ET TUBE INTUBATION & NURSING CARE

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Presentation Description

The presentation discusses the basics of ET tube insertion and nursing care of patient with ET tube

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By: vickiclavir (11 month(s) ago)

Can you allow me to download please? Cardiac2teach@msn.com

Presentation Transcript

ENDO TRACHEAL TUBE INTUBATION:

ENDO TRACHEAL TUBE INTUBATION PRASHANTH NAYAK RAK COLLEGE OF NURSING, DELHI

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DEFINITION Endo tracheal tube management consists of ensuring a patent airway, suctioning pulmonary and oral secretions, and providing frequent oral and/or nasal care.

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HISTORY 1555: Andreas Vesalius: described tracheal insufflation in animals. 1858: John Snow: intubation through tracheostomy to anaesthetize animals . 1878: William Macewan : Passed a tube from mouth to trachea, using finger as guide in conscious patient for removal of carcinoma of mouth. Through this tube he gave chloroform.

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1890: Edgar Stanley Rowbotham and Ivan Whiteside Magill passed tracheal tube via laryngoscope. 1928: Ralph Milton Waters and Arthur E. Guedel introduced Inflatable cuffs HISTORY contd …

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Endo tracheal intubation is done to open the airway to give oxygen, medication, or anaesthesia, and to help with breathing. It may also be done to remove blockages (foreign bodies) from the airway or to allow the doctor to get a better view of the upper airway. indications

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Specifically, endotracheal intubation is used for the following conditions: Respiratory arrest Respiratory failure Airway obstruction Need to control and remove pulmonary secretions (bronchial toilet). Need for prolonged ventilatory support Class III or IV haemorrhage with poor perfusion Severe flail chest or pulmonary contusion

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Multiple trauma, head injury and abnormal mental status Inhalation injury with edema of the vocal cords Protection from aspiration Supporting ventilation during general anaesthesia Inability to ventilate unconscious patient Medication administration

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Severe airway trauma or obstruction that does not permit safe passage of an endotracheal tube. Cervical spine injury, in which the need for complete immobilization of the cervical spine makes endotracheal intubation difficult. The following conditions require caution before attempting to intubate : Esophageal disease Ingestion of caustic substances Mandibular fractures Laryngeal edema Thermal or chemical burns CONTRA INDICATIONS

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NASAL ORAL ROUTES

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AIRWAY ASSESSMENT Collect history that is associated with difficult intubation: Congenital Anomalies: Down s syndrome, Pierre robin syndrome. Infection in Airway: retro pharyngeal abscess, epiglottidis Tumour in oral cavity or larynx Enlarged thyroid gland which may cause compression of trachea Burn scare at face or neck Morbidly obese or pregnancy

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INTER INCISION GAP NORMAL: > 3 FINGERS WIDTH

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THYRO MENTAL DISTANCE NORMAL: > 6CMS

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MALLAMPATI CLASSIFICATION CLASS 3, 4 - MAY BE DIFFICULT INTUBATION

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PREPARING THE ARTICLES When intubating a patient, there are certain bare essentials that must be present to ensure a safe intubation. They can be remembered by the mnemonic SALT SUCTION AIRWAY LARYNGOSCOPE TUBE

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OTHER ARTICLES Tincture of benzoin and precut tape. Introducer ( stylets or Magill forceps). Syringe, 10-mL, to inflate the cuff. Mucosal anesthetics ( eg , 2% lidocaine ) Water-soluble sterile lubricant. Gloves. Oxygen source and connecting tubes Rigid pharyngeal suction-tip catheter ET Tube tape (adhesive ( 6 to 8 in long) Stethoscope cardiac monitor pulse oximeter Adult blades No. 3 & 4 Connector- (may be required )

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TUBES TYPES OF ETTs: Portex tubes: Semi rigid, with little tendency to kink. It is most commonly used. Rubber tubes : Soft, easily kinked. Reinforced tubes : - Cuffed or non cuffed. The tube is reinforced with wire to prevent kinking. Special tubes : Double lumen ( Robertshaw tube)

