Respiratory Modalities 2

I.

Artificial Airways

Indication for Artificial Airways:

- To protect the airway (prevent aspiration)
- To facilitate suctioning
- To relieve upper airway obstruction
- To facilitate mechanical ventilation (Endotracheal & Tracheostomy tubes)
Goal of airway management: To ensure that the patient has a patent airway through
which effective ventilation can take place.
Types:
1. Oropharyngeal Airway / Oral Airway
- Used to prevent tongue from occluding the airway
- Measurement: hold the airway on the side of the patients face, measure from
the opening of the mouth to the ear (back angle of the jaw or bottom of the
earlobe.
- Check for loose teeth, food and dentures to prevent aspiration.
2.
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Nasopharyngeal Airway:
Prevents tongue from blocking airway
Tolerated by conscious or semi-conscious patient
Indications: clenched teeth, enlarged tongue, need for frequent nasal suctioning
Use water soluble lubricant to coat the distal 6-8cm for easy insertion
Measurement: hold the airway on the side of the patients face, measure from
the tragus of the ear to the nostril plus one inch.
Position: conscious semi-fowlers ; unconscious side-lying

3. Endotracheal Tube
Indications:
- Upper airway obstruction
- Apnea
- High risk for aspiration
- Ineffective clearance of secretions
- Respiratory distress route for mechanical ventilation
Special Considerations:
- Inserted by doctors
- Can be used for 3-4 weeks only
- Cuffed adult ; Uncuffed pedia (size 5 below)
4.
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Tracheostomy Tube
Inserted by doctors
To provide artificial airway which may be indicated for long term use (> 28 days)
To maintain patent airway
To provide route for mechanical ventilator if needed
Prevent infection of respiratory tract

II.

Suctioning

Suctioning process if aspirating secretions through a catheter connected to a suction

machine or wall suction outlet.
It maybe:
1. Oropharyngeal removes secretions from the back of the throat
2. Nasopharyngeal / Nasotracheal
3. Artificial Airway
Tracheostomy remove secretions from lower airway
Endotracheal
Purposes:
1. To remove secretions that obstruct the airway
2. To facilitate ventilation
3. To obtain secretions for diagnostic purposes
4. To prevent infection that may result from accumulated secretions
Positions:
- For conscious client: semi-fowlers
- For unconscious client: lateral position
- In some instances: Turning patients head to right helps suction left mainstem
bronchusl turning head to left, helps suction right mainstem bronchus
Pressure of Suction Equipment:
Adult 100-150 mmHg
Child 100-120 mmHg
Infant 80-100 mmHg
Pre-term 60-80 mmHg

Size of Suction Catheter:

Adolescent-adult Fr.10-16
Child (2-12yrs) Fr.6-10
Infant Fr.5-6

Length of Catheter Insertion: measure from tip of nose (or mouth) to angle of
mandible (or earlobe).
Duration of Suctioning:
- 10-15 seconds/suctioning; applied intermittently
- Oversuctioning can cause cardiopulmonary compromise, hypoxemia and
vagal stimulation
- Allow 20-30 seconds interval between each suction
Assess for:
1. Audible secretions during respiration.
2. Auscultate for adventitious breath sounds
3. Signs and symptoms of upper and lower airway obstruction requiring suction (p.
934)
4. Signs and symptoms associated with hypoxia and hypercapnia (p.934)
5. Risk factors for upper or lower airway obstruction (p.934)
6. Identify contraindications to nasotracheal suctioning (p.934)
Special Considerations:
- Use sterile gloves to prevent introduction of microorganisms into the respiratory
tract.
- Lubricate catheter before insertion
Nasopharyngeal tip with water soluble lubricant
Oropharyngeal tip with sterile water on NSS

For artificial airway (tracheostomy or endotracheal tube) suctioning, hyper

inflate and/or hyper oxygenate before suctioning to decrease the risk for
atelectasis.
Apply suction during withdrawal of the suction catheter (NEVER during insertion)
to prevent trauma to the mucous membrane, rotating the catheter while
withdrawing.
Encourage the client to breathe deeply and to cough between suctions to bring
up mucus secretions into the upper airways.
Provide oral and nasal hygiene
Dispose contaminated equipment/articles safely
Assess effectiveness of suctioning
Document

Procedure for Oropharyngeal Suctioning (p.670-673)

Procedure for Nasopharyngeal, Nasotracheal and Artificial Airway Suctioning (p.673681)
III.

Care for patients with Endotracheal Tube

Position: supine or side-lying

- Reposition on the opposite side of the mouth at least every 24-48 hours
- Depth and length during insertion should be maintained
- Level of the tube: gumline or bite of the patient
- Remove all the previous tapes. Check the lips for cracks and irritation *DO NOT
UNCUFF
IV.
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Tracheostomy Care
Tracheostomy care is provided at least every 8 hours or more often if indicated.
Observe for signs and symptoms of need to perform tracheostomy care: excess
peristomal secretions, excess intratracheal secretions, soiled or damp
tracheostomy ties and dressing, diminished airflow through tracheostomy tube,
and signs and symptoms of airway obstruction requiring suctioning.
Assess hydration status, humidity delivered to airway, status of existing
infection, patients nutritional status and ability to cough.
Usually on the first 24-48 hours. Tracheostomy care is done every 4 hours using
sterile technique.
PREVENT ASPIRATION inflate tube cuff before giving gavage or oral feedings,
deflate the cuff after 30 minutes to 1 hour after feeding as ordered.

