KOFF

CHAPTER 36: THE AIRWAY MANAGEMENT

BATCH 2022 HANDOUT

SUCTIONING
Equipments for suctioning:
 Suctioning is the application of negative •Suction machine (wall attachment or portable unit)
pressure ( vacuum) to the airways through a •Suction catheter
collecting tube ( flexible catheter or suction tip). •Suction bottle
Removal of foreign bodies, secretions or tissue •Sterile water
masses beyond the main stem bronchi requires •Rubber Tubing
bronchoscopy, which is generally performed by •Sterile gloves
a physician.

REMINDERS BEFORE SUCTIONING:

1. Size
›Half the size of the tube's internal diameter.
2. Pressure
 Neonate: 60 -80 mmHg
 Pediatric: 80 - 100 mmHg
3. Bag-Valve Mask
Should always be ready at patient's bedside
4. Plain NSS
›Used to help loose secretions.
Airway obstruction can be caused by Neonate: 0.30-0.50 mL

 retained secretions Children: 1 - 3 mL

 foreign bodies, and structural changes 5. Time spent

 edema, tumors, or trauma ->10s maximum

Retained secretions increase airway resistance and the

work of breathing and can cause: SPECIAL CONSIDERATIONS:

 Hypoxemia  Closed-system suctioning:

> Advantage of remaining in the ventilator circuit &
 Hypercapnia
can be readily accessible for suctioning.
 Atelectasis
 Infection
 Oral & Nasal suctioning:
>Often used only to elicit cough.
›Care must be exercised.
 ›Lubricate suction catheter. endotracheal airway without disconnecting the patient to the
 Luken traps: ventilator.
> Used to obtain secretions for culture and sensitivity
There are also two methods of suctioning based on how
testing.
deep the suction catheter is inserted in the artificial
airway : deep and shallow

 Deep suctioning is when the catheter is inserted

until resistance is met and then withdrawn approximately
POSSIBLE HAZARDS AND COMPLICATIONS
1cm before applying suction.
HAZARDS:
 Shallow suctioning is when catheter is advanced and
 Hypoxemia
predetermined depth which is usually the length of the
 Cardiac problems (e. g. arrhythmias)
airway plus the adapter.
 Tissue Trauma

Indications for intubation are varied and may

COMPLICATIONS: (1) support for oxygenation or ventilation.

 Lung Collapse (e.g. Pneumonia) (2)protection of the airway

 Hypotension and cardiac arrest
(3) cardiopulmonary arrest.

Endotracheal suctioning

There are two techniques of endotracheal suctioning :

open and closed.
 Suction pressure should always be checked by
 Open technique requires disconnecting the patient
occluding the end of the suction tubing before attaching the
from the ventilator.
suction catheter. The suction pressure should be at the
 Closed technique uses a sterile, closed in-line
lowest effective level.
suction catheter that is attached to the ventilator circuit so
 Negative pressures of 80 to 100mmHg in neonates
that the suction catheter can be advanced into the patient’s
 manual resuscitator used during suctioning,
 should be delivering approximately 0, 10 greater Fin  For neonatal 0.33 mL saline may be instilled
 Novametrix device has been reported to reduce
bradycardia and oxygen saturation
 Nasal route is the easiest route for infants
 A curved-tip catheter, or catheter coudé, is available
to help direct access to the left main-stem bronchus.

 In infants and small children, the diameter of the

suction catheter should be less than 70% of the internal
diameter of the artificial airway.

An in-line suction catheter can be used for patients

receiving ventilatory support and is recommended
over open suction because ventilation is continued
during suctioning regardless of the level of
ventilatory support provided.
However, in-line suction catheters have no effect on
risk for ventilator-associated pneumonia (VAP).

Routine instillation of sterile normal saline to aid

secretion removal before suctioning is not
recommended because there is no evidence that this
practice is beneficial, and it may increase infection
risk and destabilize the patient.

If the secretions are extremely tenacious, instillation of

acetylcysteine or sodium bicarbonate (2%) may be more
effective than normal saline; this generally requires a
physician’s order.

 25% greater pressures is normally used.

