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Care of the Intubated Patient (Adult) (7.11-A)

Care of the Intubated Patient (Adult) (7.11-A) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Pulmonary

7.11-A

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
September 30,
2016

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 7.11A

Original
Revision

Page
1
of 10

Title: Care of the Intubated Patient (Adult)

I. PURPOSE

To provide guidance for the care of the intubated patient in order to support and
maintain an airway for patients with respiratory compromise and minimize the
complications of endotracheal (ET) intubation.

II. POLICY

A. The RN will ensure the endotracheal tube (ET) is secure and in proper position.
B. The RN will ensure adequate patency of the ET tube.
C. The RN will adhere to the ventilation associated events (VAE) Bundle.
D. The RN will continually assess and evaluate adequacy of ventilation.

NOTE: For pediatric and neonatal information, refer to UWHC Nursing Patient Care Policy
7.11P, Care of the Intubated Patient (Pediatric & Neonatal).

III. GENERAL PROCEDURE

A. The nurse will perform interventions to ensure safety for the intubated patient.
1. The ET tube will be secured tightly with twill tape or the manufacturer’s
ET holder.
2. Oral hygiene will be performed on intubated patients every four (4) hours
and as needed, and will be recorded in the patient’s clinical record.
3. The ventilator setting will be checked and documented on the RT
Ventilator Flowsheet in the patient’s clinical record by the respiratory
therapist and validated by the RN at least once each shift.
4. Ventilator settings are adjusted only by respiratory therapists with the
exception of the RN who can make adjustments to the FiO2 for
suctioning.
5. Bronchoscopes on intubated patients will be assisted by respiratory
therapy.
6. A call light and/or communication tool will be readily available for all
patients capable of using them.
7. A resuscitation bag, connected to an oxygen flow meter will be at the
bedside of all intubated patients.
B. The nurse will maintain the ET tube is secure and in proper position.
1. Check clinical record to determine the documented position of the ET tube
(use centimeter markings on tube).


Page 2 of 10

a. The tube’s position should be recorded in the clinical record after
confirmation of correct tube position is verified by chest x-ray. If
there are any changes from the recorded position, the tube is
inadequately secured and should be re-secured.
b. Position of the ET tube is marked with a piece of 0.5 cm white
adhesive tape near insertion site unless contraindicated by
commercial device.
2. Assess position and security of tube and skin condition at points of
contact, at least every 12 hours or more frequently if redness or
breakdown is noted.
a. The security of the ET tube can be threatened if adhesion is lost
between tape and tube or tube holder and skin, or in agitated
patients.
b. Additional indications for re-securing the ET tube are skin or
mucus membrane breakdown, soiled tape or twill tape moist with
mucus secretions or perspiration.
c. Oral tubes should be secured near the midline so that lateral pull
from ventilator tubing does not lead to necrosis of the lips at the
corners of the mouth.
d. Repositioning the ET tube will help prevent lip and mucosal
pressure lesions. In addition, pressure points may be padded with
non-adherent foam dressing.
e. Reposition oral tubes to opposite side of the midline of lips every
24 hours or more frequently if redness or breakdown is noted.
When using a commercial ET tube, reposition tube with oral care.
f. Inspect ears for skin breakdown. Twill may be alternated daily,
with one side above and one side below the ear.
3. Securing or re-securing of the ET tube
NOTE: When securing or re-securing the ET tube, be careful to avoid
cutting the pilot balloon which will deflate the ET tube cuff. If this
happens, assess the patient’s tolerance and seek medical or anesthesia
assistance.
a. Equipment needed:
i. A duplicate tube will be available in case of airway
obstruction (see respiratory therapist note for size)
ii. Waterproof adhesive tape
iii. Adhesive remover pads
iv. 4x4 gauze pads
v. Stethoscope
vi. Cloth twill tape or commercial ET tube holder
vii. Non-adherent foam dressing (optional)
viii. Scissors (to cut twill tape)
ix. 10 mL syringe
x. Oral airway (optional)
b. Personnel:
i. Obtain assistance of a second RN or RT when re-taping or
repositioning the insertion depth of the ET tube.
ii. A physician or other person skilled in intubation should be