Position: Supine or high-fowlers

Sterile technique acute phase following tracheostomy insertion
Clean technique once it became a client procedure or home care
Tie:

One-man place the new tie first then remove the old one
Two-man first person will hold the tube while the second person removes old
tie and replace
with a new tie.
(Procedure of Tracheostomy care (p. 689-694)
V.

Care of patient with Chest Tube

Chest Tube a catheter inserted through the thorax to:

Remove air or fluids from the pleural space

Prevent re-entering of air or fluid to pleural space

Re-establish normal intrapleural and intrapulmonic pressures

Indications:
- Pneumothorax collection of air in the pleural space
- Hemothorax accumulation of blood in the pleural cavity between the parietal
and visceral pleurae, usually as the result of trauma
- Pleural Effusion accumulation of fluid
Types:
1. Single Chamber or One-Bottle System
- Serves as collector and water seal
- For removing small amount of drainage as in empyema
2. Two Chamber or Two-Bottle System
- Permits fluid to flow into the drainage chamber while air flows into the waterseal
- Allows more accurate measurement of drainage
3. Three Chamber or Three-Bottle System
- 3 separate chambers: one for drainage, one for water-seal and one for suction
Principle used in Chest Tubes

Gravity
Air and fluid flow from a higher pressure to a lower pressure
Airways keep chest drainage apparatus below the level of the clients chest

Water-Seal
Seals off pleural space from atmospheric pressure
Must be airtight, any leak may lead to development of positive pressure in the
pleural space that collapses the lung

Suction a pull force of less than atmospheric pressure: 20cm H2O

Insertion of chest tubes is done in the operating room, in emergencies, in the

treatment room and at bedside (to treat empyema)
2 catheters are usually placed:
1. One (Upper or Anterior Tube) placed anteriorly through 2nd intercostal space to
permit escape of air
2. Other (Lower or Posterior Tube) placed posteriorly through 8th or 9th intercostal
space mid-axillary line to drain fluid
NURSING MGT:
Assess patient for respiratory distress and chest pain, breath sounds over
affected lung area and vital signs
Assess chest drainage measure and document amount note characteristics of
drainage
Assess water-seal functioning
o Observe for tidaling: that is, water-seal rises with inspiration; falls with
expiration
- If tidaling is present = drainage tube is present
- If it does not occur, check for kinking, compression then milk, strip change
position; instruct client to cough/deep breath

o
o

Observe for bubbling

Bubbling is caused by air passing out of pleural space into the bottle
INTERMITTENT bubbling = normal
CONTINUOUS bubbling = during both inspiration and expiration indicates air is
leaking; check from insertion site down to length of tube
RAPID bubbling in the absence of leak indicated considerable loss of air. Refer to
physician right away.
Assess suction apparatus function
Degree of suction must be controlled
Suction force greater than 50cm H2O may damage the lungs
Provide two hemostats for each chest tube, attached to top of patients bed with
adhesive tape

Chest tubes are only clamped under specific circumstances:

- To assess air leak
- To quickly empty or change collection bottle or chamber; performed by soldier
medic who has received training in procedure
- To change disposable systems; have new system ready to be connected before
clamping tube so that transfer can be rapid and drainage system reestablished
- To change a broken water-seal bottle in the event that no sterile solution
container is available
- To assess if patient is ready to have chest tube removed (which is done by
physicians order); the soldier medic must monitor patient for recreation of
pneumothorax

Promote safety of the system

Must be placed 2-3 ft. lower than clients chest
System must be placed in a rack or box to prevent being knocked over
Support tubing with pillow, folded towel to prevent compression
Tubing should not be too long or too short to allow movement of the patient
Check patency of drainage tubing and catheter frequently
Strip or milk if needed, with doctors order

Prevent infection
- Observe asespsis when changing drainage bottle
- Chest catheters are usually not used longer than 5-7 days
Position the patient to permit optimal drainage
- Semi-fowlers position to evacuate air (pneumothorax)
- High-fowlers position to drain fluid (hemothorax)

Maintain tube connection between chest and drainage tubes intact and taped
Water-seal vent must be without occlusion
Suction control chamber vent must be without occlusion when suction is used
Coil excess tubing on mattress next to patient. Secure with rubber band and
safety pin or systems clamp
Adjusting to hang in straight line from top of mattress to drainage chamber. If
chest tube is draining fluid, indicate time that drainage was begun on drainage
bottles adhesive tape or on write-on surface of disposable commercial system.

Client with chest tube can move around and ambulate. Instruct to always
maintain level of drainage bottle lower than chest level.

 NEVER CLAMP CHEST TUBE without order to do so. May lead to tension
pneumothorax and mediastinal shift.
Document observations
Potential Emergencies/Problem:
Water-Seal bottle is accidentally elevated above chest level
Immediately lower the bottle; refer to physician immediately
Bottle is accidentally broken
Assess whether bubbling before the accident or not, if not, may clamp the
chest tube, clean turning tip with antiseptic, reconnect or immerse in a
container with water; refer to physician
o Chest tube is accidentally pulled
- Cover insertion site with sterile petroleum gauze; refer to physician; observe for
respi distress
o Dependent loops of drainage tubing have trapped fluid
- Drain tubing contents into drainage bottle; coil excess tubing on mattress and
secure in place.
o
o
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