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Course: Medical Surgical Nursing

Topic: Airway Management Part II

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Module Goals

Learners will be able to:

Describe the management of upper airway obstruction and the nurse’s role.
Discuss the indications, classification and modes of mechanical ventilation, and the nurse’s role.

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Upper Respiratory Tract

The upper respiratory tract (upper airway) includes:

nose
mouth
sinuses
pharynx (upper section of the throat)
larynx (voice box)

Alberta, 2021

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Upper Respiratory Tract (Continued)

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Upper Airway Obstruction

An occlusion or narrowing of the airway leading to compromise in ventilation.
Obstructions vary

from acute to chronic
from congenital to acquired

It can be fatal if left untreated
Most common upper airway obstructions:

Obstructive Sleep Apnea (OSA)
Nasal Obstruction
Laryngeal Obstruction

Cathain & Gaffey, 2022

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Etiology of Upper Airway Obstruction

Classified based on noise with breathing:

Stertor: low-pitched and sounds like nasal congestion.

Caused by blockage at the level of the oral or nasal cavities or the level of the oropharynx or nasopharynx

Stridor: high-pitched sound associated with obstruction at the level of the larynx

Cathain & Gaffey, 2022

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Signs & Symptoms of Upper Airway Obstruction

Agitation or fidgeting
Cyanosis
Changes in consciousness
Choking
Confusion
Difficulty breathing
Unconsciousness
Wheezing
Tachypnea
Shortness of breath
Chronic dysphonia (in recurrent respiratory papillomatosis)

MedlinePlus, 2021

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Assessment of Upper Airway Obstruction

General examination of the body.
Facial features (paying close attention to any syndrome type features).
Respiratory effort.
Signs of tobacco use or signs of drug/alcohol intoxication or dependence.

Cathain & Gaffey, 2022

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Assessment (Continued)

Anterior Rhinoscopy:

Septal deviation
Hypertrophy of the nasal turbinates
Nasal polyposis
Perform nasal misting test

Oral Cavity:

Micrognathia
Edema of the lips
Trismus
Floor of mouth or tongue edema
Tumor or palatal fullness with uvular deviation

Cathain & Gaffey, 2022

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Critical Thinking Question

A client is brought to ER with respiratory distress. The nurse suspects upper airway obstruction.

Which additional signs and symptoms would the client exhibit? (Select all that apply).

Cyanosis
Changes in consciousness
Choking
Bradypnea
Shortness of breath

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Investigations & Imaging

Flexible Laryngoscopy
Oxygen Saturation
Ultrasound (US)
Magnetic Resonance Imaging (MRI)
Computed Tomography Scan (CT)
Sleep Study

Cathain & Gaffey, 2022

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Flexible Laryngoscopy: This can help diagnose turbinate inflammation, septal deviation, adenoidal hypertrophy, Waldeyer’s ring hypertrophy, or laryngeal/hypopharyngeal pathology. It is particularly useful when assessing the dynamic function of the larynx. A dynamic assessment is essential when assessing vocal cord movement and relatively common conditions affecting the larynx, such as laryngomalacia in children. It can also diagnose a laryngeal tumor in adults.

Oxygen saturations are an essential first step in assessing a patient with airway obstruction, as it can act as a marker for the severity of their obstruction.

Ultrasound or MRI are the imaging modalities of choice in children, as they do not involve radiation.

CT is used in situations that are time-sensitive or in cases that may need surgical intervention, such as a retropharyngeal abscess or a possible inhaled foreign body.

Sleep Study

To formally assess OSA, a sleep study or polysomnography should be performed. The important results of a sleep study are the patient’s oxygen nadir and the apnea-hypopnea index (AHI). The AHI averages the number of apneic and hypopneic episodes that occur per hour. An AHI of anything above 1 is abnormal in a child, and there is a grading system of severity for increasing numbers of AHI in adults.