Page 3 of 10

available for any significant repositioning.
c. Process for MANUFACTURER’S DEVICE (preferred method
for adult patients except those without teeth/dentures, burn
patients and patients with facial hair):
i. Determine if patient is allergic to tape or has other allergies
(e.g., skin sensitivity to adhesive remover).
ii. Note the position of the ET tube prior to removal of
tape/holder.
iii. One person removes the old tape/ET tube holder while the
second person holds the ET tube.
iv. Remove all old adhesive tape from tube. If using adhesive
remover pads, wipe off residue with alcohol wipe and dry
tube with 4x4 gauze.
v. If repositioning the insertion depth of the ET tube is
needed, respiratory therapy should be assisting with the
retracting or advancing the ET position.
• Suction secretions from patient’s mouth and above ET
cuff.
• One person secures ET tube while the second person
deflates the pilot balloon.
• Advance or retract the ET tube according to physician
order.
• Inflate pilot balloon.
• Inspect for equal chest excursion. Auscultate lungs to
assess for symmetrical rise and fall and air movement
bilaterally. If the tube has been advanced into one
mainstem bronchus (usually the right), breath sounds
may be transmitted across the mediastinum to the other
lung.
• Assess pulse oximeter readings.
vi. Clean face and ET tube; dry tube completely.
vii. Place a 0.5 cm (1/2 inch) piece of adhesive tape around the
tube near the insertion site to mark tube position unless
contraindicated by commercial device. Do not tape over
pilot balloon.
viii. Reposition ET tube from side-to-side to prevent skin
breakdown in the patient’s mouth.
ix. Clean skin under old tape/holder if necessary. Secure ET
tube with manufacturer’s holder per manufacturer’s
instructions.. Do not change the position of the ET tube at
this point.
x. Inspect position and security of the tube.
• Auscultate both sides of the chest after re-taping.
• Inspect for equal chest excursion. Breath sounds and
chest excursion should be equal. If the tube has been
advanced into one mainstem bronchus (usually the
right), breath sounds may be transmitted across the
mediastinum to the other lung.


Page 4 of 10

• Assess pulse oximeter readings.
• In the event of unequal breath sounds or chest
excursion, notify physician.
xi. Document in the clinical record that tube was secured,
repositioned, new position in centimeters, whether or not
breath sounds are equal, and any other pertinent
information.
xii. Obtain chest x-ray as ordered.
xiii. Notify physician of any concerns with this process.
d. Instructions for use of TWILL TAPE (for adult patients without
teeth/dentures, burn patients and patients with facial hair):
i. Determine if patient is allergic to tape or has other allergies
(e.g., skin sensitivity to adhesive remover).
ii. Note the position of the ET tube prior to removal of
tape/holder.
iii. One person removes the old tape/ET tube holder while the
second person holds the ET tube.
iv. Remove all old adhesive tape from tube. If using adhesive
remover pads, wipe off residue with alcohol wipe and dry
tube with 4x4 gauze.
v. If repositioning of the insertion depth of the ET tube is
needed, respiratory therapy should assist with advancing or
retracting the ET tube.
• Suction secretions from patient’s mouth and above ET
cuff.
• One person secures ET tube while the second person
deflates the pilot balloon.
• Advance or retract the ET tube according to physician
order.
• Inflate pilot balloon.
• Inspect for equal chest excursion. Auscultate lungs to
assess for symmetrical rise and fall and air movement
bilaterally. If the tube has been advanced into one
mainstem bronchus (usually the right), breath sounds
may be transmitted across the mediastinum to the other
lung.
• Assess pulse oximeter readings.
vi. Clean face and ET tube; dry tube completely.
vii. Place a 0.5 cm (1/2 inch) piece of adhesive tape around
tube near the insertion site to mark tube position. Do not
tape over pilot balloon.
viii. Reposition ET tube from side-to-side to prevent skin
breakdown in the patient’s mouth.
ix. Clean skin under old tape/holder if necessary.
x. Using a length of twill tape in excess of head
circumference, tie and knot twill tape over the 0.5cm
adhesive tape on the tube. Do not tie pilot balloon into
knot.


