Obstruction of the ETT

Obstruction of the ETT

Tenacious secretions may cause the tube to become blocked. If this occurs and suctioning does not clear the tube, it must be removed immediately and patient must be ventilated using bag and mask. This is a medical emergency. Prepare for re- intubation.

Humidification

All patients must have adequate humidification of inspired gases for optimal mucocillary function and conservation of temperature. Humidification must be given to all patients with an endotracheal tube utilising a HME filter. Patients with tenacious secretions and/or pulmonary oedema require Fisher and Paykel humidification.

Hypothermic patients <>°C require Fisher and Paykel humidification to optimise rewarming. If a patient remains intubated longer than 7 days Fisher and Paykel humidifier may be utilised at the discretion of team leader.

Tracheal toilet

Tracheal toilet (endotracheal suctioning) is performed on a prn basis using an inline closed suction system (please see above). Trachcare closed system suctioning device is placed insitu for all patients. Note that these are available in two sizes (tracheostomy or ETT). The patient’s chest is osculated 2hrly to determine suction requirement. This procedure is carried out by the bedside nurse according to the protocol outlined below. Contraindications to suctioning include hypothermia (T <>°C), unstable clinical status and post operative haemorrhage as suctioning may precipitate deterioration in clinical condition.

· the patient with an endotracheal tube cannot cough effectively and depends on suction to clear secretions (performed using an aseptic technique)

· the patient care nurse should wear eye protection in case of splashing secretions

· the suction trolley is wiped with alcohol

· the patient care nurse washes her hands, gloves and connects the suction tubing to trachcare

· the nurse then explains the procedure to the patient, the patient is preoxygenated using the 100% 3 min key. The patient care nurse then inserts the catheter until the patient coughs, withdraws slightly, and then applies suction as it is withdrawn.

· for tenacious secretions consider active humidification (do not instil normal saline)

· suction is repeated until secretions are removed (rinsing the catheter with sterile water through the rinse port on completion).

· the mouth and pharynx are suctioned using a 12-g catheter

· the suction tubing is rinsed with sterile water at the completion of the procedure

· the trachcare catheter is turned to the Off position (TrachCare) and disconnected from suction when not in use (SteriCath).

Surgical tracheostomy indications
· airway maintenance
· prolonged intubation >7-10 days
· failure to wean off ventilation > 7-10 days
· airway protection Contraindications · major cerebrovascular accident · coagulopathy

Procedure
· necessitates return to theatre
· group + x-match 2 units:ABP
· coagulation screen prior to procedure (warfarin ceased 7 days prior to procedure , if applicable)
· cease N/E feeds 6 hours prior to procedure (if patient diabetic commence 5% Dext intravenously)
· Propaq physiological monitoring during transport
· continue inotropes, sedation /narcotic infusions · confer with anaesthetist re pre- medication

Post operative management

· cuff checks once per shift and whenever a leak is detected with manual hyperinflation

· tape ETT securely to prevent dislodgement

· gentle suction technique (no suction for at least four hours)

· CxR post procedure and second daily prn

· tube change by general intensive care nursing team at 14 days

Spare tracheostomy tube (same size) and hook & dilator must be kept at patient bedside at all times!

Complications

· bleeding

· haemorrhage

· laryngeal dysfunction (impaired swallowing)

· tube dislodgement