Assisting the doctor to secure a patients airway is a quality critical role. In the hands of an experienced team most rapid sequence inductions (RSI) and intubations run smoothly and without snafu. But not always.
When an intubation goes pear-shaped, knowledge of difficult airway interventions, a calm temperament, and the ability to anticipate the doctors next move are critical.
Lets have a look at some of the competencies of a nurse performing the ‘airway’ role.
Mind you, this is a very fluid scenario, and the absolute best way to become proficient (and confident under fire) is to grab a mentor from your own unit and have them run through it with you repeatedly.
Plan.
I have spoken before about the importance of having an airway checklist to guide the team through this process.
Don’tthink you need a checklist for something you perform so often? Atul Gawande a surgeon who thinks of medicine as a “test of our ability to manage extreme complexity” tells the story:
Boeing’s long distance bomber, the B–17 Flying Fortress, which made possible the precision bombing of Germany from 1943 to 1945. But the plane nearly didn’t make it into mass production:
Its 1935 demonstration flight to US military chiefs ended in disaster when the air crew forgot to unlock the elevators on the tail. The huge four engine aircraft crashed and burned on take off killing both pilots, their undoubted skills and training unable to save them or the plane.
Here is a pdf copy of the checklist that I developed for our own department.. Take a look at it now to get an idea of the flow and the decision points that need to be made as well as other roles that need to be assigned.
Preparation.
PPE: Make sure you kit up with personal protective equipment (PPE) including impermeable gown, gloves, face-shield (not just goggles)1 and P95 mask2 This is the minimum kit for an airway nurse. Often many nurses will fall short of this dress standard….so it is up to you to role model its full use no?
Equipment: There are many mnemonics for helping you to remember the equipment to set up for RSI/intubation.
One I quite like is SOAP-ME:
- Suction: Yankauer suction device. Place under the pillow/mattress just to the right of the patients head, within easy reach of the doctor or yourself. Check that you have good suction strength.
- Oxygen delivered via a bag-valve-mask. Turn oxygen up to 15 Lpm. Check that the reservoir bag is full.
Follow departmental policy regarding the use of a bacterial filter between the bag and the mask. Most bag-valve-masks now come with some sort of PEEP valve attachment, check with doc to see if this will be required.
A word on masks. After successfully passing the tube you or the doctor will need to remove the mask from the bag-valve-mask resuscitator so it can be attached to the Endotracheal tube (usually via some form of connector that includes an end-tidal CO2 adaptor). Try not to let the mask go flying off into the resuscitation wilderness at this point – you may need it later. - Airway equipment This includes Endotracheal tube, naso & oropharangeal airways and difficult airway equipment. For us, our difficult airway algorithm includes the FastTrack and Cricothyroidotomy sets.
Also think airway insertion equipment: Laryngoscope, bougie, Glidescope, whatever your unit uses.
check you have the correct tube size.
inflate the cuff to check for leaks.
deflate and lubricate the cuff with KY jelly.
Video laryngoscopy these days we seem to be moving more towards using some type of video laryngoscope such the Glidescope. Some come with their own introducer stylet that should be lightly lubricated and slid down into the Endotracheal tube during preparation. - Pre-oxygenation and Positioning If the situation allows, you will want to pre-oxygenate your patient for at least3–4 minutes with high concentration/flow oxygen ( either via the BVM, or a well fitted non-rebreather mask). This will saturate all the haemoglobin and plasma with as much oxygen as possible.Once we paralyse the patient we want their saturation (Sao2) to have a slow leisurely slide down the oxygen-dissociation curve before they hit the desaturating precipice around 90%.
- Monitoring and Medications: Including SaO2, ETCO2, cardiac and blood pressure monitoring. Intubation drugs (That is a sedation/Induction agent and paralysing agents) as well as ACLS medications must be close at hand.
- ETCO2: to confirm correct tube placement (and also as a useful aid in verifying good depth/rate of chest compressions during CPR. An ETCO2 of 10 or more is good. If it suddenly increases towards normal values (35–45) good indicator of return of spontaneous circulation)
Showtime:
You will want to position yourself to the doctors right with all the intubation equipment within easy reach before you.
- As the induction drugs are being administered pick up the laryngoscope (make sure the blade is extended and light working) in your right hand. Hold it by the tip with the handle hanging down and the blade pointing at the patients feet. Hold it over the patients mid-line, just over their sternum so the doc can reach out and grab it in its ‘business position’.
Pretty much the same scenario if a video laryngoscope is being used. - As soon as the doctor takes the laryngoscope you will need to pick up the bougie ( some docs prefer it with ETT pre-threaded, other like to have the ETT slid down over the bougie once it has passed the cords) in your right hand. Again hold it over the patient in the same position, the curve of the tube pointing away from the doc.
Once they are visualising the patients cords, they will not want to look away to see where you are waving the tube around. Have it ready to go.
Your left hand should be ready to grab the suction from under the pillow/mattress should it be needed before the tube is passed.TIP: to help the doctor visualise the cords, you can hook your finger around the right corner of the patients mouth and stretch it outwards (increasing the size of the hole the doc is looking through). Make sure you ask beforehand if the doc is OK with this. Some will not want it.