Page 5 of 10

xi. Encircle head with the longer twill tape tail; knot the two
tails over right or left cheek.
xii. Twill tape can be positioned above or below the ears. If
positioned above the ears, pressure over patient’s ears can
be relieved by use of a tracheostomy tube holder above
each ear to lift away tape off ears.
xiii. Secure ET tube with twill tape. Do not change the position
of the ET tube at this point.
xiv. Use non-adherent foam dressing under the twill tape or
between manufacturer’s device (if allowed) to decrease risk
of skin breakdown.
4. An oral airway or “bite block” may be used to prevent a patient from
mechanically obstructing the airway. Check for skin breakdown every 12
hours. Use bite block only if necessary and discontinue as soon as airway
obstruction is no longer a threat.
C. The nurse will perform interventions to promote adequate oxygenation.
1. Anterior and/or posterior breath sounds will be assessed at least every four
(4) hours and as indicated by patient condition.
2. The exit point of the ET tube will be marked with tape and the position
documented on the flowsheet.
3. Suctioning will be performed only after assessment of need, not on a
routine basis.
4. When a cuff leak is audible, the nurse will notify the respiratory therapist.
5. After any ventilator changes, oxygenation and vital signs will be
reassessed.
6. Analgesia and sedation will be provided according to MD order consistent
with the patient’s needs and change of status. Frequent reassessment of a
patient’s sedation requirements and active tapering/discontinuation (daily
“wake up”) of the infusion can prevent prolonged sedative effect
according to UWHC Clinical Practice Guideline: Assessment and
Treatment of Pain, Agitation, and Delirium in the Mechanically Ventilated
Intensive Care Unit Patient – Adult – Inpatient.
7. Head of bed (HOB) should be 30 degrees if patient tolerates, condition
allows, or according to MD order.

IV. SUCTION PROCESS

A. Suctioning Equipment
1. Wall suction gauge and bottle or portable suction unit (from Central
Services [CS])
2. Connecting suction tubing
3. Closed in-line suction device
4. Sterile disposable suction kit(s) of appropriate size (comes with suction
catheter, sterile gloves, cup)
5. Clean gloves
6. Sterile normal saline for irrigation, 100 mL bottle
7. Pink saline "jet" (5 or 15 mL size)
8. Oxygen device


Page 6 of 10

9. Resuscitation bag
10. Personal protective equipment (PPE) (i.e., gloves, mask and goggles or
face shield, gown)
11. Suction catheter sizes for various ages in relation to size of ET tube (one
size larger and one size smaller should be allowed for individual
variations)
12. Suction catheters (double the ET internal diameter for suction catheter
size; if a larger catheter size is used it could occlude the airway/bronchus
causing massive atelectasis)
B. Assess respiratory status to determine whether patient requires suctioning.
Auscultate bilateral breath sounds.
1. Signs and symptoms indicating patient may require suctioning:
a. Restlessness, agitation, apprehension, frequent or sustained coughing
b. Dyspnea, tachypnea indicating increased work of breathing
c. Tachycardia, changes in vital signs
d. Moist, noisy, rattling respirations
e. Excessive secretions
f. Gurgling over large airways
g. High pressure alarm or high peak airway pressures alarm on
ventilator activated
h. Audible or visible secretion in the ET tube
i. Pulse oximeter desaturation
j. Bradycardia
k. Decreased tidal volume during pressure controlled ventilation
l. After chest physiotherapy to clear mobilized secretions
m. Changes in ventilator flow volume loop displays
n. Change in amount of chest wall oscillation for patients on high
frequency ventilation
2. Position patient. The ideal position is semi-Fowlers unless contraindicated.
Perform hand hygiene according to UWHC Hospital Administrative
Policy 13.08, Hand Hygiene.
3. Suctioning is occasionally used to stimulate the cough reflex in adults. If
suctioning precipitates severe bronchospasms, the nurse will discuss
appropriate pharmacological interventions with the physician and
respiratory therapist.
4. Amount, color and any other description will be documented in the
clinical record.
5. Routine, unnecessary suctioning is avoided to reduce irritation to the
mucosa and the potential for infection.
6. Sterile saline instillation should not be a routine part of suctioning. Saline
installation has an adverse effect on oxygenation and does not
significantly improve secretion removal.
B. Use of closed in-line device for ventilated patients (preferred):
1. Connecting tubing should remain attached to in-line device at all times.
Turn ON suction to 120 mmHg.
2. Using the mechanical ventilator, hyperoxygenate with 100 percent oxygen
for at least 30 seconds prior to suctioning. A manual resuscitation bag
(MRB) may be used for hyperoxygenation (second staff member required


