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Artificial Airways & Airway

Management

210a
Effective Cough

Components

Adequate vital capacity (VC > 15 mL/kg)

Abdominal contraction

Glottic closure
Phases of a Cough

Irritation of airway

Inspiration of adequate volume

Compression

Glottic closure

Contraction of abdominal muscles

Increase in intrathoracic pressure


Phases of a Cough

Expulsion

Opening of glottis

Explosive expulsion of air and matter (flow


up to 500 mph)
Ineffective Cough

Inadequate vital capacity

Inadequate compression

Inadequate abdominal contraction

Inability to close glottis


Suctioning

Suctioning is the application of negative


pressure to the airways through a
collecting tube
Suctioning

Suctioning of the trachea and bronchi is


usually done through an endotracheal
tube or tracheostomy tube
Indications for Suctioning

Need to remove retained secretions

Need to maintain patency of airway

To treat atelectasis

To obtain of a sputum specimen


Hazards of Suctioning

Trauma

Hypoxia

Arrhythmias

Inadequate cerebral oxygenation


Hazards of Suctioning

Infection

Vagal stimulation

Atelectasis
Hazards of Suctioning

Bronchospasm

Increase in intracranial pressure

Gag reflex stimulation


Equipment Required For
Suctioning

Oral suctioning

Negative pressure source

Suction canister

Connective tubing
Equipment Required For Oral
Suctioning

Yankauer (tonsil tip)


Suction tip

Distilled water or
saline solution in
container

Gloves
Equipment Required For
Suctioning

Nasal and tracheal suctioning

Negative pressure source

Suction canister

Connective tubing

Suction catheter
Nasal & Tracheal Suctioning
Equipment

Water soluble gel (for nasal suction)

Distilled water or saline solution in


container

Gloves
Catheter Types

Whistle tip

Argyle

Coud

Closed catheter systems


Suction Catheters

Catheter sizes

Measured in French (French/3.14 = size in


mm)

Diameter of catheter < diameter of tube

Murphy eye
Pressure During Suctioning

Adult -100 to -120 mmHg

Child -80 to -100 mmHg

Infant -60 to -80 mmHg


Suctioning Procedure

Gather equipment, identify patient,


introduce self, explain procedure, and
wash hands

Don gloves, prepare equipment


Suctioning Procedure

Hyperoxygenate the patient, as


appropriate

If suctioning nasally, lubricate the


catheter
Suctioning Procedure

Introduce the catheter into the airway,


ensuring that no suction is applied
during introduction

Advance the catheter until resistance


is met
Suctioning Procedure

Withdraw the catheter 1 to 2 cm

Apply suction continuously, withdraw


catheter, rotating catheter during
withdrawal (NOTE: apply suction for a
maximum of 15 seconds)
Suctioning Procedure

Rinse the catheter in saline or distilled


water

Reassess the patient


Artificial Airways

Oropharyngeal airway

Used in unconscious patients only to


avoid gag reflex

Prevents tongue from occluding airway


Oropharyngeal Airway

Allows passage of suction catheter


through center or along the side of
airway
Oropharyngeal Airway

Insertion procedure

Airway is upside down as it is inserted into


mouth

Rotate sideways as airway passes over


tongue

Place in correct position once past tongue


Artificial Airways

Nasopharyngeal airway

Used in conscious patients requiring


frequent suctioning

Length of airway equals length from nostril


to ear plus one inch
Nasopharyngeal Airway

Prevents tongue from occluding airway

Change from naris to naris as required


Nasopharyngeal Insertion
Procedure

Lubricate airway with water soluble gel

Examine nares; if available, choose


nares with smaller opening
Nasopharyngeal Insertion
Procedure

Gently insert airway, avoiding forcing


past obstructions

Tip of airway should be visible just


past uvula
Artificial Airways

Endotracheal tubes
Endotracheal Tubes

Specifications established by the


American Society for Testing and
Materials (ASTM)
Endotracheal Tube Marking

I.T. Implant tested

I.D. Inner diameter

O.D. Outer diameter


Endotracheal Tube Marking

Z-79 meets standards of that


committee for non-toxicity

Radiopaque line determine position


after placement

Centimeter markings to indicate depth


of placement
Endotracheal Tube Type

Cuffed

Uncuffed

Double lumen

Jet ventilation
Indications for Intubation

Maintain airway patency

Prevent aspiration

Cardiopulmonary arrest
Indications for Intubation

Establishment/maintenance of
mechanical ventilation

Bronchial hygiene
Physiologic Effects of Intubation

Decrease in VD (approximately by )

