Airway ManaQ_e_m_e_n_t _

When you can't breathe, nothing else matters.American Lung Association Motto

Airway management i one of my favorite subjects. It is very satisfying to help patients breathe better in such a dramaticfashion. While there i no substitute for experience, Chapter 33 will help you learn how to use equipment, tubes, andtechniques to deal with airway emergencies. You will want to become an expert in every aspect of this subject so thatyou can become a skilled knowledgeable provider and a resource for other health care professionals. The chapter has aton of material but it all falls into three basic areas:

• Airwa clearance devices and techniques• Insertion and maintenance of artificial airways• Special airway management procedures

Patients \ ho can't clear their own secretions are at risk for all kinds of problems Uke increased work of breathing,atelectasis, and lung infections. It's our job to get in there and clean out those airways. Respiratory therapists (RTs)suction both the upper and lower airways. .

1. Thou shall assess thy patient.II. Thou shall use the correct vacuum setting.m. Thou shall use the right catheter size.IV. Thou shall preoxygenate and hyperinflate thy patient.V. Thou shall withdraw 1 to 2 em prior to suctioning.VI. Thou shall suction on withdrawal only.VII. Thou shall limit the duration to 10 to 15 seconds.vm. Thou shall reoxygenate and hyperinflate after each attempt.LX. Thou shall only in'igate when indicated.X. Thou shall morutor thy patient.

1. Oral suctioning alone is usually accomplished with a rigid plastic tube called a tonsil tip. What's the other commonname for this devite\ '

41!mtRJI2. Why do you need to be careful when you're putting a device in someone's mouth? (Hint: Did you ever stick your

toothbrush too far into the back of your mouth?),no, {t\:\ ty..,- c\ eurr..·~t,(, -\-~ cnUITlS /\} \ (l C\d\fe:~tlL-~ C..,\/"1 NJou3-b

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Endotracheal suctioning is a vital, but potentially risky procedure. Closely following the rules will greatly reduce yourchances of causing an adverse reaction. The AARC Clinical Practice Guidelines in your textbook give a good overviewof this subject.

COMPLICATION CAUSE PREVENTION

A. Hypoxemia \009;B. Cardiac arrhythmia

C. Hypotension

D. Atelectasis

E. Mucosal trauma

F. Increased ICP

4. Discuss the advantages and disadvantages of closed-system multiuse catheters.

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B. Disadvantages ojW

5. What special catheter is used to facilitate entry into the left mainstem bronchus?

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6. How should you position a patient for nasotracheal suctioning?

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Establishing the Artificial AirwayComplete the following paragraph by writing in the correct term(s) in the blank(s) provided.

Q X'dDV 0-Q..irL ~\ tubes are long, semirigid tubes, usually made of 0 . \ chlorideor some other type of plastic. A typical ET tube has nine basic parts. The proxima end (s cking out of. he mouth) has

-mm adaptor. The body of the tube has \.Q..N\(~_. markings

in centimeters. The tube ends in a 'YJR_,}.IL;\ t.~ tip. There is a port, or slot, cut in the side of the tip

c,lled, r, tJ.S Qh.&j~ eye. Thi, ,lot help, en""e g" flow IT the tip ;, ob"ructed. In'' ""ove the tip, ,

C~t- is bonded to the tube, that can be inflated to seal the airway to prevent aspiration or provide

for ~()':;>\ -\--l\) r...."t pressure ventilation. A small filling tube leads to a ~ 0 Co\balloon. This small balloon has a spring-loaded l 'f9..J: UL with a connector where a syringe can be

'-"attached to allow inflation or deflation. A (~1>pad~ M= indicator, or line, is embedded in the wall ofthe tube body to make it easier to see the tube position on a\el1est x-ray.

Another commonly used tube, inserted through a surgical opening in the trachea, is called at", G-Q,NS:\] )~tube. These tubes are also made of plastic, or occasionally metal such as ~~\)JU(· .The

)s-

~ cannula forms the primary structural unit of the tube. Like the ET tube, a

CA.~ may be attached near the end to seal the airway. A f1(1 n~ is

attached to the proximal end to prevent slippage and provides a means to secure the tube to the neck. Many tubes have

a removable .rC) If\J... /1' cannula with a standard t~. -mm adaptor. This

cannula can be removed for cleaning. A special device called an GbtLLYQ..;\{) ~ has a rounded blunt endand is used to facilitate insertion.