 Note : Set pressure 120 to 150
mmHg for adults, 100 to 120 mmHg for
children and 80 to 100 mmHg for
infants.

To minimize hypoxemia and lung decruitment when
suctioning a mechanically ventilated patient,
preoxygenate and suction the artificial airway with a
closed system in-line catheter to avoid disconnecting the
patient from ventilator.
EQUIPMENT AND PROCEDURES
Endotracheal suctioning : sterile water soluble lubricant
jelly is needed to aid catheter passage through the nose
 nasopharyngeal airway should be considered to help
reduce mucosal trauma in the nose of the patients who
required repeated long term nasotracheal suctioning.
 Nasotracheal suctioning: catheter insertion, after
lubricating the catheter the RT inserts it gently through
the nostrils, directing it toward the septum and floor of
the nasal cavity without applying negative pressure.
NASOTRACHEAL SUCTIONING is indicated for patients
who have retained secretions but do not have an
artificial airway
As the catheter enters the lower pharynx the
patients should assume a “ sniffing position “
 Bradycardia- most commonly problem during
nasotracheal suctioning
 Right mainstem intubation- frequently occurs on
neonates
 Tube must be largest size as possible
 Too larger risk of having decreased perfusion
 Cuffed used is not recommended under the age of 8
years
 Cricoid cartilage- the narrowest point of the airway
Correct tube internal diameter for a child is:
 Age+16/4= ID
 Height in cm / 20 = ID
 Nasotracheal Suctioning Technique
(A) Optimal position of the head to insert catheter
into the trachea. The neck is flexed, and the head is
extended. The tongue is protruded (and held by a 4 ×
4 gauze pad).
(B) After catheter has advanced into the trachea, the
tongue is released, and the patient’s head is allowed
to assume a comfortable position.
(C) View of vocal cords from above. The cords are
most widely separated during inspiration.
Sputum Sampling
This device consist of a plastic tube or cup with
flexible tubing on one end to attach to the suction
catheter. It is import to maintain sterile technique
when touching the connection points on the trap.
ESTABLISHING AN ARTIFICIAL AIRWAY
ROUTES
Artificial airways are inserted for various reasons and
involve varying degrees of invasion into the upper
airway.
 Pharyngeal airways extend only into the pharynx.
Artificial airways that are placed through the mouth or nose
into the trachea are called endotracheal tubes (ETTs).
 The process of placing an artificial airway into the
trachea is referred to as intubation.
 When the ETT is passed through the nose first, the
procedure is referred to as nasotracheal intubation.

