Endotracheal Intubation

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Connecticut Children’s Medical Center - Policy and Procedure ManualProvision of Care, Treatment and Services Date Effective: August 10, 2011<strong>Endotracheal</strong> Tube Management Date of Origin: April 01, 1996Approved By: CCMC-UCHC NICU CollaborativeGroup, Clinical CouncilDate Approved: August 04, 20114.Unless the tapes need changing, loosen only the tapes securing the ETT (not thecord clamp).5.Advance or withdraw the ETT as ordered. Verify placement by comparingmeasurements of ETT. .6.Apply benzoin to the ETT and re-secure tapes.7.Assess the patient’s breath sounds. Placement should be confirmed by X-ray.C.Care of the Patient with an ETT1.All intubated patients are monitored with oxygen saturation and cardio-respiratorymonitors. Monitor for complications, such as pneumothorax or other air leak,atelectasis, pneumonia or malpositioned ETT.2.All ventilator settings shall be checked and documented hourly. Assess vital signsand respiratory status in accordance with Connecticut Children’s policy, unlessotherwise ordered(refer to unit specific policy). Monitor and document patientresponse to ventilator changes.3. Assess abdomen for distention when vital signs are performed.4.Placement of a nasogastric or orogastric tube may be indicated to relieve gastricdistention and assist ventilation.5.Institute supportive measures/positioning to promote comfort, respiratoryexcursion, and gas exchange.D.Suctioning with Closed Suction System1.See Closed Suction System policy.2.Note: Suctioning an ETT is performed as a sterile procedure (sterile suctioncatheter and sterile gloves).3.Suctioning is performed as needed for increased peak inspiratory pressures,adventitious breath sounds, increased work of breathing, decreased O 2saturations, etc, unless otherwise ordered,.4.Explain the procedure to the patient/family as appropriate.5.Generally, two caregivers (RN, RT, credentialed practitioner) should perform theprocedure to ensure safety and to maintain sterility of equipment. Hyperoxygenationbefore and in between suction passes may be indicated if the patientis known to have significant desaturations with ETT suctioning. May use manualbreaths from the ventilator, self inflating bag, anesthesia bag, or T-pieceresuscitator.6.Normal saline drops should only be instilled if the patient has thick, tenacioussecretions, and previous attempts to remove secretions without saline have beenunsuccessful. (Instillation of normal saline solution to facilitate secretion removal isnot evidence based.)7.Determine the proper catheter level for suctioning:a)Approximate the length of the ETT from the proximal adapter to the tip.Page 6 of 10
Connecticut Children’s Medical Center - Policy and Procedure ManualProvision of Care, Treatment and Services Date Effective: August 10, 2011<strong>Endotracheal</strong> Tube Management Date of Origin: April 01, 1996Approved By: CCMC-UCHC NICU CollaborativeGroup, Clinical CouncilDate Approved: August 04, 2011b)Correlate this length to a point on the suction catheter.c)Sterilely insert the suction catheter into the ETT ensuring that catheter does notreach more than 0.5-1 cm beyond this lengthd)Apply suction and hold while withdrawing the catheter in a quick, smooth motionfor no longer than 10 seconds per passE.Note: Closed Suctioning System allows the above procedure above (D.4a.throughDf.) to be performed without disconnecting the patient from the ventilator. The systemitself is sterile. Caregiver hands should be washed thoroughly before the procedure,but sterile gloves are not required.F.Determine the proper catheter level for suctioning:1.Ensure the tip of the Y adaptor touches a marked whole centimeter number on theETT (e.g., 18 cm on the ETT).2.Add 5.5 cm to the whole number in the previous step for the correct catheterlength (e.g., 18 cm + 5.5 cm = 23.5 cm) or match the number or color on thesuction catheter with the number on the ETT.3.Advance the catheter until the calculated number is aligned with the lavage port.4.Apply suction and hold while withdrawing the catheter in a quick, smooth motionfor no longer than 10-15 seconds per pass.5.Closely observe the patient’s oxygen saturation, heart rate, and color during theprocedure.6.Repeat the procedure only until the ETT has cleared of secretions. Avoidunnecessary repeated passes, since suctioning can cause damage to the trachealmucosa, and suctioning causes acute alveolar hypoxia which may result in anincrease in pulmonary vascular resistance.7.Observe and document color, character and volume of secretions.G.Patient Safety1.ETT position and security is confirmed at minimum every 4 hours. This is doneeither by visualizing ETT marking appearing at the patient’s lip, or measuring thedistance from the patient’s lip to the end of the ETT. Findings are compared tothose previously documented to determine whether the tube has migrated in orout. If a discrepancy is noticed, discuss plan with credentialed practitioner.2.If the credentialed practitioner orders that the tube be moved in or out, suctionoropharynx to remove pooled secretions, deflate cuff if present, and reinflate oncenew position is achieved. Secure as above, confirm placement, and documentprocedure and new measurement or marking.Page 7 of 10
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