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Endotracheal intubation is a very common procedure especially in the critical care unit for patients with airway problems. Patients who require mechanical ventilation needs to be intubated: either with endotracheal tube (usually for short-term use) or tracheostomy (long-term use).

intubation-procedure-management-nurse-roles
Photo credit:aegisanesthesiapartners

Thus, this article would like to expand the knowledge of nurses with the common management for patients who are intubated. This article aims to provide information about:

  • The criteria for endotracheal intubation
  • Nursing roles during the endotracheal intubation and the equipment nurses should prepare before the intubation
  • How to insert oropharyngeal airway or bite block
  • Basic nursing interventions for patients with endotracheal tube
  • How to perform proper endotracheal suctioning

Before we dig into the basic interventions, allow me to walk you through to the criteria behind the intubation.

Why some patients need endotracheal intubation?

  • Airway obstruction
  • Hypoventilation
  • Severe hypoxemia
  • Impending airway obstruction
  • Severe cognitive impairment
  • Cardiac arrest

So what are the things you need to prepare when the doctor says “we need to intubate the patient”? Basically, as a nurse, you should be well acquainted of the basic intubation equipment and premedications by heart. This will come in handy when emergency situation arises.

Your nursing checklist of intubation equipment:

  • Endotracheal tubes: size 6, 7, 7.5, 8
  • Laryngoscope with blades of different sizes
    • Curved blades (e.g. Macintosh blades)
    • Straight blades (e.g. Miller or Wisconsin blades)
  • Bulbs and batteries for the laryngoscope
  • Syringe 10 cc for introduction of air/pressure to the cuff
  • KY jelly or lubricating gel
  • Bag valve mask
  • Face mask
  • Oropharyngeal airways
  • Leukoplast or tape to keep ET in place
  • Bite block
  • ET holder
  • Suction tip and connection tubes
  • Suction machine: portable or wall-pressured
  • Oxygen source
  • Standby mechanical ventilator machine
  • Cardiac monitor with pulse oximeter
  • Stethoscope
  • IV kit

Medications and kit to prepare

Nursing roles during insertion of endotracheal tube

It is the physician’s responsibility to insert an endotracheal tube but it doesn’t mean that nurses do not have a big role during this emergency procedure.

So what are your nurse’s roles, in the event, that this emergency happens?

  1. If the patient is in respiratory distress, oxygenate patient using bag valve mask. Attach patient to a pulse oximeter for monitoring. Make sure to ask for reinforcement of nurses to help you in this procedure. Delegate tasks immediately (E.g. medication nurse, nurse who will assist the physician and prepare the laryngoscope, nurse who will assess the condition of the patient and checks vital signs, and etc.). One nurse cannot perform all the tasks simultaneously written below.
  2. Ensure that the emergency cart is accessible to the room or the area of the patient.
  3. If the patient has no intravenous access, immediately insert a line (or ask other nurse or intravenous therapist) for premedication purposes.
  4. Position the patient and the height of bed comfortable to the physician who will insert the tube. Align patient’s head on a neutral position. Hyperextended the head to a comfortable degree.
  5. Consider premedication, optional for most patients-usually given 2-3 minutes prior to induction. Prepare and administer the sedative medication as ordered by the physician.
  6. Prepare the laryngoscope and blades. Ensure that the batteries and bulbs are working. Ask the physician what size or type of blade he/she preferred to use.
  7. Assist the physician during insertion. When the tube is already in place, inflate the cuff to the desired cuff pressure using a syringe. Check the tube position and the level in the lip line (e.g. 20 cm, 21 cm, 22 cm, and 23 cm)
  8. Fix the tube in place partially using a tape, to ensure that the tube is steady. Assessment should be done first if the tube is in the correct place.
  9. Continue to oxygenate patient using bag valve or the manual resuscitator.
  10. Verify tube position immediately. Auscultate both lung fields. Assess if both chest are rising equally.
  11. Check also the pulse oximeter to assess patient’s oxygenation.
  12. If the endotracheal tube is correctly place, secure tube in position using either a leukoplast, an ET holder, or ET ties. Suction patient’s secretions as needed.
  13. Attach patient to mechanical ventilator. Check the physician’s orders for the mechanical ventilator settings.
  14. The physician would request a standard chest x-ray to confirm ET placement. Correspondingly, the physician would order an ABG test one hour after attaching the patient to the mechanical ventilator.
  15. When ABG results are out, the physician would typically adjust the mechanical ventilator settings according to the patient’s response.

After the patient is intubated, what’s next? Getting the tube isn’t the end of the story, as a nurse, keeping and taking care of the patient with endotracheal tube is another discussion. Let’s take a look of the things you can do as nurse.

Nursing Management for patients with endotracheal tube

  1. Assess the client’s respiratory status at least every 2 hours or frequently as indicated.
  2. Assess nasal and oral mucosa for redness and irritation.
  3. Secure the endotracheal tube with tape or ET holder to prevent movement or deviation of the tube in the trachea.
  4. Place the patient in a side lying position or semi fowler’s if not contraindicated to avoid aspiration. Reposition patient every 2 hours.
  5. Ensure the ET for placement. Note lip line marking and compare with desired placement (18cm, 20cm, and 22cm).
  6. Closely monitor cuff pressure, maintaining a pressure of 20 to 25 mmHg to minimize the risk of tracheal necrosis.
  7. Move oral endotracheal tube to the opposite of the mouth every 8 hours or depending on the protocol of the hospital. This is to prevent irritation to the oral mucosa.
  8. Provide oral care at least every 4 hours using antibacterial or antiseptic solution. Use bite block to avoid patient from biting down.
  9. Communicate frequently with the client. Give patient means to communicate using white board or communication board.

