Artificial Airways & Airway Management 210a. Effective Cough Components –Adequate vital capacity (VC > 15 mL/kg) –Abdominal contraction –Glottic closure

Artificial Airways & Airway Management

210a

Effective Cough

• Components

– Adequate vital capacity (VC > 15 mL/kg)

– Abdominal contraction

– Glottic closure

• 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)

Phases of a Cough

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


• Infection

• Vagal stimulation

• Atelectasis


• 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

• Coudé

• Closed catheter systems

Suction Catheters

• Catheter sizes

– Measured in French (French/3.14 = size in

mm)

– Diameter of catheter < ½ 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


• Hyperoxygenate the patient, as

appropriate

• If suctioning nasally, lubricate the

catheter


• Introduce the catheter into the airway,

ensuring that no suction is applied

during introduction

• Advance the catheter until resistance

is met


• 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)


• 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 ½)

• 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


• 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


• 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


• Pre-oxygenate the patient

• Position patient in “sniffing” position, if

possible

• Administer paralyzing agent, if required


• Insert laryngoscope

• Visualize the vocal cords

• Insert endotracheal tube between

vocal cords


• Inflate the cuff

• Check breath sounds; adjust position of

endotracheal tube as needed

• Note and record centimeter mark at the

teeth


• 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



– Sterile water

– Cotton-tipped applicators

– Pre-cut gauze or 4 x 4 gauze pad

– Tracheostomy tube ties


• Suction the patient

• Remove and clean the inner cannula

• Clean the stoma site


• 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



– Gloves and other protective gear

– New tracheostomy tube

– Suction equipment

– Tracheostomy tube ties

– Resuscitation bag


• Pre-oxygenate the patient

• Suction the patient

• Remove 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


• Disadvantages

– Short term use only

– Cannot provide high ventilation pressures

– Potential for esophageal injury

– Aspiration may still occur, although risk is

decreased


• 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


• 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


• 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

Documents

Artificial Airways & Airway Management 210a. Effective Cough Components –Adequate vital capacity (VC > 15 mL/kg) –Abdominal contraction –Glottic closure