Boyer, 2022

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Endotracheal Intubation Preparation:

Nurse’s Role

Remove client’s dentures
Collect equipment needed for intubation
Prepare emergency drugs
Assist during the intubation procedure

Naik et al., 2021

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Intubated Clients: Nurse’s Role

Never leave the client alone
Check the ventilator settings
Maintain an open airway
Secure endotracheal tube properly to prevent unplanned extubation
Observe for tachypnea, tachycardia, diaphoresis, hypoxia
Elevate head 30 to 45 degrees (aspiration prevention)
Watch for complications (laryngeal edema, tracheal stenosis, etc.)
Assure an emergency tracheostomy tray at the bedside
Document procedure

Naik et al., 2021

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What Would the Nurse Do?

The nurse is preparing for an endotracheal intubation.

Which of the following interventions should the nurse perform? (Select all that apply).

Prepare equipment
Monitor and maintain an open airway
Observe for tachypnea, tachycardia, diaphoresis, and hypoxia
Elevate head 30 to 45 degree
Watch for complications
Keep emergency tracheostomy tray at the bedside

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Tracheostomy

A surgically-created opening (stoma) made on the front of the client’s neck into the trachea.

A tracheostomy tube is placed through the stoma directly into the trachea to maintain an open airway.

Ernstmeyer & Christman, 2021

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Tracheostomy Tube: Indication

A large object blocking the airway
Respiratory failure or arrest
Severe neck or mouth injuries
A swollen or blocked airway due to inhalation of harmful material
Cancer of the throat or neck
Paralysis of the muscles that affect swallowing
Long-term oxygen therapy via a mechanical ventilator

Ernstmeyer & Christman, 2021

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Tracheostomy Tube: Indication (Continued)

Ernstmeyer & Christman, 2021

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When a tracheostomy is placed, the provider determines if a fenestrated or unfenestrated outer cannula is needed based on the client’s condition.

A fenestrated tube is used for clients who can speak with their tracheostomy tube in place

Under the guidance of a speech pathologist and respiratory therapist, the inner cannula is eventually removed from a fenestrated tube and the cuff deflated so the patient is able to speak.
Otherwise, a patient with a tracheostomy tube is unable to speak because there is no airflow over the vocal cords, and alternative communication measures, such as a whiteboard, pen and paper, or computer device with note-taking ability, must be put into place by the nurse.
Suctioning should never be performed through a fenestrated tube without first inserting a nonfenestrated inner cannula, or severe tracheal damage can occur.

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Tracheostomy Tube: Nursing Care

Providing routine tracheostomy care
Suctioning: Checklist for Tracheostomy Suctioning

Video: Video Review of Tracheostomy Suctioning

Cleaning the skin around the stoma
Providing oral hygiene
Assessing for complications
Keeping emergency supplies on hand
Documentation: Sample

Parker, 2014

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Suctioning:

Always hyperoxygenate patients prior to and following suctioning to prevent hypoxemia and its associated risks
Closed or in-line suctioning helps to maintain oxygenation during mechanical ventilation, and also decreases the risk of aerosolized secretions.
When suctioning a tracheostomy, use a catheter that's no more than half the inner diameter of the tube and insert to just beyond the end of the tube
A#12 French suction catheter fits most patients

Cleaning the inner cannula:

Sterile technique and appropriate personal protection gear, including gown and eye protection, are required for providing tracheostomy tube care

Stoma Care and Assessing complication Read : https://journals.lww.com/nursingcriticalcare/fulltext/2014/11000/tracheostomy_care.8.aspx#:~:text=Nursing%20care,-Most%20nurses%20were&text=(See%20Tracheostomy%20tubes.),filtering%2C%20and%20humidifying%20inspired%20air.

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What Would the Nurse Do?

The nurse is preparing to suction a client with an endotracheal tube.

What is the correct order for suctioning?

Perform safety steps
Gather supplies
Verify that there are a backup tracheostomy and bag valve device available at the bedside
Place the patient in a semi-Fowler’s position and apply the pulse oximeter for monitoring during the procedure
Assess lung sounds, heart rate and rhythm, and pulse oximetry
Set the suction gauge to appropriate setting based on age of the patient

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Red Flags

Endotracheal tube:

The usual route for insertion is through the mouth: oral endotracheal tube.
Less frequent route for insertion is through the nose: nasal endotracheal tube.

Tracheostomy tube: A surgical incision is made in the trachea

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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References

Agency for Healthcare Research. (2020). Health Literacy Universal Precautions Toolkit, 2nd Edition. https://www.ahrq.gov/health-literacy/improve/precautions/tool10.html

Ahmed, R.A, & Boyer, T.J. (2022). Endotracheal Tube. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK539747/

Alvarado, A.C., & Panakos, P. (2022). Endotracheal Tube Intubation Techniques. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560730/

Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Fundamentals. By Chippewa Valley Technical College, licensed under CC BY 4.0. https://wtcs.pressbooks.pub/nursingfundamentals/

Contact info: info@nursesinternational.org

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References

Laura, P. (2014). Tracheostomy Care. Nursing Critical Care: Volume 9 - Issue 6 - p 38-41 doi: 10.1097/01.CCN.0000453466.57833.dd. https://journals.lww.com/nursingcriticalcare/fulltext/2014/11000/tracheostomy_care.8.aspx#:~:text=Nursing%20care,-Most%20nurses%20were&text=(See%20Tracheostomy%20tubes.),filtering%2C%20and%20humidifying%20inspired%20air.

Naik et al. (2021). "Role and responsibility of Intensive Care Nurses in Intubation Procedure," SSRG International Journal of Nursing and Health Science, vol. 7, no. 3, pp. 1-4. https://doi.org/10.14445/24547484/IJNHS-V7I3P101

Sethi, A. et al. (2019). Confirmation of placement of endotracheal tube: A comparative observational pilot study of three ultrasound methods. Journal of Anaesthesiology Clinical Pharmacology. 35,353-358. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6748007/pdf/JOACP-35-353.pdf

Contact info: info@nursesinternational.org

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