Page 7 of 10

to bag). If MRB is used, five to six (5-6) breaths of 100 percent oxygen
should be delivered over 30 seconds.
3. Before suction is applied, quickly but gently advance catheter into
artificial airway until slight resistance felt (this will be the carina) or the
length of the ET tube is assessed. Assess length of ET tube prior to suction
to determine how far to pass the catheter, using a bedside measuring tape
as a reference. Suction just to the end of the ET tube. Apply suction using
button on device, and withdraw catheter back into plastic sleeve, over 10
seconds or less.
4. Procedure may be repeated two to three (2-3) times to clear airway. Allow
patient to rest for 30-60 seconds between suction passes.
5. Upon completion, suction catheter MUST be rinsed with the pink saline
"jet". Withdraw catheter back until the black mark is seen inside the
sleeve. Open cap on irrigation port and instill saline jet while depressing
suction button. When catheter is clear of secretions, turn and lock suction
button. Remove pink saline jet and cap off port.
6. Clean Yankauer (tonsil tip) with sterile water if it was used to remove oral
secretions. Place on clean paper towel if not covered, to protect from
contamination. If tonsil tips are used to suction oral or nasal passages then
they are considered to be a single use item.
7. The in-line suction will be maintained as a close circuit and changed by
RT daily.
C. Use of open system:
1. When using the open system, two (2) persons should suction; one to
suction and one to manually ventilate and support the patient.
2. Open suction kit; pour sterile irrigating saline into disposable cup; turn
ON suction device; pinch tube for 10 seconds to determine amount of
suction.
3. Average range of wall suction for adults is 80-120 mmHg.
4. Amount of suction is determined by type of secretions and size of tube.
Use as little suction as possible.
5. Open the sterile disposable suction kit. Put sterile gloves on. The
suctioning hand must remain sterile throughout procedure; the other glove
can be clean. Sterile technique is used to minimize introduction of
nosocomial pathogens.
6. Attach catheter to connecting tubing and check suctioning equipment by
suctioning a small amount of saline from cup.
a. Saline serves as a lubricant for catheter.
7. Suction is created by placing thumb of non-sterile hand over thumb port of
catheter. Remove thumb to discontinue suction.
a. If suctioning equipment doesn't work:
i. Validate that suction switch is turned ON.
ii. Make sure "bell" inside suction canister is down.
iii. Check for tight fit on vacuum bottle lid.
iv. Make sure tubing and catheter connections are tight.
v. Check for kinks in catheter/tubing.
vi. Check for patency of catheter/tubing. Rinse or change as needed.
8. Preoxygenate and hyperinflate patient as appropriate.


Page 8 of 10

a. Using the mechanical ventilator, hyperoxygenate with 100 percent
oxygen for at least 30 seconds prior to suctioning. An MRB may be
used for hyperoxygenation (second staff member required to bag). If
MRB is used, five to six (5-6) breaths of 100 percent oxygen should be
delivered over 30 seconds.
9. Insert the suction catheter and suction just to the end of the ET tube.
Apply suction using button on device, and withdraw catheter out of the ET
tube over 10 seconds or less, rotating catheter as it is withdrawn.
Procedure may be repeated two to three (2-3) times to clear airway. Allow
patient to rest for 30-60 seconds between suction passes.
10. Suggestions for discontinuing suctioning:
a. No more secretions in the large airways
b. If desaturation less than 80 percent
c. Arrhythmia or bradycardia
d. Patient develops extreme agitation, signs of respiratory distress,
anxiety or pain responses, acute pulmonary hemorrhage or pulmonary
edema
11. Preoxygenate and hyperinflate patient as appropriate and assess patient’s
tolerance and need to be suctioned again.
12. Clean Yankauer (tonsil tip) with sterile water if it was used to remove oral
secretion and place on clean paper towel if not covered, to prevent
contamination. If tonsil tips are used, they are a single use item and are
thrown away after each use.
13. Recruit maneuvers should not be performed routinely after ET suctioning.