There are three specialized endotracheal tubes you should know about: double-lumen, jet ventilation tubes, and CASStubes. Pay attention, this is board material!

These are also called Carlen's, or endobronchial, tubes. What is the name of the special type of ventilation used

with this tube? \I)&l.@ Oont \~J..\·i\Cj (..Je-oti t.Qful) f\

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benefit of the CASS or Hi-Lo Evac Tube?

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16. Describe two common troubleshooting procedures used when the laryngoscope does not light up properly.

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\ ' M{Vt ~ Ih '-+-f.:t>ft-:l f"l{}eJ 10 b().(.L e:f- -j~w fa I' -!-VUh1p~18. How are tub{;ize~s~~Hl for adults? How does SIze dIffer tor men and women? Do you agree with the sizes

for men and women in~;ble 33-2 on page 707 of your textbook?

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19. Prior to insertion, how should the RT test the tube?

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wi. foc\t6

22. How long may you attempt intubation? Why do you think we have a rule like this one?

!to ~C\& ~ ~ (5XOArnt- h1jp~~

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24. Compare the use of the)tiller and Macintosh. laryngoscope blades during the intubation procedure.

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~f~glCAie ~pJqWt7J25. Your textbook describes eight methods for bedside assessment of correct tube position. While none of these

methods absolutely confirms position, they are essential assessments to make right after the tube is placed. Heartassociation says there should be three surveys of intubation. Fill in the information from Box 33-4 on page 709of your textbook.

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323

\OJftJ~5C 9'f' ~26. What is the disadvantage of using capnographic or colorimetric analysis of carbon dioxide to assess intubation in

a cardiac arrest victim?~ Ceu-dl o..c o.J {Q~t U\ l;\-\ fV\( r~U-(1:: Q\ 5 LOZ

c\lAQ- tb L,o..L1v of 0(ood Pt Dc..u

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29. Describe the two techniques used for nasal intubation.

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30. Let's compare oral and nasal intubation. Each has advantages and disadvantages. Place a letter "0" by items thatmatch oral intubation and a letter "N" by items that go with nasal intubation. Check out Table 33-1 on page 704for help.

A. avoids epistaxis and sinusitis 0B. greater comfort for long-term use NC. easier to suction DD. larger tube DE. greater risk of extubation D

324

Chapter 33 Airway Management

F. improved oral hygiene tJtJ

G. bronchoscopy more difficult

H. increased salivation 0(3

1. reduced risk of kinking

1. decreased laryngeal ulceration lJK. increased risk of sinusitis !J

TRACHEOTOMY

31. What is the primary indication for performing a tracheotomy?

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32. When is tracheotomy the preferred primary route of airway management?

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33. Describe the sequence for removing an ET during the tracheotomy procedure. You might want to remember this

procedure! dfr{~; C/~ J(2-\Ce.-~ ~US\- OS ,\-·rado \~~~S~d.- \(\10 ~e

The percutaneous, or bedside, tracheal tube insertion is by the most common method for lCU patients in our islands. Ihope you get to watch or assist while you're in school.

A. ~~ld~' _B. ~S ~O OQOe\ 00'( koJf§~)rt -.\-0 O~O;hI1C\ f1:>O~

C. \D\h?eJC \\\C;\C\€x\ffi cf ~<',o~-h~ o.cl ~~Q..h~LO'f\{\ Q\.J'-c~~ ~.

INJURY SYMPTOMS

A. Glottic edema

B. Vocal cord inflammation

C. Laryngeal ulceration

D. Polyp/granuloma

E. Vocal cord paralysis

F. Laryngeal stenosis

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/911d~1l11)n ~--rOch ~Tracheoinnominate fistula is a rare, but serious complication. What are the clues and what are the immediate andcorrective actions taken? What is the survival rate?" 15-0_. .. \

I \ ;70 \jJ\ \ \. 6( e..-5U;VOj!/y

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Once placement of an artificial airway is successfully completed the real fun begins. As an RT, you will be expected tosecure the airway. maintain adequate humidification, manage secretions, care for that cuff, and troubleshoot problemsthat arise-some of which are life threatening.

How do fi~on and extension of the neck affect tube motion? What is the average distance the tube will move(in cm)? / I

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43. People with endotracheal tubes can't talk and they shouldn't try. What device is used to help withcommunication?

