The document discusses advanced airway care techniques including oropharyngeal, nasopharyngeal, and endotracheal airways, detailing their insertion methods, indications, and potential complications. It emphasizes the importance of suctioning and manual hyperinflation for patients with artificial airways, outlining procedure steps and necessary precautions. Moreover, it addresses the risks associated with these procedures and the need for careful monitoring during airway management.

1. ADVANCED AIRWAY CARE
Intensive Care Unit Perspective
Dr.Nidhi Ahya (Asst Prof)
Cardio-Vascular & Respiratory PT
DVVPF College of Physiotherapy,
Ahmednagar 414111

2. OBJECTIVES
 Artificial Airways
 Oropharyngeal
 Nasopharyngeal
 Endo-Tracheal
 Tracheal
 Advanced Airway Clearance
 Manual Hyperinflation
 Suctioning

3. Oropharyngeal Airways
 Oropharyngeal airways help restore airway
patency by separating the tongue from the
posterior pharyngeal wall and maintain adequate
ventilation

4.  There are two basic designs:
 Guedel
 Bermen
 Both types have a external flange, a
curved body that conforms to the
shape of the oral cavity and are
available in different sizes
 Difference is between the number
of channels
 Guedel has a single centre channel
 Bermen has two parallel side
channels

5.  To choose the correct size, the therapist has to
place the device on the side of the patient’s face
with the flange even with the patients mouth.
 The correct size is measured from the corner of the
patients mouth to the angle of the jaw, following
the natural curve of the airway

6.  Technique to place Oropharyngeal airways:
 Slip Technique using a tongue depresser
 Jaw lift technique with 180˚ rotation

7.  Possible Complications:
 Insertion of an oropharyngeal airway can provoke
a gag reflex, vomiting or laryngeal spasm
 These devices are best suited for semi-conscious
or unconscious patients to maintain airway patency
as well as to assist in suctioning

8. Nasopharyngeal Airways
 Nasopharyngeal airways are inserted through the
nose instead of the mouth
 Provides passage from the external nares to the
base of the tongue
 Restore airway patency
by separating the tongue from
the posterior pharyngeal
wall

9.  Indications:
 When oropharyngeal airway cannot be used as in
case of seizures, mandible fracture, space
occupying lesion in the oral cavity
 Insertion:
 Appropriate size can be estimated by measuring
the distance from the patients ear lobe to the tip of
the nose

10.  Airway is lubricated with a water soluble jelly to
ease insertion and is positioned perpendicular to
the frontal plane of the patients face
 It is slowly advanced in the same direction through
either of the nasal cavity
 When properly placed, it gets stabilized by its own
flange

11. Bag valve Mask
 Bag valve mask combines a self-inflating bag
with a non-rebreathing valve mechanism
 These devices are capable of providing
ventilation with air or supplemental oxygen

12. Endotracheal Intubation
 Endotracheal tube intubation is a preferred
method for securing the airway during emergency
 It can-
 Prevent aspiration of
gastric contents
 Permit suctioning
 Facilitate oxygenation and
ventilation
 Route for drug administration

13. One way valve
Universal adaptor
Pilot balloon
Bevel lumen
Murphy’s eye
Cuff
Body
Filling
tube
 Parts of Endotracheal Tube:

14.  Endotracheal Intubation Procedure :
 Step 1: Visualization of vocal cords

15.  Step 2: Confirming position of trachea

16.  Step 3: Advancement of the ET tube

17.  Possible Complications :
 During Intubation
 Bradycardia caused by vagal stimulation
 Hypoxemia caused by delay in procedure
 Cardiac Arrhythmias
 Right-mainstem intubation
 Oesophageal intubation
 While tube is in situ
 Tube Malposition
 Pharyngeal edema
 Loss of cuff integrity
 Tube kinking or obstruction
 Post Extubation- Glottic stenosis, Vocal Cord Paralysis

18. Tracheal Intubation
 Tracheostomy tubes provide an airway access
directly at the level of the second or fourth tracheal
rings
 Tracheostomy is indicated when-
 Long-term secretion management is required
 To reduce dead space ventilation and airway resistance
 Protection of airway from aspiration
 Prolonged mechanical Ventilation

19.  Parts of Tracheostomy Tube :

20.  Care of Tracheostomy Tube :
 Cleaning around the stoma and external portion of
the tube
 Changing the ties and dressing
 Cannulated tracheostomy tubes require cleaning of
inner cannula
 Suctioning the tube
 Cuff care- Maintaining the cuff pressure

21.  IMMEDIATE COMPLICATION ( FIRST 24 HOUR)
• Bleeding
• Pneumothorax
• Air embolism-due to tearing of pleural veins
• Subcutaneous emphysema
 LATE COMPLICATIONS ( After 24 – 48 hours)
• Infection
• Hemorrhage
• Airway obstruction
• Dysfunction of the swallowing
• Tracheoesophageal fistula

22. SUCTIONING AND
MANUAL
HYPERINFLATION

23. WHAT IS SUCTIONING?
 The patient with an artificial airway is not
capable of effective coughing, and hence the
mobilization of secretions from the trachea
must be facilitated by aspiration.
 This application of negative pressure is
called as suctioning.

