AIRWAY MANAGEMENT

The Goal of Airway management is to anticipate and recognize

respiratory problems and to support or replace those that are compromised or

lost An individual must be able to support three specific functions:

• Protect their airway

• Adequately ventilate

• Adequately oxygenate

There are many simple, non-invasive techniques to support respiration prior to

endotracheal intubation

• Suctioning

• Positioning of the airway

• Adjuncts

• Nasopharyngeal airway

• Oropharyngeal airway

• Application of oxygen

• Application of positive pressure

• Assistance of ventilation with BVM

POSITIONING
 • Use of the chin lift and jaw thrust can help restore flow through an

obstructed upper airway by separating the tongue from posterior

pharyngeal structures.

• The goal is to line up three divergent axes: oral, pharyngeal and

tracheal.

INDICATIONS FOR INTUBATION

1. PaO2 < 60 mmHg with Fio2 ≥ 0.6 (no congenital heart disease)

2. PaCO2 > 50 mmHg (acute/ unresponsive to other therapy)

3. Upper airway obstruction

4. Neuromuscular weakness

(NIF < -20, vital capacity < 12-15 ml/kg (ch. 55 Furman))

5. Absent protective airway reflexes (cough, gag)

6. Hemodynamic instability

7. Therapeutic hyperventilation (TBI)

8. Pulmonary toilet

9. Emergency drug administration

PREPARATION FOR ENDOTRACHEAL INTUBATION

• Needed personnel
 • Monitoring

• Endotracheal tubes, laryngoscope blades- variety of sizes

• Adjuncts ( stylets, oral airway, securing mechanism)

• Suctioning equipment

• BVM attached to oxygen at proper flow

• Access/Medications - sedation/ RSI pack

• L.O.S.E.R.

• Light (blade)

• Oxygen, Bag, Mask

• Suction

• ETT, ETCO2

• Rx - Drugs

CONFIRM PLACEMENT

• Colorimetric CO2 detector

• Look

• Listen

• Remember that infants can easily transmit breath sounds to the stomach
 • There’s nothing better than watching the ETT go through the cords

POST-INTUBATION CONSIDERATIONS

• Bilateral breath sounds before tube secured

• ETCO2

• Mist in the ETT

• Chest x-ray ordered

• Tube migration into right mainstem or esophagus

• NGT in place for gastric decompression

• Suctioning the tube following placement

• Ventilator settings provided

TRACHEOSTOMY CARE

DEFINITION

DESCRIPTION

■ Required to ensure airway patency by keeping the tube free of mucus

buildup, maintaining mucous membrane and skin integrity, preventing

infection, and providing psychological support

 ■ Three types of tracheostomy tubes: uncuffed, cuffed, or fenestrated;

selection dependent on the child’s condition and the physician’s preference

1. Uncuffed plastic or metal tube allows air to flow freely around the

tracheostomy tube and through the larynx, reducing the risk of tracheal

damage

2. Plastic cuffed tube (disposable) the cuff and tube won’t separate inside

trachea because the cuff is bonded to the tube; doesn’t require periodic

deflating to lower pressure because cuff pressure is low and evenly

distributed against the tracheal wall; reduces the risk of tracheal damage

3. Plastic fenestrated tube permits speech through the upper airway when

the external opening is capped and the cuff is deflated; also allows easy

removal of the inner cannula for cleaning, but it may become occluded

EQUIPMENT

Aseptic stoma and outer-cannula care Waterproof trash bag

◆ two sterile solution containers

◆ sterile normal saline solution

◆ hydrogen peroxide

◆ sterile cotton-tipped applicators

◆ sterile 44gauze pads

◆ sterile gloves

◆ prepackaged sterile tracheostomy dressing (or 44 gauze pad)

◆ supplies for suctioning and mouth care

◆ water-soluble lubricant or topical antibiotic cream

◆ materials as needed for cuff procedures and for changing

tracheostomy ties (see below) Aseptic inner-cannula care All of the

preceding equipment plus a prepackaged commercial tracheostomy care

set, or sterile forceps

◆ sterile nylon brush

◆ sterile 6 (15-cm) pipe cleaners

◆ clean gloves

◆ a third sterile solution container

◆ disposable temporary inner cannula (for a child on a ventilator)

Changing tracheostomy ties 30 (76.2-cm) length of tracheostomy twill

tape

◆ bandage scissors

◆ sterile gloves
 ◆ hemostat Emergency tracheostomy tube replacement Sterile tracheal

dilator or sterile hemostat

◆ sterile obturator that fits the tracheostomy tube

◆ extra, appropriatesized, sterile tracheostomy tube and obturator

◆ suction equipment and supplies Cuff procedure 5- or 10-ml syringe

◆ padded hemostat

◆ stethoscope

ESSENTIAL STEPS

Prepare the equipment properly as follows:

 Wash your hands, and assemble all equipment and supplies in the

child’s room.

