Upper airway obstruction

It is one of the most serious emergency situation Early diagnosis and followed restoration of airflow is essential to prevent cardiac arrest or irreversible brain damage that occurs within minutes of complete airway obstruction

Causes Allergic reactions – bee stings, antibiotics or any cause obstruct airway Chemical burns Epiglottitis Foreign bodies Infections of the upper airway Injury to the upper airway Peritonsillar abscess Throat cancer Tarcheomalacia – weakening of the cartilage that supports trachea

Symptoms Agitation Cyanosis Changes in consciousness Chocking Confusion Difficulty breathing Gasping for air Panic Unconsciousness

Diagnostic measures Chest and neck radiographs Laryngoscopy Computed tomography Bronchoscopy

Interventions Medical interventions Invasive procedures Surgical interventions

Medical interventions Heimlich maneuver (suspected foreign body aspiration) Racemic epinephrine Helium oxygen mixture Corticosteroids

Heimlich maneuver For a conscious person who is sitting or standing, position behind the person and reach arms around his or her waist. Place fist, thumb side in, just above the person's umbilicus and grab the fist tightly with other hand. Pull fist abruptly inward and upward to increase airway pressure behind the obstructing object and force it from the windpipe.

Racemic epinephrine Action - bronchodilator Indications Partial UAO with still conscious and able to ventilate Laryngotracheobronchitis (croup) Epiglottitis, laryngeal edema It is administered by means of a nebulizer has been proven. Dose - .5 - .75 ml in 2 ml normal saline (aerosol)

Corticosteroids Reducing the airway edema Treatment of croup Ex- dexamethazone

Heliox Heliox, a helium oxygen gas mixture is effective in reducing the work of breathing by decreasing airway resistance. Post extubation laryngeal edema Tracheal stenosis Status asthmaticus oedema

Invasive procedures Oropharyngeal airways Endotracheal intubation

Artificial airway management Airway management indicated in patients with loss of consciousness, facial or oral trauma, aspiration, tumor, infection, copious respiratory secretion, respiratory distress and the need for mechanical ventilation.

Types of airways Oropharyngeal airway – curved plastic device inserted through the mouth and positioned in the posterior pharynx Usually a short term use in the unconscious patient Not used after oral surgery, or if loose teeth Does not protect against aspiration

Nasopharyngeal airway (nasal trumpet) – soft rubber or plastic tube inserted through nose into posterior pharynx Facilitates frequent nasopharyngeal suctioning Select size that is slightly smaller than diameter of nostril and slightly longer than distance from tip of nose to earlobe Check nasal mucosa for irritation or ulceration and clean airway with hydrogen peroxide and water.

laryngeal mask airway Composed of a tube with a cuffed mask like projection at the distal end Inserted through the mouth into the pharynx Seals the larynx and leaves distal opening of tube just above glottis Easier placement than ET tube because visualization of vocal cords is not necessary May cause laryngospasm and bronchospasm

Combitube double – lumen tube The distal tube enters the esophagus, where the cuff is inflated and ventilation is provided through the proximal tube, which opens at the level of the larynx In rare instance where the distal tube intubates the trachea, ventilation is provided through the distal tube while the proximal tube is clamped.

ENDOTRACHEAL TUBE Flexible tube inserted through the mouth and into the trachea beyond the vocal cords that acts as an artificial airway Maintains a patent airway Allows for deep tracheal suction and removal of secretions Permits mechanical ventilation Inflated balloon seals of trachea so aspiration from the GI tract cannot occur Generally easy to insert in an emergency, but maintaining placement is more difficult so this is not for long term use

Surgical interventions Tracheostomy Airway stenting

A Tracheostomy is a surgical opening in the anterior wall of the trachea to facilitate breathing. The tube enables airflow to enter the trachea and lungs directly, thus bypassing the pharynx and larynx.

Surgical techniques for the insertion of tracheostomy tubes There are differing surgical techniques for the insertion of Tracheostomy tubes Cricothyroidotomy- Cricothyroidotomy-is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening situations Percutaneous tracheostomy Tracheostomy

Percutaneous tracheostomy Percutaneous Tracheostomy is an alternative to surgical Tracheostomy and is performed using a guide wire and a process of gradual dilation of the trachea and surrounding tissue. A tracheostomy tube is then inserted between the first and second or the second and third tracheal rings.

