13-1 Unit 13 Airway Care GOAL On completion of this unit, the student should be able to perform the procedures necessary to maintain an airway clear of secretions, demonstrate tracheostomy tube care and perform a tracheostomy tube change. COMPETENCIES 1. Demonstrate the following aspiration methods, including selection and assembly of necessary equipment: a. nasotracheal suction b. artificial airway suction c. obtaining sterile sputum sample 2. Perform tracheostomy care on a manikin, including selection and assembly of necessary equipment. 3. Change a tracheostomy tube on a manikin, including selection and assembly of necessary equipment. 4. Correctly chart the above procedures. 5. Complete appropriate procedures in the clinical simulation lab. EQUIPMENT 1. airway care manikin 12. sterile sputum specimen in-line trap 2. tracheostomy manikin 13. nonrebreathing mask 3. sterile gloves and catheter 14. water-soluble lubricant/xylocaine jelly 4. suction source 15. sterile cotton-tipped applicators 5. manual resuscitator bag with mask 16. sterile 4 x 4 gauze 6. oxygen source 17. tracheostomy ties 7. flowmeter with nipple adaptor 18. sterile brush or pipe cleaners 8. oxygen tubing 19. hydrogen peroxide (2-3%) 9. sterile water 20. scissors 10. 10 cc syringe 21. stethoscope 11. sterile saline EXERCISE A - ARTIFICIAL AIRWAY SUCTIONING 1. Collect suction equipment: a. sterile, disposable suction catheter b. 2 sterile gloves
13-2 c. sterile water and sterile saline d. sterile basin e. vacuum source with jar and collection tubing f. adult manikin with endotracheal tube in place g. manual resuscitator h. oxygen source with flowmeter and tubing i. sterile sputum specimen trap (if collecting a specimen) 2. Obtain an assistant. 3. Wash hands. 4. Explain the procedure to the patient. 5. Place the patient in a supine position. 6. Assemble the suction equipment: a. Set the proper amount of vacuum on the suction device by occluding the end of the suction tubing with your thumb and then regulating the amount of suction desired. b. Open sterile suction kit. c. Pour sterile water into the sterile basin provided without contaminating the other items in the kit. d. Open sterile gloves package and put on gloves with proper sterile procedure. e. Connect suction catheter to the suction tubing keeping the catheter and dominant gloved hand sterile at all times. If a sterile sputum sample is to be obtained, the collection trap should be placed in-line between the suction control tubing and the sterile suction catheter. 7. Ask assistant to instill 10-20 cc sterile saline into the ETT and then hyperinflate and oxygenate patient with the manual resuscitator and 100% oxygen for 2-3 breaths. 8. Ask assistant to remove manual resuscitator. 9. Insert catheter into ETT: a. insert using firm, but gentle motion; do not force catheter b. do not occlude thumb control valve during insertion 10. Stop insertion when an obstruction is met. 11. Slightly pull back the catheter (1 cm), occlude thumb control valve intermittently and withdraw catheter in one smooth motion, rotating the catheter with fingertips as it is pulled out. 12. Do not apply suction for more than 15 seconds. 13. Constantly monitor patient during procedure; note ECG pattern and SpO2, if available. 14. After catheter is withdrawn, rinse with sterile water in the basin. Note character of the secretions. 15. Ask assistant to hyperinflate and oxygenate patient with the manual resuscitator and 100% oxygen for 2-3 breaths. Remove the sterile sputum trap and reconnect the suction control tubing to the suction catheter. 16. Repeat steps #9-15 until the airway is clear of secretions. 17. Reconnect the patient to therapy equipment. 18. Gently suction the oropharynx clear of accumulated secretions. Note: Never return to suction the ETT with a catheter that has been used to suction the oropharynx. If further ETT suctioning is required, a new catheter must be used! 19. After the procedure is finished, coil the catheter in a gloved hand. Disconnect the catheter from the suction collection tubing and pull the glove off, keeping the contaminated catheter inside the glove. 20. Dispose of all contaminated equipment. 21. Rinse the suction collection tubing with sterile water. 22. Turn off the suction source. 23. Assess the patient for any untoward effects of the procedure. 24. Auscultate for correct tube position. 25. Wash hands. 26. Chart the procedure, noting secretion color, amount, consistency and odor. Label the sputum collection trap with the patientʼs name and send to the lab ASAP according to the hospitalʼs policy.
