Airway Management Health Article

Preparation

Preparation for airway management includes explaining all procedures that will be performed to the patient. Often, patients who are receiving mechanical ventilation are kept sedated or even paralyzed to facilitate optimal ventilation. The level of sedation should be assessed. If patients are not receiving continuous infusions of a sedating drug, they may have a physician's order for sedation as needed. If they are agitated, they should be given the prescribed dose of sedation prior to performing any airway-related procedures, to ensure that the airway is not inadvertently removed.

Patients receiving mechanical ventilation also often have bilateral soft wrist restraints applied to prevent accidental removal of the artificial airway. It is recommended that these be securely fastened before starting an airway-related procedure, or that another healthcare professional be at the bedside to help calm and hold the patient. Also, all needed supplies should be at the bedside prior to starting a procedure, so as to not cause excess discomfort or stress for the patient.

Aftercare

After the procedure is finished, the patient should be reassured if necessary and their respiratory status should be reassessed. The insertion point of the airway should be confirmed to be at the same place as prior to the procedure, unless the purpose was to change the depth of the tube. If the airway has been manipulated since suctioning, the patient may require suctioning again. Any waste should be disposed of in the garbage or in a biohazard container if there is a large amount of blood. Prior to the healthcare professional leaving the room, the patient should be made comfortable, further sedation or pain medication should be administered as needed and the patient should be confirmed to be stable.

Complications

The greatest risk of airway management is that the airway may be inadvertently removed, causing the patient to have respiratory distress. Procedures that require manipulating the airway may cause fear or agitation for patients if they feel that they do not have control over their breathing. If the patient becomes combative, it can be very difficult to finish the procedure without disturbing the airway.

Results

The anticipated outcomes of airway management are a continuously open airway through which effective ventilation can take place, and prevention of infection.

Health care team roles

The nurse and respiratory therapist are equally responsible for monitoring and managing artificial airways. Both perform sterile suctioning and both document their assessment of the patient's respiratory status. The respiratory therapist is generally responsible for managing the ventilator, adding humidification, and changing ventilator tubing.

If the patient is accidentally extubated (the airway is removed), both the nurse and respiratory therapist must assist in reinsertion. This is usually done by an anesthesiologist, a certified registered nurse anesthetist (CRNA), a medical resident, or another physician. The respiratory therapist is generally responsible for ventilating the patient with a bag-valve-mask device until reintubation (reinsertion of the airway), while the nurse gathers equipment, administers medications, and monitors the patient's pulse oximetry, vital signs, and cardiac rhythm.

The nurse and respiratory therapist are also responsible for finding alternative means for the patient to communicate. Artificial airways are inserted through the vocal cords, making speaking impossible. The patient should be encouraged to try alternative methods such as mouthing words, writing, or pointing to letters, words, or pictures on a communication board. Communicating with these patients takes great patience and creativity, as well as dedication to helping them feel like their needs are being met.

KEY TERMS

Bag-valve-mask device—Device consisting of a manually compressible bag containing oxygen and a one-way valve and mask that fits over the mouth and nose of the patient.

Endotracheal tube—Tube inserted into the trachea via either the oral or nasal cavity for the purpose of providing a secure airway.

Hypoxemia—Abnormal deficiency of oxygen in the arterial blood.

Oxygen flow meter—Meter attached to a oxygen source that controls the amount of supplemental oxygen the patient receives.

Pulse oximeter—Noninvasive machine that measures the amount of hemoglobin that is saturated with oxygen.

Tracheostomy tube—Surgically created opening in the trachea for the purpose of providing a secure airway. This is used when the patient requires long-term ventilatory assistance.

Ventilator (mechanical ventilation)—Device used to provide assisted respiration and positive pressure breathing.

BOOKS

Norris, June, ed. Critical Care Skills: A Nurse's PhotoGuide. Springhouse: Springhouse Corporation, 1996.

Thelan, Lynne, et al. Critical Care Nursing: Diagnosis and Management. St. Louis, MO: Mosby, 1998.

PERIODICALS

Carroll, P. "Should Suctioning Be Left to the Nurse?" American Journal of Critical Care (March 2000):85-86.

Abby Wojahn, RN, BSN, CCRN