Egan's Fundamentals of Respiratory Care, 12th Edition.

Chapter
37. pp. 770-786

Maintenance and Care

for Artificial Airway
Sakinah Almashhed, Eman Alnasr
Objectives
At the end of the chapter students will be able to:
■ Avoid airway trauma associated with tracheal tubes
■ Secure the tube and maintain it’s placement
■ Ensure adequate humidification
■ Provide good cuff care
■ Minimize the possibility of infection
■ Manage artificial airway in emergency situations
■ Perform tracheostomy care/changing/ removal
AIRWAY TRAUMA ASSOCIATED WITH
TRACHEAL TUBES
◻ Artificial airways may result in pressure on soft tissues due
to :
◻ different airways anatomy
◻ or shift in airway position that can result in laryngeal and tracheal
injuries
● Because injury often cannot be assessed while an artificial
airway is in place, the patient’s airway should always be
evaluated carefully after extubation using the following:
○ Physical examination

○ Air tomography (CT)

○ Fluoroscopy, Laryngoscopy, Bronchoscopy

○ Magnetic resonance imaging (MRI)

○ Pulmonary function studies (PFT)

◻ Depending on the type of tube
? damage to the patient’s airway can occur anywhere
from the nose down into the lower trachea.
■ Because TTs do not pass through the larynx, structural
injury resulting from these airways is limited to
tracheal sites.
Laryngeal Lesions
◻ The most common laryngeal injuries associated with
endotracheal intubation are:
◻ Glottic edema (due pressure from the ETT or trauma during intubation)
◻ Vocal cord inflammation (due pressure from the ETT or trauma during intubation)
◻ Laryngeal or vocal cord ulcerations
◻ Vocal cord polyps or granulomas

◻ Others: vocal cord paralysis & Laryngeal stenosis

◻ Glottic edema and vocal cord inflammation occurs:
◻ after extubation and swelling worsen over 24 hours after
extubation
◻ Patients should be evaluated periodically for delayed
development of glottic edema.
◻ The primary symptoms of glottic edema and vocal cord
inflammation are:
◻ hoarseness and stridor.
◻ Hoarseness occurs in most extubated patients and usually resolves
quickly
? i.e. No treatment is indicated, symptoms usually resolve spontaneously.

◻ Stridor is a more serious symptom than hoarseness

? indicating a significant decrease in diameter of the airway
◻
Treatment of stridor
◻ Stridor is often treated with:
◻ epinephrine
◻ (2.25%) racemic solution or levo-epinephrine (1: 1000) via
aerosol
◻ The treatment goal is to reduce glottic or airway edema by
mucosal vasoconstriction.
◻ Intravenous steroids &/or diuretics may be given 24 hours before
extubation for:
◻ patients with prolonged intubation or patients who have failed
meeting extubation criteria (-ve leak test) because of glottic edema
prior extubation.
◻ Vocal cord polyps and granulomas develop more slowly,
taking weeks or months to form.
◻ Symptoms include:
◻ difficulty in swallowing, hoarseness, and stridor.
◻ If symptoms are severe or persistent
◻ the polyps or granulomas may have to be removed surgically.
◻ Vocal cord paralysis is likely in extubated
patients with hoarseness and stridor that
does not resolve with treatment or time.
◻ In some patients, symptoms may resolve
within 24 hours, and full movement of the
vocal cords can return over several days.
◻ If the obstructive symptoms continue,
tracheotomy may be indicated.
◻ Laryngeal stenosis occurs when:
? the normal tissue of the larynx is replaced by scar
tissue, which causes stricture and decreased mobility.
? The symptoms of laryngeal stenosis are similar to
symptoms of vocal cord paralysis—stridor and
hoarseness.
? Because laryngeal stenosis does not resolve
spontaneously, surgical correction is usually required.
? Some patients require a permanent tracheostomy.
Tracheal Lesions
Tracheal lesions can occur with any tracheal airway (ETT or TT) while
laryngeal lesions occur only with oral or nasal ETTs
Tracheal lesions include:
○ Granulomas
○ Tracheomalacia
○ Tracheal stenosis
○ Tracheoesophageal fistula & tracheo innominate artery fistula (less
common but more serious)
◻ Tracheomalacia is the softening of the cartilaginous rings,
which causes collapse of the trachea during inspiration and
expiration.
◻ Tracheal stenosis is a narrowing of the lumen of the trachea,
which can occur as fibrotic scarring, causes the airway to
narrow.
◻ In patients with ETTs, this type of damage most often occurs at the cuff site
◻ In patients with TTs, stenosis may occur at the cuff, tube tip, or stoma sites
◻ The stoma site is the most common.
● Stenosis occur most commonly at the stoma site.
Causes of stenosis at the stoma site are:
○ Too large stoma