 So what is oropharyngeal airway or bite block for?

This is used when you need to suction secretions from the patient’s airway. Also it keeps the air passage ways open when they are obstructed by the tongue or secretions.

  1. Prepare a size of oropharyngeal airway appropriate to the patient’s size and age.
  2. Quickly place the client in a Semi-Fowler’s position or supine position if possible.
  3. Immediately put on a clean gloves and face mask. Follow the standard precautions at all time.
  4. Hold the lubricated airway by the outer flange, with the distal end pointing up.
  5. Open the client’s mouth and insert the airway along the top of the tongues.
  6. When the distal end of the airway reaches the soft palate at the back of the mouth, rotate the airway 180 degrees downward, and slip it past the uvula into the oral pharynx. The oropharynx may be suctioned as needed by inserting the suction catheter alongside the airway.
  7. Remove after the oropharyngeal airway after use.

Patient with endotracheal tube do not have the ability to cough-out their secretions or clear their airway. So it is our responsibility as nurses, to maintain a patent airway to the patient. One basic things that we should learn is suctioning.

Your nursing checklist of how to perform endotracheal suctioning

Equipment

  1. Suction catheter and suction connecting tube
  2. Normal Saline Irrigation
  3. Suctioning machine or device: wall or portable
  4. Oxygen source
  5. Personal protective equipment
  6. Pulse oximeter
  7. Stethoscope
  8. Bag valve or manual resuscitator

Procedure

  1. Check the guidelines or standard procedure of your unit for suctioning patient with endotracheal tube.
  2. Prepare all needed equipment. Position all supplies so that they are easily accessible. Check suction setup for correct functioning.
  3. Explain the procedure to the client. Explain why you need to suction the secretions and how it could help the patient breathe easier.
  4. Assess patient first. Auscultate patient’s lung fields for abnormal breath sounds (e.g. crackles, wheezing, and stridor).
  5. Attach patient to continuous pulse oximeter monitoring device.
  6. Observe stand precaution at all times. Wear personal protective equipment. Perform hand washing.
  7. Attach suction connection tube to the suction tip. Use appropriate suction tip size.
  8. Ensure that wall or portable suction is turned on (no higher than 120 mmHg). Set vacuum setting according to policy of your unit.
  9. Hyper-oxygenate patient to 100% with the manual resuscitator for 2 – 5 minutes.
  10. Introduce catheter until a restriction is met or until you can stimulate cough reflex. You can also suction patient while he/she is coughing.
  11. Withdraw the catheter slowly while applying intermittent suction. Suction should not be applied for more than 15 seconds.
  12. Upon completion of suctioning, withdraw catheter, ensuring that tip is completely withdrawn from airway.
  13. Repeat suctioning process until the patient’s airway is clear.
  14. Use suction tip is for single-use. Discard after use.
  15. Discard personal protective equipment and wash hands.
  16. Evaluate patient’s condition by auscultating the lung fields and by monitoring patient’s oxygenation using pulse oximeter.

Conclusion.

As a nurse, it comes in handy if you are well aware of the basic interventions or management during emergency, most especially when it concerns airway management. Time is always of the essence.

However, though this article may provide basic background, it is always a nurse’s duty to be acquainted with the hospital’s protocols or guidelines for standard procedures.

Moreover, aside from being knowledgeable, every nurse should always apply what they have learned. Besides, nursing is not merely textbooks. Nursing is an applied science.

References:

  • Ashton, R. & Burkle, C. 2004. Endotracheal Intubation by Direct Laryngoscopy. American Thoracic Society. Retrieved at http://www.thoracic.org/professionals/clinical-resources/critical-care/critical-care-procedures/endotracheal-intubation-by-direct-laryngoscopy.php last May 4, 2015
  • Michael D., et. al. 2002. Guidelines for Emergency Tracheal Intubation Immediately Following Traumatic Injury. Eastern Association for the Surgery of Trauma. East Practice Management Guidelines Workgroup. St. Elizabeth
  • Doenges, M., Moorhouse, M. & Murr, A. 2006. Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span. F.A. Davis Company, Philadelphia. 7th edition.
  • Health Center 1044 Belmont Ave. Youngstown, OH retrieved at https://www.east.org/Content/documents/…/intubation.pdf last May 4, 2015
  • Kozier, B. et. al. 2008. Kozier and Erb’s Fundamental of Nursing Concepts, Process, and Practice. Pearson Education Inc. Prentice Hall. Upper Saddle River, New Jersey. 8th edition.
  • Myers, E. (2006). RNotes: Nurse’s Clinical Pocket Guide. F. A. Davis Company. Philadelphia. 2nd edition.
  • Silvestri, L. (2008). Comprehensive Review for the NCLEX-RN Examination. Saunders Elsevier. 4th edition.
  • Smeltzer, S., Bare, B., Hinkle, J., Cheever, K. (2010). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Lippincott Williams & Wilkins. 12th edition
  • Other sources: http://www.surgeryencyclopedia.com/Ce-Fi/Endotracheal-Intubation.html#ixzz3Z9AVvcty
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Rina Malones is currently working as a critical care/acute stroke nurse. Besides from blogging, she's also studying International Health at University of the Philippines Open University.