 Artificial airways (*patients in the ICU often need mechanical assistance to maintain airway
patency. Therefore, an ET tube (endotracheal intubation) or a tracheostomy is placed to
create an artificial airway*).
 Indications (*reasons for intubation*)
 Upper airway obstructions
 Apnea *when a patient is unable to breathe on their own*
 High risk for aspiration
 Ineffective clearance of secretions (mucous)
 Respiratory distress
 Endotracheal Tubes
 Endotracheal Intubation
 Equipment
 Self-inflating BMV/ambu bag, mask, and oxygen (*BMV – bag-valve-mask*)
 ET tube, guide wire, lubricant, securement device, End Tidal CO2 detector
 Suctioning equipment
 IV access and medications as indicated
 Preparation
 Consent is obtained.
 Communicate with the patient/caregiver and explain the reason for the
procedure.
 Position
 Oral intubation: (*place the pt supine with the head extended and the neck
flexed “sniffing position” *)
 Nasal intubation: the nasal passages may be sprayed with a local anesthetic
and vasoconstrictor (lidocaine with epinephrine) to reduce trauma and
bleeding.
 Preoxygenate – with BVM and 100% O2 for 3 to 5 minutes.
 During intubation
 Limit each intubation attempt to less than 30 seconds.
 Ventilate the patient between successive attempts using the BVM and 100% O2.
 Rapid-sequence intubation (RSI) (administer sedative & paralytic drug) –
decreases the risks for aspiration and injury to the patient.
 ***Propofol, etomidate (Amidate) is given to induce unconsciousness along with
an opioid (fentanyl) to blunt the pain of the procedure).
 Monitor O2 status.
 After intubation
 Inflate the cuff.
 Confirm placement – continue to ventilate patient using BVM with 100% O2.
 Use an EtCo2 detector to confirm proper placement.
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 Place detector between the BMV and ET tube and look for a color change
(indicating the presence of CO2) or a number.
 At least 5 or 6 exhalations with a consistent CO2 level must be present to
confirm tube placement in the trachea.
 Auscultate the lungs for bilateral breath sounds for the absence of air
sounds.
 Observe chest wall movement.
 Check O2 saturation.
 After placement verification
 Connect ET tube to ventilator and secure the tube.
 Suction the ET tube and pharynx as needed.
 Obtain a chest x-ray to confirm tube location (2 to 6 cm above the carina in
the adult).
 Once proper position is confirmed with x-ray, record and mark the position
of the tube at the lip or teeth or nose.
 Obtain ABGs 15 to 30 minutes after intubation to determine baseline
oxygenation and ventilation.
 Monitor O2 sat and EtCO2 continuously.
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Nursing Management: Artificial Airway
 Maintaining correct tube placement
 Maintaining proper cuff inflation
 Monitoring oxygenation and ventilation
 Maintaining tube patency
 Providing oral care and maintaining skin integrity
 Fostering comfort and communication
 Assessing for complication
Maintaining Correct Tube Placement
 Continuously monitor the pt with an ET for proper placement.
 Observe for symmetric chest wall movement.
 Auscultate to confirm bilateral breath sounds.
 *If the ET tube is not positioned properly, it is an airway emergency*.
 Safety Alert: maintain proper ET tube position by recording and marking the position of
the tube at the lip or teeth (usually 21 cm for women, and 23 cm for men).
Maintaining Proper Cuff Inflation
 Maintain cuff pressure at 20 to 25 cm H2O – to ensure adequate tracheal prefusion.
 Measure and record cuff pressure after intubation and on a routine basis using minimal
occluding volume (MOV) technique or the minimal leak technique (MLT).
 Minimal occluding volume
 Place stethoscope over the trachea and inflate the cuff to MOV by adding air
until you heat no air at peak inspiratory pressure.
Monitoring Oxygenation and Ventilation
 *Remember you want to obtain ABGs 15 to 30 minutes after intubation to determine
baseline oxygenation and ventilation*
 Oxygenation: Assess clinical findings such as ABGs, SpO2; signs of hypoxemia (change in
mental status: confusion), dusky skin, and dysrhythmias.
 Ventilation: PaCO2, respiratory rate, rhythm, & use of accessory muscles.
 Maintaining Tube Patency
 DO NOT ROUTINELY SUCTION A PATIENT – only as needed.
 Indication for suction (*why would a patient need to be suction*)
 Visible secretions in the ET tube.
 Sudden onset of respiratory distress.
 Suspected aspiration of secretions.
 Increase in RR or frequent coughing.
 Sudden decrease in SpO2.
 Increase in peak airway pressure – auscultating adventitious breath sounds over
the trachea or bronchi.
 Suctioning methods: closed-suction technique (CST) and the open-suction technique
(OST).
 Open-suction technique (OST)
 Open
 Closed-suction technique (CST)
 Connect suction to the closed suction port.
 Hyper oxygenate patient for 30 seconds.
 Gently and quickly insert the catheter – when you meet resistance, pull back
½ in.
 Withdraw catheter over 10 seconds or less.
 Hyper oxygenate again for another 30 seconds.
 Complications associated with suctioning
 Hypoxemia
 Bronchospasm
 Increased ICP
 Dysrhythmias
 Hypertension
 Hypotension
 Mucosal damage *may occur due to excessive suction pressures (greater than
120 mm Hg) – when leads to risk for infection and bleeding*
 Pulmonary bleeding
 Pain
 Infection
 *Assess the patient before, during, and after suctioning. Prevent hypoxemia by
hyper oxygenating the patient before and after each suctioning pass and limiting
each pass to 10 seconds or less. Assess both the ECG and SpO2 before, during, and
after suctioning*.
 Manage secretions
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May be thick and hard to suction due to inadequate hydration or humidification,
infection, or inaccessibility of the lower airways.
Maintain adequate hydration (IV fluids)
Provide supplemental humidification – help thin secretions
Mobilize and turn patient q2hrs to help move secretions into larger airways
Antibiotics as needed.