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45. A trach can be temporarily closed with a finger (the patient's finger or yours, with a glove of course!). A moreeffective solution in the long run is the Passy Muir valve. What do you need to do with the cuff? How about theventilator?

46. What is the worst problem that results from inadequate humidification of the artificial airway?

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48. What device can be used as an alternative to heated humidifiers for short-term humidification of the intubated

patient? t\Mz,S

50. Describe three techniques that can be used to decrease the risk of infection.

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52. Describe the shape of a modem tube cuff.

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54. Describe the two alternative cuff inflation techniques.

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B. MLT , •t-\ t\ 0C\.-~ /'

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RTs and nursing personnel may share some of the tracheostomy care duties. These tubes require daily care to keep thewound clean and the tube functioning properly.

Your textbook makes changing a trach tube sound simple. It can be a harrowing experience. The first change is oftenperformed by the surgeon. Be especially careful when:

• The neck is thick.• The site is inflamed or infected.• The trach is fresh.

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62. If you cannot clear the obstruction, what action should you be prepared to take?

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What effects will occur with a cuff leak when a patient is being mechanically ventilated?

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Extubation is a procedure commonly performed by the RT. You will need to be familiar with the indications for extuba-tion and techniques used to minimize risk during this procedure.

66. The decision to remove the airway and to remove the ventilator are NOT THE SAME! What kind of patientsmight need to remain intubated even after the ventilafor is removed?

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67. Describe two methods for performing a "cuff-leak test."A.

By the way, we have NOT come up with a magic number for a leak that predicts success. No leak is bad, more leak isgood. That's it.

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B. O~-I QLLQO~) \,

c. ~ cunteu -10~D. '!n1vJJ~'{)~f\_~~~_r_J _E. rfaCf)Jn('C, ~ ~7DJ2{2hl~ MmfL/

69. You will need to suction which two places before extubating? Name them and describe the correct sequencing for

Describe the two different strategies for removing the tube itself.

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B. C1uJ[ t net ~JA r, \J\9;fV[:A:tf~1f) deAA u£c.e d h Lj(b81l~'U.~-h 1Y) h lAg

What therapeutic modality is usually applied immediately after extubation?

72. List two or three of the most common problems that occur after extubation.

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73. The worst complication of extubation is laryngospasm. What can you do if this persists for longer than a fewseconds?

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76. State the three methods for weaning from a tracheostomy tube. Give one advantage and one disadvantage for eachtechnique. Thi i national exam material.

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You might need to have a few more airway tricks up your sleeve. LMAs are increasingly popular devices, especially inthe operating room and the EMS settings. Combitubes are also a part of the prehospital setting. Both of these tubes arenow a part of Ad "anced Cardiac Life Support (ACLS) training. Emergency cricothyroidotomy may be needed if theupper airway is ob tructed. Paramedics may put these in but RTs usually do not.

While rigid scopes are usually used in the operating room, flexible bronchoscopy is often done at the bedside with theRT playing a key role in patient preparation and monitoring during the procedure.

80. State one advantage and three disadvantages of the rigid bronchoscope.

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81. Give an example of a specific drug and the general goal for each of the following classes of premedication usedin bronchoscopy.

DRUG CLASS EXAMPLE GOAL

A. Tranquilizer

B. Drying agent

C. Narcotic-analgesic

D. Anesthetic

82. What drugs would RTs nebulize prior to the procedure on a nonintubated patient? What about after theprocedure?

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Em:i:!Im _Case 1

During your first day of clinical training in the ICU, a patient sustains a cardiac arrest. Your clinicalinstructor asks you to assist in preparing the equipment needed for endotracheal intubation. Thepatient is a small 56-year-old woman.

+e.; fDy ~ '-'\..-cd I 0\ Lok(J[Q\ vore ~ 5 \) u..Ard-l.:-

\7s-er ~ c.~ J-A()1 (h;~0srcn '\t> -r ~ rr--cct-Q-\\ \\,~~U{\) (jf\QO~ ~J ¥DO) ~

89. A colorimetric CO2 detector is attached to the ET tube. The end-tidal CO2 is 2% on exhalation and0% on inhalation as the chest rises with bagging. What does this suggest regarding the effectivenessof the chest compressions?

After your heart-pounding initiation into resuscitation, it is time to check the other ventilator patientsin the unit. A 19-year-old woman with a head injury is receiving mechanical ventilation via a cuffedNO.8 tracheostomy tube with an inner cannula. As you enter the room, the high-pressure alarm issounding.