 Check the expiration date on each sterile package and inspect for

tears.

 Place the open waterproof trash bag next to you so that you can

avoid reaching across the sterile field or the child’s stoma when

discarding soiled items.

 Establish a sterile field near the child’s bed and place equipment

and supplies on it.

 Pour normal saline solution, hydrogen peroxide, or a mixture of

equal parts of both solutions into one of the sterile solution

containers; pour normal saline solution into the second sterile

container for rinsing.

 For inner-cannula care, use a third sterile solution container to hold

the gauze pads and cotton-tipped applicators saturated with

cleaning solution.

 If replacing the disposable inner cannula, open the package

containing the new inner cannula while maintaining sterile

technique.

 Obtain or prepare new tracheostomy ties, if indicated.

 Keep supplies in full view for easy emergency access. Consider

taping a wrapped, sterile tracheostomy tube to the head of the bed

for emergencies.

 Assess the child’s condition to determine need for care.

 Explain the procedure to the child and his parents, even if he’s

unresponsive. Provide privacy.

 Place the child in semi-Fowler’s position, unless contraindicated,

to decrease abdominal pressure on the diaphragm and promote lung

expansion.

 Remove any humidification or ventilation device.

 Using sterile technique, suction the entire length of the

tracheostomy tube to clear the airway of any secretions that may

hinder oxygenation.

 Reconnect the patient to the humidifier or ventilator, if necessary.

Cleaning a stoma and outer cannula

 Put on sterile gloves if you aren’t already wearing them.

 With your dominant hand, saturate a sterile gauze pad or cotton-

tipped applicator with the cleaning solution.

 Squeeze out the excess liquid to prevent accidental aspiration.

 Wipe the patient’s neck under the tracheostomy tube flanges and

twill tapes.

 Saturate a second pad or applicator, and wipe until the skin

surrounding the tracheostomy is cleaned. Use additional pads or

cotton-tipped applicators to clean the stoma site and the tube’s

flanges. ALERT Wipe only once with each pad or applicator, and

then discard it to prevent contamination of a clean area with a

soiled pad or applicator.

 Rinse debris and peroxide (if used) with one or more sterile 44

gauze pads dampened in normal saline solution.

 Dry the area thoroughly with additional sterile gauze pads; then

apply a new sterile tracheostomy dressing.

 Remove and discard your gloves. Cleaning a nondisposable inner

cannula

 Put on sterile gloves. Using your nondominant hand, remove and

discard the patient’s tracheostomy dressing.

 With the same hand, disconnect the ventilator or humidification

device, and unlock the tracheostomy tube’s inner cannula by

rotating it counterclockwise.

 Place the inner cannula in the container of hydrogen peroxide.

 Working quickly, use your dominant hand to scrub the cannula

with the sterile nylon brush.

 If the brush doesn’t slide easily into the cannula, use a sterile pipe

cleaner.

 Immerse the cannula in the container of normal saline solution, and

agitate it for about 10 seconds to rinse it.

 Inspect the cannula for cleanliness. Repeat the cleaning process if

necessary

 If it’s clean, tap it gently against the inside edge of the sterile

container to remove excess liquid and prevent aspiration. ALERT

Don’t dry the outer surface; a thin film of moisture acts as a

lubricant during insertion.

 Reinsert the inner cannula into the patient’s tracheostomy tube.

 Lock it in place make sure it’s positioned securely. Reconnect the

mechanical ventilator. Apply a new sterile tracheostomy dressing.

 If the patient can’t tolerate being disconnected from the ventilator

for the time it takes to clean the inner cannula, replace the existing

inner cannula with a clean one and reattach the mechanical

ventilator. Then clean the cannula just removed from him, and

store it in a sterile container for the next time. Caring for a

disposable inner cannula

 Put on clean gloves. Using your dominant hand, remove the inner

cannula.

 After evaluating the secretions in the cannula, discard it properly.

 Pick up the new inner cannula, touching only the outer locking

portion. Insert the cannula into the tracheostomy and, following the

manufacturer’s instructions, lock it securely. Changing

tracheostomy ties

 Get help from another nurse or a respiratory therapist to avoid

accidental tube expulsion. Patient movement or coughing can

dislodge the tube.

