Artificial Airways

Outlines Basic techniques for opening the air way. Laryngeal Mask Airway Oropharyngeal Airway Nasopharyngeal Airway Skills and care for a patient with Artificial Airway Endotracheal Tube ( ETT) Skills and care for a patient with ETT Tracheostomy Skills and care for teacheostomy Cricothyredictomy. Alternative Methods of Communication for Patients with Artificial Airways

Artificial Airways There are a number of different artificial airways; each one has its own criteria for use based on the clinical circumstances

Basic techniques for opening the air way. The are three manoeuvers to improve an air way; 1. head tilt. 2. chin lift. 3. jaw thrust.

Laryngeal Mask Airway (LMA) is used for emergent intubation or in situations where ETT intubation has failed. The LMA looks like an ETT with an inflatable, silicone rubber collar at the bottom end. This collar surrounds and covers the supraglottic area, providing a continuous upper airway.

(LMA) Sizes: 3Small adult 4 normal adult 5Large adult Supine position. Head, neck aligned. Holding the tube like a pen. Introduce into the mouth. Connect the inflating syringe.

LMA (Laryngeal Mask ) Advantages Easy to insert and quickly. Allows ETT intubation through it, while maintaining an open airway. Disadvantages Does not prevent aspiration. Can only be used short term until another airway is established.

Oropharyngeal Airway The goal of an oropharyngeal airway is to keep the tongue from obstructing the upper pharynx. Place the patient in the supine position if possible…… suction the mouth, and remove and dentures……. estimate the appropriate size. The airway is inserted into the mouth upside down, then rotated 180o as it is placed over the tongue.

Oropharyngeal Airway Vertical distance between pt.’s incisors and the angle of the jaw. Sizes: 2, 3, 4 for adults respectively.

Oropharyngeal Airway Advantages –Prevents tongue from obstructing pharynx. –May prevent the need for intubation in patients who are temporarily unable to maintain their airway (i.e., drug overdose). Disadvantages –Causes conscious patients to gag…… thus can only be used in unconscious patients with a diminished gag reflex.

Nasopharyngeal Airway nasopharyngeal Airway airway is similar to that of the oropharyngeal, But smaller in millimeter in internal size. it’s lubricated and inserted through a nostril into the posterior pharynx.

Nasopharyngeal Airway Advantages Tolerated by conscious patients with an intact gag reflex. Can be left in place for a few days. Provides route for sterile suctioning of airway. Dis-advantages Nures must be closely monitored for skin breakdown if used for a few days.

Skills and care for a patient with Artificial Airway Hand washing before any procedure. The position of the airway in the patient’s and breath sounds should be assessed frequently. Mouth care should be done every two to four hours and as needed, can be done with a moistened swab. If the airway is coated with secretions, it can be removed and cleaned if the patient’s respiratory status is stable. Immediately insert a clean airway before cleaning the soiled one with hydrogen peroxide and water. This airway can be kept for future use with the same patient. If the patient has the oropharyngeal airway as a long-term measure, the airway should be cleaned and replaced at least once every eight hours.

Endotracheal Tube ( ETT) The endotracheal tube (ETT) is the most common artificial airway used for airway management or mechanical ventilation. Insertion of an ETT is indicated for airway maintenance, secretion control, oxygenation and ventilation, and administration of emergency medications during cardiopulmonary arrest.

Endotracheal Tube Advantages Provides route for sterile suctioning of airway. Some emergency medications can be given via the ETT (Narcan, atropine, epinephrine, lidocaine). Can be inserted either nasally or orally. Disadvantages Patients may need sedation and/or wrist restraints to prevent accidental removal. Patients not able to speak.

ETTs are available in a variety of sizes…….For adults, this generally includes tubes with an inner diameter of 6 mm to 8.5 mm. Obviously, a smaller tube may have to be used for nasal intubation, …..and…. most patients can tolerate tube sizes between 6 to 7.5 for this

Endo tracheal Intubation

The tube may be inserted either nasally or orally; However, the oral route is preferred during emergency placement because insertion is easier and a larger- diameter tube can be used.

Equipment Various sizes of ETT tubes (6 to 8.5). Larynge scope. Tape or device to secure ETT tube. Sterile gloves Lubricant. Suction catheter – port. Stethoscope. CO2 detector to confirm placement. Cardiac monitor. pulse oximeter.

Complication –Mouth and teeth and upper airway damage –Vocal cords injury –Risk for pneumonia

Skills and care for a patient with ETT  it’s vital that you know the history and the events leading up to the intubation.  prepare the room ahead of time is also helpful: This may include removing the head of the bed……. pulling the bed away from the wall…… removing extra equipment and asking visitors to step out of the room.  While the physician is intubating the patient: -be responsible for monitoring and documenting vital signs, -administering medications. - preparing equipment. 