Complication of Tracheostomy Immediate (Post Insertion) Haemorrhage (minor or severe) Surgical emphysema Delayed (Post Insertion) Tube blockage with secretions. May be sudden or gradual Infection of the stoma site and bronchial tree Tracheal ulceration and Tracheal necrosis Tracheo-oesophageal fistula formation Accidental decannulation, Haemorrhage (minor or severe) Late (Post Decannualtion) Tracheal dilation Tracheal stenosis at the cuff site Scar formation Tracheomalacia

Tracheostomy tube Firm, curved artificial airway inserted directly into the trachea at the level of the second or third tracheal ring through surgically made incision Permits mechanical ventilation and facilitates secretion removal Can be for long term use Bypasses upper airway defenses, increasing susceptibility to infection Allows the patient to eat and swallow

Tracheostomy tubes consist of three parts An outer cannula with flange (neck plate) – the outer cannula is the outer tube that holds the tracheostomy open. A neck plate extends from the sides of the outer tube and has holes to attach cloth ties or strap around the neck Inner cannula – it fits inside the outer cannula. It has a lock to keep it from being coughed out, and it is removed for cleaning An obturator – is use do insert a tracheostomy tube.

Types of Tracheostomy Tubes Single Lumen Tubes Double Lumen Tubes (inner cannula) Uncuffed Tubes or Cuffed Tubes Fenestrated Tubes Metal tracheostomy tubes

Cuffed tubes It is having cuff ,which is located on the lower part of outer cannula which seals and gives ventilation. Ventilator and other respiratory supportive devices can be attach to it The cuff blocks any air from flowing around the tube and assures that the patient is well oxygenated. All the air must therefore flow in and out through the tube itself. A pilot tube attached to the cuff stays outside the body and is used to inflate or deflate the cuff.

Fenestrated tube A fenestrated tube has an opening (fenestration) in the back of the outer cannula. The front of the tube can be blocked which allows the air to flow upwards to the upper part of the trachea and larynx. A fenestrated tube allows the patient to breathe normally and speak or cough through the mouth. A fenestrated trach tube is often used as the final step before trach tube removal. It permits the patient to speak and cough on their own, providing an experimental trial for life after the trach tube.

Cuffless tubes Cuffless tubes are primarily used in non-ventilated patients that have no difficulty swallowing and have no danger of aspiration. Since there is no cuff, it allows air to pass into the upper trachea and larynx so the patient can cough and speak normally. Cuffless tubes are usually worn over a long period of time so require a very accurate fit in order to prevent pressure sores in the trachea or at the tracheal stoma.

Single lumen and double lumen tracheostomy tubes

Metal tracheostomy tube Indication Recommendation Not used as frequently anymore.  Patients cannot get an MRI. One needs to notify the security personnel at the airport prior to metal detection screening.

Pressure monitoring

The Passy-Muir Valve and open valve Invented by a patient named David Muir, the Passy-Muir Tracheostomy & Ventilator Swallowing and Speaking Valve is a simple medical device used by tracheostomy and ventilator patients. The cuff has to be deflated while using valve When placed on the hub of the tracheostomy tube the Passy-Muir Valve redirects air flow through the vocal folds, mouth and nose enabling voice and improved communication.

Weaning from tracheostomy If the patient can adequately exchange air and expectorate secretions, the tracheosomy tube can be removed The stoma is covered with an occlusive dressing The dressing must be changed if soiled or wet Instruct the patient to splint the stoma with fingers while speaking, swallowing or speaking The opening will close in several days Surgical intervention to close the opening is not required

Nursing diagnosis Ineffective airway clearance related to presence of tracheostomy tube and difficulty expectorating sputum Interventions Auscultate breath sounds Remove secretions by suctioning to clear airway Encourage slow deep breathing, turning and coughing to assist in mobilizing secretions Position to alleviate dyspnea – head of the bed elevated 30-40 degree Provide 100 % humidified oxygen

Ineffective therapeutic regimen management related to lack of knowledge about care of tracheostomy at home Interventions Demonstrate skill for the patient Give clear, step by step instructions Provide written information Provide practice sessions Explain regarding disease condition and the management done – so the patient will get an overall idea for self care Instruct the patient to watch signs and symptoms and secretions

Impaired verbal communication related to use of cuffed artificial airway Interventions Listen attentively Use picture board Provide information to patient about condition Provide reassurance about patients condition to relive fear and frustration Provide information to patient regarding different types of tracheostomy tubes and speaking valve.

Risk for infection related to bypass of upper airway defense mechanisms and impaired skin integrity Interventions Monitor for systemic and localized signs and symptoms of infection Monitor complete blood count Maintain sterile technique when suctioning and providing Tracheostomy care Provide trachea care every 4 – 8 hours as appropriate – clean the inner cannula, clean and dry the area around the stoma and change tracheostomy ties. Inspect the area around the tube insertion site for redness and skin breakdown

Impaired swallowing related to tracheostomy tube Interventions Determine patients ability focus attention on learning/performing eating and swallowing tasks Deflate the cuff before swallowing Close the stoma site during swallowing Monitor body weight to determine need for enteral feedings to maintain nutrition