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Emergency Management of

Upper Airway Obstruction


by Ma. Veronica C. Doceo, MAN, RN

Adequate ventilation is dependent on free


movement of air through the upper &
lower airways.
In many disorder the airway becomes
narrowed or blocked as a result of
disease, bronco constriction, foreign body
secretions

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Causes:
Food particles
Vomitus
Blood clots
Other particles that enters & obstruct the
larynx & trachea
Patient w/ altered LOC (loss of protective
reflexes)

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ORAL AIRWAYS
Are stiff plastic tubes inserted into the
patients mouth to prevent the tongue from
sliding back into the pharynx and blocking
the airway.

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Functions of ORAL AIRWAYS


1. Maintain an open airway in patients who
have had anesthesia or have altered
mental status.
2. Maintain an open airway in patients
having seizure activity.
3. Maintain an open airway in the patient
needing support by a bag-valve-mask
apparatus.
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4. Used to prevent the patient who is orally


intubated from biting the endotracheal
tube.
NOTE: it is important that the oral airway
be inserted properly to prevent pushing
the tongue back and blocking the airway.

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Nursing Responsibilities
Choose the proper size for the patient
(measures from the corner of the patients
mouth to the tip of the earlobe).
Explains the procedure to the patient or to
the relatives.
Suction equipment available at bedside.
Check the patency
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Monitor the respiratory status of the


patient.
Maintain proper head alignment and
position

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NASAL AIRWAYS
-referred to as nasal trumpets
- are soft, flexible tubes that are inserted
into the nasal passage to maintain an
open airway
-commonly used for patients who require
frequent nasotracheal suctioning.

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Nursing responsibilities
Choose the appropriate size for the
patient-measure the oral airway from the
nares to the tip of the earlobe and then
adding 1 inch.
Nasal airway should be lubricated with
water soluble lubricant.
Explain the procedure

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Assess patency and monitor for


complications
Bleeding
Patient may be at risk for sinusitis

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ENDOTRACHEAL TUBE (ETT)


-Refers to the passage of a tube into the
trachea through either the mouth or nares
to maintain an open airway.
Has an inflated balloon on the end to help
aid ventilation of the patient.
Adaptor on the opposite end is designed
to fit an ambo-bag-valve device for
ventilatory assistance or to attach it to a
mechanical ventilator.
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Equipments:
Crash cart
Suction equipment with tonsil tip suction
catheter.
ETT tray should include;
Laryngeal scope (curved/straight)
ETT
lubricant

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Stylet
Syringe for balloon inflation
Oral airway
Magill forceps
Personal protective eyewear & gloves
Tape

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Nursing Responsibilities
ETT is lubricated and stylet is placed in
center of the tube to ease insertion.
Check patency by auscultation
CXR after the procedure to verify
appropriate placement.
Secures tube with tape.
Document the centimeter marking at the
lip of the patient to monitor for tube
movement
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TRACHEOSTOMY
Is placed by surgical incision in the
trachea, either in the operating room or in
the bedside.
Is placed and is secured by sutures.
Is required for all patients who require
long-term ventilator support

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1.
2.
3.
4.
5.

Vocal folds
Thyroid cartilage
Cricoid cartilage
Tracheal ring
Balloon cuff

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Current recommendations related to


tracheostomy placement and mechanical
ventilation include:

Patients who require high levels of


sedation to tolerate the artificial airway.
Patients with extremely weak respiratory
muscles.
Patients who might have psychological
benefit from eating and speech
Patients who may need more mobility to
compliment physical therapy.
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MECHANICAL VENTILATION
INDICATIONS FOR MECHANICAL
VENTILATION:
Decreased oxygen saturation or oxygen
deficit
Increased work of breathing and respiratory
rate with impending respiratory failure.
Apnea

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Ventilatory failure as evidenced by rising


PaCo2
Protection of airway with altered LOC
Worsening CXR

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Two types of Mechanical


Ventilation
Negative pressure ventilation- includes the
iron lung and does not require an artificial
airway.
Positive pressure ventilation- most
common type of ventilatory support.
Air is forced to the lungs via an artificial
airway, an ETT, or tracheostomy

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Negative Pressure Ventilation

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Common positive pressure


ventilator modes:
SIMV-synchronized intermittent mandatory
ventilation
CMV- continuous mandatory ventilation

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Continuous Mandatory
Ventilation (CMV)
Is a mode of ventilation that delivers a
minimum preset respiratory rate to a
patient
This mode is frequently used for patients
who have underlying chronic respiratory
problems and come into the ICU with an
acute exacerbation.