○ Infection of the stoma

○ Movement of the tube

○ Frequent tube changes

○ Advanced age
◻ Tracheoesophageal fistula is a direct communication
between the trachea and the esophagus.
◻ Occurs soon after a tracheotomy:
◻ due to incorrect surgical technique
Signs of possible tracheal damage before
extubation:

◻ Difficulty in sealing the trachea with the cuff

◻ Evidence of tracheal dilation on chest x-ray
 A tracheoinnominate artery fistula (rare)
◻ Can occur when a TT causes tissue erosion through the
innominate artery
? massive hemorrhage and, in most cases, death.
◻ probably caused by:
? improper low positioning of the stoma or
? excessive movement of the tube.
◻ Pulsation of the TT may be the only clue before actual
hemorrhage.
◻ When hemorrhage begins, hyperinflation of the cuff may slow
the bleeding, but the patient still needs surgical intervention.
◻ Even with proper corrective action, only 25% of patients who
develop this serious complication survive.
 Prevention
Actions that can minimize the trauma caused by tracheal
airways:
○ Sedation (limit movement)
○ Using nasotracheal tubes instead orotracheal tubes
○ Swivel adaptor ( minimize tube traction)
○ Tracheostomy masks (collar) are preferred to T-tubes
○ Selection of the correct airway size
○ Minimize changing endotracheal and tracheostomy tubes
○ Maintain tracheostomy tube cuff between 20 to 30 cm
H2O.
Airway Maintenance
Airway maintenance when a tracheal airway is in place include:
● Securing the tube and maintaining its proper placement
● Providing for patient communication
● Ensuring adequate humidification
● Minimizing the possibility of infection
● Aiding in secretion clearance
● Providing appropriate cuff care
● Troubleshooting airway-related problems
Securing the Airway and Confirming
Placement
There are many ways to secure ETT in place include:
◻ Tape (most common used)

◻ Stabilizers (different types & sizes)

Case reports indicate that use of these stabilizers can

result in:
■ less skin damage, tube movement, and self-extubations
than with traditional taping.
●
◻ Stabilizing devices cannot prevent airway or skin trauma
? So, the skin around the mouth or nose should be checked

regularly.
? If there is evidence of skin irritation, the tube should be
moved to the other side of the mouth or the other nares
and then resecured.
■ Alternation of securing sites for ETTs should be done on

a routine basis to prevent skin breakdown

Tape

○ Secured to one side of the face and then wound around

the tube and airway once or twice before the end is
secured to the skin again
○ Cloth tape is better than silk tape. why?
Stabilizers
● Less tube movement
● Low chance of self-extubations compared with traditional
taping
● Stabilizers might cause skin trauma
● Endotracheal tube holder (AnchorFast)
○ Easier to change and does not cause skin ulceration

○ If there is evidence of skin irritation, the tube should be

moved to the other side of the mouth and then resecured
◻ Proper placement of an endotracheal or tracheostomy tube
normally is confirmed by radiograph
◻ The tube tip should be approximately 3 to 5 cm above the
carina in adults, or between the 2nd and 4th tracheal rings
◻ ETT position changes with movement of the head and neck
◻ Flexion of the neck moves the tube down toward the

carina
◻ Extension of the neck pulls the tube up toward the larynx
◻ When reviewing a chest x-ray for tube placement, the clinician should
also check the position of the head and neck

◻ If the tube is malpositioned, the old tape should be removed and the tube
repositioned, using the centimeter markings as a guide
◻ This maneuver usually requires two people to prevent extubation.
 Securing TT

