Airway Management of the

Intubated and Mechanically

Ventilated Patient
Yohanes WH George, SpAn
Intensive Care Unit
Pondok Indah Hospital
Jakarta
Remember….

INTUBATED PATIENT

“COMPROMISED HOST”

LOST OF NORMAL UPPER AIRWAY

DEFENSES THAT PROTECT THE LUNGS
FROM;
• BACTERIA
• FOREIGN BODIES
• ASPIRATION OF SECRETIONS
AIRWAY MANAGEMENT OF THE ;

E NT SEC
G EM UR
ING
ANA THE
F M
CUF Intubated patient TUB
E

HU
MI
Mechanically Ventilated ENT
DI EM
FIC AC
AT TUBE SUCTIONING PL
RE
IO BE
N TU
 SECURING THE TUBE
• Prevent accidental extubation
• Prevent advancement into one
of the main bronchus
• Minimize frictional damage to
the upper airway, larinx, and
trachea caused by the patient
motion
• Adhesive tape wrapped
arround the tube and applied
to the patient cheeks
• Tincture of benzoin sprayed on
the skin provides greater
fixation
• Alternatively, tape, IV tubing,
or umbilical tape brought
arround the patient’s neck to
secure the tube
• Bite block
• Marker on the portion
protruding from the patient’s
mouth or nose
CUFF MANAGEMENT
Murphy eye

Low pressure High volume tube

Patient End

Markedly reduced the incidence of tracheal ishemia

 CUFF MANAGEMENT

 Low Pressure High volume


High Pressure Low volume
 CUFF MANAGEMENT
– The cuff should be inflated just beyond the point
where an audible air leak occurs
– Maintenance air cuff pressure between 17-23 mmHg
– Intracuff pressure should be checked periodically
(pressure gauge and syringe with a three-way
stopcock)
– The need to add air continually to the cuff, indicates;
• The cuff or pilot tube has a hole on it
• The pilot tube valve is broken or cracked
• The tube is positioned incorrectly and the cuff is between
the vocal cord
 CUFF MANAGEMENT
• If The valve is broken;
– Attaching a three-way stopcock to it
• If the valve housing is cracked;
– Cutting the pilot tube and inserting a blunt
needle with a stop cock into the lumen of the
pilot tube
• Change the tube
 HUMUDIFICATION
• ETT / Tracheostomy  bypass the upper airway
• Relative Humidity of inspired gas falls below
50%; (Chalon J, 1974)
– Increased mucus viscocity
– Depressed ciliary function
– Cytological damage to the tracheobronchial
epithelium, including mucosal ulceration, tracheal
inflamation and necrotizing tracheobronchiolitis (Circeo
LF, 1991)
– Microatelectasis from obstruction of small airways
– Airway obstruction due to tenacious or inspissated
sputum
 HUMUDIFICATION

• METHOD AND DEVICES

– Water bath humidifiers
– Cold water humidifiers
– Hot water humidifiers “Gold Standard” :
• Fisher-Paykel (blow-by)
• Bennett Cascade (Bubble/Cascade)
– HME (heat and moisture exchangers)
 HUMUDIFICATION
• Complications of Humidification
– Inadequate humidification
– Overhumidification
– Imposed work of breathing
– Infection
• “Self-colonization” of the circuit within the first 24 h of use
(Craven DE et al 1984, Dreyfuss et al 1991)  not-significant
• “Outside contamination”  circuit is changed too frequently
(every 24 h  Craven DE et al 1982) and (every 48 h 
Dreyfuss et al 1991)
• HME filters  efficiency 99.9977%
• Incidence of NP is not altered whether heated humidifiers or
HMEs (Misset B et al 1991  prospective randomized)
 TUBE REPLACEMENT

• Need to be replace; air leak, obstruction

• Conversion to tracheostomy if suspected prolong MV:
– Optimal time remain controversial (Berlauk JF 1986, Stauffer JL
1981, Heffner JE 1986)
– Early tracheostomy (7 days) in selected neurosurgical patients
with poor GCS scores was associated with reduced incidence of
tracheobronchial colonisation by multiple pathogens,
improvement in chest infection, and rapid weaning from
ventilatory support (WHL Teoh, 2001)
 AIRWAY MANAGEMENT OF THE
MECHANICALLY VENTILATED PATIENT
Enhance the mucocilliary clearance:

1. Mechanical augmentation of mucocilliary

clearance
 Chest physiotherapy
 Closed-chest oscillation technique
 PEEP
 Suctioning
2. Pharmacologic augmentation of mucocilliary
clearance
 Bronchodilators
 Mucolytics
 Chest physiotherapy
Combination of the;
– therapeutic positioning
– Percussion to the chest wall over the affected area
– Vibration of the chest wall and
– coughing

To improve and mobilized secretions

(gravity and external manipulation to the thorax)

Optimizing V/Q ratio

 Chest physiotherapy

Postural drainage:
– Turning or rotating
• movement/flow of secretions toward the central airways
– Percussion and vibration
• mobilized secretion that are adherent to bronchial wall

(no convincing evidence demonstrated the superiority

of one method over the other)
 Chest physiotherapy
Turning or rotating
• Indication:
– Bronchiectasis
Thomas J et al. 1995
– Cystic fibrosis
– COPD who produce > 30 ml of sputum/day Murray JF, 1979
– Lobar atelectasis Marini JJ, 1979
• Contraindication:
– Asthma patients Murray JF, 1979
– When proper positioning cannot be performed
– When injuries would preclude it
– When preexisting disease might be exacerbated by it
Peruzzi WT, 1995
 Chest physiotherapy
• Specific contraindication to the:
– Trendelenburg position:
  ICP
• Recent neurosurgical procedure
• Unclipped cerebral artery aneurysm
• Uncontrolled hypertension
• CPE
• Increased risk of aspiration
• Recent eye surgery
– Reverse trendelenburg position:
• Hypotension
• Hemodynamic instability
 Chest physiotherapy
Percussion and vibration

