Artificial Airways & Airway Management

Effective Cough Components Adequate vital capacity (VC > 15 mL/kg) Abdominal contraction Glottic closure

Phases of a Cough Irritation of airway Inspiration of adequate volume Compression Glottic closure Contraction of abdominal muscles Increase in intrathoracic pressure

Phases of a Cough Expulsion Opening of glottis Explosive expulsion of air and matter (flow up to 500 mph)

Ineffective Cough Inadequate vital capacity Inadequate compression Inadequate abdominal contraction Inability to close glottis

Suctioning Suctioning is the application of negative pressure to the airways through a collecting tube

Suctioning Suctioning of the trachea and bronchi is usually done through an endotracheal tube or tracheostomy tube

Indications for Suctioning Need to remove retained secretions Need to maintain patency of airway To treat atelectasis To obtain of a sputum specimen

Hazards of Suctioning Trauma Hypoxia Arrhythmias Inadequate cerebral oxygenation

Hazards of Suctioning Infection Vagal stimulation Atelectasis

Hazards of Suctioning Bronchospasm Increase in intracranial pressure Gag reflex stimulation

Equipment Required For Suctioning Oral suctioning Negative pressure source Suction canister Connective tubing

Equipment Required For Oral Suctioning Yankauer (tonsil tip) Suction tip Distilled water or saline solution in container Gloves

Equipment Required For Suctioning Nasal and tracheal suctioning Negative pressure source Suction canister Connective tubing Suction catheter

Nasal & Tracheal Suctioning Equipment Water soluble gel (for nasal suction) Distilled water or saline solution in container Gloves

Catheter Types Whistle tip Argyle Coudé Closed catheter systems

Suction Catheters Catheter sizes Murphy eye Measured in French (French/3.14 = size in mm) Diameter of catheter < ½ diameter of tube Murphy eye

Pressure During Suctioning Adult – -100 to -120 mmHg Child – -80 to -100 mmHg Infant – -60 to -80 mmHg

Suctioning Procedure Gather equipment, identify patient, introduce self, explain procedure, and wash hands Don gloves, prepare equipment

Suctioning Procedure Hyperoxygenate the patient, as appropriate If suctioning nasally, lubricate the catheter

Suctioning Procedure Introduce the catheter into the airway, ensuring that no suction is applied during introduction Advance the catheter until resistance is met

Suctioning Procedure Withdraw the catheter 1 to 2 cm Apply suction continuously, withdraw catheter, rotating catheter during withdrawal (NOTE: apply suction for a maximum of 15 seconds)

Suctioning Procedure Rinse the catheter in saline or distilled water Reassess the patient

Artificial Airways Oropharyngeal airway Used in unconscious patients only to avoid gag reflex Prevents tongue from occluding airway

Oropharyngeal Airway Allows passage of suction catheter through center or along the side of airway

Oropharyngeal Airway Insertion procedure Airway is upside down as it is inserted into mouth Rotate sideways as airway passes over tongue Place in correct position once past tongue

Artificial Airways Nasopharyngeal airway Used in conscious patients requiring frequent suctioning Length of airway equals length from nostril to ear plus one inch

Nasopharyngeal Airway Prevents tongue from occluding airway Change from naris to naris as required

Nasopharyngeal Insertion Procedure Lubricate airway with water soluble gel Examine nares; if available, choose nares with smaller opening

Nasopharyngeal Insertion Procedure Gently insert airway, avoiding forcing past obstructions Tip of airway should be visible just past uvula

Artificial Airways Endotracheal tubes

Endotracheal Tubes Specifications established by the American Society for Testing and Materials (ASTM)

Endotracheal Tube Marking I.T. – Implant tested I.D. – Inner diameter O.D. – Outer diameter

Endotracheal Tube Marking Z-79 – meets standards of that committee for non-toxicity Radiopaque line – determine position after placement Centimeter markings to indicate depth of placement

Endotracheal Tube Type Cuffed Uncuffed Double lumen Jet ventilation

Indications for Intubation Maintain airway patency Prevent aspiration Cardiopulmonary arrest

Indications for Intubation Establishment/maintenance of mechanical ventilation Bronchial hygiene

Physiologic Effects of Intubation Decrease in VD (approximately by ½) If tube is too small, may increase resistance and work of breathing

Equipment Needed for Intubation Suction equipment Laryngoscope Macintosh blade – curved Miller blade – straight

Equipment Needed for Intubation Stylet – only for oral intubation Magill forceps – only for nasotracheal intubation Oropharyngeal airway

Equipment Needed For Intubation Syringe Tape or other securing equipment Endotracheal tube – choice of sizes to meet unexpected conditions