◻ A TT can be secured by threading cloth ties through the

tube flange and tying them together on the side of the
patient’s neck.
◻ Alternatively, a commercial TT holder made of soft foam
with Velcro attachments threaded through the tube
flange can be used.
? This soft TT holder is easier to change and does not cause skin
ulceration as often as cloth ties.
◻
Securing TT con’t
◻ Whichever tube holder is used, skin damage
can be minimized by keeping the ties loose
enough to slip one finger underneath easily.
Providing For Patient Communication

◻ ETTs prevent vocal cord movement and airflow through the

cords resulting in lack of phonation.
◻ Without the ability to speak, the patient cannot easily inform
the health care providers of changes in symptoms or make
basic requests.
Ways to enhance phonation in a ventilator dependent patients
with tracheostomy tubes:
1. “ talking” tracheostomy tube
○ Provide a separate inlet for compressed gas, which
escapes above the tube, allowing phonation
Problems associated:
◻ Air leaks, mucosal drying and irritation, and secretions may

occlude the speaking gas outlets

2. The Blom fenestrated tracheostomy tube
○ It has a special speech cannula that allows ventilator
dependent patients to speak with the cuff fully inflated
○ During inhalation the flap valve opens and the flexible
bubble valve expands, blocking the fenestrations.
○ During exhalation the flap valve closes and the bubble
valve collapses, which allows air to pass through the
fenestrations so the patient can speak
3- Speaking valve (passy muir valve)
○ Placed on the external opening of the tracheostomy tube

○ Tracheostomy tube cuff should be deflated before

insertion to allow airflow around the tube
○ The patient inhales around and through the tube and
exhales only around the tube through the larynx
○ Assessment of heart rate, respiratory rate, and saturation
should follow initial placement of the valve for all patients
Ensuring Adequate Humidification

◻ Artificial tracheal airways bypass the normal humidification,

filtration, and heating functions of the upper airway.
◻ The decreased humidity and might lead to impair mucociliary
clearance and thick secretions.
To deliver humidity to non-ventilated patients with a
tracheostomy, RT should use one of the following devices
● Heated humidifier

● Large-volume jet nebulizer

● HME

○ Pts do not require O2

○ Pts do not have thick secretions.

 Minimizing the Possibility Of Infection

● Patients with tracheal airways are very susceptible to bacterial

infection of the lower respiratory tract.
The presence of infection is suggested by the following:
○ Changes in the patient’s sputum (color, consistency, or
amount)
○ Changes in the patient’s breath sounds (wheezes, crackles,
or rhonchi)
○ Chest radiograph (infiltrates or atelectasis)

○ Fever, increased heart rate, and leukocytosis

● Ways to decrease chance of infection include:
○ Adhering to sterile technique during suctioning
○ (do not introduce the organism to the airway)
○ Ensuring that only aseptically clean or sterile respiratory
equipment is used for each patient
○ Consistently performing hand hygiene between patient
contacts
◻ Efforts should be made to prevent retention of
secretions by
? Suctioning
? chest physiotherapy
? Adequate humidification
◻ Closed suction systems may be preferred to open
suction systems in preventing infection.
◻ Routinely cleaning or changing the inner cannula
on TTs also may help to minimize bacterial
contamination and infection.
◻
Providing Appropriate Cuff Care

◻ Tracheal tube cuffs are used to seal the airway for

mechanical ventilation (prevent the leak) or to prevent or
minimize aspiration
◻ Too high cuff pressure might lead to:
◻ impeding the flow of blood causing tissue damage
◻ Too low cuff pressure lead to:
◻ silent aspiration of pharyngeal secretions causing the
development of VAP
◻ The goal is to keep cuff pressures below the tracheal
mucosal capillary perfusion pressure, estimated to range
from 19 to 25 mm Hg
◻ Minimal occluding volume and minimal leak inflation
techniques are no longer recommended because they
increase the risk for silent aspiration
There are two types of cuffs:
○ Low pressure high volume