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Treatment & Management

The initial step is ABC (Airway, Breathing, Circulation)
Monitor oxygen saturation
Perform imaging studies
Initiate antibiotic treatment if prescribed

Cathain & Gaffey, 2022

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Management: Unconscious Patient

Outside the hospital:

Call ambulance
Pulse check
Managed client as per Basic Life Support Protocols (BLS)
If choking is suspected, perform Heimlich maneuver

In a hospital setting:

Call a code for help
Call the Airway Team or the Rapid Response (emergency) Team involved in the management of cardiorespiratory arrest
Initiate the BLS algorithm

Cathain & Gaffey, 2022

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Acute Upper Airway Obstruction: Management

Awake Fibreoptic Intubation

Cricothyroidotomy

Tracheostomy

Cathain & Gaffey, 2022

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In the case of Ludwig’s angina, i.e., a bacterial infection of the oral cavity, causing tongue and floor of mouth edema, it may be possible to perform awake fibreoptic intubation.

The Doctor slides an endotracheal tube (ETT) onto a flexible endoscope. The nose is decongested, and the scope is passed to the level of the glottis while the patient is sitting upright. Lidocaine is inserted through the side port of the scope and onto the cords to anesthetize them to avoid laryngospasm. When this has worked, the scope is passed through the level of the vocal cords, and the ETT is then pushed down past the cords using the Seldinger technique. The patient is then given a general anesthetic, and the dental abscess is drained. The patient will likely need to be sedated for one to two days to allow the edema to settle prior to pulling the ETT.

Where intubation would be considered difficult or impossible, a cricothyroidotomy is a very quick procedure that can be performed in adults in cases of a true emergency. While the patient is lying supine, the operator holds the larynx in place, makes a vertical incision between the thyroid and cricoid cartilage, and inserts a blunt instrument such as a hemostat through the cricothyroid membrane. It is helpful to insert a bougie with a lumen at this point and then railroad a small, i.e., size six, ETT over this to secure the airway.

Tracheostomy is sometimes necessary in upper airway obstruction cases where intubation is anticipated to be very difficult or impossible. This can be performed under local anesthetic. If time allows, it should be performed in the OR with experienced staff and with anesthesiology involved. Before the procedure, it is helpful to administer at least 5 to 10 ml of nebulized 1% Lidocaine. In the OR, the patient should have oxygen via face mask or nasal prongs and be comfortable in a supine position, or sometimes semi-recumbent if in respiratory distress.

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Chronic Upper Airway Obstruction:

Management

A common cause of upper airway obstruction in adults is OSA

Education

Lifestyle modifications such as weight loss
Continuous Positive Airway Pressure (CPAP)

Surgery is reserved for patients who have failed CPAP therapy

Cathain & Gaffey, 2022

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Management (Continued)

The treatment goals:

Reduce side effects from OSA or other causative agent
Improve sleep quality
Reduce the apnea-hypopnea index (AHI)

Cathain & Gaffey, 2022

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Complications

If acute upper airway obstruction goes untreated, results in respiratory distress → bradycardia → tiring of the patient → loss of consciousness → cardiorespiratory arrest
If upper airway obstruction is due to foreign body aspiration, it can be acutely fatal.
Smaller size foreign body may enter the lungs causing:

atelectasis
pneumonia
pneumothorax

Cathain & Gaffey, 2022

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Nursing Management

Auscultate breath sounds: assess for respiratory stridor
Assess client’s ability to remove secretions
Instruct client to:

Eat slowly and chew food completely
Maintain proper hydration status
Do not drink too much alcohol before or while eating
Make sure dentures fit properly
Avoid cigarette smoking
Use incentive spirometer as recommended
Implement effective coughing techniques

MedlinePlus, 2021

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

The nurse is conducting a teaching session for a client diagnosed with OSA.

Which of the following interventions would the nurse include in the teaching plan? (Select all that apply).

Eat slowly and chew food completely
Maintain proper hydration status
Do not drink excess amounts of alcohol before or while eating
Make sure dentures fit properly
Avoid cigarette smoking
Use incentive spirometer as recommended
Implement effective coughing techniques

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Mechanical Ventilation: Definition

The application of positive or negative pressure to the airways through a mechanical ventilator.

