Safe Care of the Intubated Patient
In this article, Dr Andy Higgs, Consultant in Anaesthesia and Intensive Care Medicine at Warrington Hospitals NHS Trust, discusses safe care for intubated patients and how to prevent airway complications developing.
What should we do to avoid losing the airway after intubation?
Any concerns should be discussed at shift handovers. Bed head signage describing any previous intubations can help with communication.
- Who intubated the patient?
- What equipment was used?
- How was intubation achieved?
- What was the view at laryngoscopy? Were there any difficulties in advancing the tracheal tube?
- What is the depth of the tracheal tube at the lips?
Share the strategy. Have a written plan to manage patients with difficult airways.
Continuous waveform capnography. Capnography is a standard of care in Critical Care areas and healthcare staff who work in these areas should be trained in it’s use. This infographic is very popular with many ICU nurses.
Equipment. Team members should be familiar with the equipment commonly used on their unit. Equipment should always be chosen with the most junior airway operator in mind.
Humidification. Earlier in the week you covered the importance of humidification in patients with tracheostomies. It is just as important in patients with tracheal airways, as normal, physiological warming and humidifying is bypassed.
Chest X-ray. A chest x-ray ensures that the tube is correctly positioned in the trachea and endobronchial intubation is identified and promptly corrected.
Patient Position. Nursing patients at least 30° head-up minimises airway oedema and occult aspiration of oro-pharyngeal secretions.
Securing the tracheal tube. Tight tube ties which impair venous drainage should be avoided. Tube fixation devices are available but well-trained nurses are probably the best way to minimise inadvertent extubation.
Fluid management. Inflamed airways are exquisitely susceptible to tissue oedema, so be careful to avoid very positive fluid balances.
Vigilance. There is a risk of accidental loss of the airway during turning and any procedure near the airway. Prone positioning is unwise if the airway is difficult.
‘Cuff Leak’. Reports of a ‘cuff leak’ should always be presumed to be partial extubation until this is this has been excluded with laryngoscopy.
A flexible bronchoscope should be immediately accessible on the ICU for examination of the airway when there are concerns.