Artificial Airways & Airway

Management

210a
Effective Cough

Components

Adequate vital capacity (VC > 15 mL/kg)

Abdominal contraction

Glottic closure
Phases of a Cough

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)
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

Hazards of Suctioning

Infection

Vagal stimulation

Atelectasis
Hazards of Suctioning

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

Coud

Closed catheter systems

Suction Catheters

Catheter sizes

Measured in French (French/3.14 = size in

mm)

Diameter of catheter < 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

Suctioning Procedure

Hyperoxygenate the patient, as

appropriate

If suctioning nasally, lubricate the

catheter
Suctioning Procedure

Introduce the catheter into the airway,

ensuring that no suction is applied
during introduction

Advance the catheter until resistance

is met
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)
Suctioning Procedure

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 )

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

Equipment Needed for Intubation

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
Equipment Needed for Intubation

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
Intubation Procedure

Pre-oxygenate the patient

Position patient in sniffing position, if

possible

Administer paralyzing agent, if required

Intubation Procedure

Insert laryngoscope

Visualize the vocal cords

Insert endotracheal tube between

vocal cords
Intubation Procedure

Inflate the cuff

Check breath sounds; adjust position of

endotracheal tube as needed

Note and record centimeter mark at the

teeth
Intubation Procedure

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
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

Care of The Tracheostomy Tube

Suction the patient

Remove and clean the inner cannula

Clean the stoma site

Care of The Tracheostomy Tube

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

Changing of The Tracheostomy
Tube

Assemble and check equipment

Gloves and other protective gear

New tracheostomy tube

Suction equipment

Tracheostomy tube ties

Resuscitation bag
Changing of The Tracheostomy
Tube

Pre-oxygenate the patient

Suction the patient

Remove the tracheostomy tube

Changing of 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

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
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

LMA Placement
Alternative Airway Devices

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
Alternative Airway Devices
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