○ Low volume high pressure

● Manometers are used to measure the cuff pressure with the
“acceptable range” of pressure 20 to 30 cm H2 O
● The pilot tube is attached to the manometer
○ If the cuff pressure is more than 30 cm H2O, evacuate
some volume from the cuff
○ If the cuff pressure is lower than 20 cm H2 O, inflate the
balloon
Intracuff pressure measurements should be done regularly to maintain the cuff
pressure in the safe range to avoid tracheal wall injury and minimize risk for aspiration
of oral secretions.
High cuff pressures are a result of:
◻ The need to overinflate the cuff to seal the airway due to:
■ The tube chosen is too small for the patient’s trachea
■ or positioned too high in the trachea
■ or if the patient has developed tracheomalacia (softening of
the tracheal tissue).
■ High airway pressures generated by mechanical ventilation,
which may require adding air to the cuff to maintain an
adequate tracheal seal
Different types of cuffs have been designed to minimize mucosal
trauma
TTS Cuff (Tight-to-shaft
Foam Self-inflating Cuff cuff)

Tight-to-shaft cuff.
Foam cuff

Seal the trachea with atmospheric pressure in the cuff

■ Before insertion, the foam cuff must be deflated by actively
withdrawing air from the cuff with a cuff pressure device or
syringe
■ When in position, the pilot tube is opened to the atmosphere,
and the foam expands against the tracheal wall
■ Expansion of the cuff stops when the tracheal wall is
encountered
■ Foam cuff tubes are not commonly used except in patients who have already
developed tracheal injury
Foam cuff cont.
◻ Advantages
? minimize tracheal mucosal trauma
◻ Disadvantages
? May not minimize the risk for aspiration of oral secretions
? may make mechanical ventilation difficult.
TTS cuff-
■ Low-volume, high-pressure cuff designed to maximize
airflow around the tube when it is deflated.
■ It should be inflated only intermittently for airway
protection or short-term ventilation.
■ Because the cuff is made of a porous silicone material, it can
be inflated only with sterile water and not air.
https://www.youtube.com/watch?v=622RUlwk4SY
Minimizing Likelihood of Aspiration
Ways to minimize aspiration include:
○ Keeping the cuff pressure between 20 and 30 cm H2O
○ To minimize aspiration & injury
○ Swallowing test
○ To identify the risk of aspiration
○ False negative result can occur
○ Modified barium swallow test
○ Tube that continually aspirates subglottic secretions
○ Frequent oropharyngeal suctioning
Modified barium swallow test
Ways to minimize aspiration include (cont)
○ Tube that continually aspirates subglottic
secretions
○ Frequent oropharyngeal suctioning
Ways to minimize aspiration include (cont)

? Use of medications for stress ulcer prophylaxis, such as sucralfate,

that maintain normal gastric pH
? Positioning of patients with the head of the bed elevated 30 degrees
or more to decrease reflux
? Regular oral care
? The feeding tube can be inserted into the duodenum, with its position
confirmed by imaging.
? The use of slightly higher cuff pressure during and after feedings may
minimize aspiration. Caution !
Total Parenteral Nutrition (TPN)
ETT continuous subglottic suctioning
Accidental damage to ETT
Cuff leak can occur due to a damage to any of the following:
○ ETT cuff
○ Pilot line
○ Pilot balloon
○ Pilot balloon valve
Damage of ETT can cause:
■ Leak
■ Pressure loss
■ Inadequate ventilation
■ Unsecure airway.

● While damage to the ETT cuff itself necessitates replacement

of the tube, however, ETT can be easily fixed until the time of
changing.
How to detect cuff leak
◻ Small cuff leak can be detected by noting decreasing cuff pressures over
time
? Large leak, such as occurs with a ruptured cuff, generally has a more rapid
onset
◻ Breath sounds are decreased
? BUT spontaneously breathing patient has air movement through the tube
◻ Airflow often is felt at the mouth with positive pressure ventilation
Ways to Correct Accidental damage
to ETT
There are different techniques with equipment readily available
in any emergency situation caused by accidental cut of the pilot
balloon depend on the situation:
Situation No. 1. The one-way valve malfunctions, but the pilot
balloon and line are intact.
Situation No. 2. The pilot balloon or pilot line is ruptured.
To correct situation No. 1.
● Attach a T-piece