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Male : Female : New born- 3 mths : 3-9 months : 9-18 months : 2- 6 yrs : 6 yrs : ID 8.0 mms ID 7.5 mms ID 3.0 mms ID 3.5 mms ID 4.0 mms ID = (Age/3) + 3.5 ID = (Age/4) + 4.5 1) SIZE OF TUBES

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Midtrachea or below vocal cord~2 cm Adult Male ~23 cm Female ~21 cm Children Oral ETT = (Age/2) + 12 (cm) Nasal ETT = (Age/2) + 15 (cm ) DEPTH OF INSERTION

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Extension at atlanto -occipital joint. Flexion at lower cervical spine Neck flexion is maintained by placing a few inches of padding behind the head. This position serves to align the oral, pharyngeal, and laryngeal axis, so that the passage from the lips to the glottic opening is almost a straight line. This position permits better visualization of the glottis and vocal cords and allows easier passage of the endotracheal tube. For children under 1 month of age, the head should be in a neutral position. POSITION OF PATIENT

TECHNIQUE:

A. Mask ventilation: (Oxygen delivered with a face mask at a rate of 10-15 L/min.): 1. Select the proper-sized mask; it should cover the mouth and nose and fit snugly against the cheeks. 2. Place the patient in the sniffing position. 3. Place the mask over the patient's mouth and nose with the right hand. TECHNIQUE

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4. With the left hand, place the small and ring fingers under the patient's mandible, and lift up to open the airway. Grasp the mask with the thumb and index finger, and press it to the patient's face while lifting the mandible with the ring and small fingers. 5. Compress the bag with the right hand. 6. The chest should rise with each breath, and airflow should be unimpeded. If not, reposition the mask, and try again. Occasionally, insertion of an oral or nasal airway facilitates ventilation by mask. Because of the lack of support for the lips, elderly edentulous patients may be especially hard to ventilate using a mask.

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B. Topical Anaesthesia: Anesthetize the mucosa of the oropharynx , and upper airway with lidocaine 2%, if time permits and the patient is awake. C . Direct Laryngoscopy : 1. Place the patient in the sniffing position. 2. Check the laryngoscope and blade for proper fit, and make sure that the light works. 3. Make sure that all materials are assembled and close at hand.

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4. Curved blade technique: a. Open the patient's mouth with the right hand, and remove any dentures. b. Grasp the laryngoscope in the left hand. c. Spread the patient's lips, and insert the blade between the teeth, being careful not to break a tooth. d. Pass the blade to the right of the tongue, and advance the blade into the hypopharynx , pushing the tongue to the left.

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e. Lift the laryngoscope upward and forward, without changing the angle of the blade, to expose the vocal cords. 5 . Straight blade technique: Follow the steps outlined for curved blade technique, but advance the blade down the hypopharynx , and lift the epiglottis with the tip of the blade to expose the vocal cords. The tip of the laryngoscope blade fits below the epiglottis, which is no longer visible with the blade in position.

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D. Orotracheal Intubation: 1. Select the proper-sized tube. 2. With the 10-mL syringe, inflate the balloon with 5-8 mL of air. Make sure that the balloon is functional and intact. 3. Lubricate the end of the tube (optional). 4. Insert the stylet , and bend the tube and stylet gently into a crescent shape so that the tip of the stylet is at least 1 cm proximal to the end of the tube. 5. Ventilate the patient with the bag-valve combination for 1-2 minutes with 100% oxygen.

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6. Proceed the direct laryngoscopy (as explained above), and when visualizing the glottis and vocal cords, gently pass the tube next the laryngoscope blade through the vocal cords into trachea, far enough so that the balloon is just beyond the cords. Occasionally, gently pressing posteriorly on the anterior neck at the level of the larynx will help to bring an anteriorly placed larynx into view and facilitate intubation. 7. Withdraw the stylet . 8. Connect the bag-valve combination, and begin ventilation with 100% oxygen.

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9. Confirm that the tube is properly positioned. First, listen over the stomach with a stethoscope while ventilating the patient. If sounds of airflow are heard or if distension of the stomach occurs, the tube is in the esophagus , then remove the tube and try again. 10. Listen to each side of the chest; be sure that breath sounds are equal in both sides of the thorax. If not, reposition the tube. When breath sounds are equal on both sides and the thorax rises equally on both sides with each inspiration,inflate the cuff with the 10-mL syringe until there is no air leak around the tube when positive pressure is applied.