• Contraindication:
– Skin wounds, burns, skin graft
– Thoracic or spinal injury, ribs fracture, flail
chest, pulmonary contusion, bronchopleural
fistula, recent or unstable spine fracture
– Severe coagulapathy or active bleeding
 Chest physiotherapy

• Complication:
– Massive pulmonary haemorrhage
– Decreased PaO2
– Rib fractures
– Increased ICP
– Decreased CO
– Decreased lung function
 Alternative airway clearance
method

• PEEP therapy (mask)

• Force expiratory technique
• Autogenic drainage

ICU patients and those with short-term pulmonary

complication are less viable candidates
 High-Frequency Chest Wall
Oscillation
• Produces transient increases in airflow at low
lung volumes
• Cough-like shear forces
• Alterations in the physical properties of mucus
• Increases in mucus mobilization

Gross D et al 1985, Piquet J et al 1987, King M et al 1983, Arens R et al 1994

 Suctioning

= Mechanical aspiration
– Removing bronchial secretion
– Safe and effective if performed properly

Demers RR 1975, Demers RR 1982

 Suctioning
• Equipment for
suctioning
– Suction units
• Portable (hand, foot,
oxygen, or battery
operated)
• Stationary (electrical or
vacuum)
• Must generate vacuum
levels of at least 300
mm Hg and flow rate of
30 liters per minute
 Suctioning
• Equipment for • Equipment for suctioning
suctioning in mechanically
– Suction catheters ventilated patient
• Hard suction (tonsil tip) – Suction catheters
– Rigid tube with holes • Soft suction (whistle tip)
at distal end
– Long flexible tube that can
– Used to remove large extend into the respiratory
particles from upper tract
airway
– Cannot remove large
– Can be inserted along particles or large volumes
oral airway of secretions
– Can cause soft tissue – Cannot cause soft tissue
damage damage
 Suctioning

• How often? How should it be done to

prevent hypoxemia?
• Conventional
– Hyperinflation
– Hyperoxygenation
– Hyperventilation
• Closed System vs Open System technique
 Suctioning
Preoxygenation:
– Patients should be ventilated with manual
resc. bag (10-15 l/m of O2) or,
– Six extra ventilator breath on 100% O2

Minimizes hypoxemia
 Suctioning
Strict aseptic technique;
– Sterille gloves over freshly washed hands
– Sterille suction catheter
– Cath should be placed into the airway and advanced, without
application of a vaccum, until it can no longer easily be advanced
– The cath should be withdrawn slightly before suction is applied
– Gradual withdrawal of the catheter in rotation fashion
– The duration of the procedure should not exceed 20 seconds.
(limit each attempt to 10 seconds)
– After completion of suctioning, the patient should be manually
ventilated or provided with six extra ventilator breath 21% to
ensure adequate lung reexpansion and oxygenation
 Suctioning

Contraindication:
– Patients with high PEEP
– Unstable haemodynamic
profile
 Suctioning
• Closed suction (CS)
catheter system
– Allow flexibility to
advance or retract the
catheter into the
patient airway without
disconnecting the
patient or interrupting
MV
– Suctioning through the
adapter
– The catheter can be
left in line and
discarded after 24
hours
 Suctioning
• Effect of Different Endotracheal Suctioning
System on Cardiorespiratory Parameters of
Ventilated Patients. CKS Lee et al 2001
– Prospective randomised cross-over study
– CS vs OS
– Results ;
• OS suctioning results in more adverse changes in
cardiorespiratory parameters compared to CS suctioning
• CS found to better maintain SpO2 and less increase in HR
and MAP
• Very significantly, no cardiac dysrhythmia during CS
compared to a 38.5% incidence with OS
 Suctioning
Complication;
– Trauma
– Laryngospasm
– Bronchospasm
– Hypoxemia
– Cardiac arrhythmias
– Respiratory arrest
– Cardiac arrest
– Atelectasis
– Pneumonia
– Misdirection of catheter
– death
Pharmacologic augmentation
of mucocilliary clearance

 Bronchodilators
 Mucolytics
Pharmacologic augmentation of
mucocilliary clearance
Nebulised bronchodilators

a) General Principles
i) These agents are the mainstay of treatment for
bronchospasm in Intensive Care (including acute severe
asthma).
ii) They are not routinely used in all ventilated
patients.
iii) Once commenced, they must be reviewed daily regarding
efficacy. This is assessed by improvements in audible
wheeze, lung compliance, respiratory rate and blood gases.
b) Indications:
i) Pre-existing asthma / chronic airflow obstruction
(CAO)
ii) Acute severe asthma
iii) Acute bronchospasm due to infection, aspiration
or during mechanical ventilation
iv) Acute exacerbation of CAO
Pharmacologic augmentation of
mucocilliary clearance

Parenteral therapy
a) Indications:
i) Adjunctive therapy for acute severe asthma in
patients not responding to nebulised agents
ii) Selected patients who are difficult to wean from
ventilation (usually due to CAO)
iii) Maintenance in patients with chronic airflow
obstruction
b) Complications
i) Hypokalaemia, metabolic alkalosis
ii) Arrhythmias (theophylline)
iii) Intercurrent infection (steroids)
iv) Polyneuropathy (steroids)
THANK YOU FOR
Royal Adelaide Hospital, Intensive Care Unit,

YOUR ATTENTION
Medical Manual, 2003 Edition