Hickey & Giwa, 2022

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Mechanical Ventilator: Functions

Delivers high concentrations of oxygen into the lungs
Assists with the elimination of excess carbon dioxide
Decreases the amount of energy a client uses on breathing
Breathes for an individual who is not breathing due to injury to the nervous system or who is unconscious.

American Thoracic Society, 2020

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Invasive and Noninvasive Mechanical Ventilation

Positive Invasive mechanical ventilation:

Placement of an endotracheal tube through a client’s mouth or nose into the trachea.

Noninvasive Positive-Pressure Ventilation (NIPPV):

Uses devices to enhance gas exchange (e.g., face mask)
Most frequently used in clients with acute or chronic medical conditions who have moderate difficulty breathing.

Walter, 2021

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Positive Mechanical Ventilation

Classified according to:

Volume controlled mode
Pressure controlled mode

Other modes:

Dual modes
Interactive modes

Open Anesthesia, 2022

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Mechanical Ventilation: Volume Mode

Assist-Control Ventilation (ACV)
Synchronized Intermittent-Mandatory Ventilation (SIMV)
ACV vs. SIMV

Open Anesthesia, 2022

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Assist-Control Ventilation (ACV): Also known as continuous mandatory ventilation (CMV). Each breath is either an assist or control breath, but they are all of the same volume. The larger the volume, the more expiratory time required. If the I:E ratio is less than 1:2, progressive hyperinflation may result. ACV is particularly undesirable for patients who breathe rapidly – they may induce both hyperinflation and respiratory alkalosis. Note that mechanical ventilation does not eliminate the work of breathing, because the diaphragm may still be very active.

Synchronized Intermittent-Mandatory Ventilation (SIMV)

Guarantees a certain number of breaths, but unlike ACV, patient breaths are partially their own, reducing the risk of hyperinflation or alkalosis. Mandatory breaths are synchronized to coincide with spontaneous respirations. Disadvantages of SIMV are increased work of breathing and a tendency to reduce cardiac output, which may prolong ventilator dependency. The addition of pressure support on top of spontaneous breaths can reduce some of the work of breathing. SIMV has been shown to decrease cardiac output in patients with left-ventricular dysfunction.

ACV vs. SIMV

Personal preference prevails, except in the following scenarios: 1. Patients who breathe rapidly on ACV should switch to SIMV 2. Patients who have respiratory muscle weakness and/or left-ventricular dysfunction should be switched to ACV

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Mechanical Ventilation: Pressure Mode

Pressure-Controlled Ventilation (PCV)

Pressure Support Ventilation (PSV)

Pressure Controlled Inverse Ratio Ventilation (PCIRV)

Airway Pressure Release Ventilation (APRV)

Open Anesthesia, 2022

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Pressure-Controlled Ventilation (PCV)

Less risk of barotrauma as compared to ACV and SIMV. Does not allow for patient-initiated breaths. The inspiratory flow pattern decreases exponentially, reducing peak pressures and improving gas exchange [Chest 122: 2096, 2002]. The major disadvantage is that there are no guarantees for volume, especially when lung mechanics are changing. Thus, PCV has traditionally been preferred for patients with neuromuscular disease but otherwise normal lungs.

Pressure Support Ventilation (PSV)

Allows the patient to determine inflation volume and respiratory frequency (but not pressure, as this is pressure-controlled), thus can only be used to augment spontaneous breathing. Pressure support can be used to overcome the resistance of ventilator tubing in another cycle (5 – 10 cm H20 are generally used, especially during weaning), or to augment spontaneous breathing. PSV can be delivered through specialized face masks.

Pressure Controlled Inverse Ratio Ventilation (PCIRV)

Pressure controlled ventilatory mode in which the majority of time is spent at the higher (inspiratory) pressure. Early trials were promising, however the risks of auto PEEP and hemodynamic deterioration due to the decreased expiratory time and increased mean airway pressure generally outweigh the small potential for improved oxygenation.