Equipment Needed for Intubation Topical anesthetics (lidocaine, xylocaine) – may be required Paralyzing agents (Pavulon, succinylcholine) – for combative patients

Intubation Procedure Assemble and check all equipment Ensure patient is hyperoxygenated and hyperventilated, if possible Determine desired endotracheal tube size, lubricate with topical anesthetic, if required; insert stylet for oral intubation

Intubation Procedure Pre-oxygenate the patient Position patient in “sniffing” position, if possible Administer paralyzing agent, if required

Intubation Procedure Insert laryngoscope Visualize the vocal cords Insert endotracheal tube between vocal cords

Intubation Procedure Inflate the cuff Check breath sounds; adjust position of endotracheal tube as needed Note and record centimeter mark at the teeth

Intubation Procedure Secure the endotracheal tube Insert oropharyngeal airway Obtain chest X-ray to ensure proper tube placement Check cuff pressure

Intubation Hazards Intubation of the esophagus Trauma to the vocal cords or trachea Tracheal malacia, necrosis, T-E fistula Aspiration Fracture of teeth

Tracheostomy Tubes

Indications for Tracheotomy Long term ventilation Provide patent airway when upper airway is impassable

Hazards of Tracheotomy Trauma – laryngeal lesions, tracheal lesions Hemorrhage

Hazards of Tracheotomy Subcutaneous emphysema Infection Tracheal malacia, necrosis, T-E fistula

Types of Tracheostomy Tubes Portex / Shiley Jackson Kamen-Wilkensen Fenestrated

Care of The Tracheostomy Tube Performed as needed according to hospital protocol Assemble and check equipment Gloves and other protective gear Suction equipment Hydrogen peroxide

Care of The Tracheostomy Tube Assemble and check equipment Sterile water Cotton-tipped applicators Pre-cut gauze or 4 x 4 gauze pad Tracheostomy tube ties

Care of The Tracheostomy Tube Suction the patient Remove and clean the inner cannula Clean the stoma site

Care of The Tracheostomy Tube Change the tracheostomy tube ties Re-insert the inner cannula Assess the patient

Changing of The Tracheostomy Tube Performed as needed Perforated cuff Mucus plug Change in size of tube

Changing of The Tracheostomy Tube Assemble and check equipment Gloves and other protective gear New tracheostomy tube Suction equipment Tracheostomy tube ties Resuscitation bag

Changing of The Tracheostomy Tube Pre-oxygenate the patient Suction the patient Remove the tracheostomy tube

Changing of The Tracheostomy Tube Insert the new tube Secure the tracheostomy tube with the ties Assess the patient

Management of The Cuff Pressure should be kept between 20 and 25 mmHg

Management of The Cuff Techniques for maintaining cuff pressure Minimal occluding volume Minimal leak technique Direct measurement of cuff pressure by manometer

Alternative Airway Devices Laryngeal mask airway (LMA)

Laryngeal Mask Airway (LMA) Advantages Ease and speed of insertion Avoidance of laryngeal and tracheal trauma Intubation possible without removing LMA

Laryngeal Mask Airway (LMA) Disadvantages Short term use only Cannot provide high ventilation pressures Potential for esophageal injury Aspiration may still occur, although risk is decreased

Laryngeal Mask Airway (LMA) Placement Lubricate posterior surface of the mask Fully deflate cuff Using index finger, guide the insertion along the palate and into the oropharynx Inflate cuff to maximum of 60 cmH2O

LMA Placement

Alternative Airway Devices Combitube (Double lumen airway)

Combitube Advantages Little skill required for insertion Protects against aspiration Aids in positive pressure ventilation

Combitube Disadvantages Short term use only Aspiration may occur during removal If placed in esophageal position, cannot suction airway

Combitube Disadvantages Potential for esophageal injury Difficulty in distinguishing between esophageal and tracheal intubation

Combitube Placement Insert tube blindly through the oropharynx into the trachea or esophagus Inflate the cuffs

Combitube Placement Assess placement of the tube Ventilate through the appropriate external adapter

Combitube Placement

Alternative Airway Devices Tracheal buttons Used to maintain a tracheal stoma

Tracheal Buttons Advantages Removes the airway resistance of a tracheostomy tube Aids in the removal of secretions by allowing continued access when cap is removed Allows patient to communicate verbally, when able

Tracheal Buttons Disadvantages Will not allow attachment of mechanical ventilators Must be removed and replaced with tracheostomy tube in emergency situations

Tracheal Buttons Placement Fits through the skin to just inside the anterior wall of the trachea