 Hi and welcome to nursing school explained in this video on artificial airways. Now artificial airways can be by any means really the most common one that we see in the emergency setting is endotracheal intubation but it can also be if it's needed for longer care it can be a tracheostomy which is usually a surgically inserted airway or there can be intubation required through the nose through the other access between the nasal and the oral fairings and reason for nasal intubations would be for example trauma to the jaw where there's a lot of surgery required or some other injury to the jaw and mouth areas. So this video will mostly focus on endotracheal intubation and the procedure and then the nursing care related to it and I'll do my best to explain the devices to you so that you can kind of picture how this is done. So indications for intubation are usually any kind of upper airway obstruction apnea so a patient that is unable to breathe on their own when there's a high risk for aspiration when the patient is in respiratory distress and when there's ineffective clearance of secretions and so ineffective clearance of secretions can be anything that relates to the airway so lots of mucus but it can also relate to the stomach such as if the patient has projectile vomiting due to an upper GI bleed and they just keep vomiting and vomiting sometimes you really have to protect the airway and intubation is required and then respiratory distress really encompasses a wide variety of disorders this can be an acute asthma exacerbation this can be somebody with a severe pneumonia or maybe even from a car accident or anything like that. So let's look into the different artificial airways here. I'm kind of drawn out an endotracheal tube over here you can see in blue here this is the tube and it's usually not too long and it's usually inserted with a what's called a stylet because the tube itself is somewhat stiff but the stylet just helps the provider to guide it down and keep in mind you have to be trained in how to insert an endotracheal tube because it's a it's a highly skilled procedure and most of the times you'll see either doctors maybe specially trained nurse practitioners or physician assistants but also paramedics are able to insert artificial airways. So the tube typically there is a stylet and then at the end it has a balloon like a lot of other devices that you might know such as a catheter or maybe even a feeding tube a gastrostomy tube that will just kind of help to keep the tube in place once it's been inserted. Then there's also a little port here for the balloon to inflate the balloon to actually keep it there once it's inserted and then there's a subglottic suctioning a lot of the more newer endotracheal tubes come with a sub suctioning here which will allow you to suction right above this balloon because the patient will still have oral secretions that then fall down into the airway although the balloon is inflated on the bottom but if you need to check the balloon of it for some reason deflates then these secretions would drop down into the patient's airways or the lungs really and could cause some trouble there. So that subglottic suctioning port is a very nice invention that's just come out over the past 10 years or so that I've seen it. Now for the intubation procedure itself the complications that might occur is a chipped teeth because usually it's done with a laryndoscope again by a trained provider and it requires a certain amount of kind of leverage and to open up the airways so chipped teeth are always a possibility but that's why it's a specialized skill and these providers have to go through rigorous training to actually do that and then we always want to be cautious in patients with C-spine or cervical spine precautions. So again back to that example for somebody who has had a motor vehicle accident and we are not sure if they have injured their neck but they require an artificial airway we always need to be particularly aware of this and assist the provider that performs the intubation to best protect the patient's neck because usually we hyperextend the patient's neck so that the airway can be easier visualized by the person performing the intubation but if there's a concern for cervical spine injury we certainly can't do that and the patient will have some sort of a C-collar on and so we have to go with the jaw thrust maneuver rather than the head-tailed chin lift and if you haven't taken CPR in a while go ahead and redo that these two maneuvers and then the size of the in the tracheal tube will depend mostly on the patient's height and weight and again the provider performing the intubation will be selecting the equipment. Now a very important role in this whole procedure and really maintaining the artificial airways as well as the ventilators is our friends the respiratory therapists remember they go to school specifically and they're especially trained in these kind of airways and they are the experts on the mechanical ventilator so you really want to always have the respiratory therapist there with you when the procedure is occurring. Now certainly there can be circumstances where the respiratory therapist might not be available and then you and most likely another nurse will help the provider perform the procedure and go through all these steps it certainly can't be done without a respiratory therapist but certainly when they're there it's always much smoother and easier and so we collaborate with them very closely. So the equipment they define intubation certainly we need an in the tracheal tube we need a bag valve mask and the valves and the bags have a usually they have the mask attached if you would do rescue breathing for example or during CPR but then that mask just comes off and the tubing from the bag then hooks up to the in the tracheal tube once it's placed and then you can manually ventilate the patient. Certainly we will need oxygen and the bag valve mask again has that connecting system to the actual oxygen tank or the oxygen device on the wall. We will need suction to clear any secretions that might be in the way certainly we do want to have IV access and this most likely you'll want two different IV accesses with a fairly large gauge IV preferably an 18 gauge in the AC if you can get it. We will leave the ventilator because eventually the patient we're not going to continue bagging them we're going to need to place them on that machine to help them breathe and again our respiratory therapist will help us with that then we need an entire CO2 detector and I'll go a little bit more into what that is we'll need to remove dentures because they could get in the way and it's going to be much easier and then certainly we'll need medications again it depends on the patient care situation we'll definitely need sedatives and paralytics because we want to basically nullify that gag reflex that the patient has because most of the patient care scenarios the patient will still