2. Managing the Artificial Airway RC 275

3. Tracheotomy/Tracheostomy When intubation can’t be done or the need for the airway is indefinitely long Traditional surgical incision or PDT (Percutaneous Dilatational Tracheotomy) PDT may not be as damaging to tracheal cartilage

4. RCP’s Role During the Procedure Monitor the patient! Maintain adequate ventilation and oxygenation Assist physician as needed

5. Try to leave the fresh trach undisturbed for 48 hours Suctioning obviously must be performed but as gently as possible

6. Complications Associated with ET and Trach Tubes Can be due to the insertion procedure or from having the tube in the airway

7. Intubation Complications Trauma to oral cavity, pharynx, and vocal cords Bleeding Laryngospasm Sub-Q Emphysema (from perforation of trachea) Improper tube placement Contamination/Infection

8. Tracheotomy Complications Bleeding (can be life-threatening) Pneumothorax Sub-Q Emphysema Contamination/Infection

9. Complications due to irritation from the tube and cuff Contamination/Infection Obstructed Tube Tracheitis (sore throat) Glottic and/or sub-glottic edema (may not manifest until tube is removed) Vocal cord damage (ET tubes only) Paralysis, polyps, granuloma formation

10. Complications Due to High Cuff Pressures Normal Mean Hemodynamics in the Tracheal Mucosa Lymphatic: 5mmhg Venous: 18 mmhg Arterial: 30 mmhg Impeding/occluding arterial flow causes ischemia! Impeding/occluding lymphatic or venous flow causes edema

11. Effects of Excessive Cuff Pressure Ischemia Inflammation Necrosis Fibrosis Stenosis Tracheal Malacia T-E Fistula

12. Cuff Pressure Should NOT Exceed 25-30 cmH2O! The pressure in the cuff should be checked often, eg each ventilator check

13. Cuff Inflation Management Techniques MOV – Minimal Occlusive Volume MLT- Minimal Leak Technique

14. MOV- Minimal Occlusive Volume Air is slowly added to cuff until either pressure cycling occurs (if applicable) or exhaled volume equals inhaled tidal volume Cuff pressure is then checked to make sure it does not exceed 25-30 cmH20 and adjusted to still allow pressure cycling or returned exhaled volume

15. Minimal Leak Technique Like MOV except after cycling or volume return is achieved, a slight amount of air is removed to cause either: (1) a loss of no more than 50 ml of set Vt (2) An audible leak heard around trachea

16. Again, these techniques should be utilized each time the cuff is checked If high pressures are needed initially, the artificial airway is probably too small If cuff pressures gradually increase, damage to the trachea may be occurring

17. Extubation Done when none of the four indications for an artificial airway exist

18. Extubation Technique Have suction, BVM and O2, and intubation supplies ready(including tracheotomy tray) In Fowler’s or semi- Fowler’s, suction through tube and pharynx Loosen tape and deflate cuff Insert new suction catheter into tube and have patient take a deep breath Apply suction as tube is pulled out and have patient cough at the same time Monitor vitals and respiratory status

19. Possible Complications Inspiratory stridor due to glottic or sub- glottic edema Stridor that develops immediately after extubation is an ominous sign Laryngospasm/Bronchospasm Dyspnea

20. Post-Extubation Treatment O2 Therapy For stridor, nebulized racemic epinephrine and a steroid If distress is not helped by nebulized drugs, re-intubate If not possible, tracheotomy

21. Time to face the music!