 Sterile suction should be set up and ready for use as soon as the ETT is placed. Often, suctioning of mucus or aspirate is all that’s needed to restore spontaneous breathing after a respiratory arrest After intubation you should have a stethoscope ready to listen for bilateral breath sounds. Many institutions also use CO2 detectors to confirm that the ETT is in the lungs, and not the esophagus.

chest x-ray is necessary to confirm the position of the ETT. You should have tape or an ETT holder ready to secure the tube, as well as wrist restraints for the patient, in order to prevent accidental removal of the tube. Monitor respiratory status and monitor signs of hemorrhage. Following placement, keep the area clean with frequent dressing changes and frequent suction to prevent infection. Maintain appropriate endotracheal cuff to prevent aspiration and tube displacement…..Monitor cuff pressure every 4-8hrs during expiration.

 Tilt the patient’s head back to open the airway, unless neck injury is present. In this case, use a jaw thrust.  The patient’s chest should rise with each squeeze of the bag.  Ensure that 100% oxygen is hooked up to the resuscitation bag.  Condensation in the mask indicates ventilation is taking place in the lungs.  Listen for lung sounds or tracheal sounds of air entering the lungs.  If the patient has dentures, intubation may be easier to perform if the dentures are left in.  If the patient has any spontaneous breaths, manual breaths should be coordinated with the patient’s own breaths.

Observational methods to confirm correct tube placement Direct visualization of the tube passing through the vocal cords. vocal cords Clear and equal bilateral breath sounds on auscultation of the chestbreath sounds Absent sounds on auscultation of the epigastriumepigastrium Equal bilateral chest rise with ventilationventilation An absence of stomach contents in the tube Instruments to confirm correct tube placement Pulse oximetry (patients with a pulse) - delay in fall of saturation, especially if pre-oxygenatedPulse oximetry

Tracheostomy

A tracheostomy tube is the preferred artificial airway for patients requiring long-term mechanical ventilation (longer than three weeks). It’s also indicated for other conditions such as upper airway obstruction or malformation, failed or repeated intubations, complications from endotracheal intubations, glottic incompetence, sleep apnea, or chronic inability to clear secretions.

Tracheostomy Advantages Can be used long-term; up to years. More comfortable for patient.Allows speaking and eating if respiratory status is stable. Patients can be taught how to care for their tracheostomy at home.

Complications and disadvantaged of insertion include: Hemorrhage. Pneumothorax. Laryngeal nerve injury Tracheoesophageal fistula (opening between trachea and esophagus). Cardiopulmonary arrest. Wound infection. Subcutaneous emphysema (air in subcutaneous tissue). Tube obstruction. Tube displacement may also occur

Skills and care for teach.  Monitor respiratory status and monitor signs of hemorrhage  Explain procedure and rational to the patient and assist as needed with placement  Following placement, keep the area clean with frequent dressing changes and frequent suction to prevent infection  Maintain appropriate tracheal cuff to prevent aspiration and tracheal pressure necrosis  Perform routine cleansing of inner cannula and ostomy site as needed  Monitor cuff pressure every 4-8hrs during expiration  Auscultate for presence of lung sounds bilaterally after insertion and after changing trach.  Assist with chest X rays exam as needed

Cricothyredictomy Cricothyredictomy is immediate and rapid technique. Patient supine, head is slightly extended. Identify the cricothyroid membrane …… between thyroid cartilage and cricoid cartilage. The membrane is punctured vertically in the midline using cannula 14 guage attached to a syringe. Aspiration of air to confirms the correct position. The cannula is angeled 45˚ and advanced gradulay. Attach to high oxygen using Y connector.

Complication. Co2 alimentation is less efficient. Can cause surgical emphysema. Hemorrhage. Cannula displacement. Osephegeal displacement.

Alternative Methods of Communication for Patients with Artificial Airways The ETT prevents speech because it passes through the vocal cords; this may increase anxiety. Caregivers must enter the room (so the patient can see them) frequently to reassure the patient that he or she is being carefully monitored. Some patients may be able to mouth words well enough for caregivers to read their lips.

Having the patient write notes and draw pictures is another option. The patient may have to use their nondominant hand because of IVs and arterial lines. These are posters that usually have large-type letters and numbers on one side, and pictures of typical patient requests on the other side. The pictures include items such as medication, pain, nurse, doctor, family, call light, TV and water.