have a gag reflex and that certainly is counterproductive to intubation and passing that tube down the throat because the patient will be gagging and that will be very very uncomfortable so sedatives and paralytics are mandatory really and the selection of medications will depend on the provider and the patient's medical history and other circumstances then before the tube gets placed the patient gets pre-oxygenated with 100 or two for at least three to five minutes because the intubation itself if we are not ventilating the patient the patient doesn't get any oxygen so we want to give them a little bit of extra oxygen before the procedure and then each attempt hopefully the whoever is performing the procedure they will be able to get it on the first try but if multiple attempts are required we want to make sure that each attempt is less than 30 seconds so that again the patient doesn't become hypoxemic because now they might not be breathing at all and now we are not ventilating them because we're trying to get that artificial airway in and it's really our responsibility to hold the provider accountable to that 30 seconds to really support the patient and best care for our patient. Now let's look to the actual procedure like I mentioned before we want to put the patient in the sniffing position anything that will help to open up the patient's airway whether that's the head tilt chin lift maneuver or the jaw thrust that will kind of help us open the airway. Now once the tube's been placed we want to inflate the cuff here to hold the tube in place and again most likely that's done by the respiratory therapist then we want to place that famous end-tidal CO2 detector and this is a little device that again goes between the endotracheal tube and the back valve that you're going to ventilate the patient with and it is a nice visual to see if you're getting CO2 back or if you're not getting CO2 back and so if the color changes to gold that's good so gold is good but if it stays purple that usually means that the endotracheal tube is now in the esophagus and so now we're in the wrong spot and we need to pull that tube and re-intubate of course after we've taken some time to pre-opternate the patient beginning. Now once we think that the tube is in the correct place once the end-tidal CO2 detector turns golden then we want to auscultate over the epigastric area because if we would be in the esophagus which is still possible we would hear that kind of a gurgling sound with every BVM that we're providing for the patient just as you would with an NG tube because now we pump an air into their stomach and it's this loud gurgling sound so if we hear that then we automatically know that we're in the wrong spot then we need to re-do the procedure and certainly again if the end-tidal CO2 shows that it's golden it's good and we auscultate over the epigastric area we don't hear any gurgling sounds there certainly we'll need to observe for symmetrical movement of the chest wall because now that we know that we are in the correct airway just like we would observe the patient's breathing for symmetrical chest wall movement same thing if we breathe for the patient we need to make sure if we're in the trachea that we are now inflating and deflating both lungs and then we want to auscultate for bilateral breast sounds again for conformation and certainly check the patient's O2 set right because if the attempt has taken maybe more than 30 seconds the O2 set might drop so now we need to make sure that we provide the patient with the appropriate amount of oxygen so that their O2 set can come back up then we will place the patient on a ventilator in the game that's done by the respiratory therapists because they are the experts on that device and for definitive placement we want to snap a chest x-ray and while the chest x-ray will tell us the proper placement is usually two to six centimeters above the carina so let's look at this here so over here we have a picture of the trachea and then the right and left main stem bronca so this is the airways that go down from the trachea and the junction here is called the carina and so we want the tube to be about two to six centimeters above the carina to make sure the air gets in here and then distributed through both lungs now what can happen sometimes if the tube gets placed the right main stem broncus over here is a little bit more vertical than the left one so if the tube gets placed too far then it usually ends up in the right main stem broncus so now if we go through our confirmation here we would not see the we would not observe the symmetrical chest wall movement because now if we're in that right main stem then only the left lung gets aerated and we would also ascultate for bilateral breast sounds and not hear any breast sounds over the left side because now we're in that right main stem broncus and that's really what it's called it's called right main stem broncus intubation which is definitely not good so then once we have that chest x-ray right after intubation and after we've gone through all these other verifications then the reading will come back from the radiologist and they'll say okay let's pull the tube back two centimeters three centimeters whatever that might be then we'll pull the tube back out now we're now in the trachea and now both sides here get ventilated we also once this has been completed we want to mark the depth of the tube because now we want to know what's the ideal depth for this patient and just like most tubes the endotracheal tube will have markings on the tube so you can see what level of centimeters that you are and your marking either at the teeth or at the lips depending on the patient's mouth and teeth circumstances and this will get charted and then that will with the patient so that everybody knows where that endotracheal placement is supposed to be now after about 15 or 30 minutes after the intubation we want to take some arterial blood gases because now we want to see how the patient is doing and adjust the ventilator settings as needed and then certainly we will need continuous monitoring of O2 sat and entire CO2 to see how our patient's oxygenation and ventilation is doing now over here as for nursing care and I put here shared with the respiratory therapist because again they are our best friends when it comes to ventilators and artificial airways because that is their specialty but certainly we're always collaborating so first we need to maintain correct placement and that kind of goes along with the marking that I just talked about because remember this is going to be a patient that's going to the ICU so they're going to have sedatives they're going to have other medications on board and they will not be able to turn themselves so we will need to do all that for them so whenever a procedure is done or the patient is to simply transfer it for a gurney to a bed there is a chance that that ET tube might become dislodged or move out or move in a