connector or a clave to
the pilot balloon, and
then inflate with a
syringe.
● Clamp the T piece with a

hemostat or IV tubing
clamp, and disconnect
the syringe
To correct situation No. 2.
● Cut the line below the
break. Insert either a
blunt needle or a 22G
catheter into the lumen
of the line.
● Connect it to a syringe
and inflate the cuff.
● Clamp the line, and
cover needle or catheter
with a transparent film
dressing or clave.
How to correct the leak?
◻ If the pilot tube or valve is leaking
? The tube needs to be changed as
soon as possible.
◻ However, a pilot valve (pilot balloon)
repair kit,
? permits the insertion of a
replacement valve into the pilot
tubing,
? It can offer a safe and effective
alternative until a replacement
tube can be inserted.
Algorithm for solving
leaking cuff problems (Fig.
37.43)
Care of Tracheostomy and Tube
◻ Tracheostomy tubes require daily care to:
◻ clean the site
◻ change the tie or holder securing the tube.
◻ The tubes also may be removed and replaced for routine
cleaning or in an emergency, such as obstruction of the tube
Tracheostomy Care
● Step 1: Assemble and Check Equipment.
○ Kit includes a basin and brush to clean the inner cannula
of the tube.
The function of the manual
resuscitator, O2 flow, and
suction control must be
checked before starting.
Precut gauze pad or precut Cotton-tipped
Water-soluble lubrican
foam dressing applicators
● Step 2: Explain Procedure to Patient.
○ Confirm the patient understands what will be done.

● Step 3: Suction Patient.

○ A tracheostomy tube is much shorter than an ETT.

○ The catheter is inserted just to the end of the

tracheostomy tube to avoid causing mucosal injury to the
carina.
● Step 4: Clean Inner Cannula (If Present and Non-disposable).
○ The inner cannula is removed and placed in the basin.

○ In the case of a ventilator-dependent patient, the spare

inner cannula is inserted
○ the cannula then is left to soak in sterile water and
hydrogen peroxide
○ The brush is used to remove any dried secretions from the
inner lumen or the outside of the cannula.
○ The cannula is rinsed with sterile water and allowed to air
dry on sterile gauze.
 Step 5: Clean and Examine Stoma Site.

○ The dressing (if present) is removed and disposed.

○ Applicators that have been dipped in sterile normal saline are used to
clean around the stoma site.
○ After cleaning liquid, a skin barrier should be applied to protect the
skin from moisture.
○ A clean dressing, if needed to absorb drainage, is placed under the
flange of the tube.
○ An absorbent foam dressing, especially if there is excessive drainage
around stoma, should be used.
clean dressing

Absorbent foam dressing

◻ If the stoma site appears red or swollen, has pus around it, or
is emitting a foul smell, the physician and nurse should be
notified.
● Step 6: Change Tie or Holder
○ The clinician cuts the old tie or loosens the Velcro holder.

○ One hand is kept on the flange of the tracheostomy tube

to keep it secure
○ The old tie or holder is removed and discarded.

○ The clinician replaces the tie or holder, keeping one finger-

width of space between the neck and tie or holder.
● Step 7: Replace Clean Inner Cannula (If Present)
○ If the inner cannula is marked disposable and is not to be
reused, a new one is inserted
● Step 8: Reassess Patient
○ The clinician checks for:
○ adequate breath sounds
○ checks vital signs and oxygenation
○ and confirms no adverse effects
Changing a Tracheostomy Tube
● Tracheostomy may be changed in the following cases:
○ Mucus plug development in the inner cannula of tracheostomy tube.
○ Damage to the cuff
○ If a different size or type of tube is needed
○ Because a single cannula tube has no inner cannula to remove for cleaning, it
may need to be replaced periodically.
● Intubation equipment should also be available during time of
changing tracheostomy tube.
● Step 1: Assemble and Prepare Equipment.
○ In addition to the equipment described previously, the
new tube, an extra tube one size smaller, and water-
soluble lubricant are necessary.
? For partial closure of the stoma site and difficulty reinserting initial size tube

● Step 2: Explain Procedure to Patient.

