Here is a review of the advantages and disadvantages of each artificial airway.

  Combitude LMA
Advantages
  • Easy to insert quickly.
  • Don’t have to worry about accidentally intubating esophagus; balloon prevents aspiration.
  • Easy to insert quickly.
  • Allows ETT intubation through it, while maintaining an open airway.
Disadvantages
  • Can only be used for a few hours.
  • Does not prevent aspiration.
  • Can only be used short term until another airway is established.
  Oropharyngeal Nasopharyngeal
Advantages
  • Prevents tongue from obstructing pharynx.
  • May prevent the need for intubation in patients who are temporarily unable to maintain their airway (i.e., drug overdose).
  • Same as oropharyngeal.
  • Tolerated by conscious patients with an intact gag reflex.
  • Can be left in place for a few days.
  • Provides route for sterile suctioning of airway.
Disadvantages
  • Causes conscious patients to gag, thus can only be used in unconscious patients with a diminished gag reflex.
  • Nares must be closely monitored for skin breakdown if used for a few days.
  Endotracheal Tube Tracheostomy
Advantages
  • Can be used for up to three weeks.
  • Provides route for sterile suctioning of airway.
  • Some emergency medications can be given via the ETT (“NAVEL”= Narcan, Atropine, Versed, Epinephrine, Lidocaine).
  • Can be inserted either nasally or orally (oral route generally preferred unless patient had jaw trauma or surgery).
  • Can be used long-term; up to years.
  • More comfortable for patient.
  • Allows speaking and eating if respiratory status is stable.
  • Patients can be taught how to care for their tracheostomy at home.
  • Stoma can be plugged, but kept patent if needed.
Disadvantages
  • Patients may need sedation and/or wrist restraints to prevent accidental removal.
  • Patients may feel like they’re breathing through a straw.
  • Patients not able to speak.
  • Requires surgical procedure to insert.
  • Long-term use can cause fistulas between trachea and skin, esophagus, or innominate artery.

Nursing Interventions Related to ETT Intubation

Endotracheal intubation is usually done under stressful conditions; the patient is either experiencing significant respiratory distress, or has already respiratory arrested. It’s helpful for you to know what your responsibilities are prior to the event occurring, in order to minimize stress and provide the best outcome for the patient. Your responsibilities differ based on the type of unit you work in. If you work in a critical care environment, are ACLS certified, and/or are part of a code team, you’ll have a large role in the intubation. If you work in the emergency department, you know that things often happen more quickly than in the rest of the hospital. You may not have time to prepare much, or the patient may arrive with a Combitube or ETT from the field. If you work in a different area from these, you’ll primarily be expected to gather equipment and medications, monitor the patient during the intubation, and document on the code record.

Prior to intubation, all necessary equipment and medications should be at the bedside.

Note: As nurses gain experience, they can often predict when a patient is going to need intubation and mechanical ventilation. They may gather the intubation equipment hours before the patient actually needs it and keep it near the room “to ward off evil spirits.” (Nurses can be a superstitious lot! Sometimes it actually works.) Nurses who have this ability, and who are assertive in notifying the physician, are a great asset in improving the patient’s outcome.

Of course, the first step in intubation is recognizing that the patient needs it and notifying the respiratory therapist and the staff member who intubates patients in your practice setting. This is usually an anesthesiologist, a Certified Registered Nurse Anesthetist (CRNA), a medical resident, or another physician. Prior to intubation, all necessary equipment and medications should be at the bedside. It saves time if you know who will be doing the intubation, and what their personal preferences are. Most hospitals have intubation trays or kits that are part of the code cart. The entire tray should be brought to the room, so that extra equipment is available. Murphy’s Law always prevails in these situations, and you’ll appreciate having back-up equipment! You should have a laryngoscope with both Macintosh (curved like a Macintosh apple) and Miller (straight like the i in Miller) blades. Make sure that the battery in the laryngoscope handle and the light bulbs in all of the blades are working.

Here’s a list of some of the other things you should have ready.

Equipment Medications Patient History

Various sizes of ETT tubes (6 to 8.5)

Sedative (i.e., Versed)

Medical history/reason for admit

Tape or device to secure ETT tube

Paralytic (i.e., succinylcholine)

Events leading to intubation

Bite block

Pain medication (i.e., morphine)

Vital signs

Sterile gloves

 

Breath sounds

Suction – sterile and Yankauer

 

Allergies

Saline

 

If on anticoagulants

Stethoscope

 

Labs (electrolytes, ABGs)

CO2 detector to confirm placement

 

Latest chest x-ray result

Cardiac monitor/pulse oximeter

 

Presence of dentures (remove them)

 

 

Last oral intake

If you have been caring for the patient, it’s vital that you know the history and the events leading up to the intubation. Here’s an important bit of trivia: succinylcholine (Anectine) is a depolarizing neuromuscular blocker that’s often used to paralyze the patient prior to intubating. However, the prolonged depolarization causes potassium to leave the muscle cells, raising the serum potassium level by 0.5-1.0 mEq/L. If your patient is already hyperkalemic, it’s important that this drug not be used. (A perfect example of why you should know your patient’s latest lab values.)

