What to do when a patient starts vomiting during oral care while being intubated (intubation)?

From the Guidelines

If a patient who is intubated begins to vomit during oral care, immediately stop the procedure and position the patient's head to the side if possible to allow drainage of vomitus away from the airway. This is based on the most recent and highest quality study available, which emphasizes the importance of prompt action in managing difficult airway situations, including those involving vomiting during oral care in intubated patients 1.

Key Steps to Take:

• Suction the oropharynx promptly using a Yankauer or similar suction device to remove the vomitus and prevent aspiration.
• Check the endotracheal tube cuff pressure to ensure it remains properly inflated, as this helps protect the airway.
• Notify the healthcare team immediately, particularly the respiratory therapist and physician.
• After the episode resolves, assess the patient for any signs of aspiration such as decreased oxygen saturation, abnormal breath sounds, or respiratory distress.
• Document the incident, including the patient's response and interventions performed. The risk of aspiration and subsequent complications like aspiration pneumonia or respiratory compromise is significant, even with an endotracheal tube in place, especially if the cuff is not properly inflated or if the tube becomes displaced during vomiting 1.

Considerations:

• The presence of blood, secretions, and vomitus in the airway can complicate both fiber-optic visualization and video-laryngoscopy, making management more challenging 1.
• Awake intubation techniques may not be suitable in all situations, particularly when there is a risk of aspiration or when the patient has significant glottic narrowing 1. Given the potential for serious complications, it is crucial to prioritize the patient's airway protection and take immediate action to prevent aspiration when vomiting occurs during oral care in an intubated patient.

From the Research

Patient Vomiting During Oral Care While Intubated

• If a patient starts to vomit while doing oral care but is intubated, it is essential to prioritize their safety and prevent aspiration.
• According to 2, oral care practices for intubated patients may vary, but suctioning the mouth before and after oral care is a common practice.
• In the event of vomiting, the nurse should immediately suction the patient's mouth and airway to prevent aspiration, as recommended by 3.
• The use of antiemetic medications, such as ondansetron or metoclopramide, may be considered to prevent further vomiting, as studied in 4.
• However, the primary focus should be on maintaining the patient's airway and preventing aspiration, rather than solely on managing nausea and vomiting.

Oral Care Practices for Intubated Patients

• Oral care is an essential nursing intervention for intubated patients to maintain patient comfort and prevent colonization of dental plaque by respiratory pathogens, as highlighted in 3.
• The frequency and method of oral care may vary, but most nurses report providing oral care at least twice daily using various methods and products, such as suction toothbrush, manual toothbrush, and foam swab, as reported in 3 and 5.
• The use of chlorhexidine gluconate oral rinse is a common practice, as preferred by 97.8% of nurses in 3.

Factors Influencing Oral Care in Intubated Patients

• The practice of oral care in intensive care settings remains inconsistent among intubated patients, and factors such as perceived behavioral control, attitude, knowledge, and available resources can influence nurses' behavior, as studied in 5.
• Continuing education programs and intensive care orientation programs tailored to the needs of nurses may be essential to promote the importance of oral care and improve patient outcomes, as suggested by 5.