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11. Apply tincture of benzoin to the cheeks, upper lip, and endotracheal tube. 12. Wrap adhesive tape around the tube where it comes out of the mouth. Then carry the tape over the cheek and around the back of the head onto the other cheek. Fasten the end of the tape around the tube. 13. Obtain a chest x-ray film immediately to check tube placement, and also obtain arterial blood gas measurements to assess the adequacy of ventilation.

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E. Nasotracheal Intubation 1. Check for nasal patency 2. Topical lidocaine or phenylephrine should be applied to the nasal passages 10 -15 min before. Generously lubricate the nares 3. ETT: Select ETT 0.5-1.0mmID smaller than that recommended for orotracheal intubation. 4 . ETT should be advanced through the nose directly backward toward the nasopharynx Laryngoscope and Magill forceps can be used to guide the endotracheal tube into the trachea under direct vision.

Confirmation of tube placement:

PRIMARY CONFIRMATION: Listen over the epigastrium and observe the chest wall for movement. If stomach gurgling and no chest wall expansion – oesophagus intubated : deflate the cuff and remove ET tube Reattempt intubation after re -oxygenation If chest wall rises and stomach not gurgling, perform 5-point auscultation. If still doubt, use laryngoscope to see the tube passing through the vocal cords (best). Confirmation of tube placement

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SECONDARY CONFIRMATION: End-Tidal CO2 Detectors: it is a Commercial device, that reacts with a colour change to CO2 exhaled from the lungs: Qualitative detection device indicates exhaled CO2 indicates proper tracheal tube placement Absence of CO2 (unless prolonged CPR), indicates oesophageal intubation.

Orotracheal intubation:

ADVANTAGES Larger tube can be inserted Tube can be inserted with more speed and usually with less trauma Easier suctioning Less air flow resistance Reduced risk of tube knicking Orotracheal intubation

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DISADVANTAGES Loss of Gagging and Coughing reflux Cannot be used in temporomandibular joint ankylosis Not suitable for oral surgery. eg . toncillectomy

nasotracheal intubation:

ADVANTAGES Comfortable for prolong intubation in postoperative period. Suitable for oral surgery: tonsillectomy, mandible surgery. Less salivation, easier to swallow. Decreased gagging. Difficult to accidental extubation . Improved mouth care. nasotracheal intubation

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DISADVANTAGES Trauma to nasal mucosa Trauma to nasopharynx Risk of sinusitis on prolonged intubation Risk for bacteraemia Smaller diameter and longer than oral route - difficult for suction, increased resistance and work of breathing.

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complications DURING INTUBATION Trauma to lips, tongue or teeth Arytenoid Dislocation Pulmonary Aspiration Endo bronchial Intubation Vocal cord Injury Esophageal Intubation

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WHILE INTUBATED Tracheal stenosis Tracheo esophagus fistula Laryngeal stenosis Accidental extubation Tracheomalacia Disconnection from breathing circuit

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AFTER EXTUBATION Paralysis of vocal cords Hoarseness Ulceration of mouth Laryngeal granuloma Necrosis of trachea Paralysis of tongue

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advantages Provides an unobstructed airway when properly placed Prevents aspiration of secretions (blood, mucous, stomach / bowel contents) into the lungs Can be easily maintained for a lengthy period of time Decreases anatomic dead space by approximately 50% Facilitates positive pressure breathing without gastric inflation Facilitates body positioning and movement of the patient May be utilized to administer medications

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Need advanced training to properly perform procedure Bypasses the nares function of warming and filtering the air Increased incidence of trauma due to neck manipulation when spinal cord injury is suspected May increase respiratory resistance Improper placement disadvantages

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Observe for signs and symptoms of need to perform ET tube care: soiled or loose tape; pressure sore or nares , lips, or corner of mouth; and excess nasal or oral secretions. Observe for factors that increase risk of complications from ET tube: type and size of tube, movement of tube up and down trachea (in and out), duration of tube placement, cuff over inflation or under inflation, presence of facial trauma, malnutrition, and neck or thoracic radiation. Assess client's knowledge of procedure Nurses role ASSESSMENT AND PREPARATION