Anything you can do to prepare the room ahead of time is also helpful. This may include removing the head of the bed, pulling the bed away from the wall, removing extra equipment (such as unused orthopedic trapeze), and asking visitors to step out of the room.

While the physician is intubating the patient, you’ll be responsible for monitoring and documenting vital signs, administering medications, and preparing equipment. Sterile suction should be set up and ready for use as soon as the ETT is placed. Often, suctioning of mucus or aspirate is all that’s needed to restore spontaneous breathing after a respiratory arrest.

After intubation, you should have a stethoscope ready to listen for bilateral breath sounds. Many institutions also use CO2 detectors to confirm that the ETT is in the lungs, and not the esophagus. (However, this is not a foolproof method of confirmation, since it can detect CO2 in the esophagus of a patient who recently drank a carbonated beverage.) A chest x-ray is necessary to confirm the position of the ETT. There are centimeter markings along the length of the tube; the depth of the ETT in most adults should be between 20-22 centimeters. On the chest x-ray, the end of the ETT should be approximately two finger widths above the carina. You should have tape or an ETT holder ready to secure the tube, as well as wrist restraints for the patient, in order to prevent accidental removal of the tube.

Case Study

Remember Mr. Hill? We left him in the middle of a respiratory arrest, but fortunately, you and your coworker have been successfully manually ventilating (bagging) him until now. (You can bag this long in real life. Just don’t give the patient any long-acting paralytics!)

Joe, RN, CRNA arrives to intubate Mr. Hill. The RT arrives at the same time and takes over bagging. Mr. Hill’s cardiac rhythm has remained sinus tachycardia with a pulse. You realize that you’re the most experienced nurse in the room and that the other three nurses are looking at you, so you step in to assist Joe with the intubation.

Seven things that you should get ready:

1. Assemble laryngoscope handle and blade (ask Joe which blade he wants and make sure light bulb is working).
2. Ask Joe what size ETT he plans to use and have it ready (inflate/deflate balloon to check for leaks, but keep the tube sterile).
3. Have a sedative and paralytic at the bedside (i.e., Versed and succinylcholine-delegate someone to find out the patient’s last potassium).
4. Have tape ready for securing the ETT.
5. Have a stethoscope and CO2 detector ready for confirming placement.
6. Have sterile suction ready to use as soon as the ETT is inserted.
7. Delegate someone to monitor the cardiac monitor and pulse oximeter.

The intubation goes smoothly. Breath sounds are present bilaterally and the CO2 detector indicates the ETT is in the lungs.

A chest x-ray diagnostic test should also be done to confirm the position of the ETT.

Joe orders initial ventilator settings until the pulmonologist can be called, and the RT sets up the ventilator. Mr. Hill’s vital signs are stable, and he’s still sedated from the Versed given prior to intubation.

Alternative Methods of Communication for Patients with Artificial Airways

The ETT prevents speech because it passes through the vocal cords.

Patients who are mechanically ventilated are often heavily sedated to prevent them from "bucking" the ventilator or feeling discomfort while breathing through the ETT. (Remember that this has been compared to breathing through a straw.) However, some patients may be alert, especially during weaning when they must be able to follow commands. The ETT prevents speech because it passes through the vocal cords; this may increase anxiety if the patient thinks no one will know if he or she is having trouble breathing. Caregivers must enter the room (so the patient can see them) frequently to reassure the patient that he or she is being carefully monitored. Alternative means of communication should be used as well, to ensure the patient feels that his or her needs are being acknowledged and met.

Some patients may be able to mouth words well enough for caregivers to read their lips around the ETT. However, this takes great patience on the part of both the caregivers and the patient. Having the patient write notes and draw pictures is another option, but this also requires time and patience. The patient may have to use their nondominant hand because of IVs and arterial lines, they may not have their glasses on, or they may be positioned awkwardly in the bed, all of which result in illegible writing and frustration. Communication boards can be a terrific alternative. These are posters that usually have large-type letters and numbers on one side, and pictures of typical patient requests on the other side. The pictures include items such as medication, pain, nurse, doctor, family, call light, TV, reposition, and water. Some patients may be able to spell out words using the side with the letters. These boards are usually large enough to be seen without glasses, and they can be kept in the patient’s room for family to use. (The only problem is finding one on your unit when you need one. They seem to always be missing!)

Stable patients with a trach can have a capped, fenestrated trach tube inserted that allows speech. This tube has an opening in the posterior wall that allows the patient to breathe through the upper airway when the tube is capped. The cuff must be deflated to allow airflow around the tube, and the patient should be closely monitored for respiratory distress. A special valve can be attached to the tube instead of a cap (Passey-Muir or Montgomery valve), which allows the patient to inhale through the tracheostomy tube, but requires exhalation through the upper airway, enabling speech. There are also tracheostomy tubes that have speaking ports attached. Oxygen is delivered through a port above the inflated cuff, while occluding the speaking port with a finger causes airflow to move through the upper airway and vocal cords.