13-3 EXERCISE B - NASOTRACHEAL SUCTIONING 1. Collect suction equipment: a. sterile, disposable suction catheter b. 2 sterile gloves c. sterile water and sterile saline d. sterile basin e. vacuum source with jar and collection tubing f. adult manikin with endotracheal tube in place g. manual resuscitator h. oxygen source with flowmeter and tubing i. sterile sputum specimen trap (if collecting a specimen) j. water-soluble lubricant 2. Wash hands. 3. Explain the procedure to the patient. 4. Place the patient in a Semi-fowlerʼs position. 5. Assemble the suction equipment: a. Set the proper amount of vacuum on the suction device by occluding the end of the suction tubing with your thumb and then regulating the amount of suction desired. b. Open sterile suction kit. c. Pour sterile water into the sterile basin provided without contaminating the other items in the kit. d. Open sterile gloves package and put on gloves with proper sterile procedure. e. Connect suction catheter to the suction tubing keeping the catheter and dominant gloved hand sterile at all times. If a sterile sputum sample is to be obtained, the collection trap should be placed in-line between the suction control tubing and the sterile suction catheter. 6. Preoxygenate the patient with a nonrebreathing, simple or venturi mask and ask the patient to take 4-5 deep breaths. 7. Lubricate the catheter tip with water-soluble lubricant. 8. Insert catheter into either naris parallel to the hard palate: a. insert using firm, but gentle motion; do not force catheter b. do not occlude thumb control valve during insertion 9. Stop insertion when an obstruction is met. 10. To guide the catheter into the trachea, ask the patient to cough or take a deep breath while you advance the catheter. Coughing cause the vocal cords to open widely. Entrance into the trachea is usually followed by spontaneous coughing. Continue to advance the catheter until you meet the resistance of the carina. 11. Slightly pull back the catheter (1 cm), occlude thumb control valve intermittently and withdraw catheter in one smooth motion, rotating the catheter with fingertips as it is pulled out. 12. If secretions are thick, instill 10-20 cc sterile saline through the catheter. 13. Do not apply suction for more than 15 seconds. 14. Constantly monitor patient during procedure; note ECG pattern and SpO2, if available. 15. After catheter is withdrawn, rinse with sterile water in the basin. Note character of the secretions. 16. Reoxygenate the patient. Remove the sterile sputum trap and reconnect the suction control tubing to the suction catheter. 17. Repeat steps #7-14 until the airway is clear of secretions. 18. Gently suction the oropharynx clear of accumulated secretions. Note: Never return to suction the trachea with a catheter that has been used to suction the oropharynx. If further tracheal suctioning is required, a new catheter must be used! 19. Reconnect the patient to therapy equipment. 20. After the procedure is finished, coil the catheter in a gloved hand. Disconnect the catheter from the suction collection tubing and pull the glove off, keeping the contaminated catheter inside the glove. 21. Dispose of all contaminated equipment.
13-4 22. Rinse the suction collection tubing with sterile water and turn off the suction source. 23. Assess the patient for any untoward effects of the procedure. Auscultate for correct tube position. 24. Wash hands. 25. Chart the procedure, noting secretion color, amount, consistency and odor. Label the sputum collection trap with the patientʼs name and send to the lab ASAP according to the hospitalʼs policy. EXERCISE C - TRACHEOSTOMY TUBE AND STOMA CARE 1. Assemble the necessary equipment: a. disposable tracheostomy care kit b. artificial airway suction equipment (see 1) sterile cotton applicators Exercise A, step #1) 2) sterile 4 x 4 gauze c. hydrogen peroxide (H2O2 2-3%) 3) fabric tracheostomy ties d. scissors 4) sterile brush or cotton pipe cleaners e. spare tracheostomy tube 5) sterile gloves f. syringe 6) sterile towel g. cuff pressure manometer 7) 2 sterile basins h. stethoscope i. tracheostomy manikin 2. Explain the procedure to the patient. 3. Place the patient in a supine position. 4. Wash hands. 5. Auscultate the chest: a. ascertain correct tube position b. determine the need for suctioning prior to beginning the cleaning procedure 6. Open the disposable trach care kit and prepare a sterile field by unfolding the towel. All of the sterile supplies should be placed on this sterile field. 7. Pour sterile water and H2O2 into the 2 basins. 8. Put on the sterile gloves. 9. Using 1 hand, stabilize the tracheostomy tube by holding the flange. With the other hand, remove the inner cannula by twisting the lock or rotating it to the unlocked position and removing it. (If the patient requires mechanical ventilation, insert a tracheostomy adaptor and reconnect the patient to the ventilator. If supplemental oxygen is required, a tracheostomy mask may be used while the inner cannula is being cleaned.) 10. Soak the inner cannula in the H2O2 and scrub it with the brush provided in the tracheostomy kit. Remove any dried or inspirated secretions from both inside and outside of the cannula. 11. Thoroughly clean, with H2O2, the area where the flange of the outer cannula meets the locking mechanism. 12. Rinse the inner cannula in sterile water and shake it dry. 13. Replace the inner cannula. Be sure to lock cannula into the correct position. Following the replacement of the cannula, return the patient to the previous mode of therapy. 14. Stabilize the tracheostomy tube with 1 hand and remove the old dressing. Cut and remove the old ties. It is essential, once the ties are cut, that the tube be stabilized at all times to prevent accidental decannulation. 15. Clean the stoma site: a. It may be necessary to clean the stoma area with 4 x 4 gauze pads dipped in H2O2 if a large amount of secretions are present. Begin cleaning at the stoma and move out from the site. b. Use each pad for a single pass only and discard them by placing them in your dirty area. c. Observe the stoma for unusual redness, swelling, or pulsation of the tracheostomy tube. d. Following the removal of most of the secretions, use the cotton-tipped applicators dipped in H2O2 for the detail cleaning. Clean very carefully around the stoma and the flange of the tube. e. Rinse the site using gauze pads dipped in sterile water. f. Pat the area dry with sterile gauze pads.