If the doc is using the video laryngoscope you should hold the ETT with introducer by the top of the tube and in the same position (and skip to point 4). - Once the doc takes the bougie from you, pick up the ETT if it has not been pre-threaded. When he has passed the bougie through the patients vocal cords he will ask for it make sure the doc has hold of the bougie as you slide the ETT down over it.
Hold on the boogie should be maintained as the tube slides down. The doc will advance the tube until he is happy with its position (there is a mark on the tube that should just pass the cords to assist with this). - You will then need to pick up a 10ml syringe to inflate the cuff. Once the doc is happy with the position of the tube he will ask for the bougie to be removed and the ETT cuff to be inflated. Don’t worry about the cuff pressure too much right now (it will usually be a bit less than 10 mls), just inflate until ‘it feels snug’.
Later, listen to check you cannot hear any air leak on expiration. Once the tube has been secured you can check for correct cuff pressure ( 15 – 30 cmH2O) with a cuff manometer (Obtaining a correct cuff pressure is important. The pressure should be regularly recorded in the nursing documentation notes. Over inflated cuffs can cause injury or necrosis to the tracheal wall. If your department does not have a cuff manometer you should look at getting one). - Once the cuff has been inflated you will need to be swift. Make sure someone is holding the patients endotracheal tube securely. Attach the ETT connector + ETCO2 to the BVM and then attach this to the patients tube. Ventilate the patient with a few breaths and watch the monitor screen for a nice squarish ETCO2 waveform to confirm placement. At this point someone should be auscultating both lung fields to confirm equal air entry.
- The tube. The tube. Securing the ETT is your next priority. I have seen many different ways to do this, from commercially available devices to a piece of tape tied in a big bow. This is a topic deserving its own post, and I will cover it in more detail shortly.
The bottom line is you are the airway nurse and the tube security buck stops with you. Oh, and tying the tube is a 2-person job, -always have an assistant holding the ETT whilst you secure it.
That all sounds mega-confusing:
So just to recap the order of things to juggle.
Ready to go:
- R hand: laryngoscope.
- L hand suction.
Then.
- R hand bougie.
- Both hands: ETT over bougie (or if pre-threaded, hold bougie whilst doctor passes the tube).
- L hand pick up 10ml syringe.
- Both hands: cuff up.
- Both hands: bougie removed.
- Both hands: connector (and ETCO2 attachment) on.
- Both hands: Attach BVM and ventilate.
- Secure tube.
Of course being a good airway nurse you need to have your situational awareness turned up to eleven. Watch what is going on and anticipate what will be needed next. It will not always run to plan.
Support and augment the doctor performing the intubation. Remember, an intubation not going exactly to plan can quickly place the doc under some stress stress. Different docs will respond to this in different ways3 Be cool.
Finally. In summary: Use a checklist. Plan your work, then work your plan.
If the plan does not work, work *that* plan.
Finally Finally: Tips comments, corrections and additions from experienced airway nurses encouraged…..
- anyone who just wears goggles during a big trauma should take a moment to examine the face-shield of someone who is wearing one….ew, that stuff is all over your face and in your hair dude [↩]
- intubation is a very high procedure for producing aerosolised particles. The potential for transmission of infective disease is high. [↩]
- ie the best will become quiet, contemplative and systematic, others will get in a flap. Just like us. [↩]
I’m a former Anaesthetics Nurse and current
ICU Nurse.
Include in the plan somewhere to go: can’t get an ETT in- what next?
Standard LMA’s are a idea good to give everyone thinking space.
An appropriate size allows for BVM, which isn’t the definitive airway, but is good to
buy some time.
Remember to have someone doing ‘cricoid pressure’ (or Sellick Manouvre)
and able to provide BURP, both of which (done properly) can turn a
‘difficult airway’ easy (& vice versa).
Experienced airway persons do it all, but always have another nurse to back them up if it does get difficult.
Remember, if you genuinely get into trouble, most practitioners will accept
a calmly delivered word of suggestion of what might work next. Every time you think about it (after a failed attempt) go back with the BVM or LMA and give more O2.
I’m working in Anaesthetics as an “Airway -Nurse” during Inductions and your sheet is great, beginners in my department especially have problems with the fact, that they have too many hands to put things in and don’t really know to coordinate them in a difficult situation, which your sheet solves very good.
But:
1) Doctors , especially if not trained well or experienced tend to fuzz around giving the word “difficult” airway to the assisting nurse if they don’t see the vocal cords during their first try of intubation. I tend to ask them very directly and clearly, if I see them picking around with the laryngoscope, so you can get a second nurse preparing.
2) Once the word “difficult airway” has been given, the first thing I prepare is a bronchoscope with a tube over it as it is department policy. Many nurses and doctors have problems inserting the FASTTRACH LAMA and preparing it for use because they never hold it in their hands.
3) Nasal airways and nasal intubation are very good options, but in many cases they are blacked out in the list of options and I really don’t know why except for the fact, that many doctors are not well trained in placing nasal airways.
Anyway. Good Stuff !