Upper Airway Obstruction

An airway obstruction can be complete or partial. Complete is a medical emergency. Partial may occur as a result of aspiration of food or a foreign body, as well as laryngeal edema following extubation, laryngeal or tracheal stenosis, CNS depression, and allergic reactions. The typical symptoms of an airway obstruction are stridor, use of accessory muscles, suprasternal and intercostal retractions, wheezing, restlessness, tachycardia and cyanosis. The main interventions for an airway obstruction are Heimlick manuever, cricoidthyroidotomy, endotracheal intubation, and tracheostomy (Lewis et al, 2011). Assessment The initial assessment of objective and subjective data should include: Vital signs Oxygen saturation level Presence of spontaneous breathing Rate, depth, and effort of respirations Presence of grunting or wheezing Use of accessory muscles of respiration Symmetry of chest expansion Quality of the voice, such as hoarse, raspy, weak, muffled, normal, or nonexistent Stridor or any type of noisy breathing Patient complaint of not getting enough air. The patients orientation, mental status, and general appearance should be monitored on an ongoing basis, because the patient may be cooperative and able to answer questions properly initially, but as the obstruction increases the patient may begin to appear anxious and agitated or confused (Lewis et al, 2011). Assessment also should include the patients ability to handle oral secretions, and the whether the patient is having pain with speaking or swallowing. Any frequent drooling or productive coughing to clear the airway should be noted. Drooling is an ominous sign that signifies an inability to swallow oral secretions, indicating near complete obstruction. It is essential to determine how long it has been since the patient has noticed voice or respiratory changes. Symptoms that have developed over a period of days may indicate a slower progressing airway problem (Sommers, 2011). Hoarseness and early respiratory distress are signs that must not be overlooked or discounted on initial exam. Patients with blunt neck trauma should be carefully assessed for hoarseness, respiratory distress, hemoptysis (bloody sputum), and dysphagia because these symptoms indicate airway injury and respiratory compromise (Lewis et al, 2011). Planning A patient with complete airway obstruction usually appears very anxious, agitated, and apprehensive, and progresses quickly to cyanosis and respiratory arrest. The chest wall may be moving in and out as the individual tries to breathe, but there will be no air exchange. As the patient becomes more hypoxic, agitation, combativeness, and loss of consciousness may result. There is no cough and the patient will be cyanotic and unable to speak. If the patient is unable to speak, a Heimlich maneuver should be performed in case the obstruction is from a foreign object

or food. Supplies should be kept at the bedside for creating an immediate artificial airway, such as tracheostomy insertion, cricothyroidotomy, or endotracheal intubation equipment. Resuscitation equipment should be brought to the bedside in case there is a subsequent cardiac arrest (Lewis et al, 2011). Outcomes and Evaluation Parameters The outcome is relief of the obstruction and return of normal oxygenation. Evaluation parameters include an alert oriented patient who has normal oxygen saturation levels, respiratory rate and depth, and vital signs. It is necessary to continuously monitor vital signs and pulse oxygen saturations. It is the overall assessment of respiratory effort, stridor, body positioning, restlessness, agitation, cyanosis, and decreasing level of consciousness that will provide the true picture of how the patient is doing (LWW, 2011). A. Tracheostomy A tracheotomy is a surgical incision into the trachea for the purpose of establishing an airway. Now, the stoma (opening) that results from the tracheotomy is a tracheostomy. Usually the indications for a tracheostomy are for a bypass of an upper airway obstruction, facilitate removal of secretions, permit long term mechanical ventilation, and permit oral intake and speech in the patient who requires long term mechanical ventilation. Tracheostomys can either a standard surgical tracheostomy, usually performed in the OR under general anesthesia, or percutaneous tracheostomy, which is performed at the bedside in emergency situations under local anesthesia and some sedation/analgesia (Lewis et al, 2011).

