Care of Endotracheal tube patients

 CARE OF ENDOTRACHEAL TUBE

1. Description

• The endotracheal tube is used to maintain a patient airway. 
• Endotracheal tubes are indicated when the client needs mechanical ventilation. 
• If the client requires an artificial airway for longer than 10 to 14 days, a tracheostomy may be created to avoid mucosal and vocal cord damage that can be caused by the endotracheal tube.
• The cuff ( located at the distal end of the tube), when inflated, produces a seal between the trachea and the cuff to prevent aspiration and ensure delivery of a set tidal volume when mechanical ventilation is used; an inflated cuff also prevents air from passing to the vocal cords, nose,  or mouth. 
• The pilot balloon permits air to be inserted into the cuff, prevents air from escaping and is used as a guideline for determining the presence or absence of air in the cuff. 
• The universal adapter enables attachment of the tube to mechanical ventilation tubing or other type of oxygen delivery systems. 

Types of tubes: Orotracheal and Nasotracheal

Orotracheal tubes

• Allows use of a larger diameter tube and reduces the work of breathing. 
• Indicated when the client has a nasal obstruction or a predisposition to epistaxis. 
• Uncomfortable and can be manipulated by the tongue, causing airway obstruction, an oral airway may be needed to keep the client from biting on the tube. 

Nasotracheal tubes

• This smaller tube increases resistance and the client's work of breathing 
• Its use is avoided in clients with bleeding disorders.
• It is more comfortable for the clients, and the client is unable to manipulate the tube with tongue. 

INTERVENTION 

• Placement is confirmed by chest x-ray film    (correct placement is 1 to 2 cm above the carina).
• Assess placement by auscultating both sides of chest while manually ventilating with a resuscitation (Ambu) bag ( if breath sounds and chest wall movement are absent in the left side the tube may be in the right mainstem bronchus ).
• Perform auscultation over the stomach to rule out oesophagal intubation. 
• If the tube is in the stomach, louder breath sounds will be heard over the stomach than over the chest, and abdominal distension will be present. 
• Secure the tube adhesive tape immediately after intubation. 
• Monitor the position of the tube at the lip or nose.
• Suction the tube only when needed. 
• The oral tube needs to be moved to the opposite side of the mouth daily to prevent pressure and necrosis of the lip and mouth area,  prevent nerve damage, and facilitate inspection and cleaning of the mouth; moving the tube to the opposite side of the mouth should be done by two health worker providers.
• Prevent dislodgment and pulling or tugging on the tube; suction, coughing, and speaking attempts by the client place extra stress on the tube and can cause dislodgment
• Keep a resuscitation (AMBU) bag at the bedside at all times.
• Assess the pilot balloon to ensure that the cuff is inflated; maintain cuff inflation, which creates a seal and allows complete mechanical control of respiration. 
• Monitor cuff pressure at least 8 hours to ensure that they do not exceed 20 mm Hg; minimal leak and occlusive techniques are used for cuff inflation to check cuff pressure. 

Minimal leak technique 

• This is used for cuff inflation and checking cuff pressure for cuffs without pressure relief valves. 
• Inflate the cuff until a seal established; no harsh sound should be heard through a stethoscope placed over trachea when the client breathes in, but a slight air leak on peak inspiration is present and can be heard.
• The client cannot make verbal sounds, and no air is felt coming out of the client's mouth.

Occlusive technique

• For cuff inflation and checking cuff pressure for cuffs with pressure relief valves.
•  Provide an adequate seal in the trachea at the lowest possible cuff pressure. 
• Uses same procedure as minimal leak technique without an air leak.

Extubation 

• Hyperoxygenate the client and suction the endotracheal tube and oral cavity.
• Place the client in a semi Fowler's position. 
• Deflate the cuff, have the client inhale and, at peak inspiration, remove the tube, suctioning the airway through the tube while pulling it out.
• After removal, instruct the client to cough and deep-breathe to assist in removing accumulated secretions in the throat.
• Apply oxygen therapy, as prescribed. 
• Monitor for respiratory difficulty; contact the physician if respiratory difficulty occurs.