Airway Pressure Release Ventilation (APRV)

Airway pressure release ventilation is similar to PCIRV – instead of being a variation of PCV in which the I:E ratio is reversed, APRV is a variation of CPAP that releases pressure temporarily on exhalation. This unique mode of ventilation results in higher average airway pressures. Patients are able to spontaneously ventilate at both low and high pressures, although typically most (or all) ventilation occurs at the high pressure. In the absence of attempted breaths, APRV and PCIRV are identical. As in PCIRV, hemodynamic compromise is a concern in APRV. Additionally, APRV typically requires increased sedation.

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Mechanical Ventilation:

Dual & Interactive Modes

Pressure Regulated Volume Control (PRVC): A volume target backup is added to a pressure assist-control mode.

Proportional Assist Ventilation (PAV): The care provider sets the percentage of breathing work to be provided by the ventilator.

Open Anesthesia, 2022

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Critical Thinking Question

The mechanical ventilator performs various functions.

Which of the following statements reflect these functions? (Select all that apply).

Deliver high concentrations of oxygen into the lungs
Assist with the elimination of excess carbon dioxide
Decrease the amount of energy a client uses on breathing
Breathe for an individual who is not breathing due to injury to the nervous system or who is unconscious

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Indication for Mechanical Ventilation

Airway protection in a client who is obtunded or has a damaged airway (e.g., from trauma or oropharyngeal infection).
Hypercapnic respiratory failure due to a decrease in minute ventilation.
Hypoxemic respiratory failure due to a failure of oxygenation.
Cardiovascular distress whereby mechanical ventilation can offload the energy requirements of breathing.
Expectant course (e.g., anticipated client decline).

Hickey & Giwa, 2022

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Risks of Mechanical Ventilation

Infection
Collapsed lungs (pneumothorax)
Lung damage
Medication adverse effects
Inability to discontinue life support

American Thoracic Society, 2020

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Nursing Management

Minimize ventilator exposure

Provide excellent oral hygiene care

Coordinate care for subglottic suctioning

Maintain optimal positioning and encourage mobility

Ensure adequate staffing

Boltey et al., 2017

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Minimize ventilator exposure:

The most important evidence-based practice for lowering VAP risk is minimizing a patient’s exposure to mechanical ventilation, which can be achieved in two ways:

Encourage and advocate for the use of noninvasive ventilation approaches, such as bilevel positive airway pressure or continuous positive airway pressure.
When mechanical ventilation can’t be avoided, work to minimize its duration. Ventilator weaning protocols or evidence-based care bundles (for example, the Awakening, Breathing Coordination, Delirium, and Early mobility (ABCDE) bundle) can be effective in shortening mechanical ventilation duration.

Provide excellent oral hygiene care:

Oral health quickly deteriorates in mechanically ventilated patients. Some patients sustain injuries to the oral mucosa during the intubation procedure, and after intubation, patients are prone to dry mouth. These factors, in addition to a severely compromised immune system, can cause an increase in bacteria colonization in the oral mucosa, with the endotracheal tube serving as a direct route to the lungs.

Coordinate care for subglottic suctioning:

Aspiration of secretions that accumulate around the endotracheal tube of mechanically ventilated patients can lead to VAP. Subglottic secretion suctioning can be performed by both the nurse and respiratory therapist and can aid in prevention. Coordinating subglottic suctioning when conducting oral care may be a good mechanism to cluster care and ensure both of these practices are routinely delivered.

Maintain optimal positioning and encourage mobility:

Proper positioning (keeping the head of the bed between 30–45 degrees) and encouraging early mobility of mechanically ventilated patients aid in the prevention of VAP. Gastric reflux and aspiration can also lead to VAP in mechanically ventilated patients. Keeping the head of the bed elevated between 30–45 degrees (semi-recumbent position) is recommended to reduce reflux and subsequent risk for VAP.

