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To guarantee patency of airway To improve airway protection To allow positive pressure ventilation To facilitate suctioning
Nasopharyngeal airway
It is made of soft rubber, silicone or polyvinyl chloride (PVC) Part ; flange at the proximal end and with a beveled distal end Size; distance from the nares to angle of mandible
Indication
Indicated when oropharyngeal airways are contraindicated Advantage of the nasal airways over the oral airways is that it is better tolerated by conscious and semi-conscious patient.
Contraindication
Nasal trauma Basilar Skull fractures Deformities of the nose Coagulation disorders
Hazards
Sinusitis Otitis media Gastric insufflation (if the airway is too long) Intubation of meninges (in case of head or facial trauma) Occlusion of the airway by secretion Tissue necrosis Bleeding
Oropharyngeal airway
Gudeal
Berman
Holds the tongue away from pharyngeal wall Bite block after intubation Size; lip to the angle of mandible Inserted only in deep comatose patients
Berman airway has an J beam construction with a channel along each side Guedel airway is open down the middle Size range from 000 to 6 ( premature to adult)
Indication
Unconscious patients
Contraindication
Oropharyngeal trauma Conscious or semiconscious patients --------induce (vomiting and aspiration )
Hazards
Oral trauma Pressure necrosis (if left in place too long) Gagging Vomiting Aspiration Airway obstruction ( with improper insertion)
at lips premature New born 1- 6 months 6 12 months 2 years 4 6 8 10 12 > 14 female > 14 male 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7 8
ET size10
11 11 12 13 14 15 16 16- 17 17- 18 18- 22 20 24 (21) 20 24 (23)
Rule of thumb ; outer diameter of the suction catheter should be or < the inner diameter of tracheal tube
It is usually constructed of polyvinyl chloride (PVC) or silicone The construction of Endotracheal is standard;----------------------- Distal end is beveled and rounded to minimize trauma on insertion Murphy eye ----------- ( allows passage of gas through it if the end becomes occluded by secretion. A cuff------- is present distal end of the tube
Pilot tube ------- (extends past proximal end of the tube and terminate with a pilot balloon and spring loaded valve Radiopaque line that allows for ready visualization of the tube on radiography Proximal end of the tube is fitted with a standard 15 mm adapter (universal adaptor)
Contraindication
Generally not addressed, but two important ones are complete obstruction of the upper airway Lack of person trained and experienced in tracheal intubation
Complication
Bronchospasm Laryngospasm Hypoxemia Esophageal intubation/gastric distention Rupture of trachea/cuff Aspiration (blood,tooth ,gastric contents) Airway obstruction Sore throat, dysphasia
Paralysis of vocal cords Vocal cord adhesions Tracheal stenosis Laryngeal edema/ulceration Ulceration of lips, mouth, pharynx Tracheal bleeding
Assemble and check equipment Position the patient Pre- oxygenate Insert laryngoscope Visualize and displace glottis Insert tube Assess tube position Secure and stabilize airway
Intubation
Laryngoscope
Two principal parts; handle and blade Two type of blade ;-------- straight and curved Straight blade ( Miller );------ directly lift the epiglottis to allow visualization of the vocal cords Curved blade; (Macintosh)------- indirectly lift the epiglottis
Ascultation of chest and epigastrium Observation of chest movement Tube length (cms of teeth) Airway condensation Capnometry/ copnography Gastric contents
Goals ;
Relief of upper air way obstruction Long term mechanical ventilation Acute / chronic neuromuscular conditions Brain injury
Tracheostomy tube
Advantages of Tracheostomy
Suctioning is facilitated It is better tolerated by the conscious patient Fixation of tube is easier Eating and even speaking (with proper tube )
Tracheostomy is used when Endotracheal intubation is impossible (complete upper airway obstruction ) It is used when a long term airway is needed, and it is usually considered after 10 to 14 days of intubation
Tracheostomy tubes made from a plastic, such as PVC or silicone and also made of silver or stainless steel. Several manufacturs also produce a fenestrated tube (or window)
It has four parts ;----------- Inner cannula, outer cannula, obturator and cuff The inner cannula can be removed to clean secretions and blood from interior surface without removing the entire tube. The obturator prevents blood or mucus from entering the tube as it is being inserted and provides a smoothly tapered surface to facilitate introduction of the tube into the airway.
Complication of Tracheostomy
Hemorrhage Subcutaneous emphysema Obstruction Wound infection Recurrent laryngeal nerve damage Tracheal stenosis Dysphagia Tracheoesophageal fistula Subglottic edema Aspiration and atelectasis
Increased patient mobility More secured airway Increased comfort Enchanced airway suctioning Early transfer and mobilization Improved oral hygiene and nutrition Enhances communication and phonation Reduced airway resistance
bad
good
Increased pressure --- ischemia and stenosis Decreased pressure --- microaspiration
Remove inner cannula prior to humdification and suctioning Wash inner cannula with saline and hydrogen peroxide Wet gauze pads for continuous humdification Home care