 Step 3: prepare equipment
Sterile technique must always be maintained for the distal portion of the
cannula, which goes into the trachea.

○ Inner cannula is removed and placed on a sterile surface

○ The obturator is inserted
○ The tie or tracheostomy tube holder is attached to one
side of the flange of the tube
○ The clinician inflates the cuff, checks for leaks, deflates
the cuff, and apply lubricant in the distal part.
● Step 4: Prepare Patient.
○ The patient should be placed with the neck extended so
that the tracheal stoma is accessible.
○ The patient is suctioned and hyperoxygenated.
Step 5: Remove Old Tube.

○ The tie is cut, or the Velcro tracheostomy tube holder is opened.

○ The cuff is deflated.
○ The clinician removes the tube by following the curve of the tube.
○ The clinician grasps the outer portion of the tracheostomy tube
with one hand and rotates the wrist toward the chest.
○ The stoma is inspected for any bleeding or other problems, such as
granuloma or ulceration.
● Step 6: Insert New Tube and Assess Patient
○ The new tube is picked up by the proximal portion.

○ The surface that enters the trachea should not be touched.

○ The tip of the obturator is inserted into the stoma, and the
tube is advanced following the curve of the tube.
○ While holding the flange of the tube against the neck, the
clinician immediately removes the obturator.
◻ The clinician assesses for airflow through the tube.
◻ Coughing may reflect pressure on the outside of the trachea.
The patient is assessed for proper tube placement and
tolerance of the procedure.
◻ If extreme difficulty is encountered inserting the new tube,
insertion of the “stand-by” tube, which is one size smaller, is
attempted.
◻ Step 7: Secure Tube.
• While still holding onto the flange, the clinician secures
the tracheostomy tube tie or holder without
overtightening.
• Inner cannula is inserted.

• The clinician reassesses for airflow and reapplies the O2

therapy device or ventilator
◻ Step 8: Reassess Patient.
• Suctioning may be required again.
• The clinician checks vital signs and O2 saturation
(SaO2 ) and assesses the patient’s overall tolerance
of the procedure.
Tracheostomy Tube Removal
(Decannulation)
◻ Decannulation refers to removal of the tracheostomy tube.
• Patients who received a tracheostomy due to upper
airway obstruction
■ TT should be removed in one step
• Patients who have been on mechanical ventilation for an
extended time
■ Weaning process is used rather than abrupt removal of
the tube
◻ Weaning is accomplished by using the following:
• Fenestrated tubes

• Progressively smaller tubes

• Tracheostomy buttons
◻ Before decannulation, a comprehensive patient assessment
is required:
• Sufficient muscle strength (peak expiratory pressure >40
cm H2O) to generate an effective cough
• No active pulmonary infection

• Accepted volume and thickness of secretions

• Adequate swallow
◻ After decannulation, the following should be ensured:
• The ability of the stoma to close on its own in a few days

• Cleaning around the stoma

• Sterile occlusive dressing should be applied over the

stoma until it closes
Assessment After Tracheostomy Decannulation

◻ The patient should be assessed for vocal cord responses.

◻ Vocal cord abnormalities can result in either aspiration or acute airway
obstruction.
? Symptoms such as stridor, retractions, and inability to feel airflow
through the upper airway indicate upper airway obstruction.
? A replacement TT and suctioning equipment should be available in
case the patient develops any of these symptoms of obstruction.
Fenestrated Tracheostomy Tubes
◻ A fenestrated tracheostomy tube is a double cannulated
tube that has an opening in the posterior wall of the outer
cannula above the cuff
◻ Removal of the inner cannula opens the fenestration,
allowing air to pass into the upper airway.