(Regan & Dallachiesa, 2009)

Nursing implications and considerations The tracheostomy incision is below the prominent thyroid cartilage (Adams apple) and below the cricoid cartilage, usually between the second and third, or third and fourth tracheal cartilages, and continues on through the anterior tracheal wall. It is initially sutured into place to prevent inadvertent dislodgement. In addition, ties are placed through the faceplate of the tracheostomy tube and around the neck to further secure the tube. The tube remains sutured in place until the tract from the anterior neck into the trachea becomes well established. A post-tracheostomy tray must be kept at the bedside or on the nursing unit; in it should be tools and instruments to help with reinsertion in the event of early accidental decannulation or early tube obstruction. The advantages of a tracheostomy are fewer risks of long term damage to the airway compared with an endotracheal tube, patient comfort may be increased because no tube is present in the mouth, and the patient can eat with a tracheostomy because the tube enters the lower airway. Additionally, a tracheostomy tube is more secure and the patients mobility is increased (Regan & Dallachiesa, 2009). Nursing suctioning tips and precautions: Regardless of the type of tube used, suctioning always involves: assessment, oxygenation management, use of correct suction pressure, liquefying secretions, using the proper-size suction, catheter and insertion distance, appropriate patient positioning, and evaluation (Nance-Floyd, 2011). Suctioning can be an uncomfortable and scary experience for the patient, so thoroughly explain the procedure to him before you start. Maintain aseptic technique while suctioning. Indications for suctioning include coughing or intent to cough, secretions in the airway, respiratory distress, presence of rhonchi on auscultation, increased peak airway pressures on the ventilator, and decreasing SaO2 or PaO2. Suctioning raises the risk of hypoxemia, bronchospasm, and other adverse reactions, so suction only when needed, suctioning for the shortest time necessary to clear secretions (Lewis et al, 2011). Other complications associated with suctioning include atelectasis, dysrhythmias (including bradycardia), increased intracranial pressure, and airway trauma (NanceFloyd, 2011). Bradycardia is attributed to vagal nerve stimulation. Atelectasis may occur when the outer diameter of the suction catheter is greater than one-half of the inner diameter of the tracheostomy tube, which can prevent airflow around the catheter. Choosing a catheter that is the right size can help prevent greater negative pressures in the airway and potentially minimize falls in PaO2. To help prevent hypoxemia, the patient must be hyperoxygenated before and after suctioning. As you suction, look for signs of hypoxemia, such as hypertension, dysrhythmias, and a drop in SpO2 by pulse oximetry. If this occurs, stop suctioning and hyperoxygenate the patient. Limit the duration of each suction pass to 5 to 10 seconds or less, and make only 1 or 2 passes (Nance-Floyd, 2011). Before suctioning, hyperoxygenate the patient. Ask a spontaneously breathing patient to take two to three deep breaths; then administer four to six compressions with a manual ventilator bag. With a ventilator patient, activate the hyperoxygenation button. Experts recommend using suction pressure of up to 120 mm Hg for open-system suctioning and

up to 160 mm Hg for closed-system suctioning. For each session, limit suctioning to a maximum of three catheter passes. During catheter extraction, suctioning can last up to 10 seconds; allow 20 to 30 seconds between passes (Nance-Floyd, 2011). Limit suction pressure to 120 mm Hg or less to minimize airway trauma. If the patient is on mechanical ventilation, allow time for the increased oxygen percentage to come through the ventilator tubing and reach the patient. Ensuring patients are adequately hydrated can facilitate removal of respiratory secretions. When evaluating the patient after suctioning, assess and document physiologic and psychological responses to the procedure, including his vital signs, cardiac rhythm, oxygen saturation, amount and consistency of secretions, breath sounds, and the frequency of needed suctioning. Convey your findings verbally during nurse to- nurse shift report and to the interdisciplinary team during daily rounds (Nance-Floyd, 2011).