 Wash your hands and put on sterile gloves if you aren’t already

wearing them.
 If you aren’t using commercially packaged tracheostomy ties,

prepare new ties from a 30 (76.2-cm) length of twill tape by

folding one end back 1 (2.5 cm) on itself; then, with bandage

scissors, cutting a 1 ⁄2 (1.3-cm) slit down the center of the tape

from the folded edge.

 Prepare the other end of the tape the same way.

 Holding both ends together, cut the resulting circle of tape so one

piece is approximately 10(25 cm) long and the other is about 20(51

cm) long.

 Assist the child into semi-Fowler’s position if possible.

 After your assistant puts on gloves, instruct her to hold the

tracheostomy tube in place to prevent its expulsion during

replacement of the ties. (If performed without assistance, fasten the

clean ties in place before removing the old ties to prevent tube

expulsion).

 With the assistant’s gloved fingers holding the tracheostomy tube

in place, cut the soiled tracheostomy ties with the bandage scissors

or untie them and discard. ALERT Be careful not to cut the tube of

the pilot balloon.

 Thread the slit end of one new tie a short distance through the eye

of one tracheostomy tube flange from the underside; use the

 hemostat, if needed, to pull the tie through. Thread the other end of

the tie completely through the slit end and pull it taut so it loops

firmly through the flange. This avoids knots that can cause throat

discomfort, tissue irritation, pressure, and necrosis.

 Fasten the second tie to the opposite flange in the same manner.

 Instruct the child to flex his neck while you bring the ties around to

the side, and tie them together with a square knot. Flexion produces

the same neck circumference as coughing and helps prevent an

overly tight tie.

 Have your assistant place one finger under the tapes as you tie

them to ensure they’re tight enough to avoid slip page but loose

enough to prevent choking or jugular vein constriction.

 Placing the closure on the side allows easy access and prevents

pressure necrosis at the back of the neck when the patient is

recumbent.

 After securing the ties, cut off the excess tape with the scissors and

have your assistant release the tracheostomy tube.

 Make sure the child is comfortable and can reach the call button

easily.

 Check tracheostomy-tie tension frequently on children with

traumatic injury, radical neck dissection, or cardiac failure because

 neck diameter can increase from swelling and cause constriction;

also check neonatal or restless children frequently because ties can

loosen and cause tube dislodgment. Concluding tracheostomy care

 Replace any humidification device.

 Provide oral care as needed because the oral cavity can become dry

and malodorous or develop sores from encrusted secretions.

 Observe soiled dressings and any suctioned secretions for amount,

color, consistency, and odor.

 Properly clean or dispose of all equipment, supplies, solutions, and

trash, according to your facility’s policy, then remove and discard

your gloves.

 Make sure that the child is comfortable and that he can easily reach

the call button.

 Make sure all necessary supplies are readily available at the

bedside.

 Repeat the procedure at least once every 8 hours or as needed.

 Change the dressing as often as necessary regardless of whether

you also perform the entire cleaning procedure. A wet dressing

with exudate or secretions predisposes the patient to skin

excoriation, breakdown, and infection.

NURSING CONSIDERATIONS
■ If the child is being discharged with a tracheostomy, start self-

care teaching with the child and his parents as soon as they are

receptive.

■ Teach the child, if appropriate, and his parents, how to change

and clean the tube.

■ If the child is being discharged with suction equipment, make

sure that he and his parents feel knowledgeable and comfortable

about using the equipment.

■ Keep appropriate equipment at the patient’s bedside for

immediate use in an emergency.

■ Consult the physician about first-aid measures you can use for

your tracheostomy patient should an emergency occur. ALERT

Follow your facility’s policy if a tracheostomy tube is expelled or

if the outer cannula becomes blocked. If the patient’s breathing is

obstructed, call the appropriate code and provide manual

resuscitation with a handheld resuscitation bag or reconnect the

patient to the ventilator. Don’t remove the tracheostomy tube; the

airway may close completely. Use caution when reinserting, to

avoid tracheal trauma, perforation, compression, and asphyxiation.

■ Don’t change tracheostomy ties unnecessarily during the

immediate postoperative period before the stoma track is well

formed (usually 4 days) to avoid accidental dislodgment and

expulsion of the tube. Unless secretions or drainage is a problem,

ties can be changed once a day.

■ Don’t change a single-cannula tracheostomy tube or the outer

cannula of a double-cannula tube. Because of the risk of tracheal

complications, the physician usually changes the cannula; the

frequency depends on the child’s condition.

■ If the child’s neck or stoma is excoriated or infected, apply a

water-soluble lubricant or topical antibiotic cream as ordered.

Don’t use a powder or an oil-based substance on or around a

stoma; aspiration can cause infection and abscess.

■ Replace all equipment regularly (including solutions) to reduce

the risk of nosocomial infections