This nursing clinical protocol outlines the management of patients with artificial airways such as tracheostomy tubes or endotracheal tubes. It provides guidelines for assessment, suctioning, tube care, safety measures, communication, emergency management and documentation. Key points include assessing the patient and tube placement every 4 hours, suctioning as needed based on clinical signs, cleaning and changing tubes as indicated, ensuring emergency equipment is available, educating patients and families, and notifying physicians of any issues. The protocol aims to standardize care to safely manage patients with artificial airways.
This nursing clinical protocol outlines the management of patients with artificial airways such as tracheostomy tubes or endotracheal tubes. It provides guidelines for assessment, suctioning, tube care, safety measures, communication, emergency management and documentation. Key points include assessing the patient and tube placement every 4 hours, suctioning as needed based on clinical signs, cleaning and changing tubes as indicated, ensuring emergency equipment is available, educating patients and families, and notifying physicians of any issues. The protocol aims to standardize care to safely manage patients with artificial airways.
This nursing clinical protocol outlines the management of patients with artificial airways such as tracheostomy tubes or endotracheal tubes. It provides guidelines for assessment, suctioning, tube care, safety measures, communication, emergency management and documentation. Key points include assessing the patient and tube placement every 4 hours, suctioning as needed based on clinical signs, cleaning and changing tubes as indicated, ensuring emergency equipment is available, educating patients and families, and notifying physicians of any issues. The protocol aims to standardize care to safely manage patients with artificial airways.
This nursing clinical protocol outlines the management of patients with artificial airways such as tracheostomy tubes or endotracheal tubes. It provides guidelines for assessment, suctioning, tube care, safety measures, communication, emergency management and documentation. Key points include assessing the patient and tube placement every 4 hours, suctioning as needed based on clinical signs, cleaning and changing tubes as indicated, ensuring emergency equipment is available, educating patients and families, and notifying physicians of any issues. The protocol aims to standardize care to safely manage patients with artificial airways.
LAC+US C HEALTHCARE NETWORK DEPARTMENT OF HEALTH SERVICES
NURSING CLINICAL PROTOCOL
ARTIFICIAL AIRWAY
PURPOSE: To outline the management of patients with an artificial airway.
SUPPORTIVE Tracheostomy tube and oral/nasal endotracheal tube (ETT) are examples of artificial airways. DATA: Pulsating tracheostomy indicates close proximity of the trachea to an artery. This proximity may lead to erosion and an arterial bleed. Overinflation of Err or tracheostomy tube cuff may lead to a tracheal injury.
Normal saline lavage with suctioning may be harmful and may not loosen secretions. Therefore, routine normal saline lavage is not recommended.
Shallow suctioning (as opposed to deep suctioning) is recommended (e.g. the catheter should be inserted to the end of the artificial airway rather than until resistance is met).
Errs with a subglottic suction port assist in reducing the accumulation of secretions above the cuff.
ASSESSMENT: I. Assess the fol,lowing a minimum of every 4 hours:
• Vital signs • Respiratory rate, pattern • Breath sounds • Chest expansion • Use of accessory muscles, retractions, nasal flaring • Secretions: quantity, color, characteristics • Cough • Skin and nail bed color • ETT placement:
Location in (cm) at: teeth, lips, nares, ETT holders
Securely taped
• F or pressure sores • Nasa'! ETT for signs/symptoms of sinusitis
Drainage
Fever
• Suture sites (if visible):
New tracheostomy
• Pulsation of tracheostomy tube
2. Assess for cuff leak a minimum of every 4 hours. 3. Assess for the need for suctioning a minimum of every 2 hours 4. Monitor for the following continuaHy as ordered: • Oxygen saturation via pulse oximeter • End-tidal carbon dioxide (ETC0 2) • Transcutaneous carbon dioxide monitor (T CO 2 M) - Peds
SUCTIONING: 5. Pre-oxygenate prior to suctioning.
6. Suction artificial airway and mouth at the beginning of each shift and as indicated by the following: • Course breath soundslrhonchi present • Unexplained respiratory distress • Noisy breathing • Audible secretions • Secretion present in the tubing • Increased peak inspiratory pressure or high pressure alarm on ventilator • Increased RR, HR and BP
ARTIFICIAL AIRWAY Page 101'4
• Decreased oxygen saturation per pulse oximeter) 7. Monitor for signs and symptoms of hypoxia during suctioning, including: • Decrease in oxygen saturation • Tachycardia, bradycardia • Agitation • Pallor, diaphoresis
SUBGLOTTIC 8. Ensure suction lumen of ETT with subglottic suction capability is connected to one of the following: SUCTION: • 20-30 cm H20 continuous suction (preferred) • 100-lS0 cm H20 intermittent suction
9. Aspirate secretions from suction port with::: 10 ml syringe every 4 hours if suction machine is not available. 10. Instill 3-S ml air into suction ,lumen if a blockage of the lumen is suspected. 11. Cap suction lumen when not connected to suction (e.g., during transport).