What size suction catheter is suggested using the Rule of Thumb found in Egan's?

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After suctioning, you will need to check the cuff pressure. What is a safe cuff pressure?I'} ~or U -''20 ~ t\ZU

Chapter 33 is the longest one we've had so far! That must mean this is extremely important material. The NBRC agrees!The Examination Matrix says you must perform procedures to achieve maintenance of the airway including artificial

airway care, adequate humidification, cuff monitoring, positioning, and removal of secretions. They go on to includemodification of the management of artificial airways including changing the type of humidification, inflating or deflat-ing the cuff, and initiating suctioning. You should be able to assemble and check the function of the airways and theintubation equipment. Finally, you need to assist the physician in performing bronchoscopy, tracheostomy, and, of course,intubation. The actual number of airway questions varies from exam to exam, but you should be prepared for at leastsix to eight questions on any given test.

95. Which of the following will decrease the risk of damage to the trachea from the endotracheal tube cuff?I. minimal leak techniqueII. maintaining cuff pressures of 30 to 35 cm H20III. minimum occluding volume techniqueIV. inflating the cuff to 25 mm Hg

~ I and IIc.!V I and III

C. II and IIID. III and IV

96. The diameter of the suction catheter should be no larger thanA. one-tenth the inner diameter of the ET tube

~ one-third the. inner ~iameter of the ET tube~_>)lle-half the lllner dIameter of the ET tube

D. three-fourths the inner diameter of the ET tube

97. A patient with a tracheostomy tube no longer requires mechanical ventilation. All of the following would facili-tate weaning from the tracheostomy except a(n) _

dJAfenestrated tracheostomy tube. B.' cuffed tracheostomy tube

. tracheostomy buttonD. uncuffed tracheostomy tube

98. Extubation is performed on a patient with an endotracheal tube. Presence of which of the following suggests thepresence of upper airway edema?A. rhonchiB. cracklesb wheezes® stridor

99. All of the following are useful in nasotracheal intubation except a _A. laryngoscope handle

~ styletteC. Miller bladeD. Magill forceps

100. While performing endotracheal suctioning, an RT notes that flow through is minimal and secretion clearance issluggish. Which of the following are possible causes of this problem?I. The vacuum setting is greater than 120 mm Hg.II. The suction canister is full of secretions.III. There is a leak in the system.IV. The tube cuff is overinflated.

A. I and IIB. I and IV

(C:""''II and III~IIIandIV

101. Rapid, initial determination endotracheal tube placement can be achieved by _I. auscultationII. arterial blood gas analysisIII. measurement of end-tidal CO2

IV. measurement of SP02A. I and II

'2I:l9 I and IIIC. II and IVD. III and IV

102. A patient with a tracheostomy tube shows signs of severe airway obstruction. A suction catheter will only passa short distance into the tube. The RT should _A. remove the tracheostomy tubeB. inflate the cuff of the tubeC. ventilate the tube with positive pressure® remove the inner cannula

103.~iCh of the following can be used to assess pulmonary circulation during closed-chest cardiac compressions?. capnometry. arterial blood gas analysis

C. pulse oximetryD. blood pressure monitoring

104. Prior to performing bronchoscopy, an RT is asked to administer a nebulized anesthetic to the patient. Whatmedication is most appropriate to place in the nebulizer?A. VersedB. atropinek- morphine\E) lidocaine

Here's an idea that could help you learn a topic as huge, complex, and important as this one: digital flashcards. Takephotographs of equipment, scan pictures from books, and download from the Internet to create a pile of pictures. Setup a slide show and you've got digital flashcards. My students find this a fun and effective way to learn, and they helpeach other out on the project.

When I searched Google for "endotracheal tube PowerPoint presentations," I got about 35,000 hits! You can do betterthan that!

Try• The Internet Journal of Airway Management: www.ijam.at. It has good stuff and a cool "virtual airway

museum."• E-medicine has a good area on tracheostomy at www.emedicine.com/entitopic356.htm.There is literally an astonishing amount of material on airway management on the Internet, so you need to have a

pretty good idea of what you are looking for when you start to search. You'll want to narrow things down with "artifi-cial airway emergencies," not "airway emergencies," if that's what you're hoping to find. If you do use Google, tryswitching to images or video mode; you might be pretty surprised at what you get!