13-5 16. Apply a clean dressing: a. Never cut a gauze pad to make a dressing. Small cotton fibers from the cut gauze may be absorbed into the healing stoma and later cause an abscess. b. Construct a clean dressing using a 4 x 4 gauze pad if a sterile dressing is not supplied in the trach care kit. The figure on the next page shows how to fold the dressing for use. 17. Apply new ties: a. The ties should be cut prior to performing the procedure so that the tube may be stabilized at all times. b. Tie a square knot to secure the tracheostomy tube; a bow knot is too easy to untie. The figure below shows how to tie a square knot. 18. Reassess the tracheostomy tube position. 19. Check cuff pressure with cuff pressure manometer. 20. Dispose of all dirty equipment. 21. Chart the procedure. EXERCISE D - TRACHEOSTOMY TUBE CHANGE 1. Assemble the necessary equipment: a. artificial airway suction equipment (see Exercise A, step #1) b. tracheostomy manikin c. scissors d. new tracheostomy tube for replacement e. sterile towel f. 10 cc syringe g. sterile gloves h. water-soluble lubricant or Xylocaine jelly i. stethoscope 2. Explain the procedure to the patient.
3. Place the patient in a supine position. 4. Wash hands. 5. Auscultate the chest: a. ascertain correct tube position b. determine the need for suctioning prior to beginning the tube change procedure 6. Prepare a sterile field by unfolding a sterile towel. All of the clean equipment should be placed on this towel. 7. Open the box with the new trach tube, unwrap it from itʼs clear plastic covering and place all parts on the sterile towel, being careful NOT to touch the tube parts or the towel. 8. Open a 10 cc syringe and place it on the towel, being careful NOT to touch the syringe. 9. Put on the sterile gloves. 10. Check the new trach tube cuff for leaks: a. Fully inflate the cuff with air. b. Gently press on the inflated cuff. Notice if the cuff leaks air. Also check to see if the cuff is inflated symmetrically. c. Actively deflate the cuff with the syringe, while at the same time gently push the cuff in the direction of the flange, until the cuff is completely flat against the tube. 11. Place clean trach ties on the flange of the new tube. Your instructor will demonstrate the procedure. 12. Insert the tracheostomy tube obturator into the new trach tube. 13. Coat the tip of the tube with water-soluble lubricant or Xylocaine jelly. 14. Have an assistant remove the trach tube needing replacement: a. Hyperinflate and hyperoxygenate the patient using a manual resuscitation bag with 100% oxygen. a. Deflate the trach tube cuff. b. Cut the ties around the patientʼs neck. c. Gently pull out the tube. Caution: If the tube does not remove easily, stop the procedure at this point, reinflate the cuff and call the physician! 15. Insert the new trach tube following the curved line of the tube. 16. Immediately remove the obturator. 17. Replace the inner cannula. Be sure to lock cannula into the correct position. 18. Following replacement of the inner cannula, the assistant should inflate the cuff to a safe pressure level using the cuff pressure manometer, then hyperinflate and hyperoxygenate the patient using a manual resuscitation bag with 100% oxygen while you stabilize the tube. 19. Return the patient to the previous mode of therapy. 20. Securely knot the ties around the patientʼs neck. 21. Auscultate the patientʼs chest to ascertain correct tube position. 22. Dispose of all dirty equipment. 23. Chart the procedure. 13-6
13-7 WORKSHEET 1. Why is it important to use aseptic technique when suctioning through an endotracheal tube? 2. Discuss the importance of the following factors when suctioning: a. preoxygenation b. deep breaths (hyperinflation) after suctioning c. postoxygenation 3. Why should you limit your suctioning time to <15 seconds? 4. Why is an assistant helpful when retying the ties on a tracheostomy tube? 5. For what conditions should a tracheostomy tube be changed? (List at least 2.)