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Outline
Overview
Artificial Airways
Mrs. Samson is a 44 year old female who presents to the Emergency Department (ED) by ambulance. She is restless and struggling to breathe. Her family reports she has a history of Multiple Sclerosis and has had increasing weakness in the last few months. She has had a productive cough for 2 weeks. Today, they report her secretions have become excessive and she is struggling to clear them.
What nursing assessments should be performed at this time for Mrs. Samson?
- Heart and Lung sounds
- Full set of vital signs
- Evaluate character and consistency of any secretions from cough/mouth
What action would you take if Mrs. Samson can’t clear her secretions effectively?
- Use a Yankauer to suction oropharynx or a small catheter to suction deeper
- May need to insert a nasopharyngeal airway
You assessment findings include coarse rhonchi throughout Mrs. Samson’s lungs, with audible gurgling with respirations. S1 and S2 are present, bowel sounds are active, and pulses are 2+ x 4 extremities. Her skin is pale, cool, and dry. She is alert, but appears distressed. Vital signs are as follows:
BP 132/80 mmHg HR 112 bpm
RR 42 bpm Temp 99.0°F
SpO2 86% on room air
The ED Provider orders to keep sats >92%.
Which artificial airway would be most appropriate at this time? Explain.
- A nasopharyngeal airway or nasal trumpet is the most appropriate airway at this time
- The patient is conscious and alert, and breathing, just having difficulty clearing secretions. The nasal trumpet will allow us access to suction deeper with less agitation to the patient.
You apply 4L O2 via nasal cannula and suction Mrs. Samson using a 10fr suction catheter through a nasal trumpet. Mrs. Samson’s SpO2 increases to 90%, but she is beginning to get drowsy. You come back in 5 minutes to find she is unresponsive. She has a rapid pulse and is making efforts to breathe, with audible snoring respirations.
What action(s) would be most appropriate at this time?
- Call a Rapid Response or the Respiratory Therapist and/or Charge Nurse to get help
- Perform head tilt, chin lift to open airway and use Bag-Valve Mask to help with breathing
- Patient may require supplemental oxygen as well – should check SpO2
What lab value should be checked to evaluate Mrs. Samson’s oxygenation and ventilation?
- Arterial Blood Gas
You notify the Respiratory Therapist who comes to the bedside to assist. Together, you utilize head tilt chin lift, place Mrs. Samson on 50% venturi mask, and use a Yankauer to suction Mrs. Samson’s oropharynx. An ABG is drawn and rapid results show the following:
pH 7.30, pCO2 50, PaO2 40, HCO3– 26 SaO2 88%
Interpret the ABG results. Explain.
- Mrs. Samson is in Respiratory Acidosis and is Hypoxic
- She is struggling to clear her secretions and has become drowsy – likely because of the hypoxia. This made her breathe slower, therefore she retained CO2 and become more somnolent because of CO2 narcosis.
Which artificial airway would be most appropriate at this time? Explain.
- An oropharyngeal airway should be inserted to improve airway opening while the patient is bagged with the bag-valve-mask
- Then, the provider should be called because the patient should be intubated with an endotracheal tube (ETT) to secure her airway and provide mechanical ventilation.
- She is unconscious and not effectively protecting her airway – though there is some respiratory effort, it seems she will need mechanical ventilation for ventilatory support and there is no indication that she will be able to protect her airway any time soon. Using an oral airway is an effective measure to ventilate the patient until an advanced airway (ETT) can be secured.
The ED provider arrives to intubate Mrs. Samson to provide mechanical ventilation, which is successful. Mrs. Samson is admitted to the ICU, officially diagnosed with pneumonia, and started on antibiotics. Over the next 7 days, as her condition improves, providers make attempts to wean her from the ventilator, but her weakness from her Multiple Sclerosis (MS) is making it difficult. The provider determines she may need a more long-term solution for airway protection and possible vent weaning.
Which artificial airway is used for easier weaning from the vent and long-term airway protection? Explain.
- A tracheostomy tube can help with weaning because it is shorter and has less resistance to air flow. The patient doesn’t have to work as hard to breathe through a tracheostomy tube as they do through an ETT.
- A tracheostomy is also a secured airway that can be utilized even without a mechanical ventilator for airway protection and patients can be discharged home with one long-term.
Mrs. Samson has a tracheostomy tube placed and is successfully weaned from the ventilator over the next two weeks. Her family has arranged for home health care and providers have agreed that she is well enough to be discharged home.
What discharge teaching topics should be included for Mrs. Samson and her family in regards to the care and management of a tracheostomy at home?
- Tracheostomy care should include changing the ties at least daily, cleaning or changing the inner cannula twice daily or more often if secretions build up.
- Patients should be taught how to suction themselves with a portable suction machine if secretions build up
- Patients should be taught to always have the obturator available in case their tracheostomy gets dislodged and should be taught how to replace it if necessary
- Patients should be taught when to call 911 or what to report to their provider
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