V. UWHC CROSS REFERENCES

A. Appendix A, Bedside Suction Information Sheet (see Related section on U-
Connect)
B. Clinical Practice Guideline: Assessment and Treatment of Pain, Agitation, and
Delirium in the Mechanically Ventilated Intensive Care Unit Patient – Adult –
Inpatient
C. Prevention of Ventilator Associated Events (VAE)-Adult-Inpatient- Clinical
Practice Guideline
D. Hospital Administrative Policy 13.08, Hand Hygiene
E. Nursing Patient Care Policy 7.11P, Care of the Intubated Patient (Pediatric &
Neonatal)
F. Nursing Patient Care Policy 7.19A, Care of the Patient with a Tracheostomy Tube
(Adult)
G. Nursing Patient Care Policy 13.12A, Basic Care Standards (Inpatient Adult)
H. Respiratory Care Services Policy 1.40, Cleaning and Changing of Patient Care
Equipment
I. Respiratory Care Services Policy 1.55, Manual Resuscitation
J. Respiratory Care Services Policy 2.09, Guidelines for Administration of Invasive
& Noninvasive Respiratory Support in Nuclear Medicine Procedures
K. Respiratory Care Services Policy 3.20, Pulse Oximetry Check & Continuous
Monitoring (Includes Ambulating SPO2)



Page 9 of 10

L. Respiratory Care Services Policy 3.43, Placement, Care and Removal of
Endotracheal Tubes

VI. REFERENCES

A. AACN Practice Alert: Ventilator Associated Pneumonia (VAP). January 2008.
Retrieved from http://www.aacn.org/wd/practice/content/vap-practice-
alert.pcms?menu=practice.
B. Caroff, D.A., Muscedere, J., & Klompas, M. (2016) Subglottic secretion drainage
and objective outcomes: a systematic review and meta-analysis. Critical Care
Medicine, 44(4): 830-40.
C. Centers for Disease Control and Prevention (2004). Guidelines for Preventing
Health-Care Associated Pneumonia, 2003. MMWR, 53(RR03), 1-36. Retrieved
from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm.
D. Coffin, S. E., Klompas, M., Classen, D., Arias, K. M., & et al. (2008). Strategies
to prevent ventilator-associated pneumonia in acute care hospitals. Infection
Control and Hospital Epidemiology, 29(1), S31-39.
E. Cutler, L.R. & Sluman, P. (2014). Reducing ventilatory associated pneumonia in
adult patients through high standards of oral care: historical control study.
Intensive Critical Care Nurse. 30(2): 61-8.
F. Cooper, V. B., & Haut, C. (2013). Preventing ventilator-associated pneumonia in
children: an evidence-based protocol. Critical Care Nurse, 33(3), 21-29.
G. Fitch, Z.W. & Whitman, G.J.R. (2014). Incidence, risk and prevention of
ventilator-associated pneumonia in adult cardiac surgical patients: a systematic
review. Journal of Cardiac Surgery, 29:196-203.
H. John, R. E. (2004). Airway management. Critical Care Nurse, 24(2), 93-96.
I. Kollef, M. H. (2004). Prevention of hospital associated pneumonia and ventilator
associated pneumonia. Critical Care Medicine, 32, 1396-1405.
J. Lanken, P. N. (Ed.) (2001). The intensive care unit manual. Philadephia, PA:
W.B. Sauders.
K. Loughead, J. L., Brennan, R. A., DeJuilio, P., Camposeo, V., Wengert, J., &
Cooke, D. (2008). Reducing accidental extubation in neonates. Jt Comm J Qual
Patient Saf, 34(3), 164-70, 125.
L. Lynn-McHale Wiegand, D. J., & Carlson, K. K. (Eds.) (2005). AACN Procedure
Manual for Critical Care (6th Ed.). Philadelphia, PA: WB Saunders Co.
M. MacIntyre, N. R., & Branson, R. D. (2001). Mechanical Ventilation. Philadelphia,
PA: W.B. Saunders.
N. Noto, M.J., Domenico, H.J., Byrne, D.W., Talbot, T., Rice, T.W., Bernard, G.R.,
& Wheeler, A..P. (2015). Chlorhexidine bathing and healthcare associated
infections: a randomized clinical trial. JAMA, 313(4): 369-78
O. Villar, C.C., Pannuti, C.M., Nery, D.M., Morillo, C.M., Carmona, M.J. & Romito,
G.A. (2016). Effectiveness of intraoral chlorhexidine protocols in prevention of
ventilator-associated pneumonia: meta-analysis and systematic review.
Respiratory Care, published online.






Page 10 of 10

VII. REVIEWED BY

Clinical Nurse Specialist, Cardiac Surgery and Cardiopulmonary Transplant
Clinical Nurse Specialist, Trauma Life Support Center (TLC)
Director, Respiratory Care Services
Nursing Patient Care Policy and Procedure Committee, September 2016

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer