Emergency Airway Management and

Artificial Airway Care

Prepared by: Josephine Grace P. Camarillo, RTRP

 KEY TERMS
▣ Anterior mandibular ▣ Laryngeal mask airway
displacement (LMA)
▣ Combitube airway ▣ Laryngeal obstruction
▣ Endotracheal pilot tube ▣ Laryngoscope
and balloon ▣ Macintosh blade
▣ Endotracheal tube ▣ Miller blade
▣ Endotracheal tube cuff ▣ Nasopharyngeal airway
▣ Extubation ▣ Oropharyngeal airway
▣ Head tilt ▣ Soft tissue obstruction
▣ Intubation
AARC Clinical Practice Guideline: Resuscitation and
Defibrillation in the Health Care Setting 2004
Revision & Update

RAD INDICATIONS:

▣ Cardiac arrest, respiratory arrest, or the presence of

conditions that may lead to cardiopulmonary arrest
as indicated by rapid deterioration in vital signs,
level of consciousness, and blood gas values
 Conditions:
▣ Airway
obstruction—partial or
complete
▣ Acute myocardial
infarction with
cardiodynamic instability
▣ Life-threatening
dysrhythmias
▣ Hypovolemic shock
▣ Severe infections
▣ Spinal cord or head injury
▣ Drug overdose
▣ Pulmonary edema
▣ Anaphylaxis
▣ Pulmonary embolus
▣ Smoke inhalation
▣ Defibrillation is indicated
when cardiac arrest results
in or is due to ventricular
fibrillation
▣ Pulseless ventricular
tachycardia
 AARC Clinical Practice Guideline: Resuscitation and
Defibrillation in the Health Care Setting 2004
Revision & Update

RAD CONTRAINDICATIONS:
Resuscitation is contraindicated when
▣ The patient’s desire not to be resuscitated has been clearly
expressed and documented in the patient’s medical record
▣ Resuscitation has been determined to be futile because of
the patient’s underlying condition or disease
▣ Defibrillation is also contraindicated when immediate
danger to the rescuers is present due to the environment,
patient’s location, or patient’s condition.
 AARC Clinical Practice Guideline: Resuscitation and
Defibrillation in the Health Care Setting 2004
Revision & Update
PRECAUTIONS/ HAZARDS ▣ Eye injury
AND/OR COMPLICATIONS: ▣ Facial trauma
Airway management: ▣ Problems with ETT cuff
▣ Failure to establish a patent airway ▣ Bronchospasm
▣ Failure to intubate the trachea ▣ Laryngospasm
▣ Failure to recognize intubation of ▣ Dental accidents
the esophagus ▣ Dysrhythmias
▣ Upper airway trauma, laryngeal, ▣ Hypotension and bradycardia due
and esophageal damage to vagal stimulation
▣ Vocal cord paralysis ▣ Hypertension and tachycardia
▣ Aspiration ▣ Inappropriate tube size
▣ Cervical spine trauma ▣ Bleeding
▣ Unrecognized bronchial intubation ▣ Pneumonia
 AARC Clinical Practice Guideline: Resuscitation and
Defibrillation in the Health Care Setting 2004
Revision & Update
PRECAUTIONS/ HAZARDS Circulation/Compressions
AND/OR COMPLICATIONS: ▣ Ineffective chest compression
Ventilation ▣ Fractured ribs and/or sternum
▣ Hypo- and/or hyperventilation ▣ Laceration of spleen or liver
▣ Gastric insufflation and/or rupture ▣ Failure to restore circulation despite
▣ Barotrauma functional rhythm
▣ Hypotension due to reduced ◼ Severe hypovolemia

venous return secondary to high ◼ Cardiac tamponade

◼ Hemo- or pneumothorax
mean intrathoracic pressure
◼ Hypoxia
▣ Vomiting and aspiration ◼ Acidosis
▣ Prolonged interruption of ◼ Hyperkalemi
ventilation for intubation ◼ Massive acute myocardial infarction
◼ Aortic dissection
◼ Cardiac rupture
◼ Air embolus, pulmonary embolism
▣ Central nervous system impairment
 AARC Clinical Practice Guideline: Resuscitation and
Defibrillation in the Health Care Setting 2004
Revision & Update
PRECAUTIONS/ HAZARDS AND/OR ▣ The initial 3 shocks should be delivered
COMPLICATIONS: in sequence, without delay, interruption
for CPR, medication administration, or
Electrical therapy
pulse checks for ventricular fibrillation
▣ AEDs may be hazardous in patients and pulseless ventricular tachycardia.
weighing <25 kg ▣ Induction of malignant dysrhythmias
▣ Failure of defibrillator ▣ Interference with implanted pacemaker
▣ Shock to team members function
▣ Pulse checking between sequential
shocks of AEDs delays rapid
identification of persistent
ventricular fibrillation, interferes
with assessment capabilities of the
devices, and increases the possibility
of operator error
 AARC Clinical Practice Guideline: Resuscitation and
Defibrillation in the Health Care Setting 2004
Revision & Update
PRECAUTIONS/ HAZARDS AND/OR ▣ The aluminized backing on some
COMPLICATIONS: transdermal systems can cause electric
arcing during defibrillation, with
Electrical therapy
explosive noises, smoke, visible arcing,
Fire hazard patient burns, and impaired transmission
▣ AEDs may be hazardous in an of current; therefore, patches should be
▣ oxygen-enriched environment. removed before defibrillation
▣ Alcohol should never be used as
conducting material for paddles
because serious burns can result
▣ Superficial arcing of the current
along the chest wall can occur as a
consequence of the presence of
conductive paste or gel between the
paddles
AARC Clinical Practice Guideline: Resuscitation and
Defibrillation in the Health Care Setting 2004
Revision & Update
PRECAUTIONS/ HAZARDS AND/OR COMPLICATIONS:

Drug Administration:

▣ Inappropriate drug or dose

▣ Idiosyncratic or allergic response to drug
▣ Endotracheal-tube drug-delivery failure. The endotracheal tube dose
should be 2 to 2.5 times the normal I.V. dose, diluted in 10 mL of normal
saline (or distilled water).
AARC Clinical Practice Guideline: Resuscitation and
Defibrillation in the Health Care Setting 2004 Revision
& Update
RAD: ASSESSMENT OF NEED:
Assessment of patient condition
▣ Pre-arrest—Identification of patients in danger of imminent
arrest and in whom consequent early intervention may
prevent arrest and improve outcome. These are patients with
conditions that may lead to cardiopulmonary arrest as
indicated by rapid deterioration in vital signs, level of
consciousness, and blood gas values
▣ Arrest—absence of spontaneous breathing and/or circulation
 AARC Clinical Practice Guideline: Resuscitation and
Defibrillation in the Health Care Setting 2004 Revision
& Update
RAD: ASSESSMENT OF NEED:
Assessment of patient condition
▣ Post-arrest—Once a patient has sustained an arrest, the
likelihood of additional life-threatening problems is high, and
continued vigilance and aggressive action using this Guideline
are indicated. Control of the airway and cardiac monitoring
must be continued and optimal oxygenation and ventilation
assured.
◼ After arrival of defibrillator: The patient should be evaluated immediately
for the presence of ventricular fibrillation or ventricular tachycardia by
the operator (conventional) or the defibrillator (automated or
semi-automated). Inappropriate defibrillation can cause harm.
AARC Clinical Practice Guideline: Resuscitation and
Defibrillation in the Health Care Setting 2004 Revision
& Update
RAD:ASSESSMENT OF PROCESS AND OUTCOME:
▣ Timely, high-quality resuscitation improves patient outcome in
terms of survival and level of function. Despite optimal
resuscitation performance, outcomes are affected by
patient-specific factors. Patient condition post-arrest should be
evaluated from this perspective.
▣ Documentation and evaluation of the resuscitation process (eg,
system activation, team member performance, functioning of
equipment, and adherence to guidelines and algorithms) should
occur continuously and improvements be made
▣ Equipment management issues. Use of standard checklists can
improve defibrillator dependability.
 AARC Clinical Practice Guideline: Resuscitation and
Defibrillation in the Health Care Setting 2004 Revision
& Update
RAD:ASSESSMENT OF PROCESS AND OUTCOME:
Defibrillation process issues
▣ System access
▣ Response time
▣ First-responder actions
▣ Adherence to established algorithms
▣ Patient selection and outcome
▣ First responder authorization to defibrillate
AARC Clinical Practice Guideline: Resuscitation and
Defibrillation in the Health Care Setting 2004 Revision
& Update
RAD: MONITORING:
Patient
▣ Clinical assessment—continuous observation of the
patient and repeated clinical assessment by a trained
observer provide optimal monitoring of the
resuscitation process.
AARC Clinical Practice Guideline: Resuscitation and
Defibrillation in the Health Care Setting 2004 Revision
& Update
RAD: MONITORING:
Patient:
▣ Special consideration should be given to the
following:
◼ Level of consciousness
◼ Adequacy of airway
◼ Adequacy of ventilation
◼ Peripheral/apical pulse and character
◼ Evidence of chest and head trauma
◼ Pulmonary compliance and airway resistance
◼ Presence of seizure activity
AARC Clinical Practice Guideline: Resuscitation and
Defibrillation in the Health Care Setting 2004 Revision &
Update
RAD: MONITORING:
Patient:
▣ Assessment of physiologic parameters— Repeat
assessment of physiologic data by trained professionals
supplements clinical assessment in managing patients
throughout the resuscitation process. Monitoring
devices should be available, accessible, functional, and
periodically evaluated for function. These data
▣ include but are not limited to95

▣ 11.1.2.1 Arterial blood gas studies

▣ (although investigators have suggested

▣ that such values may have a limited role

 AARC Clinical Practice Guideline: Resuscitation and
Defibrillation in the Health Care Setting 2004 Revision
& Update
RAD: MONITORING:
Patient:
▣ These data include but are not limited to:
▣ Arterial blood gas studies (although investigators have suggested that
such values may have a limited role in decision-making during CPR
▣ Hemodynamic data
▣ Cardiac rhythm
▣ Ventilatory frequency, tidal volume, and airway pressure
▣ Exhaled CO2
▣ Neurologic status
 AARC Clinical Practice Guideline: Resuscitation and
Defibrillation in the Health Care Setting 2004 Revision
& Update
RAD: MONITORING:
Patient:
▣ Resuscitation process—properly performed
resuscitation should improve patient outcome.
Continuous monitoring of the process will identify
areas needing improvement. Among these areas are
response time, equipment function, equipment
availability, team member performance, team
performance, complication rate, and patient survival
and functional status.
 AARC Clinical Practice Guideline: Resuscitation and
Defibrillation in the Health Care Setting 2004 Revision
& Update
RAD: MONITORING:
Patient:
▣ Equipment—All maintenance should be documented and records
preserved. Included in documentation should be routine checks of
energy output, condition of batteries, proper functioning of monitor
and recorder, and presence of disposables needed for function of
defibrillator, including electrodes and defibrillation pads.
Defibrillators should be checked and documented each shift for
presence, condition, and function of cables and paddles; presence of
defibrillating and monitoring electrodes, paper, and spare batteries (as
applicable); and charging, message/light indicators, monitors, and
ECG recorder (as applicable).91 AEDs should be checked and
documented each day for function and appropriate maintenance.
 AARC Clinical Practice Guideline: Resuscitation and
Defibrillation in the Health Care Setting 2004 Revision
& Update
RAD: MONITORING:
Patient:
▣ Training—Records should be kept of initial training and
continuing education of all personnel who perform
defibrillation as part of their professional activities.
AARC Clinical Practice Guideline: Management of
Airway Emergencies

MAE: INDICATIONS:

Conditions requiring management of the airway, in

general, are impending or actual

▣ (1) airway compromise

▣ (2) respiratory failure and
▣ (3) need to protect the airway
 AARC Clinical Practice Guideline: Management of
Airway Emergencies
Specific conditions include but ▣ Severe bronchospasm
are not limited to: ▣ Severe allergic reactions with
▣Airway emergency prior to
cardiopulmonary compromise
▣ Pulmonary edema
endotracheal intubation
▣ Sedative or narcotic drug effect
▣Obstruction of the artificial
▣ Foreign body airway obstruction
airway
▣ Choanal atresia in neonates
▣Apnea
▣ Aspiration
▣Acute traumatic coma
▣ Risk of aspiration
▣Penetrating neck trauma ▣ Severe laryngospasm
▣Cardiopulmonary arrest and ▣ Self-extubation
unstable dysrhythmias
AARC Clinical Practice Guideline: Management of
Airway Emergencies
MAE: INDICATIONS:
Conditions requiring emergency tracheal intubation
include, but are not limited to:
▣ Persistent apnea
▣ Traumatic upper airway obstruction (partial or complete)
▣ Accidental extubation of the patient unable to maintain adequate
spontaneous ventilation
▣ Obstructive angioedema (edema involving the deeper layers of
the skin, subcutaneous tissue, and mucosa)
▣ Massive uncontrolled upper airway bleeding
▣ Coma with potential for increased intracranial pressure
 AARC Clinical Practice Guideline: Management of
Airway Emergencies
MAE: INDICATIONS:
Conditions requiring emergency tracheal intubation
include, but are not limited to:
▣ Infection-related upper airway obstruction (partial or
complete):
◼ Epiglottitis in children or adults
◼ Acute uvular edema
◼ Tonsillopharyngitis or retropharyngeal abscess
◼ Suppurative parotitis
AARC Clinical Practice Guideline: Management of
Airway Emergencies
MAE: INDICATIONS:
Conditions requiring emergency tracheal intubation
include, but are not limited to:
▣ Laryngeal and upper airway edema

▣ Neonatal- or pediatric-specific:
◼ Perinatal asphyxia
◼ Severe adenotonsillar hypertrophy
◼ Severe laryngomalacia
◼ Bacterial tracheitis
◼ Neonatal epignathus
◼ Obstruction from abnormal laryngeal closure due to arytenoid masses
◼ Mediastinal tumors
◼ Congenital diaphragmatic hernia
◼ Presence of thick and/or particulate meconium in amniotic fluid
AARC Clinical Practice Guideline: Management of
Airway Emergencies
MAE: INDICATIONS:
Conditions requiring emergency tracheal intubation
include, but are not limited to:
▣ Absence of airway protective reflexes

▣ Cardiopulmonary arrest

▣ Massive hemoptysis
AARC Clinical Practice Guideline: Management of
Airway Emergencies
MAE: INDICATIONS:
▣ The patient in whom airway control is not possible by
other methods may require surgical placement of an
airway (needle or surgical cricothyrotomy).
AARC Clinical Practice Guideline: Management of
Airway Emergencies
MAE: INDICATIONS:
▣ Conditions in which endotracheal intubation may not
be possible and in which alternative techniques may be
used include but are not limited to:
◼ Restriction of endotracheal intubation by policy or statute
 AARC Clinical Practice Guideline: Management of
Airway Emergencies
MAE: INDICATIONS:
▣ Difficult or failed intubation in the presence of risk factors associated with
difficult tracheal intubations such as:
◼ Short neck or bull neck
◼ Protruding maxillary incisors
◼ Receding mandible
◼ Reduced mobility of the atlantooccipital joint
◼ Temporomandibular ankyloses
◼ Congenital oropharyngeal wall stenosis
◼ Anterior osteophytes of the cervical vertebrae, associated with diffuse
idiopathic skeletal hyperostosis
◼ Large substernal and/or cancerous goiters
◼ Treacher Collins syndrome
◼ Morquio-Brailsford syndrome
◼ Endolaryngeal tumors
AARC Clinical Practice Guideline: Management of
Airway Emergencies

MAE: CONTRAINDICATIONS:
▣ Aggressive airway management (intubation or
establishment of a surgical airway) may be
contraindicated when the patient’s desire not to be
resuscitated has been clearly expressed and
documented in the patient’s medical record or other
valid legal document.
 AARC Clinical Practice Guideline: Management of
Airway Emergencies

MAE: PRECAUTIONS/HAZARDS AND/OR

COMPLICATIONS:
The following represent possible hazards or complications
related to the major facets of management of airway
emergencies:
▣Translaryngeal intubation or cricothyrotomy is usually the route of choice.
It may be necessary occasionally to use a surgical airway. Controversy
exists as to whether intubation is hazardous in the presence of an unstable
injury to the cervical spine. In one series the incidence of serious cervical
spine injury in a severely injured population of blunt trauma patients was
relatively low, and commonly used methods of precautionary airway
management rarely led to neurologic deterioration.
 AARC Clinical Practice Guideline: Management of
Airway Emergencies

MAE: PRECAUTIONS/HAZARDS AND/OR

COMPLICATIONS:
The following represent possible hazards or complications related to
the major facets of management of airway emergencies:
▣Failure to establish a patent airway
▣Failure to intubate the trachea

▣Failure to recognize intubation of esophagus

▣Upper airway trauma, laryngeal, and esophageal damage

▣Aspiration

▣Cervical spine trauma

▣Unrecognized bronchial intubation

▣Eye injury

▣Vocal cord paralysis

 AARC Clinical Practice Guideline: Management of
Airway Emergencies

MAE: PRECAUTIONS/HAZARDS AND/OR

COMPLICATIONS:
The following represent possible hazards or complications related to
the major facets of management of airway emergencies:
▣Problems with ETT tubes:
◼ Cuff perforation
◼ Cuff herniation
◼ Pilot-tube-valve incompetence
◼ Tube kinking during biting
◼ Inadvertent extubation
◼ Tube occlusion
 AARC Clinical Practice Guideline: Management of
Airway Emergencies
MAE: PRECAUTIONS/HAZARDS AND/OR
COMPLICATIONS:
▣Bronchospasm

▣Laryngospasm

▣Dental accidents
▣Dysrhythmias

▣Hypotension and bradycardia due to vagal stimulation

▣Hypertension and tachycardia

▣Inappropriate tube size

▣Bleeding

▣Mouth ulceration
 AARC Clinical Practice Guideline: Management of
Airway Emergencies
MAE: PRECAUTIONS/HAZARDS AND/OR COMPLICATIONS:
▣Nasal-intubation specific:
◼ Nasal damage including epistaxis
◼ Tube kinking in pharynx
◼ Sinusitis (100–102) and otitis media

▣Tongue ulceration
▣Tracheal damage including tracheoesophageal Fistula, tracheal
innominate fistula, tracheal stenosis, and tracheomalacia
▣Pneumonia

▣Laryngeal damage with consequent laryngeal stenosis, laryngeal

ulcer, granuloma, polyps, synechia
 AARC Clinical Practice Guideline: Management of
Airway Emergencies
MAE: PRECAUTIONS/HAZARDS AND/OR COMPLICATIONS:
▣Surgical cricothyrotomy or tracheostomy-specific
◼ Stomal stenosis
◼ Innominate erosion
▣Needle cricothyrotomy–specific
◼ Bleeding at insertion site with hematoma formation
◼ Subcutaneous and mediastinal emphysema
◼ Esophageal perforation
 AARC Clinical Practice Guideline: Management of
Airway Emergencies
MAE: PRECAUTIONS/HAZARDS AND/OR COMPLICATIONS:
▣Emergency ventilation
◼ Inadequate oxygen delivery
◼ Hypo- or hyperventilation
◼ Gastric insufflation and/or rupture
◼ Barotrauma
◼ Hypotension due to reduced venous return secondary to high mean intrathoracic
pressure
◼ Vomiting and aspiration
◼ Prolonged interruption of ventilation for intubation
◼ Failure to establish adequate functional residual capacity in the newborn
◼ Movement of unstable cervical spine (more than by any commonly used method of
endotracheal intubation)
◼ Failure to exhale due to upper airway obstruction during percutaneous transtracheal
ventilation
 AARC Clinical Practice Guideline: Management of
Airway Emergencies

MAE: ASSESSMENT OF NEED:

The need for management of airway emergencies is
dictated by the patient’s clinical condition. Careful
observation, the implementation of basic airway
management techniques, and laboratory and clinical
data should help determine the need for more aggressive
measures. Specific conditions requiring intervention
include:
◼ Inability to adequately protect airway (e.g. coma, lack of gag
reflex, inability to cough) with or without other signs of
respiratory distress
AARC Clinical Practice Guideline: Management of
Airway Emergencies

MAE: ASSESSMENT OF NEED:

▣ Partially obstructed airway. Signs of a partially obstructed
upper airway include ineffective patient efforts to ventilate,
paradoxical respiration, stridor, use of accessory muscles,
patient’s pointing to neck, choking motions, cyanosis, and
distress. Signs of lower airway obstruction may include the
above and wheezing.
▣ Complete airway obstruction. Respiratory efforts with no
breath sounds or suggestion of air movement are indicative
of complete obstruction.
AARC Clinical Practice Guideline: Management of
Airway Emergencies

MAE: ASSESSMENT OF NEED:

▣ Apnea. No respiratory efforts are seen. May be
associated with cardiac arrest.
▣ Hypoxemia, hypercarbia, and/or acidemia seen on
arterial blood gas analysis, oximetry, or exhaled gas
analysis.
▣ Respiratory distress. Elevated respiratory rate, high
or low ventilatory volumes, and signs of
sympathetic nervous system hyperactivity may be
associated with respiratory distress.
 AARC Clinical Practice Guideline: Management of
Airway Emergencies
MAE: ASSESSMENT OF PROCESS AND OUTCOME:
▣Timely intervention to maintain the patient’s airway can improve
outcome in terms of survival and level of function. Under rare
circumstances, maintenance of an airway by nonsurgical means may not
be possible. Despite optimal maintenance of the airway, patient
outcomes are affected by patient-specific factors. Lack of availability of
appropriate equipment and personnel may adversely affect patient
outcome. Monitoring and recording are important to the improvement
of the process of emergency airway management. Some aspects (e.g.,
frequency of complications of tracheal intubation or time for
establishment of a definitive airway) are easy to quantitate and can lead
to improvement in hospitalwide systems. Patient condition following
the emergency should be evaluated from this perspective.
AARC Clinical Practice Guideline: Management of
Airway Emergencies

MAE: MONITORING:
Patient:
▣ Clinical signs—Continuous observation of the
patient and repeated clinical assessment by a trained
observer provide optimal monitoring of the airway.
 AARC Clinical Practice Guideline: Management of
Airway Emergencies
MAE: MONITORING:
Patient:
Special consideration should be given to the following:
◼ Level of consciousness
◼ Presence and character of breath sounds
◼ Ease of ventilation
◼ Symmetry and amount of chest movement
◼ Skin color and character (temperature and presence or absence of diaphoresis)
◼ Presence of upper airway sounds (crowing, snoring, stridor)
◼ Presence of excessive secretions, blood, vomitus, or foreign objects in the
airway
◼ Presence of epigastric sounds
◼ Presence of retractions
◼ Presence of nasal flaring
 AARC Clinical Practice Guideline: Management of
Airway Emergencies
MAE: MONITORING:
Patient:
Physiologic variables—Repeated assessment of physiologic data by
trained professionals supplements clinical assessment in
managing patients with airway difficulties. Monitoring devices
should be available, accessible, functional, and periodically
evaluated for function. These data include but are not limited to:
Ventilatory frequency, tidal volume, and airway pressure
Presence of CO2 in exhaled gas
Heart rate and rhythm
Pulse oximetry
Arterial blood gas values
Chest radiograph
 AARC Clinical Practice Guideline: Management of
Airway Emergencies
MAE: MONITORING:
Endotracheal tube position:
Tracheal intubation is suggested but may not be confirmed
by:
◼ Bilateral breath sounds over the chest, symmetrical chest
movement, and absence of ventilation sounds over the
epigastrium
◼ Presence of condensate inside the tube, corresponding with
exhalation
◼ Visualization of the tip of the tube passing through the vocal
cords
◼ Esophageal detector devices may be useful in differentiating
esophageal from tracheal intubation
 AARC Clinical Practice Guideline: Management of
Airway Emergencies
MAE: MONITORING:
Endotracheal tube position:
▣ Tracheal intubation is confirmed by detection of CO2 in
the exhaled gas, although cases of transient CO2
excretion from the stomach have been reported.
▣ Tracheal intubation is confirmed by endoscopic
visualization of the carina or tracheal rings through the
tube.
▣ The position of the endotracheal tube (i.e., depth of
insertion) should be appropriate on chest radiograph.
 AARC Clinical Practice Guideline: Management of
Airway Emergencies
MAE: MONITORING:
▣ Airway management process:
◼ A properly managed airway may improve
patient outcome. Continuous evaluation of the
process will identify components needing
improvement. These include response time,
equipment function, equipment availability,
therapist performance, complication rate, and
patient survival and functional status
 ANATOMY OF THE UPPER AIRWAY

Tongue
▣First Structure

▣Common cause of upper airway

obstruction.
▣unconscious patient - flaccid
 REFLEXES OF THE UPPER
AIRWAY*
1. SWALLOW
2. GAG
3. LARYNGEAL
4. TRACHEAL
5. CARINAL
 SWALLOW
▣ The first reflex
▣ swallowing receptors
▣ A patient without the swallow reflex needs oral suctioning
frequently.
 GAG
▣ vagal receptors - cause gagging
▣ It may include: vomiting, further compromising the patency of the
airway.
▣ strong reflex
▣ The reflex may be depressed with Central Nervous System (CNS)
depression, anesthesia, or drug overdose, or it may be intentionally
depressed using lidocaine topically.
 LARYNGEAL*
▣ slam shut
▣ The approximation of the vocal cords causes
laryngospasm.

Other causes of laryngospasm are:

▣ anaphylaxis and

▣ epiglottitis.
 TRACHEAL
▣ induce a cough.
▣ very sensitive to foreign material.
▣ presence of secretions
▣ placement of an artificial airway
 CARINAL
▣ extremely sensitive to stimulation.
▣ Stimulation of this area causes a cough reflex.
 REFLEXES AND LOSS OF
CONSCIOUSNESS:
▣ The level of consciousness is reflected in the
presence or absence of the reflexes.
▣ evaluating coma
▣ assessing the need for intubation
 AIRWAY ANATOMY

A. Normal

B. Obstructed Airway
 UPPER AIRWAY
OBSTRUCTION
▣ Causes:
▣ soft tissue or laryngeal obstruction
▣ CONTRIBUTING FACTORS:
◼ CNS depression
◼ cardiac arrest;
◼ loss of consciousness;
◼ space-occupying lesions
 LARYNGEAL OBSTRUCTION
▣ result of muscle spasm (laryngospasm)
▣ edema from croup
▣ Epiglottitis
▣ presence of foreign material.
▣ laryngeal spasm - result of
◼ anaphylactic reaction
◼ post-intubation
◼ foreign body aspiration
◼ in the near-drowning victim.
 Clinical Findings:
▣ very noisy inspiratory efforts.
▣ mild snoring sound to a roar
▣ Silence - total obstruction.*
▣ severe obstruction:
◼ retraction of the intercostal muscles accompanied by sternal and
clavicular retraction.
▣ Retractions - infant or child.
▣ Total airway obstruction may lead to death in 5 to 10
minutes.
Positional Maneuvers to Open the Airway

▣ The goal: to prompt restoration of airway patency.

▣ Establish airway - evaluate the adequacy of
ventilation.
 Positional Maneuvers to Open the
Airway
Head Tilt Maneuver:
▣involves tilting the head back to relieve soft tissue
obstruction from the tongue and soft palate.
 HEAD TILT
Two ways:
1.The head tilt-chin lift maneuver is
performed by tilting the head back and
lifting the chin to open the airway.
2.The other maneuver is most easily
performed while standing behind the
patient, using both hands, place one hand
on the forehand and push back, with the
other hand, lift the mandible. *
How to open the airway
 ANTERIOR MANDIBULAR
DISPLACEMENT
▣ performed by grasping the jaw
at the ramus on each side and
lifting the jaw forward.
 TRIPLE AIRWAY MANEUVER
▣ The Triple Airway Maneuver is a combination of the
head tilt, anterior mandibular displacement and the
separation of the teeth to open the mouth.
Triple Airway Maneuver
 RESUSCITATORS
▣ two main types of manual resuscitators:
1. self-inflating and
2. flow-inflating
 Self-inflating Resuscitator
▣ will automatically
inflate after the bag is
squeezed for
inspiration
▣ useful in the
emergency setting
 Flow-inflating Resuscitator
▣ depends on the flow of source gas to inflate
▣ will not operate without a compressed gas source
▣ easy to assess the compliance of a patient’s lungs and thorax.
▣ deliver 100% oxygen
 Gas-Powered Resuscitators
▣ using a 50 psi oxygen source
▣ pressure-limited resuscitator or
▣ as a demand valve
 Valve Types Used in Self-
Inflating Manual Resuscitators
▣ purpose of all valves: deliver gas to the patient
during inspiration and to allow the patient to exhale
to the ambient atmosphere on exhalation.
Self-Inflating Manual Resuscitators
IMPORTANCE OF
INSPIRATORYEXPIRATORY
RATIO DURINGRESUSCITATION
▣ applying pressure or squeezing the bag
▣ forcing gas into the airway to ventilate the patient’s
lungs
▣ I:E ratio of 1:2
 Hazards of
Manual Resuscitation
▣ Gastric distention
▣ Aspiration and
▣ Diminished cardiac output
▣ Inadequate ventilation
▣ Equipment malfunctions
 Pharyngeal Airways
in Manual Resuscitation
▣ specialized devices - maintain a patent airway
▣ most common:
▣ Nasopharyngeal airways (NPA)
▣ Oropharyngeal airways (OPA)
▣ laryngeal mask airways (LMAs) and
▣ Combitube airways
 Nasopharyngeal Airway
▣ nasal horn or trumpet
▣ inserted through one of the nares
 OROPHARYNGEAL AIRWAY
▣ larger than the nasopharyngeal airway
▣ inserted into the mouth - rotated with the tip resting
against the base of the tongue.
▣ separate the tongue from the posterior palate
▣ COMPLICATIONS: gagging and vomiting
 Laryngeal Mask Airway (LMA)
▣ small triangular-shaped inflatable mask that is secured to
a tube
▣ designed to be inserted such that once the mask is
inflated, the tip rests against the upper esophageal
sphincter and the sides face into the pyriform fossae,
lying just under the base of the tongue.
 Combitube Airway
▣ double-lumen airway that is inserted blindly
▣ shorter tube, longer tube
▣ esophagus or trachea - ventilation can be established
 AIRWAY INSERTION
Insertion of the Nasopharyngeal Airway
▣different diameters and lengths.

▣soft rubber or plastic.

▣shape and mark for right or left naris use

▣Contraindicated: receiving anticoagulant

therapy or have bleeding disorders.
▣proper sizing of a nasopharyngeal airway
Insertion of the Nasopharyngeal Airway
▣ Lubricate with a water-soluble lubricant.
▣ Insert through the nostril, parallel to the floor of the
nasal cavity, match the curve of the airway with the
patient’s airway
▣ the bevel should face medially
▣ Gently advance the airway
▣ Potential complications:
◼ hearing problems
◼ mucosal irritation
◼ trauma
▣ changed every 8 hours
 Insertion of the Oropharyngeal Airway
▣ rotating the tip
▣ rotated 180°
▣ tip points down toward
the throat
▣ gagging and vomiting
– do not use
OROPHARYNGEAL AIRWAY
INSERTION
NASOPHARYNGEAL AIRWAY
INSERTION
 INTUBATION:
▣ It involves the placement of an endotracheal tube
into the trachea.
▣ There are two routes, oral or nasal routes
 ORAL ROUTE
▣ fastest and most direct.
▣ Visualize the vocal cords by the use of laryngoscope
▣ DISADVANTAGE:
◼ oral care if difficult;
◼ gag or cough from the movement of the tube
 NASAL ROUTE
Criteria for intubation
▣Failure of other artificial airways to maintain a patent
airway
▣Need for repeated deep tracheal suctioning

▣Need for long-term mechanical ventilation

▣Protection of the airway

 NASAL ROUTE

▣ oral or facial
▣ ADVANTAGE:
1. if a patient suffered trauma to the mouth or face
2. making the oral route impractical
3. makes oral care much easier
4. stabilize the endotracheal tube
▣ DISADVANTAGE:
1. a smaller tube - increases resistance must be used;
2. smaller tubes make suctioning the airway more difficult
3. length of time taken for the procedure is longer
Equipment For Endotracheal Intubation
▣ Laryngoscopes:
▣ 2 Types Of Laryngoscopes
1. Conventional
2. Fiberoptic
 Conventional Laryngoscope
▣ Most common type
▣ Handle with batteries
▣ a switch and a
▣ To turn it on, position the blade at a
right angle to the handle by snapping it
up.
▣ A blade is inserted by holding the
handle vertically and aligning the
socket on the blade with the handle
socket.
How operate laryngoscope
 Fiberoptic Laryngoscope
▣ transmit light to its distal
tip.
▣ self-contained battery pack
▣ flexible fiberoptic bundle
▣ ADVANTAGE: the ability
to visualize the carina once
the tube is in place.
 Two (2) types of laryngoscope blades

▣ The MILLER – straight ▣ The MACINTOSH –

blade curved blade
 Characteristics
of Endotracheal Tubes
▣ polyvinyl chloride (PVC)
▣ polymer is semirigid and is
molded into a gentle curve
▣ Stripe line - radiopaque
 Parts of the ETT
▣ Murphy eye – it is an eye or opening
opposite the bevel on the distal end of
the tube.
▣ Endotracheal Tube Cuff – is an inflatable
balloon near the tip of the tube.
▣ Endotracheal Pilot tube – conducts air to
the cuff of the tube.
▣ Endotracheal Pilot Balloon - located on
the proximal end of the pilot tube.
▣ Markings –centimeter increments, rough
guide, best to rely on a chest radiograph
COMPLICATIONS OF INTUBATION
Early Complications:
▣Esophageal intubation
◼ Auscultation - diminished or absent
◼ End-tidal CO2 - exhaled CO will quickly fall to zero
2

▣Trauma to the dentition or the oral cavity

▣If the endotracheal tube is advanced too far, the right or
left mainstem bronchus will be intubated
▣kinking the tube

▣Vomiting and aspiration

 COMPLICATIONS OF INTUBATION

Late Complications:
▣Vocal cord damage

▣Tracheal stenosis— narrowing of the trachea by scar

tissue
method to determine cuff inflation:
◼ Minimal Occlusion Volume (MOV)
◼ Minimal Leak Technique
▣Infection
 Extubation
▣ manage secretions or the underlying cause for
intubation has been resolved
▣ COMPLICATIONS:
▣ Edema - cool aerosol
▣ Laryngospasm
▣ Aspiration - complete suctioning
 PREPARATION OF MANUAL RESUSCITATORS
▣ Check the valves
▣ Attach the reservoir
▣ Attach the oxygen connecting
tubing - 15 L/min
▣ Reassess the operation of the
valves
▣ Occlude the patient outlet
▣ squeeze the bag
▣ Pressure should be maintained
within the bag
To assemble a flow-inflating manual resuscitator:

▣ anesthesia elbow with

an oxygen inlet
▣ 3- or 5-liter anesthesia
bag
▣ oxygen connecting
tubing and
▣ oxygen flowmeter
 VENTILATION WITH
A MANUAL RESUSCITATOR
▣ Patient Positioning
◼ supine position
◼ open the airway
▣ Mask Placement
◼ Face
◼ apply to the bridge of the nose and
secure a tight seal below the lower lip
▣ other hand - compress the bag,
inflating the lungs
 Ventilation
▣ Apneic - begin immediately
▣ 8 to 12 breaths per minute
▣ Tidal volumes should range between 6 and 7 mL/kg
normal body weight or 500 to 600 mL/breath
▣ I:E ratio - 1:2
 Patient Assessment during the Procedure
▣ Observe chest expansion
▣ Signs of cyanosis
▣ Gastric distention
▣ Nasogastric tube
▣ Assess the pulse frequently
 EQUIPMENT PREPARATION AND
ASSEMBLY FOR INTUBATION
▣ Laryngoscope
▣ Laryngoscope blades
▣ Spare batteries
▣ Spare bulbs
▣ Oropharyngeal airways (several sizes)
▣ Yankaur suction (tonsil tip)
▣ Endotracheal tube sized from 6.5mm ID to 10
mm ID
▣ (2) 12 cc syringes
▣ Cloth first-aid tape
▣ Water soluble lubricant
▣ Magill forceps
▣ stylet
 General Notes
▣ No more than 30 seconds should elapse from the time the
laryngoscope enters the mouth until the endotracheal
tube has been inserted.

Patient Positioning
▣ supine with a small roll under the shoulders and the head
slightly hyperextended

Hyperinflation and Oxygenation

▣ Two or three minutes of vigorous resuscitation with
100% oxygen
“sniffing” position
 INTUBATION TECHNIQUES
Oral Intubation
▣Position the patient

▣Miller Blade (Straight Blade)

▣Macintosh Blade (Curved Blade)

▣Evaluation

▣Use of End-Tidal CO2 Detectors or

Esophageal Detectors
 Nasal Intubation
▣ assemble and test all of the equipment
▣ Position in a “sniffing” position
▣ Manually ventilate for 2 or 3 minutes using
100% oxygen.
▣ Anesthetize the nasal passage
▣ Lubricate the endotracheal tube
▣ Advance the tube down the nasal passage
▣ Blind Intubation
◼ If the patient is breathing spontaneously, wait for
the inspiratory phase and try to advance the tube
past the epiglottis into the trachea
INTUBATION PROCEDURE
 EXTUBATION
▣ EXTUBATION is the process of removing an artificial
tracheal airway (endotracheal tube).
▣ Position the patient in full Fowler’s position
▣ Hyperinflate and oxygenate with a manual resuscitator.
▣ Suction the airway prior to removing the endotracheal tube.
▣ Attach the syringe to the pilot balloon
▣ Inflate the lungs using the manual resuscitator
▣ Extubate by removing the endotracheal tube
▣ Instruct the patient to cough vigorously
▣ Administer supplemental oxygen
 EXTUBATION OF ENDOTRACHEAL
TUBES
▣ EQUIPMENT NEEDED:
1. Suction catheter of appropriate size
2. Normal Saline
3. Scissors
4. 10cc syringes
5. Appropriate oxygen delivery system
6. Hand held nebulizer with racemic epinephrine (if
ordered)
7. Manual Resuscitator with face mask
 Monitoring after Extubation
▣ ensure to maintain adequate ventilation and to
control secretions effectively
▣ Auscultate the chest
▣ Assess the patient’s breathing
▣ Swallow reflex is intact
▣ Hoarseness sound
▣ Minimize speech about 8 hours
▣ NPO for 8 hours
 RATIONALE for SUCTIONING?
▣ COUGH - normal defense mechanisms that protects the
airway.
▣ Effective cough - generate high intrathoracic pressure

▣ Huff cough

The cough reflex is depressed, bypassed, or even absent

▣ Central Nervous System (CNS) depression

▣ Brainstem injury

▣ Cerebrovascular accident (CVA)

▣ Pain and

▣ Muscle weakness.
 What is SUCTIONING?
▣ Is an invasive procedure that involves the insertion of a
small catheter into the airway and the application of a
vacuum to aspirate secretions or foreign material.
What is SUCTIONING?
 SUCTION CATHETER DESIGNS:
Whistle Tip
▣eye on the side of the catheter
proximal to the distal opening.
▣ADVANTAGE: if the tip comes in
contact with the mucosa, the eye
should provide a relief for the
applied vacuum.
▣inadvertent biopsy of mucosal tissue
is prevented.
 SUCTION CATHETER DESIGNS:
Coudé Tip
▣angled tip design.
▣It permits the selective entry into the
right or left mainstem bronchus.
▣advance the catheter and rotate the tip
right or left
 SUCTION CATHETER DESIGNS:
Closed Suction Systems
▣sterile suction catheter - protective
sheath

Trach Care catheter

▣encased in a sealed plastic protective
sheath
▣distal end is attached to T adaptor

▣proximal end is attached to a control

valve
 INDICATIONS

1. Patient with an artificial airway.

2. Retention of clearing secretions
3. Infectious disorders: COPD, cystic fibrosis
4. Conditions that impair the cough mechanism: CNS
depression or NMD
 Complications and Hazards
of Suctioning
1. Tissue trauma
2. Hypoxemia
3. Microatelectasis
4. Cardiac arrhythmias
5. Hospital Acquired
6. Pneumonia
Vacuum Pressures for Suctioning
Pressure Ranges: Catheter sizes

80-100 mmHg infants 5-8 french

80 – 100 mmHg children 10-12 french

80 – 120 mmHg (never adult 14-18 french

exceed 150 mmHg
 Oxygenation and Hyperinflation
Using Mechanical Ventilation
▣ increasing the delivered oxygen level to 100% and
allowing sufficient time for at least 30 to 60
seconds.
▣ Suctioning
▣ Washout volume is the volume internal to the
ventilator and the ventilator circuit
 Oxygenation and Hyperinflation
Using Mechanical Ventilation
Positive End-Expiratory Pressure
▣more susceptible to hypoxemia when disconnected
from mechanical ventilation for suctioning
▣fall in PaO
2
▣Takes time to regain the level of oxygen saturation

▣closed suction system

 Prevention of Ventilator-
Associated Pneumonia (VAP)
▣ one of the most common hospital-acquired
infections
Prevention:
1. Elevation of the Head of the Bed
◼ 30 to 45°
2. Subglottic Secretion Drainage
▪ Hi-Lo Evac
4. Maintenance of Cuff Pressures
Humidification of Inspired Gases
◼ heat and moisture exchanger (HME) or
◼ a heated humidifier.
 REMEDIES TO MINIMIZE
COMPLICATIONS:
▣ Limit duration of suctioning
▣ Limit negative pressure
▣ Lung hyperinflation
▣ Increase FiO2
▣ Administer extra breaths before & after suctioning
CUFF PRESSURE MONITORING
▣ maintained as low as possible but not more than 25
to 30 cmH2O
▣ Monitor regularly to prevent tracheal mucosal
damage and VAP.
▣ use of Minimal Occlusive Volume (MOV) by
inflating the cuff to provide a seal is recommended.
 METHODS OF CUFF PRESSURE
MEASUREMENT
1. Minimal Occlusion Volume (MOV)
2. Minimal Occlusion Pressure
3. Minimal Leak Technique
 Minimal Occlusion Volume (MOV)

▣ inflate the cuff with a syringe until all air leakage

under positive pressure stops.
▣ auscultation at the larynx with a stethoscope is an
easy way to detect any leak past the cuff.
 Minimal Occlusion Pressure
▣ it is similar to MOV, except a pressure manometer
is used to lieu of a syringe.
▣ the cuff is inflated until any leak under positive
pressure stops.
▣ as with MOV, auscultation at the larynx with a
stethoscope is an easy way to detect any leak past
the cuff.
 Minimal Leak Technique
▣ it is one in which the cuff is inflated until a slight
leak is heard past the cuff during inspiration.
▣ the cuff is inflated until no leak is detected, then a
small amount of air is removed from the cuff until a
slight leak occurs.
 INDICATION FOR
TRACHEOSTOMY
▣ Provide a patent airway following intubation or
when intubation is contraindicated.
▣ Protect the lower airway from aspiration
▣ Frequent aspiration of secretions
▣ Long-term mechanical ventilation
▣ Reduce anatomical dead space
 Purpose of Tracheostomy
and Stoma Care
▣ to prevent infection and to preserve the patency of
the airway
▣ What is TRACHEOSTOMY?
▣ It is a surgical procedure requiring the incision by
opening the skin into the trachea.
▣ Tracheostomy is a particularly dirty area due to the
expectoration of secretions through the
tracheostomy tube and seeping around it.
 Hazards and Complications
of Tracheostomy Care
1. Displacement and Decannulation of the
Tracheostomy Tube
▪ may result in its lodging in the subcutaneous tissue

▣ Decannulation is the removal of the tracheostomy

tube.
2. Infection
▪ every 4 hours
Types of Tube
 Single Cannula Tracheostomy Tube

▣ the most common type of tube

used.
▣ It is made up of PVC 9, nontoxic
type of plastic.
▣ It does not have removable inner
cannula
 Single Cannula Tracheostomy Tube with a
Disposable or Removable Inner Cannula

▣ This type of tube is similar to

the single cuff tracheostomy
tube - removable inner cannula.
▣ By removing the inner cannula,
cleaning is facilitated and it
becomes easier to maintain the
patency of the airway.
 Single CAnnula Fenestrated
Tracheostomy Tube
▣ has a fenestration or window in
the outer cannula.
▣ Removing the inner cannula and
deflating the cuff, the patient can
breathe through the upper airway.
▣ Facilitate weaning from the
tracheostomy appliance.
 Silver Holinger Tracheostomy Tube
▣ Jackson Tube
▣ nondisposable, reusable tracheostomy
tube with a removable inner cannula.
▣ It is cuffless.
▣ It made up of sterling silver.
▣ used in long term
 Bivona Foam Cuff
▣ foam cuff that self-inflates.
▣ the foam expand
▣ exert no more than 25 mmHg of
pressure against the tracheal wall.
▣ *important: do not inflate
high pressure
 SPECIALIZED TRACHEOSTOMY
TUBES AND APPLIANCES
▣ Communi-Trach
▣ Tracheostomy Button
▣ Kistner Button
▣ Olympic Trach-Talk
 Communi-Trach
▣ Pitt Speaking Tube.
▣ A fitting directs a flow of oxygen above
the cuff
▣ When patient occludes a thumb port, gas
flows up and through the vocal cords,
allowing the patient to speak.
▣ The phonation is hoarse sound but may be
understood
 Tracheostomy Button
▣ It is a useful device that facilitates weaning a patient
from tracheostomy.
▣ spacer ring for neck sizes
▣ It is inserted into the stoma with the distal tip resting
just inside the trachea.
 Kistner Button
▣ plastic tube that is inserted into the stoma
▣ A plastic cap containing a one-way valve
▣ the patient may inhale through the tube
and on exhalation the one-way valve
closes, forcing air up through the upper
airway.
▣ the patient may speak
 Olympic Trach-Talk
▣ modified aerosol T with the one-way
valve.
▣ When the device is in used, the cuff of
the tracheostomy tube is deflated and
the Trach-Talk is then placed on the
tube.
▣ When the patient inhales, the one-way
valve opens, allowing the gas flow into
the lower airway.
▣ On exhalation, the valve closes forcing
the air up through the upper airway.
 Passy-Muir Valve
▣ this device consists of a leaf or diaphragm valve
▣ it is important to deflate the cuff prior to installing the
Passy-Muir valve onto the airway.

▣ Failure to deflate the cuff prior to installing the

passy-muir valve results in the patient not having the
ability to exhale.
 SUCTIONING PROCEDURE

▣ Assembled individually, or a suction kit may be

used
▣ The first three items—suction catheter, gloves, and
goggles
 EQUIPMENT NEEDED FOR
SUCTIONING
▣ Sterile suction catheter
▣ Sterile gloves
▣ Sterile basin or container
▣ Sterile normal saline for irrigation
▣ Sterile distilled water to clean the
catheter
▣ Vacuum regulator or pump with
suction trap
▣ Flow or self-inflating manual
resuscitator
▣ Water soluble lubricant
 EQUIPMENT PREPARATION
▣ Assemble and test the manual resuscitator
▣ connect the vacuum regulator or suction pump
▣ Open the package of gloves and catheter or open the
suctioning kit
▣ Open the sterile distilled water container and pour
some into the sterile basin to irrigate the suction line
following suctioning.
 Positioning for Artificial
Airway Aspiration
▣ Semi-Fowler’s

▣ affords better chest

expansion for hyperinflation,
 Preaspiration Patient Assessment

▣ Auscultate the chest

▣ Presence of crackles is a good indication for
suctioning.
▣ Assess the patient if sustioning is needed
 Oxygenate the Patient

▣ turn the oxygen percentage control to 100%, or

press the 100% suction soft key
 NASOTRACHEAL SUCTIONING PROCEDURE
1. Glove your dominant hand using sterile technique.
2. Pick up the catheter with your gloved hand, wrapping it around
your finger to maintain the cleanliness and keep it under control
at all times
3. Expose approximately 8 to 10 inches of distal end of the catheter
and lubricate it with water soluble lubricant.
4. Connect the distal end of the suction catheter to the vacuum line,
which should already be set to the correct level of vacuum.
5. Gently insert the catheter into one of the nares with your gloved
hand.
6. Slowly advance the catheter.
7. After inserting approximately 8 to 10 inches of the catheter,
watch the patient inhale.
NASOTRACHEAL SUCTIONING PROCEDURE

8. You will be able to tell when the catheter is

inserted into the trachea because the patient will be
coughing violently.
9. As soon as you entered the trachea, connect the
vacuum and apply intermittent suction while
withdrawing the catheter.
10. the application of vacuum to no more than 15
seconds.
 NASOTRACHEAL SUCTIONING PROCEDURE

11. Withdraw the catheter. Disconnect the vacuum line

and oxygenate the patient.
12. Oxygenate and hyperinflate the patient again for 1
to 2 minutes.
13. Assess the patient to assure that the airway has
been cleared. Repeat the procedure if necessary.
14. Dispose of your equipment and clean up the area.
15. Reassure the patient and ensure that the patient is
safe and comfortable.
 Use of a Nasopharyngeal Airway

▣ will facilitate repeated suctioning while minimizing

trauma to the nose and nasopharynx.
 Artificial Airway Aspiration
provides a direct passage to the airway below the larynx
1.Apply gloves to both hands

2.Gently insert the catheter down the airway until resistance is felt

3.Withdraw the catheter 1 to 2 cm and apply intermittent suction

4.Withdraw the catheter 1 to 2 cm, and reapply vacuum.

5.Oxygenate the patient for 1 or 2 minutes

6.Repeat as required

7.Clean up the area and dispose of your equipment appropriately.

8.Ensure that the patient is safe and comfortable

9.return the patient to oxygen therapy.

 Types
▣ Temporary
▣ Permanent
▣ Emergency
▣ Surgical
▣ Percutaneous
▣ Minitracheostomy
▣ Cricothyroidotomy
 Indications
▣ Upper Airway obstruction
− Trauma
− Burns
− Corrosive poisoning
− Laryngeal dysfunction
− Foreign body
− Infections
− Inflammatory conditions
− Neoplasms
− Postoperatively
− Obstructive sleep apnea
 Absolute Contraindications
• Severe Local Sepsis

• Uncontrollable Coagulopathy
 How to measure:
▣ By rotating the valve of the stopcock, you choose
which ports are open to one another.
▣ By pointing the valve toward the patient’s pilot
tube, the syringe and pressure manometer are open
to one another and the pilot tube is “off”.
▣ When the valve is rotated opposite to the syringe, all
three ports (patient, pressure manometer and
syringe) are open to one another.
 Minimal Occlusion Volume (MOV)

▣ Procedure to inflate:
1. Turn the valve so that the open port (patient) is off.
2. Pressurize the manometer and tubing to 18 cmH2O adding
air from the syringe.
3. Attached the cuff manometer to the pilot tube by pushing
the connector together.
4. Rotate the valve so it is opposite the syringe.
5. Add or subtract air using the syringe just until no leak is
heard at the patient’s mouth. Measure the cuff pressure
 Minimal Leak Technique
▣ First turn the valve so that the open post (patient) if off.
▣ Pressurize the manometer and tubing to 18 cmH2O by
adding air from the syringe.
▣ Attach the cuff manometer to the pilot tube by pushing the
connector together.
▣ Rotate the valve so it is opposite the syringe.
▣ Add or subtract air using the syringe just until a small leak is
heard at the patient’s mouth during a positive pressure
breath.
▣ Measure the cuff.
Nasotracheal Suctioning
Tracheostomy tube Suctioning
 Relative Contraindications
• Difficult anatomy:
• Morbid obesity • Moderate coagulopathy
• Lack of neck mobility • Proximity to site of recent
• Cervical spine injury surgery or trauma
• Known difficult intubation • Potential aggravated morbidity
• Tracheal pathology
• Severe gas exchange problems:
• Thyroid pathology,
• Age: <12 years
• Aberrant vessels
• Friable tissues
• COPD with bullae
 Hazards and complications
▣ Displacement and decannulation of the
tracheostomy tube
▣ Infection
Tracheostomy
 PURPOSE OF TRACHEOSTOMY
AND STOMA CARE
1. To prevent infection and
2. Preserve the patency of the airway.
Tracheostomy cleaning and care
Extubation