Airway Management - Heath Care

1. Artificial Airways & Airway
Management
210a

2. Effective Cough
• Components
– Adequate vital capacity (VC > 15 mL/kg)
– Abdominal contraction
– Glottic closure

3. Phases of a Cough
• Irritation of airway
• Inspiration of adequate volume
• Compression
– Glottic closure
– Contraction of abdominal muscles
– Increase in intrathoracic pressure

4. Phases of a Cough
• Expulsion
– Opening of glottis
– Explosive expulsion of air and matter (flow
up to 500 mph)

5. Ineffective Cough
• Inadequate vital capacity
• Inadequate compression
– Inadequate abdominal contraction
– Inability to close glottis

6. Suctioning
• Suctioning is the application of negative
pressure to the airways through a
collecting tube

7. Suctioning
• Suctioning of the trachea and bronchi is
usually done through an endotracheal
tube or tracheostomy tube

8. Indications for Suctioning
• Need to remove retained secretions
• Need to maintain patency of airway
• To treat atelectasis
• To obtain of a sputum specimen

9. Hazards of Suctioning
• Trauma
• Hypoxia
– Arrhythmias
– Inadequate cerebral oxygenation

10. Hazards of Suctioning
• Infection
• Vagal stimulation
• Atelectasis

11. Hazards of Suctioning
• Bronchospasm
• Increase in intracranial pressure
• Gag reflex stimulation

12. Equipment Required For
Suctioning
• Oral suctioning
– Negative pressure source
– Suction canister
– Connective tubing

13. Equipment Required For Oral
Suctioning
• Yankauer (tonsil tip)
Suction tip
• Distilled water or
saline solution in
container
• Gloves

14. Equipment Required For
Suctioning
• Nasal and tracheal suctioning
– Negative pressure source
– Suction canister
– Connective tubing
– Suction catheter

15. Nasal & Tracheal Suctioning
Equipment
• Water soluble gel (for nasal suction)
• Distilled water or saline solution in
container
• Gloves

16. Catheter Types
• Whistle tip
• Argyle
• Coudé
• Closed catheter systems

17. Suction Catheters
• Catheter sizes
– Measured in French (French/3.14 = size in
mm)
– Diameter of catheter < ½ diameter of tube
• Murphy eye

18. Pressure During Suctioning
• Adult – -100 to -120 mmHg
• Child – -80 to -100 mmHg
• Infant – -60 to -80 mmHg

19. Suctioning Procedure
• Gather equipment, identify patient,
introduce self, explain procedure, and
wash hands
• Don gloves, prepare equipment

20. Suctioning Procedure
• Hyperoxygenate the patient, as
appropriate
• If suctioning nasally, lubricate the
catheter

21. Suctioning Procedure
• Introduce the catheter into the airway,
ensuring that no suction is applied
during introduction
• Advance the catheter until resistance
is met

22. Suctioning Procedure
• 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)

23. Suctioning Procedure
• Rinse the catheter in saline or distilled
water
• Reassess the patient

24. Artificial Airways
• Oropharyngeal airway
– Used in unconscious patients only to
avoid gag reflex
– Prevents tongue from occluding airway

25. Oropharyngeal Airway
• Allows passage of suction catheter
through center or along the side of
airway

26. 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

27. Artificial Airways
• Nasopharyngeal airway
– Used in conscious patients requiring
frequent suctioning
– Length of airway equals length from nostril
to ear plus one inch

28. Nasopharyngeal Airway
• Prevents tongue from occluding airway
• Change from naris to naris as required

29. Nasopharyngeal Insertion
Procedure
• Lubricate airway with water soluble gel
• Examine nares; if available, choose
nares with smaller opening

30. Nasopharyngeal Insertion
Procedure
• Gently insert airway, avoiding forcing
past obstructions
• Tip of airway should be visible just
past uvula

31. Artificial Airways
• Endotracheal tubes

32. Endotracheal Tubes
• Specifications established by the
American Society for Testing and
Materials (ASTM)

33. Endotracheal Tube Marking
• I.T. – Implant tested
• I.D. – Inner diameter
• O.D. – Outer diameter

34. 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

35. Endotracheal Tube Type
• Cuffed
• Uncuffed
• Double lumen
• Jet ventilation

36. Indications for Intubation
• Maintain airway patency
• Prevent aspiration
• Cardiopulmonary arrest

37. Indications for Intubation
–Establishment/maintenance of
mechanical ventilation
–Bronchial hygiene

38. Physiologic Effects of Intubation
• Decrease in VD (approximately by ½)
• If tube is too small, may increase
resistance and work of breathing

39. Equipment Needed for Intubation
• Suction equipment
• Laryngoscope
– Macintosh blade – curved
– Miller blade – straight

40. Equipment Needed for Intubation
• Stylet – only for oral intubation
• Magill forceps – only for nasotracheal
intubation
• Oropharyngeal airway