Ensure adequate staffing:

Adequate nurse staffing in the ICU, especially for mechanically ventilated patients, can help minimize VAP risk. It provides nurses with the time, opportunity, and resources to implement care practices that reduce risk, and it allows them to spend more time with their patients, which may lead to early identification of VAP and prompt treatment (Boltey et al., 2017)

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Weaning the Client from the Ventilator

Criteria for readiness for weaning trial:

Subjective assessment
Objective measurements
Adequate oxygenation

Criteria for successful spontaneous breathing:

Respiratory rate < 35 breaths/minute
Good tolerance to spontaneous breathing trials
Heart rate < 140 /minute
No signs of increased work of breathing or distress

Zein et al., 2016

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Subjective assessment:

Adequate cough
No neuromuscular blocking agents
Absence of excessive trachea-bronchial secretion
Reversal of the underlying cause for respiratory failure
No continuous sedation infusion or adequate mentation on sedation

Objective measurements:

Stable cardiovascular status Heart rate ≤ 140 beat/minute
No active myocardial ischemia
Adequate hemoglobin level ( ≥ 8 g/dl) Systolic blood pressure 90–160 mmHg Afebrile (36◦ C < temperature < 38◦ C)
No or minimal vasopressor or inotrope (< 5 µg/kg/minute dopamine or dobutamine)

Adequate oxygenation:

Tidal volume > 5 mL/kg Vital capacity >10 mL/kg
Proper inspiratory effort
Respiratory rate ≤ 35/minute PaO2 ≥ 60 and PaCO2 ≤ 60 mmHg
Positive end expiratory pressure ≤ 8 cmH2O
No significant respiratory acidosis (pH ≥ 7.30)
Maximal inspiratory pressure (MIP) ≤ -20 – -25 cmH2O O2 saturation > 90% on FIO2 ≤ 0.4 (or PaO2/FIO2 ≥ 200)
Rapid Shallow Breathing Index (respiratory Frequency/Tidal Volume) < 105

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Risk Factors of Extubation Failure

Failure of two or more consecutive spontaneous breathing trials
Chronic heart failure
PCO2 > 45 mmHg after extubation
More than one coexisting condition other than heart failure
Weak cough
Upper-airway stridor at extubation
Age ≥ 65 years
APACHE II score >12 on the day of extubation
Patients in medical, pediatric or multispecialty ICU
Pneumonia as a cause of respiratory failure

Zein et al., 2016

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Considerations

Mechanical ventilation changes client’s natural negative pressure ventilation to positive pressure ventilation.
This affects the heart-lung physiology and can alter the client's hemodynamic status.
The positive pressure ventilation increases intrathoracic pressure.
Increased intrathoracic pressure will lead to a decrease in right ventricular preload and left ventricular preload and afterload.
It will also increase the right ventricular afterload.

Hickey & Giwa, 2022

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Critical Thinking Question

Describe the risks associated with mechanical ventilation.

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Red Flags

Stridor should be recognizable by all staff, from respiratory therapists and nursing staff to physicians of all specialties.

All Emergency Department and ward staff should be aware that it is imperative to contact the airway team on-call in the case of new-onset stridor in the setting of respiratory distress.

Healthcare staff should regularly undergo Basic Life Support (BLS) training.

Cathain & Gaffey, 2022

Contact info: info@nursesinternational.org

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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

Alberta. (2021). Respiratory System. https://myhealth.alberta.ca/Health/Pages/conditions.aspx?hwid=ug2841

American Thoracic Society. (2020). Mechanical Ventilation. https://www.thoracic.org/patients/patient-resources/resources/mechanical-ventilation.pdf

Boltey, E. et al. (2017). 5 Nursing strategies to prevent ventilator-associated pneumonia. Am Nurse Today. 12(6): 42–43. https://doi.org/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5706660/

Cathain, E. & Gaffey. M. (2022). Upper Airway Obstruction. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK564399/

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References

Hickey, S. & Giwa, A. (2022). Mechanical Ventilation. In: StatPearls. Treasure Island (FL): StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK539742/

MedlinePlus. (2021). Blockage of Upper Airway. https://medlineplus.gov/ency/article/000067.htm

Open Anesthesia. (2022). Modes of Mechanical ventilation. https://www.openanesthesia.org/modes_of_mechanical_ventilation/

Walter K. (2021). Mechanical Ventilation. JAMA. 2021;326(14):1452. doi:10.14423/SMJ.0000000000000905

Zein, H. et al., (2016). Ventilator weaning and spontaneous breathing trials; an Educational Review. Emergency. 4 (2): 65-71. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4893753/

Contact info: info@nursesinternational.org

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