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Obtain another nurse's assistance in this Procedure. Explain procedure and client's participation, including importance of the following: not biting or moving ET tube with tongue; trying not to cough when tape is off ET tube; keeping hands down and not pulling on tubing; removal of tape from face can be uncomfortable. Assist client to assume position comfortable for both nurse and client (usually supine or semi-Fowler's) Wash hands and Administer Endotracheal , nasopharyngeal, and oropharyngeal suction.

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Check suction source and regulator. Adjust suction pressure until it reads 120mmHg with tubing occluded. Lubricate the catheter tip with water and gently insert catheter until obstruction is met. Do not apply suction during insertion. After catheter is inserted, withdraw 1cm. Apply suctioning intermittently while withdrawing catheter in rotating manner. If secretion volume is large, apply suction continuously. SUCTIONING

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Limit suction time to 10 seconds. Discontinue suctioning, if heart rate decreases, from baseline by 20bpm, increases from baseline by 40bpm, or a dysrhythmia occurs. After suctioning, oxygenate 4 to 5 breaths by manual resuscitation bag or ventilator. Rinse catheter with sterile water and suction the oropharynx . Discard all equipments in proper container. Auscultate to assess changes in lung sounds: record time, amount and character of secretions and clients response to suctioning.

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Apply gloves. Instruct helper to apply pair of gloves and hold ET tube firmly at client's lips or nares . Note the number marking on the ET tube at the gum line. Carefully remove tape from ET tube and client's face. Use adhesive remover swab to remove excess adhesive left on face after tape removal. Clean mouth, gums, and teeth opposite ET tube with non-alcohol-based mouthwash solution and sponge-tipped applicators. Brush teeth as indicated. Oral ET tube only: Remembering "cm" ET tube marking at lips or gums, with help of assistant, move ET tube to opposite side or centre of mouth. Do not change tube depth. Repeat oral cleaning on opposite side of mouth. ET TUBE CARE

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Clean face and neck with soapy washcloth, rinse, and dry. Shave male client as necessary. Pour small amount of skin protectant on clean 2 X 2 inch gauze and apply on upper lip (oral ET tube) or across nose (nasal ET tube) and cheeks to ear. Allow to dry completely Slip tape under client's head and neck, adhesive side up. Take care not to twist tape or catch hair. Do not allow tape to stick to it. On one side of face, secure tape from ear to naris (nasal ET tube) or over lip to ET tube (oral ET tube). Tear remaining tape in half lengthwise, forming two pieces that are 1/2 to 3/4 inches wide. Secure bottom half of tape across upper lip (oral ET tube) or across top of nose (nasal ET tube) to opposite ear. Wrap top half of tape around tube and up from bottom. Tape should encircle tube at least two times for security.

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Discard soiled items in appropriate receptacle. Remove towel and place in laundry. Reposition client. Remove gloves and face shield, discard in receptacle, and wash hands. Place clean items (e.g., tincture of benzoin , mouthwash, access swabs) in place of storage. Compare respiratory assessments before and after ET tube care Observe depth and position of ET tube according to physician recommendation. AFTER CARE

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Assess security of tape by gently tugging at tube. Assess skin around mouth and oral mucous membranes for intactness and pressure areas. Note appropriate depth of ET tube, frequency of ET tube care, pressure sore care needed, and designated intervals. Record in nurses' notes: assessments before and after care, supplies used, client's tolerance of procedure, and frequency and extent of ET tube care.

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Determine that endotracheal intubation is no longer required Patient begins spontaneous respiration’s Physicians orders removal of endotracheal tube Remove tape from endotracheal tube Remove oropharyngeal airway from patient’s mouth PROCEDURE FOR EXTUBATION

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Suction the endotracheal tube, the patient’s mouth, and the patient’s posterior pharyngeal area Deflate the endotracheal tube’s cuff Withdraw the endotracheal tube with one smooth motion Monitor the patient for signs / symptoms of respiratory distress or difficulty

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