24.  Indications :
 Therapeutic
Presence of artificial airway
Coarse Crackles
Visible secretions in the airway
Decreased SpO2 by pulse oximeter reading
Deterioration of arterial blood gas values
Clinically increased work of breathing
Patient’s inability to generate an effective cough
Increased PIP; decreased Vt during MV
 Diagnostic
 The need to obtain a sputum specimen / ETA (Endo
Tracheal Aspiration) for Bacteriological or
microbiological or investigations
 During bronchoscopy

25.  Contra-indications :
 Most contraindications are relative to the
patient's risk of developing adverse reactions
Suctioning is contraindicated only when there
is fresh bleeding
There is no absolute contraindication
suctioning

26.  Hazards and Complications :
Hypoxia / hypoxemia
Tracheal and / or bronchial mucosal trauma
Cardiac or respiratory arrest
Pulmonary hemorrage / bleeding
Cardiac dysrhythmias
Pulmonary atelectasis
Bronchoconstriction / bronchospasm
Hypotension / hypertension
Elevated ICP
Interruption of mechanical ventilation

27.  Necessary Equipment:
 Vaccum source with suction jar and adjustable
regulator
 Sterile gloves
 Sterile catheter of appropriate size
 Clear protective goggles, apron & mask
 Sterile normal saline
 Ambu bag to preoxygenate the patient

29.  Type and Size of Suction Catheters:

30.  Monitoring:
 Breath sounds
 Oxygen saturation
 RR & pattern
 HR and BP
 Cough effort
 ICP (If indicated and
available)
 Sputum characteristics
 Ventilator parameters
(PIP, Vt & FiO2)

31.  Patient Preparation:
 Explain the procedure to the patient (If patient
is concious)
The patient should receive hyper oxygenation
by the delivery of 100% oxygen for >30 seconds
prior to the suctioning (Either with Bain’s circuit
or by increasing the FiO2 by mechanical
ventilator)
Position the patient in supine position
 Auscultate the breath sounds

32.  Procedure:
 Perform hand hygiene, wash
hands. It reduces transmission of
microorganisms.
Turn on suction apparatus and
set vacuum regulator to
appropriate negative pressure.
•For adult a pressure of 100-120
mmHg
•For pediatric 80-100mmhg
•For neonates 60-80mmhg

33.  Wear Personal Protective
Equipment
 Open the end of the suction
catheter package & connect it to
suction tubing (If you are alone)
 Disconnect ventilator
 Kink the suction tube & insert
the catheter in to the ETtube
until resistance is felt
 Resistance is felt when the
catheter impacts the carina or
bronchial mucosa, the suction
catheter should be withdrawn
1cm out before applying suction

34.  Apply continuous suction while
rotating the suction catheter
during removal
 The duration of each suctioning
should be less the 15sec
 Instill 3 to 5ml of sterile normal
saline in to the artificial airway, if
required
 Resumes the ventilator
 Give four to five manual breaths
with bag or ventilator
 Wash the suction catheter with
saline
 Discard the used equipments

35.  Assessment of Outcome:
 Improvement in breath sounds
 Decreased peak inspiratory pressure
 Increased tidal volume delivery during
ventilation
Improvement in arterial blood gas values or
saturation as reflected by pulse oximetry
 Removal of pulmonary secretions

36.  Limitations of Suctioning:
 Suctioning is potentially an harmful procedure if
carried out improperly
 Can cause barotrauma
 Suctioning should be done when clinically
necessary (not routinely)
 The need for suctioning should be assessed at
least every 2hrs or more frequently as need
arises.

37. Manual Hyperinflation
 This technique is used in patients with an artificial
airway who are mechanically ventilated or on a
tracheostomy. It can also be used on non-intubated
patients using a naso-oral seal mask
 This method of airway clearance promotes
mobilization of secretions and reinflates collapsed
areas of the lung.
 Two caregivers are necessary to provide this
treatment
 A manual ventilation bag attached to an oxygen
source is needed for lung inflation
Dr.Nidhi Ahya(MPT Cardio-
Vascular& Respiratory PT)
37

38.  One caregiver squeezes the bag slowly to
inflate the lungs
 A pause is maintained momentarily at the peak
of inflation to allow collateral ventilation
 Release of the bag should be rapid and result in
high expiratory flow rate
After 6 cycles of inspiration/expiration, patients
airway is suctioned using sterile technique.
 It a potential to cause significant barotrauma
with inflation and this technique is therefore
contraindicated in patients with unstable
hemodynamics, pulmonary edema, severe
bronchospasm

39. Squeeze- 1,2
Release- 1
5-6 times
Can be combined
with vibrations
Dr.Nidhi Ahya(MPT Cardio-
Vascular& Respiratory PT)
39

40. SUMMARY
 Artificial Airways
 Advanced Airway Clearance
 Manual Hyperinflation
 Suctioning

41. QUESTION
 WRITE ABOUT MANUAL
HYPEROVERINFLATION.