◻ Capping or placing a speaking valve on the proximal opening

of the tube’s outer cannula, accompanied by deflation of the
cuff, allows for assessment of upper airway function
◻ Removal of the cap or speaking valve allows
access for suctioning.
◻ If mechanical ventilation is needed, the inner
cannula can be reinserted and the cuff reinflated.
Limitations:
◻ Malposition of the fenestration, such as between the skin
and stoma or against the posterior wall of the larynx
◻ Granular tissue formation on the posterior tracheal wall
Progressively Smaller Tubes
◻ This technique is also indicated in patients whose airway is too
small for the available fenestrated tubes
◻ The use of progressively smaller tubes may also allow for better
healing of the stoma.
Limitations:
◻ The continued presence of a tube within the lumen of the airway
(increasing Raw)
◻ Impair coughing

◻ The fit of the tube within the trachea

Tracheal Buttons
◻ Tracheal button fits through the skin to just inside the
anterior wall of the trachea (No Raw)
◻ Relieve airway obstruction and aid in the removal of
secretions
Limitations:
◻ When the inner cannula is removed, the clinician needs to

hold the outer cannula in place to prevent it from being

coughed out during suctioning
Management of Artificial Airway (ETT or TT)
Emergencies
◻ Respiratory distress; changes in breath sounds; decrease in
air movement are all emergency situations that may occur as
a result of the following:
• Tube obstruction

• Cuff leaks

• Accidental extubation
Tube Obstruction
Tube obstruction can be caused by:
• The kinking of the tube or the patient biting on the tube

• Herniation of the cuff over the tube tip

• Obstruction of the tube orifice against the tracheal wall

• Mucous plugging
◻ With partial obstruction:
• Pt spontaneously breathing (CPAP, BiPAP, VS)
• Decreased breath sounds
• Decreased airflow through the tube
• Pt on volume-controlled ventilation
• Peak inspiratory pressures increase
• High pressure
• Pt on pressure-controlled ventilation
• Delivered VTs decrease
◻ With complete tube obstruction:
• Patient will exhibit severe distress

• No breath sounds are heard

• No gas flow through the tube

Problem
Tube is kinked or positioned
against the tracheal wall
Herniated cuff blocking the
airway
Suction catheter does not pass
through the tube (mucus plug)
Troubleshooting
Moving the patient’s head
and neck or repositioning the tube
If this action does not relieve the
obstruction, a herniated cuff may
be blocking the airway
Deflating the cuff
• Suctioning the tube try 1st
• Instillation of sterile normal
saline into the tube
• Use mucus shaving device
• Change/remove inner cannula
Mucus Shaver
Mucus Shaver
The Mucus Shaver is a concentric, inflatable catheter for the
removal of mucus and secretions from the interior surface of
the ETT.
The Mucus Shaver is advanced to the distal ETT tip, inflated
and subsequently withdrawn over a period of 3–5 seconds
device to keep the endotracheal tube free from secretions
◻ If the obstruction cannot be cleared by using these
techniques, the airway should be removed and replaced
◻ In patients who have undergone recent tracheotomy (4 or 5
days earlier), the stoma may close when the tube is removed
◻ If suture ties were left in place by the surgeon, they can be
used to pull open the stoma.
◻ After the obstructed airway is removed, restore adequate
ventilation and oxygenation
◻ For a patient with a tracheotomy stoma, the stoma need to
be covered with a gauze pad and the patient need to be
manually ventilated with a mask
 Obstruction

1 Reposition the neck or tube Pass a suction catheter; where

3 the catheter stops = Where the
2 Deflate the cuff (herniation) obstruction is

Catheter does not go beyond

the tip of ETT = Mucus plugging

▪ Suction
▪ Mucolytics
▪ Saline
▪ Mucus shaving device

4 Remove the tube

 Cuff leak
(↓ cuff pressure, ↓BS, air flow felt in mouth)

1 Cuff rupture 3 Tracheomalacia causing

trachial dilation
2 ETT position too high
Emergent re- causing leak
intubation using Increase the cuff
Bougie pressure to seal the
Advance ETT and re- trachea
assess
 Accidental extubation

1 ↓BS, ↓ air flow ?

Ablt to psss the whole suction cateter w/o feeling

2 resistance or coughing ? pt on MV >
decrease in
delivered volumes
3 Airflow into the stomach? or pressures
occurs.

▪ Remove the ETT

▪ BVM until re-intubation
Any Question?