little bit too far so we need to make sure that we maintain that correct tool placement number two maintain proper cuff inflation again this is that cuff that balloon that we have at the end of the endotracheal tube that keeps it in place now if we inflate that with too much air it can cause a pressure ulcer inside the patient's airway which clearly we don't want that's not very good so checking the cuff on a daily or per the policy and procedures at the facility that you're working with will be very very important to again make sure that we protect the patient's airway another thing is that the endotracheal tube goes through the patient's vocal cords so we want to make sure that we don't exert too much pressure on those because that can be permanent damage if the ET tube is in place for too long we certainly want to monitor the patient's oxygenation and ventilation and so whenever we think about hypoxemia we always have to think of changes in mental status and although the patient might be sedated you might notice certain signs that the patient is now not getting enough oxygen so always be aware of those and check for any signs such as agitation or maybe they start to pull on the tool but they get a little bit more alert or they wake up but anything like that and then you will have to provide the proper medications to keep the patients sedated so that now they're able to breathe easier and that their oxygenation is in order and then for ventilation again we keep auscultating the lungs we keep checking the chest wall movement to make sure everything is in the correct place and then we have to make sure that the endotracheal tube remains patent that endotracheal tube is the patient's lifeline right it's their airway so if we don't have an airway we don't have anything according to our ABs and Cs so the endotracheal tube could become obstructed such as with secretions or vomit or or really anything else that can occur there so we need to suction the patient and so before we perform any kind of suction just like with the intubation we need to hyper-oxygenate the patient before the procedure and the max for suctioning is always 10 seconds and this is something that likes to come up on a on a test on an exam so you might want to take note of that and really the reason is because when we're suctioning the patient we're trying to remove the secretions but we're also suctioning oxygen out of the patient's lungs and so if we don't hyper-oxygenate them before then they might have signs and symptoms of hypoxemia like we just discussed and then oral and oral care and skin integrity are also very important the endotracheal tube is going to require the patient to have their mouth open so their mouth will dry out they are not they're unable to swallow the lips might get chapped and that endotracheal tube is usually on the side of the mouth so again when anything is in place for too long it can cause a pressure so then it's our responsibility to check around the tube and then maybe move it from one side of the mouth to the other to prevent these kind of injuries and also provide oral care and suctioning and that again comes back to not only oral suctioning but we also want to usually have a low suction low continuous suction hooked up to the subclotic port so that whatever secretions do drip down from the mouth into that patient's airway and end right there at the cuff that we want to make sure that we remove these as well and then certainly complications right again if we don't have an airway we don't have an endotracheal tube and the patient requires it then we have nothing if you don't have an airway you don't have anything so it's very important to maintain that but if an unplanned extubation occurs for whatever whatever happens we always need to make sure we stay with the patient we have a bvm at the back at the bed we provide the oxygenation certainly we want to call for help and then get the patient re-intubated as soon as possible and then another complication is aspiration sometimes no matter how much attention we pay to meticulous oral care and suctioning aspiration can happen so we need to make sure we again check lung sounds frequently check the patient's conditions perform the oral care with the subclotic suctioning and all these measures to prevent the aspiration and certainly another one that's real big here is to make sure that we keep the head of the bed elevated because again when the patient's flat maybe they have a gag reflex now or they're throwing up or they're getting feeding through an ng-tube or a g-tube when there's some regurgitation we don't want them to aspirate so keeping the bed elevated will definitely help with that and then here's a very nice acronym in case you notice that something is going on with your patient that is not normal if they're intubated so it's called the dope acronym so there's a quick way to remember all the things that could be going wrong with your patient who has an artificial airway so it could be D the slosh that the tube has come the slosh because the patient has been moved or maybe they're starting to wake up and they want to remove that tube maybe there's an obstruction so again we need to be careful to pay attention to the patient's secretions and suction them as needed P for normal thorax because the patient will be on an on an ventilator and a lot of times they will receive positive pressure ventilation which means that the machine pushes the air into the patient's lungs now if that is too much pressure or there are any other complications it could put too much pressure in that lung and then the alveoli will rupture causing a pneumothorax and certainly that's an emergency that we need to take care of and we would assess that by again listening to bilateral breath sounds and maybe find absent breath sounds over one side and then E is for equipment so equipment failure maybe our suctioning is not working correctly or maybe the ventilator has failed maybe the settings are not correct maybe the patient has come off the monitor and the O2 sap probe is no longer attached to them and we think it's an equipment failure or an emergency but it's really just that the sticker has come off so that's the other thing here for equipment so it's a very nice acronym to follow here to kind of problem solve if the patient has an artificial airway or is on a ventilator or both of those so if you haven't already done so please watch the video on mechanical ventilation where I go into explaining the different ventilator settings and a little bit more to this positive pressure that can cause this pneumothorax I also have videos on pneumothorax and hemothorax so I highly encourage you to watch these as well in my critical care playlist please like this video give me a thumbs up if you enjoyed it also check on Instagram at nursing school explain for any new videos that are being released and some study tips and I'll see you again soon right here on nursing school explain thanks for watching