B. adventitious breath sounds There are three normal breath sounds: vesicular sounds, which are relatively soft, low pitched, gentle, rustling sounds, and are heard everywhere except in the major bronchi; bronchovesicular sounds, which are medium pitch and their intensity is heard over mainstream bronchi on either side of sternum and posterior between the scapulae; and bronchial sounds, which are louder and higher pitched, being similar to sound of air blowing through a hollow pipe (Lewis et al, 2011). Adventitious sounds are abnormal extra breath sounds; they include wheezes, stridor, crackles, ronchi, and pleural friction rub. Wheezing: musical, whistling sound 1. Usually more pronounced during expiration 2. From narrowed airways (bronchoconstriction, secretions)

(Ed4Nurses, 2012)

Interventions: bronchodilation, hydration, coughing Stridor: intense continuous monophonic wheezes 1. Heard loudest over extrathoracic airways (continuous musical or crowning sound of soft pitch; result of partial obstruction of larynx or trachea). 2. They tend to be accentuated during inspiration when extrathoracic airways collapse due to lower internal lumen pressure.

3. Often be heard without the aid of a stethoscope. 4. Careful auscultation can identify area of maximum intensity that is associated with the airway obstruction (typically either at the larynx or at the thoracic inlet). 5. Stridor is significant and indicates upper airway obstruction. Interventions: depends on the reason of stridor (i.e., airway obstruction, asthma) Rales: crackling sound 1. Heard at the end of inspiration 2. From collapsed or waterlogged alveoli 3. Fine crackles: beginning of fluid buildup / or atelectasis (of short duration, high-pitched, heard just before the end of inspiration. (it sounds like rolling hair just behind the ears). 4. Coarse crackles: greater volume of fluid buildup (of long duration, low-pitched, evident on inspiration. (it sounds like blowing through a straw under water).

(Ed4Nurses, 2012)

Interventions: manage fluids (budget volume resuscitation, diuretics); expectorate (turn & position, deep breathing, forced expiration, vibration & percussion) Rhonchi: bubbling 1. The sound will be heard throughout inspiration and expiration (continuous rumbling, snoring or rattling sounds; result of obstruction in large airways). 2. Louder than rales due to larger secretions 3. Results from air bubbling past secretions in the airways

(Ed4Nurses, 2012)

Interventions: deep breathing, coughing, hydration (encourage fluids, if no restriction), humidify air, mobilize (Ed4Nurses, 2012). Friction rub: creaking, leathery sound

1. End of inspiration and beginning of expiration (creaking or grating sound from roughened, inflamed pleura). 2. Caused by rubbing of inflamed pleural surfaces against lung tissue.

(Ed4Nurses, 2012)

Interventions: chest x-ray; anti-inflammatory medications (Ed4Nurses, 2012). c. allergic rhinitis. Allergic rhinitis is simply the reaction of the nasal mucosa to a specific antigen (antigen specific immunoglobulin E [IgE]). It can be intermittent (less than 4 days a week, or less than 4 weeks per year) or persisent (more than 4 days a week and for more than 4 weeks a year). Usually occur in the spring and fall and caused by allergy to pollen from trees, flowers or grasses. What occurs is that after exposure, mast cells and basophils release histamine, prostaglandins and leukotrienes, which cause the early symptoms of sneezing, itching, rhinorrhea, and moderate congestion. Two to four hours after exposure, there is an infiltration of inflammatory cells into the nasal tissue causing and maintaining the inflammatory response. Then, the clinical manifestations of allergic rhinitis are sneezing, watery itchy eyes, and nose, altered sense of smell, and thin watery nasal discharge that can lead to a more sustained nasal congestion. In chronic exposure headache, congestion, pressure, nasal polyps, and postnasal drip are common cause of cough. Snoring may be also present due to congestion (Lewis et al, 2011). Basically, the main nursing considerations for patients with allergic rhinitis are to identify and avoid the triggers, and provide medication therapy as prescribed. The medication treatment may include nasal spray corticosteroids, nasal spray mast cell stabilizer, leukotriene receptor antagonists (LTRAs) and inhibitors, anticholinergic nasal sprays, antihistamines first generation and second generation, decongestants oral and topical (LWW, 2012). Assessment The examination and history of the patient reveal sneezing, often in paroxysms; thin and watery nasal discharge; itching eyes and nose; lacrimation; and occasionally headache. The health history includes a personal or family history of allergy. The allergy assessment identifies the nature of antigens, seasonal changes in symptoms, and medication history. The nurse also obtains subjective data about how the patient feels just before symptoms become obvious, such as the occurrence of pruritus, breathing problems, and tingling sensations. In addition to these