41. Equipment Needed For Intubation
• Syringe
• Tape or other securing equipment
• Endotracheal tube – choice of sizes to
meet unexpected conditions

42. Equipment Needed for Intubation
• Topical anesthetics (lidocaine,
xylocaine) – may be required
• Paralyzing agents (Pavulon,
succinylcholine) – for combative
patients

43. 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

44. Intubation Procedure
• Pre-oxygenate the patient
• Position patient in “sniffing” position, if
possible
• Administer paralyzing agent, if required

45. Intubation Procedure
• Insert laryngoscope
• Visualize the vocal cords
• Insert endotracheal tube between
vocal cords

46. Intubation Procedure
• Inflate the cuff
• Check breath sounds; adjust position of
endotracheal tube as needed
• Note and record centimeter mark at the
teeth

47. Intubation Procedure
• Secure the endotracheal tube
• Insert oropharyngeal airway
• Obtain chest X-ray to ensure proper
tube placement
• Check cuff pressure

48. Intubation Hazards
• Intubation of the esophagus
• Trauma to the vocal cords or trachea
• Tracheal malacia, necrosis, T-E fistula
• Aspiration
• Fracture of teeth

49. Tracheostomy Tubes

50. Indications for Tracheotomy
• Long term ventilation
• Provide patent airway when upper
airway is impassable

51. Hazards of Tracheotomy
• Trauma – laryngeal lesions, tracheal
lesions
• Hemorrhage

52. Hazards of Tracheotomy
• Subcutaneous emphysema
• Infection
• Tracheal malacia, necrosis, T-E fistula

53. Types of Tracheostomy Tubes
• Portex / Shiley
• Jackson
• Kamen-Wilkensen
• Fenestrated

54. 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

55. Care of The Tracheostomy Tube
• Assemble and check equipment
– Sterile water
– Cotton-tipped applicators
– Pre-cut gauze or 4 x 4 gauze pad
– Tracheostomy tube ties

56. Care of The Tracheostomy Tube
• Suction the patient
• Remove and clean the inner cannula
• Clean the stoma site

57. Care of The Tracheostomy Tube
• Change the tracheostomy tube ties
• Re-insert the inner cannula
• Assess the patient

58. Changing of The Tracheostomy
Tube
• Performed as needed
– Perforated cuff
– Mucus plug
– Change in size of tube

59. Changing of The Tracheostomy
Tube
• Assemble and check equipment
– Gloves and other protective gear
– New tracheostomy tube
– Suction equipment
– Tracheostomy tube ties
– Resuscitation bag

60. Changing of The Tracheostomy
Tube
• Pre-oxygenate the patient
• Suction the patient
• Remove the tracheostomy tube

61. Changing of The Tracheostomy
Tube
• Insert the new tube
• Secure the tracheostomy tube with
the ties
• Assess the patient

62. Management of The Cuff
• Pressure should be kept between 20
and 25 mmHg

63. Management of The Cuff
• Techniques for maintaining cuff
pressure
– Minimal occluding volume
– Minimal leak technique
– Direct measurement of cuff pressure by
manometer

64. Alternative Airway Devices
• Laryngeal mask
airway (LMA)

65. Laryngeal Mask Airway (LMA)
• Advantages
– Ease and speed of insertion
– Avoidance of laryngeal and tracheal
trauma
– Intubation possible without removing LMA

66. Laryngeal Mask Airway (LMA)
• Disadvantages
– Short term use only
– Cannot provide high ventilation pressures
– Potential for esophageal injury
– Aspiration may still occur, although risk is
decreased

67. Laryngeal Mask Airway (LMA)
• 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

68. LMA Placement

69. Alternative Airway Devices
• Combitube
(Double lumen
airway)

70. Combitube
• Advantages
– Little skill required for insertion
– Protects against aspiration
– Aids in positive pressure ventilation

71. Combitube
• Disadvantages
– Short term use only
– Aspiration may occur during removal
– If placed in esophageal position, cannot
suction airway

72. Combitube
• Disadvantages
– Potential for esophageal injury
– Difficulty in distinguishing between
esophageal and tracheal intubation

73. Combitube
• Placement
– Insert tube blindly through the oropharynx
into the trachea or esophagus
– Inflate the cuffs

74. Combitube
• Placement
– Assess placement of the tube
– Ventilate through the appropriate external
adapter

75. Combitube Placement

76. Alternative Airway Devices
• Tracheal buttons
– Used to maintain a tracheal stoma

77. 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

78. Tracheal Buttons
• Disadvantages
– Will not allow attachment of mechanical
ventilators
– Must be removed and replaced with
tracheostomy tube in emergency situations

79. Tracheal Buttons
• Placement
– Fits through the skin to just inside the
anterior wall of the trachea