Page 410 - ACCCN's Critical Care Nursing

Ventilation and Oxygenation Management 387

disposable) prevent secretion build up on the tracheos- for cardiac arrhythmias. Manual hyperinflation is dis-
tomy tube, while fenestrated and talking tracheostomies couraged due to the risk of barotrauma and lack of
facilitate communication, as do Passe Muir valves used benefit. Similarly, installation of saline is not supported
with the cuff deflated. due to increased risk of flushing pathogens into distal
lung regions. 60
TRACHEOSTOMY CARE
The aim of tracheostomy care is to keep the site free of METHODS
infection, and prevent tube blockage or dislodgement. The three methods of suctioning are:
The site is cleaned with normal saline and fixation devices
changed at least 12-hourly with two nurses to safely ● open suction: a suction catheter is passed under
46
perform tape changes. Velcro tapes are easier to change aseptic technique directly into the ETT/tracheostomy
47
and more comfortable than cotton tape. Lint-free or after disconnection from the ventilator circuit. Disad-
superabsorbent foam dressings may be placed under the vantages include loss of PEEP resulting in loss of alve-
flange to absorb secretions. Adequate humidification and olar recruitment and increased risk of transmission of
suctioning will usually prevent tube obstruction (see later infective organisms. A surgical mask and protective
61
in this chapter). The use of inner cannulae has obviated eyewear should be worn.
the need for frequent tracheostomy tube changes. Single ● semi-closed suction: a suction catheter is passed
lumen (no inner cannula) tracheostomy tubes should be through a swivel connector with a self-sealing rubber
changed every 7–10 days. 46 flange.
● closed suction: in-line system is attached between the
COMPLICATIONS OF ENDOTRACHEAL ETT/tracheostomy tube and the ventilator circuit
where the suction catheter is contained in an inte-
INTUBATION AND TRACHEOSTOMY grated plastic sleeve. Alveolar derecruitment occurs to
Tube blockage, tube dislodgement and aspiration are a lesser degree than with open suction.
major complications. Partial ETT or tracheostomy tube There is no difference between techniques in relation to
dislodgement can cause greater harm than complete development of ventilator-associated pneumonia (VAP)
removal because of delays in diagnosis and resultant aspi- and quantity of secretions removed.
ration or worsening gas exchange. Tube dislodgement is
most likely to occur when turning the patient, if the The diameter of the suction catheter should not be greater
patient is agitated or when nursing staff are distracted or than half the diameter of the airway, using the formula:
48
on breaks. While physical restraint may be considered suction catheter size [Fr] = (ET tube size [mm] − 1) × 2.
to prevent tube dislodgement, multiple studies noted The suction catheter should be inserted to the carina, then
patients were restrained at the time of self-extubation or withdrawn 2 cm before suction is applied to prevent
device removal. 49-54 Effective levels of analgesia and seda- damage to the carina. Suction should only last 15 seconds,
tion is therefore most appropriate in minimising the risk using continuous, rather than intermittent, suction. Use
of self-extubation. of ETTs or tracheostomy tubes with integrated subglottic
suction ports may assist in preventing VAP, especially when
Complications during and immediately after endotra- performed with other prevention strategies such as semi-
cheal intubation and tracheostomy include cardiovascu- recumbant positioning and good cuff seal management.
lar compromise, bleeding, injury to the tracheal wall,
damage to the vocal cords, pneumothorax, pneumome- ADVERSE EFFECTS
diastinum and subcutaneous emphysema. Late compli- Adverse effects of suction can include hypoxaemia, intro-
cations of tracheostomy include tracheal stenosis, duction of infective organisms, tracheal trauma, bradycar-
tracheomalacia and tracheo-oesophageal fistula and dia, hypertension and increased intracranial pressure.
infection. As noted earlier, damage to the trachea is exac- Tracheal suctioning causes discomfort, and should there-
55
erbated by high cuff pressures. PDT results in fewer fore be performed only when clinically indicated, such as
wound infections, decreased incidence of bleeding and audible presence of secretions and desaturation. 58
reduced mortality compared to ST. 56
TRACHEAL SUCTION EXTUBATION
Following successful weaning from mechanical venti-
Patients with an ETT or tracheostomy tube require tra-
cheal suction to remove pulmonary secretions that can lation (see later in this chapter), assessment of the patient
lead to atelectasis or airway obstruction and impair gas prior to extubation should include adequate gas exchange,
exchange. Suction should be performed as clinically respiratory rate and work of breathing on minimal
57
indicated, with assessment of visible or audible secre- support for prolonged periods, respiratory muscle
tions, rising inspiratory pressure, decreasing V T or strength, the ability to cough and clear secretions spon-
58
increased work of breathing. A sawtooth pattern on the taneously and a stable haemodynamic status and mental
62
flow-volume waveform may also indicate the need for status. Serious post-extubation complications of laryn-
63
suction (discussed later in this chapter). 59 gospasm and stridor cannot be reliably predicted, so
the ease/grade of intubation should be considered
Preoxygenation using a FiO 2 of 1 for 60 seconds prior to prior to extubation and provision made for immediate
performing suction minimises hypoxia and the potential re-intubation. 64