 When the tube is passed through the mouth on its
way into the trachea, the procedure is called orotracheal
intubation.
PHARYNGEAL AIRWAYS
 Pharyngeal airways prevent airway obstruction by
keeping the tongue pulled forward and away from the
posterior pharynx.
 Pharyngeal airways are used mainly in emergency
life support.
 Nasopharyngeal airway is most often placed in a
patient who requires frequent nasotracheal suctioning,, it
minimizes damage to the nasal mucosa that can be caused by
the suction catheter.
may be placed in a patient who was recently
extubated after facial surgery. The nasopharyngeal
airway helps to maintain the patency of the upper
airway despite
swelling.
nasopharyngeal airway should be considered to help
reduce mucosal trauma in the nose of the patients
who required repeated long term nasotracheal
suctioning.
 Oropharyngeal airways are inserted into the
mouth over the tongue.
Use of oropharyngeal airways should be restricted to
unconscious patients to avoid gagging and
regurgitation. These airways maintain a patent
airway when the tongue would otherwise obstruct
the oropharynx. The airway also can be used as a
bite block for patients with oral tubes. Pharyngeal
airways are used mainly in emergency life support.
TRACHEAL AIRWAYS
 Tracheal airways extend beyond the pharynx into
the trachea. The two basic types of tracheal airways are
endotracheal (translaryngeal) tubes and tracheostomy tubes
(TTs).
 ETTs are inserted through either the mouth or the
nose (orotracheal or nasotracheal), through the larynx, and
into the trachea.
 Tracheostomy tubes are inserted through a
surgically created opening in the neck directly into the
trachea.
 ETT are semi-rigid tubes most often composed of
polyvinyl chloride or related plastic polymes and use stylet for
insertion.
 15mm- proximal end of the tube
 Murphy eye- ensures gas flow if the main port
should become obstructed .
 Angle of the bevel- minimizes mucosal trauma
 Cuff to pilot balloon- used to monitor cuff status and
pressure when the tube is in place.
 Special mechanical ventilation may require unique
types of ETT
THERE ARE IMPORTANT POINTS TO CONSIDER
WHEN USING DOUBLE LUMEN ETT’s
- Stiffer and Bulkier
Fiberoptic broncoscopy- should be performed to
ensure the proper placement
A suction source is run continuously at negative
pressure of 20 to 30 cmH2O.
TRACHEOSTOMY CARE
Tracheostomy is specifically indicated
when:
 Prolonged mechanical ventilation
 Oral and nasal intubation become difficult
 Upper airways need to be bypassed
  Double cannula- are specially
recommended for patients who are going home
with tracheostomy tube.
 Orotracheal intubation- is the usual
method of choice for emergency because the
oral passage is the quickest and easiest route in
the most cases.
However in prolonged intubation, nasotracheal
intubation may be appropriate
 Nasotracheal tubes are used somewhat less often in
the neonatal population than in other age groups.
To ease insertion , the outer surface of the tube
should be lubricated with water- soluble gel.
For the position, RT flexes the patient’s neck
and tilts the head backward with his or her hand
, placing the patient into sniff position.
A patient in need of intubation is often apneic or
in respiratory distress. Providing ventilation and
oxygenation by manual resuscitating bag and
mask with 100% before intubation helps to
ensure the patient tolerates the intubation
procedure.
No more than 30 secs should be devoted to any
intubation attempt.
If intubation fails, immediate ventilation and
oxygenation of the patient for 3 to 5 minutes
before the next attempt.
Ideally, the tip of an ETT should be positioned in
the trachea about 3 to 6 cm above the carina.
BEDSIDE METHODS TO ASSESS ENDOTRACHEAL
TUBE POSITION
- Auscultation of chest and abdomen
- Observation of the chest movement
- Tube length ( centers to teeth)
- Esophageal detection device
- Lights wand
- Capnometry
- Colorimetry
- Fiberoptic bronchoscopy
- Videolaryngoscopy
Air movement or gurgling sounds over the
epigastrium indicate possible esophageal
intubation.
 The combination of the decreased breath sounds
and chest wall movement on the left side may indicate right
mainstem intubation
Right mainstem intubation is corrected by
withdrawing the tube while listening for the left-side
breath sounds.
 Decreased breath sounds in the left lung:
- Atelectasis
- Pleural effusion
 Esophageal detection device- may used to
determine wether the tube is in the
esophagus or trachea. It is not
recommended for detecting esophageal
intubation in children younger than 1 year.
 If the tube is in the trachea, aspirating air in the
syringe is easy.  Macintosh blade- a curve blade that does not allow
straight displacement of the epiglottis
Esophageal intubation- can be assessed using
exhaled carbon dioxide, analysis capnometry.

 Inspired air – contains approximately 0.04% CO2

 End tidal gas- contains 5% CO2

ETT in the respiratory tract causes CO2 levels to

increase abruptly during expiration.

If the tube is in the esophagus, CO2 levels remain

zero.

 Colorimetric devices – are portable and disposable

and are commonly used in hospitals.

Proper tube placement in the trachea can be

confirmed without a chest radiograph by using
fiberoptic or bronchoscope

The most common complication of emergency

airway management is tissue trauma.

While the serious complications are acute

hypoxemia, hypercapnia, bradycardia, and cardiac
 Tracheostomies- can be difficult to maintain with
arrest.
the infant patient
These problems can be minimized by using proper
ventilation and oxygenation ( before, during and
after)

 Anaesthesia and sedation- can reduce compilations

and facilitate intubation in a semi comatose and combative
patient.

Difficult intubations occur because of inability to

open the patient’s mouth, inability to position the
patient unusual airway anatomy.

An endotracheal tube has a tapered tip (Cole)

is not the best choice because the tip may cause
cord damage or hinder suctioning efforts.

 Miller blade- it should be long enough to reach the

epiglottis easily