If tube is too small, may increase


resistance and work of breathing
Equipment Needed for Intubation

Suction equipment

Laryngoscope

Macintosh blade curved

Miller blade straight


Equipment Needed for Intubation

Stylet only for oral intubation

Magill forceps only for nasotracheal


intubation

Oropharyngeal airway
Equipment Needed For Intubation

Syringe

Tape or other securing equipment

Endotracheal tube choice of sizes to


meet unexpected conditions
Equipment Needed for Intubation

Topical anesthetics (lidocaine,


xylocaine) may be required

Paralyzing agents (Pavulon,


succinylcholine) for combative
patients
Intubation Procedure

Assemble and check all equipment

Ensure patient is hyperoxygenated and


hyperventilated, if possible

Determine desired endotracheal tube


size, lubricate with topical anesthetic, if
required; insert stylet for oral intubation
Intubation Procedure

Pre-oxygenate the patient

Position patient in sniffing position, if


possible

Administer paralyzing agent, if required


Intubation Procedure

Insert laryngoscope

Visualize the vocal cords

Insert endotracheal tube between


vocal cords
Intubation Procedure

Inflate the cuff

Check breath sounds; adjust position of

endotracheal tube as needed

Note and record centimeter mark at the

teeth
Intubation Procedure

Secure the endotracheal tube

Insert oropharyngeal airway

Obtain chest X-ray to ensure proper


tube placement

Check cuff pressure


Intubation Hazards

Intubation of the esophagus

Trauma to the vocal cords or trachea

Tracheal malacia, necrosis, T-E fistula

Aspiration

Fracture of teeth
Tracheostomy Tubes
Indications for Tracheotomy

Long term ventilation

Provide patent airway when upper


airway is impassable
Hazards of Tracheotomy

Trauma laryngeal lesions, tracheal


lesions

Hemorrhage
Hazards of Tracheotomy

Subcutaneous emphysema

Infection

Tracheal malacia, necrosis, T-E fistula


Types of Tracheostomy Tubes

Portex / Shiley

Jackson

Kamen-Wilkensen

Fenestrated
Care of The Tracheostomy Tube

Performed as needed according to


hospital protocol

Assemble and check equipment

Gloves and other protective gear

Suction equipment

Hydrogen peroxide
Care of The Tracheostomy Tube

Assemble and check equipment

Sterile water

Cotton-tipped applicators

Pre-cut gauze or 4 x 4 gauze pad

Tracheostomy tube ties


Care of The Tracheostomy Tube

Suction the patient

Remove and clean the inner cannula

Clean the stoma site


Care of The Tracheostomy Tube

Change the tracheostomy tube ties

Re-insert the inner cannula

Assess the patient


Changing of The Tracheostomy
Tube

Performed as needed

Perforated cuff

Mucus plug

Change in size of tube


Changing of The Tracheostomy
Tube

Assemble and check equipment

Gloves and other protective gear

New tracheostomy tube

Suction equipment

Tracheostomy tube ties

Resuscitation bag
Changing of The Tracheostomy
Tube

Pre-oxygenate the patient

Suction the patient

Remove the tracheostomy tube


Changing of The Tracheostomy
Tube

Insert the new tube

Secure the tracheostomy tube with


the ties

Assess the patient


Management of The Cuff

Pressure should be kept between 20


and 25 mmHg
Management of The Cuff

Techniques for maintaining cuff


pressure

Minimal occluding volume

Minimal leak technique

Direct measurement of cuff pressure by


manometer
Alternative Airway Devices

Laryngeal mask
airway (LMA)
Laryngeal Mask Airway (LMA)

Advantages

Ease and speed of insertion

Avoidance of laryngeal and tracheal


trauma

Intubation possible without removing LMA


Laryngeal Mask Airway (LMA)

Disadvantages

Short term use only

Cannot provide high ventilation pressures

Potential for esophageal injury

Aspiration may still occur, although risk is


decreased
Laryngeal Mask Airway (LMA)

Placement

Lubricate posterior surface of the mask

Fully deflate cuff

Using index finger, guide the insertion


along the palate and into the oropharynx

Inflate cuff to maximum of 60 cmH2O


LMA Placement
Alternative Airway Devices

Combitube
(Double lumen
airway)
Combitube

Advantages

Little skill required for insertion

Protects against aspiration

Aids in positive pressure ventilation


Combitube

Disadvantages

Short term use only

Aspiration may occur during removal

If placed in esophageal position, cannot


suction airway
Combitube

Disadvantages

Potential for esophageal injury

Difficulty in distinguishing between


esophageal and tracheal intubation
Combitube

Placement

Insert tube blindly through the oropharynx


into the trachea or esophagus

Inflate the cuffs


Combitube

Placement

Assess placement of the tube

Ventilate through the appropriate external


adapter
Combitube Placement
Alternative Airway Devices
Tracheal buttons
Used to maintain a tracheal stoma
Tracheal Buttons

Advantages

Removes the airway resistance of a


tracheostomy tube

Aids in the removal of secretions by allowing


continued access when cap is removed

Allows patient to communicate verbally, when


able
Tracheal Buttons

Disadvantages

Will not allow attachment of mechanical


ventilators

Must be removed and replaced with


tracheostomy tube in emergency situations
Tracheal Buttons

Placement

Fits through the skin to just inside the


anterior wall of the trachea