Stabilize the ETT
Nebulisation
Tracheobronchial Hygiene:
Placement of tube: Chest movement
Auscultation
Post intubation X-ray
Cuff pressure: If insufficient
- Leak - Displacement of the tube, Aspiration
- high pressure - Tracheal stenosis
Desired Pressure - 20-30cm water
Humidification Filling water & adjusting temperature
appropriately :
If inadequate: secretions would become thicker and
lead to tube block
Medication:
Besides specific therapautic drugs the
following basic drugs are to be given.
Sedatives & paralysing agents if needed.
Analgesics
Diuretics to reduce circulating fluid and volume
overload
Reduce Gastric Acid: H2 blockers
Should be done on PRN basis
Ascultate and assess
View the chest X-ray
Determine the need and for effective
suctioning
Hyperoxygenation & ventilation
ambu/normal
Keep strict vigil on the cardiac monitor
pulse oximeter during and soon
after suctioning
If necessary carry out effective chest physio
Monitoring:
Continuous and Periodic monitoring of
Vital parameters such as temperature,SpO
2
, Pulse,
BP,ECG pattern, breath rate etc.
Ventilator settings: All settings should be
recorded as per the doctors order
Sensorium
Intake and output
Level of comfort
Arterial blood gases twice daily
It is advisable to put all the
patients on bronchodilators on
regular basis.
Nebulise as per the doctors order
Colour, consistency, and amount of the
sputum / secretions with each suctioning
should be observed.
Fever and other parameters have to closely
observed for any other infection. (central line,
etc)
Try and maintain a SpO
2
of > 90% and PaO
2
of
60 90 mmHg with minimum possible FiO
2
to prevent O
2
toxicity.
Especially for COPD patients :
Maintain SpO
2
of 85 90% and PaO
2
of 55 70 mmHg.
Enteral nutrition to support the patients
metabolic needs and defend against
infection.
Avoid high carbohydrate diet during weaning.
NG tube if necessary relieves gastric
distension and prevents aspiration.
Very common in critically ill patients
Send stools for occult blood and gastric juice
for pH estimation
Auscultate bowel movements
Sedation and antacids adequately.
Never keep alarm system muted
Never ignore even when you know the cause
for the alarm and may not be fatal
Place the patient in low or semi Fowlers
position to improve comfort and facilitate
respiration.
If conscious, explain the environment,
procedures, co-operation expected etc.
Use verbal & non verbal methods
Use paper & pen if necessary
Provide calling bell if necessary
Reassurance and support the patient during
the period of anxiety, frustration and
hopelessness
Document patients emotional response and
any signs of psychosis
Include family in the care
Co-operation with medical and nursing
interventions
Certain breathing techniques
The patient to recognize the importance of
breathing techniques.
Frequent assessment of consciousness level,
adequate rest etc. are necessary.
Multiply the tracheal tubes inner diameter by 2.
Then use the next smallest size catheter.
Example: 6mm ETT: 6 x 2 = 12; next
smallest catheter is 10 French
Example: 8mm ETT: 6 x 2 = 16; next
smallest catheter is 14 French
Hypoxemia - #1 complication
give oxygen before and after
catheter size
if the catheter is too big, there will be little or no air
entrained
Time suction no more that 15 secs.
Tissue trauma
May be able to prevent it . . .
catheter selection?
intermittent vs. continuous
a delicate touch
vacuum adjustment
Complications and Hazards of Suctioning
Cardiac arrhythmias
Vagal stimulation will cause
bradycardia
Hypoxemia can cause
PVCs
tachycardia
If these occur
STOP procedure and give oxygen
The nurse should explain the procedure to
the patient and prepare suction. The
patient should be sitting up at least 45
degrees.
Prior to extubating, the patient should be
suctioned both via the ETT and orally.
All fasteners holding the ETT should be
loosened.
A sterile suction catheter should be
inserted into the ETT and withdrawn as
the tube is removed.
The ETT should be removed in a steady,
quick motion as the patient will likely
cough and gag.
The patient should be asked to cough and
speak. Quite often, the patients first
request is for water because of a dry, sore
throat. Generally, you can immediately
swab the patients mouth with an oral
swab dipped in water.
Humidified oxygen
Respiratory exercises
Assessment and monitoring
Prepare for intubation