ENDOTRACHEAL 12. Retape ETT a minimum of every 24 hours or when loose or soiled: TUBE CARE: • Reposition oral ETT to prevent ulceration • Change ETT holder and tape ONL Y when loose or soiled (Peds) • Clean/replaceireposition oral airway 13. Secure ETT with securing device
TRACHEOSTOMY 14. Clean tracheostomy site every 8 hours or more frequently if soiled .
TUBE CARE: IS. Clean non-disposable inner cannula every 8 hours with hydrogen peroxide and saline.
16. Change disposable inner cannula with same size cannula when soiled or at least every 72 hours.
17. Change tracheostomy ties:
• Every 24 hours or more frequently if soiled
• If new tracheostomy, see Physicians Order
\FETY: 18. Ensure the following equipment is at the bedside at all times: • Complete suction set-up • Manual resuscitation bag • For infants less than S kg
Anesthesia bag
Attached elbow with inline pressure manometer with safety devices
Appropriate mask size
• Obturator in plastic bag and taped to bed
• Extra tracheostomy tube (same size) with obturator 19. Ensure that suction lumen of ETT is used ONLY for suction/aspiration of secretions. 20. Provide safety measures for patients whose mental status or developmental age precludes cooperation with airway maintenance (Peds).
ORAL HYGIENE: 21. Provide oral care a minimum of every 4 hours while awake. COMMUNI 22. Communicate with patient a minimum of every 4 hours regarding needs (lCU every 2 hours). CATION NEEDS : 23. Assist patient in developing alternate non-verbal communication and encourage expression of feelings /concerns (e.g., communication board).
EMERGENCY 24. Provide the following emergency care if accidental ETT extubation occurs: MANAGEMENT: • Assess patient's ability to maintain effective ventilation • Provide oxygen support to maintain oxygen saturation greater than 9S% • Use resuscitation bag with mask if ventilation is ineffective • Notify physician 2S. Reinsert new tracheostomy tube to reestablish airway patency for accidental tracheostomy removal. 26. Change tracheostomy tube if occluded. The following are exceptions: • Physician must change tracheostomy tube if patient has:
New tracheostomy
ShOlt fat neck
Known tracheoesophageal pathology
ARTlFICAL AlRWAY Page 2 of 4
PATIENT/ 27 . Instruct patient/family regarding the following: FAMILY • Purpose of artificial airway ? ACHING: • Report respiratory distress to nurse • Method of cleaning non-disposable inner cannula (if appropriate) • Alternate methods of communication
COLLABO 28. Collaborate with other disciplines as indicated:
RATION: • Respiratory therapy • Food and Nutrition Services
REPORTABLE 29 . Notify physician of the foltowing:
CONDITIONS: • Air leak • Tube occlusion/dislodgement • Signs/symptoms sinusitis with nasa! ETT • Tracheostomy site bleeding or pulsation • Signs/symptoms tracheostomy site infection:
Fever
Redness
Purulent secretions/drainage
30. Notify physician if sutures not removed after 72 hours on new tracheostomies (Peds after one week).
ADDITIONAL 31. Implement the following as indicated:
..,OCUMENTA 32. Document in accordance with documentation standards .
nON:
Initial date approved: 08/03 Reviewed and approved by: Revision Date: Critical Care Committee 1 1/94, 01/00 , 10/00, Professional Practice 03/05,03 /08, 10/1 0 Committee Pharmacy & Therapeutic Committee Nurse Executive Council Attending Staff Association Executive Committee
REFERENCES: American Association of Respiratory Care (2010). AARC clinical practice guidelines: Endotracheal suctioning of mechanically ventilated patients with art·ificial airways 20 I O. Respiratory Care, 55(6), 758-764.
Joanna Briggs Institute for Evidence Based Nursing and Midwifery (2000). Tracheal suctioning of adults with an artificial airway. Best Practice, 4(4), ISSN 1329-1874
Margo, A. H., & Krisko-Hage, K . (2008). Instilling normal saline with suctioning. American Journal of Critical Care, 17(5),469-472.
Pederson, C. M., Rosendahl-Nielsen, l-ljermind, 1., & Egerod, I. (2009). Endotracheal suctioning of the adult intubated patient - what is the evidence? Intensive and Critical Care Nursing, 25, 21-23.
Excerpt From "Pain Killer: A "Wonder" Drug's Trail of Addiction and Death" by Barry Meier. Copyright 2013 by Barry Meier. Reprinted Here by Permission of Rodale Books. All Rights Reserved.
