general indications for endotracheal tube
failure to oxygenate/ventilate
failure to maintain/protect airway
predation of decompensation
intubation criteria
ventilatory failure - hypoventilation relief of an obstructed airway protection of the airway (four reflexes) clearance of secretions direct instillation of medication bronchoscopic examination
whats the minimum endotracheal tube
7.5 tube
causes of ventilatory failure
drugs
midbrain abnormalities (head injuries, stroke injuries)
peripheral nervous system abnormalities
diseases of the respiratory muscles
ventilatory failure cont’d
disease of the myoneural junction - myashtenia gravis
acute or chronic lung disease
damage, inflammation, infection, or collapse of a lung
cardiovascular collapse
inhalation burns
relief of an obstructed airway
airway obstruction (foreign body, loss of muscle tone, bleeding, and airway edema) traumatic injury (infection allergic reaction)
obstructed airway symptoms
stridor and muscle exertion, a slight coughing, and vocal hoarseness
more severe, accessory muscles, intercostal retractions, and a tracheal tug
facial burns - causes severe inflammation
protection reflexes
pharyngeal reflex, laryngeal reflex, tracheal reflex, carinal reflex, altered LOC, aspiration, higher risks of vomiting
clearance of secretions
access for suctioning, chronic lung disease, chronic bronchitis, pneumonia
how does direct instillation of medication work
during emergencies medicine can be directly instilled down endotracheal tube
name the parts of the endotracheal tube
body, bevel, murphy eye, cuff, inflation tube, pilot balloon, one way valve, 15mm adapter, radiopaque line
why does the endotracheal tube have a beveled end
less chance to attach to tissue
what is the murphys eye for
to make sure the pt can always breath
why do the cuff and pilot balloon mirror each other
so you know if the cuff is inflated or deflated based off of the pilot balloon
what connection do the vocal cords and the bevel have in common
helps visualize the vocal cords easier and makes it easer to insert through them
what can low volume and high pressure of a cuff lead to
tracheal tissue necrosis
what is the best choice for cuff inflation
high volume and low pressure
what is the internal and outer diameter on the et tube measured in
millimeter or french measurement
why are the centimeter marks on the et tube
to measure and mark how deep the tube is in the trachea
where do you measure and mark the tube
at the lip or teeth line
what 3 things do you check to make sure you properly inserted an ET tube
- XRAY
- bilateral breath sounds
- easy cap
why is a neonatal tube uncuffed
bc the cricoid bone is the smallest part of airway and it seals around the cuff
complications of tubes
friction, reaction to materials, infection, poor humidification, poor secretion removal, right mainstem bronchus, increased RAW b/w 5-7, filtering, no talking, no effective cough
what are 3 things that block airways
muscle, secretions, swelling
what is MLT or minimal leak technique
listen to breath sounds around cuff and during peak inspiration pressure if air goes around the cuff then it is ok to inflate past 30 mmHg bc blood flow is possible during that time
what is a major clinical sign for laryngeal complication
inspiratory stridor
laryngeal stenosis
as the laryngeal heals it tightens and the airway can close after removing the tube
what is tracheal mylagia
trachea muscles becomes flappy and no muscle control so airway collapses
what happens when cuff pressure greater than 25 occurs
it inhibits lymphatic flow
what happens when cuff pressure is greater than 35
obstructs venous flow
what happens when cuff pressure is greater than 30
causes arterial blood flow to stop and tissue necrosis to develop
what happens if the cuff pressure is not great enough
the weight of the secretions will be to heavy for the cuff and they will be able to fall down into the lungs
how does vocal cord paralysis happen
caused by damage to the recurrent laryngeal nerve
how does glottic/subglottic edema work
edema that occurs below the cricoid cartilage
if hoarseness lasts for more than one week after ET tube removal what causes it
traumatic intubation, tight fitting tube, allergic reaction, excessive movement
what is the maximum time an ET tube can be in
2 weeks
laryngeal web
occurs several days after extubation, and caused by necrotic tissue around glottis, stridor and acute airway obstruction occur along with fibrin forming
what helps with a tracheal stenosis and what is it
MLT and its a lesion that constricts the airway
what can happen specifically with oral tubing
erosion of the corners of the mouth, pt may bite tube, harder to attach equipment, harder to communicate
how do you prevent accidental changes in tube position
routine assessment and marking cm marks at teeth or gums or nare
average cm marks for adult
oral male: 21-23 cm
oral female: 19-21
nasal: 26-29
how do you secure an ET tube
with tape or ET collar
what do you look for in a chest xray of ET tube
radiopaque line, 2-4 cm above carina, around T2-T4 vertebrae
what happen if there is a cuff leak
causes reduced delivery of tidal volume and requires extubation and reintubation
how can you tell if there is an accidental extubation
decreased breath sounds, decreased airflow through tube, difficulty passing a catheter past the end of tube
what should patient have and be able to do in order to be ready for extubation
clear airway secretions (cough) and have intact gas reflex
steps of extubation
get equipment, suction above the cuff and pharynx, oxygenate the pt, deflate cuff, remove tube, apply more oxygen, assess pt, check for good air flow
what is a bronchoscopy used for
inspect airway, collect samples, remove foreign objects, and place devices into the airway
what are the specialized endotracheal tubes
double lumen tubes, tubes with special adaptors for jet ventilation, tubes with subglottic suction ports
double lumen tubes
also called carlens tube, unilateral lung disease, independent lung ventilation
what is the carlens tube essentially
2 ventilators for each lung
high frequency jet ventilation
gas goes in and out of lungs all the time
what does the CASS tube help with
reducing VAP
laryngeal mask airway
consists of a short tube and a small mask that is inserted deep into oropharynx
can the LMA be used in conscious or semicomatose pt’s
no due to stimulation of the gas reflex
combitube
double lumen airway that will ventilate lungs if put into esophagus or trachea