symptoms, hoarseness, wheezing, hives, rash, erythema, and edema are noted. Any relationship between emotional problems or stress and the triggering of allergy symptoms is assessed. Nursing Diagnoses Based on the assessment data, the patients major nursing diagnoses may include the following: Ineffective breathing pattern related to allergic reaction Deficient knowledge about allergy and the recommended modifications in lifestyle and self-care practices Ineffective individual coping due to chronic condition and need for environmental modifications (Ackley & Ladwig, 2011). Collaborative Problems/Potential Complications Based on assessment data, potential complications may include the following: Anaphylaxis Impaired breathing Non-adherence to the therapeutic regimen Planning and Goals The goals for the patient may include restoration of normal breathing pattern, increased knowledge about the causes and control of allergic symptoms, improved coping with alterations and modifications, and absence of complications. General Nursing Interventions Teach the client the proper use of saline nasal sprays by blowing his nose first then administer the nasal medication. Assist the client when he or she is advised for immunotherapy. Administer antihistamines, decongestants and topical corticosteroids. Caution clients to avoid driving vehicles whenever he or she is on antihistamines or decongestants. Encourage a routine cleaning of the house, furnitures and equipments which may house dust and other pollens. There are second generation anti-histamines that are non-drowsing. These are appropriate for clients who cannot avoid working while the allergy is going on. Their work wont be interfered (Ackley & Ladwig, 2011). Improving Breathing Pattern The main interventions are to teach and assist the patient to modify the environment to reduce the severity of allergic symptoms or to prevent their occurrence. The patient should be instructed on reducing exposure to people with upper respiratory tract infections. If an upper respiratory infection occurs, the patient should be encouraged to take deep breaths and to cough frequently to ensure adequate gas exchange and prevent atelectasis. Also, the patient should be encouraged to seek medical attention, because the presence of allergy symptoms along with an upper respiratory tract infection may compromise adequate lung function. Adherence to medication schedules and other treatment regimens must be encouraged and reinforced (Sommers, 2011).

Ackley, B. J., and Ladwig, G. B. (2011). Nursing diagnosis handbook: An evidence-based guide to planning care (9th ed.). St. Louis, MO: Mosby Elsevier. Ed4Nurses. (2012). Breath sounds tutor: Adventitious sounds. Retrieved from http://www.ed4nurses.com/breathsnds.aspx Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., and Camera, I. M. (2011). Medical surgical nursing: Assessment and management of clinical problems (8th ed). St. Louis, MO: Elsevier Mosby LWW, (2012). Medical-Surgical Nursing made Incredibly Easy. (3rd ed.). Ambler, PA. Wolters Kluwer: Lippincott Williams & Wilkins Nance-Floyd, B. (2011). Tracheostomy care: An evidence-based guide to suctioning and dressing changes. Retrieved from http://www.americannursetoday.com/article.aspx?id=8022&fid=7986 Regan, E.N. and Dallachiesa, L. (2009). How to care for a patient with a tracheostomy. Retrieved from http://www.nursingcenter.com/prodev/ce_article.asp?tid=926654 Sommers, S. Marilyn. (2011). Diseases and disorders: A nursing therapeutics manual. (4th ed). Philadelphia, PA: Davis.