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Synchronized Intermittent
Mandatory Ventilation (SIMV)
Will deliver a preset tidal volume or
pressure for every preset breath.
This mode is frequently used for patients
being weaned from mechanical ventilation
or for patients who require short term
ventilatory support and have no underlying
lung disease.

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Pressure control Ventilation versus


Volume Control Ventilation
Pressure control ventilation- delivers
breaths at a preset target pressure.
This mode of ventilation is used when the
patients condition warrants close
monitoring of pressure.
Volume control ventilation-solves this
volume for gas exchange problem.

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Ventilator Settings
Patients who are being mechanically
ventilated have prescribed ventilator
settings that are adjusted according to
patient condition.
FiO2 may be set anywhere from 21-100
percent.
Tidal volume- is the amount of air
exchanged or delivered with each
inspiration and expiration.
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Mechanical Ventilation
Pressure-control versus volume-control
Ventilator settings
Fraction of inspired oxygen (FiO2)
Tidal volume (Vt)

Additional settings and modes


Positive end expiratory pressure (PEEP)

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Additional Ventilator Settings


and Modes
Positive end expiratory pressure (PEEP) is
an additional ventilator setting, which adds
pressure at the end of expiration on
ventilator breaths.
It helps to keep the alveoli open and
available to participate in gas exchange.

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Continuous Positive Airway


Pressure (CPAP)
Adds to the functional residual capacity in
patients who are spontaneously breathing.
May be delivered via mask or by a
ventilator.
Frequently used for patients who suffer
from sleep apnea.
Used to augment spontaneous breaths
that are taken during the weaning
process.
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Pressure Support Ventilation


(PSV)
Used to support the patients breath and to
help increase the patients tidal volume.
Often used as weaning mode to help the
patient overcome the dead space in the
ventilator circuit during spontaneous
inspiration.

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Inverse Ratio Ventilation


Is a comparison of the inspiratory and
expiratory times known as the I/E ratio
(inspiration to expiration ratio).

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Airway Pressure Release


Ventilation (APRV)
Unites two levels of CPAP pressures.
Helpful in preventing lung injury
associated with mechanical ventilation.
ADVANTAGES:
Lower airway pressures
Lower minute ventilation
Spontaneous breathing
Decreased need for sedation or
neuromuscular blockade
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Mandatory Minute Ventilation


(MMV)
This setting instructs the ventilator to
monitor the minute ventilation (Ve) and
deliver additional breaths when the patient
falls below the minimum minute ventilation
during spontaneous breaths

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Proportional Assist Ventilation


(PAV)
Is a mode that allows the ventilator to act
in response to the patients work of
breathing on a breath-by-breath basis.

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Complications of Intubation and


Mechanical Ventilation
1. Tracheal damage- occurs in cuffs that
have too much pressure or are in place for
long periods of time.
2. Unplanned extubation - accidentally pull
the ETT out when turning the patient or
adjusting the ventilator tubing.

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3.Ventilator-Associated Pneumonia (VAP)


common complication in the mechanically
ventilated patient and has a high mortality
rate.
4.Barotrauma- occurs due to excessive
Vts or elevated levels of PEEP or has
existing chronic lung conditions that cause
over distention of alveoli.
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5. Stress Ulcers- are also complications of


mechanical ventilation and often occur
within 72 hours of illness.
6. Communication- patient is intubated
and mechanically ventilated will be unable
to speak.

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7. Anxiety- commonly experience by


mechanically ventilated patients
8. Impaired nutrition- unable to eat eat
normally.

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Nursing Management of
Mechanically-Ventilated Patients
Indications for ventilator weaning
Resolution or marked improvement of illness
Adequate nutritional status
Normal electrolytes
Hemodynamically stable
Ventilatory muscle strength

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Nursing Management of
Mechanically-Ventilated Patients
Nursing care during weaning
Psychological support-should be provided
during the process of weaning
Education/information- the process should
be explained to the family and patient and
both should be kept informed of the
patient progress.

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Reduction of Sedation- sedation should be


decreased during the process of weaning
to prevent hypoventilation.
Respiratory assessment- patient should
be closely monitored for any evidence of
respiratory compromise during the
weaning trials.

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Protection of airway- RR, HR, BP should


always be monitored.

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Nursing Management of
Mechanically-Ventilated Patients
Withdrawal of life support
Patient request
Health care team
Ethics committee

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