1. Airway Management Part III
RET 2275
Respiratory Care Theory 2

2. Tracheostomy Tubes
A long-term airway placed through an incision made between the 2nd and 3rd tracheal rings and inserted directly into the trachea

3. Tracheostomy Tubes Indications for tracheostomy:
Airway obstruction due to the following:
Inflammatory disease
Benign laryngeal pathology, e.g., webs, cysts, papilloma)
Malignant laryngeal tumors
Laryngeal trauma or stenosis
Tracheal stenosis
Pulmonary toilet
Obstructive sleep apnea

4. Tracheostomy Tubes
Advantages over prolonged translaryngeal intubation:
Eases airway care and suctioning
Eliminates the ongoing risks of oral, nasal, pharyngeal, and most laryngeal complications of translaryngeal intubation
Reduces risk of tracheal extubation
Eases tube reinsertion
Facilitates oral communication and speech
Improves oral, nasal, and facial hygiene

5. Tracheostomy Tubes
Advantages over prolonged translaryngeal intubation:
Raises patient comfort level
Improves patient appearance
Facilitates nursing care of the overall airway
Improves patient mobility
Eases disposition to long-term care facility
Less airway resistance

6. Tracheostomy Tubes
Most experts agree that patients requiring ET intubation for more than 7 days should have a tracheostomy
Some evidence indicates that a tracheostomy performed early, i.e., within 3 days of intubation, may decrease the risk for pneumonia, the length of mechanical ventilation, and the length of stay in the ICU

7. Tracheostomy Tube
Outer Cannula; primary structural unit of the tube, to which is attached the cuff and flange
Flange; prevents tube slippage into the trachea and provides means to secure the tube to the neck
Inner Cannula; cannula within the outer cannula that can be removed for routine cleaning – can be locked in place

8. Tracheostomy Tube
Cuff; seals off the lower airway, either for protection from aspiration or to provide positive pressure ventilation – inflation tube (aka: pilot tube) leads from the cuff to a pilot balloon and spring loaded valve.
Tie strings; stabilizes the tube at the stoma site - attached to the flange and is tied around the neck

9. Tracheostomy Tube
Obturator; placed within the outer cannula with its tip extending just beyond the far end of the tube – minimizes mucosal trauma during insertion
Radiopaque Indicator; helps confirm tube position on radiograph

10. Airway Trauma with Tracheal Tubes
Laryngeal Lesions
Glottic edema
Vocal cord inflammation
Both are transient changes that occur as a result of pressure from the ETT, or trauma during intubation
Symptoms include hoarseness and stridor
Primarily a concern after extubation and can worsen over 24 hours

11. Airway Trauma with Tracheal Tubes
Laryngeal Lesions
Laryngeal and vocal cord ulcerations
May cause hoarseness after extubation
Symptoms usually resolve spontaneously
Vocal cord polyps and granulomas
Develop more slowly – taking weeks or months
Symptoms include:
Difficulty swallowing
Hoarseness
Stridor
May have to be removed surgically

12. Airway Trauma with Tracheal Tubes
Laryngeal Lesions
Vocal cord paralysis
Symptoms may resolve within 24 hours
If obstructive symptoms continue, tracheotomy may be indicated
Laryngeal stenosis
Normal tissue is replaced by scar tissue, which causes stricture
Symptoms include stridor and hoarseness
Surgical correction is usually required

13. Airway Trauma with Tracheal Tubes
Tracheal Lesions
Granulomas
Circumscribed mass of cells (mainly histiocytes) normally associated with the presence of chronic infecton or inflammation
Tracheomalacia
Softening of the cartilaginous rings, which causes collapse of the trachea during inspiration

14. Airway Trauma with Tracheal Tubes
Tracheal Lesions
Tracheal stenosis
Narrowing of the lumen of the trachea, which can occur a fibrous scarring causes the airway to narrow
With ETT, most often occurs at the site of the cuff
With tracheostomy tubes, occurs at the cuff, tube tip, or stoma site (most common)

15. Airway Trauma with Tracheal Tubes
Tracheoesophageal fistula
A direct communication between the trachea and esophagus
Development is related to sepsis, malnutrition, tracheal erosion from the cuff and tube and esophageal erosion from nasogastric tubes

16. Airway Trauma with Tracheal Tubes
Tracheal Lesions
Tracheoinnominate fistula
Occurs when a tracheostomy tube causes tissue erosion through the innominate artery
Results in hemorrhage and, in most cases, death

17. Prevention of Tracheal Lesions
Limit Tracheal Tube Movement
Sedation
Nasotracheal tube intubation
Swivel adaptors for equipment attached to tracheostomies
Tracheostomy collars instead of T-tubes

18. Prevention of Tracheal Lesions
Selection of correct size airway
Limit cuff pressure
Maintain sterile technique when caring for tracheal tubes to limit infection
Good and regular tracheostomy care

19. Providing for Patient Communication
To help facilitate communication between healthcare givers and patients who cannot speak because of having an endotracheal or standard tracheostomy tube in place, various devices can be utilized

20. Providing for Patient Communication
Communication Board

21. Talking Tracheostomy Tube
Provides a separate inlet for compressed gas, which escapes above the tube allowing phonations

22. Passy-Muir Speaking Valves

23. Passy-Muir Speaking Valves
A one-way valve on the external end of the tracheostomy tube that allows the patient to inhale through the tube and exhale through the larynx
The cuff on the tracheostomy tube must be deflated)

24. Passy-Muir Valve Candidates for PMV
Awake and alert tracheostomized (ventilator or non-ventilator dependent patients) – adult, pediatric and neonatal

25. Passy-Muir Valve Benefits
Tracheostomized and ventilator dependent patients can produce clearer speech
Improved swallowing due to increased pharyngeal/laryngeal sensation decreasing the need for tube feeding
Decreased need for suctioning by enabling the patient to produce a stronger, effective cough

26. Passy-Muir Valve Benefits
Decreased aspiration due to increased pharyngeal/laryngeal sensation
Improved weaning by improving physiologic PEEP, which can improve oxygenation
Reduces decannulation time by allowing the patient to begin to adjust to a more normal breathing pattern through the upper airway
Decreased length of stay

27. Passy-Muir Valve Contraindications
Unconscious and/or comatose patients
Inflated tracheostomy tube cuff
Foam filled cuffed tracheostomy tube
Severe airway obstruction which may prevent sufficient exhalation
Thick and copious secretions
Severely reduced lung elasticity that may cause air trapping
This device is not intended for use with endotracheal tubes

28. Ensuring Adequate Humidity
Artificial airways (ETT/Tracheostomy tubes) bypass the normal humidification, filtration, and heating function of the upper airway, which can cause:
Secretions to thicken
Impairment of ciliary function
Impairment of mucocilary clearance
Secretion retention

29. Ensuring Adequate Humidity
Heated humidification
Large volume nebulizer
Heat and moisture exchanger (HME)

30. Minimizing Nosocomial Infection
Patient with tracheal airways (ETT/Tracheostomy tube) are susceptible to bacterial colonization and infection of the lower respiratory tract
Minimize by:
Consistently wash hands before and after each patient contact
Adhering to sterile technique during suctioning
Use only aseptically clear or sterile respiratory equipment for each patient

31. Care of the Tracheostomy Tube
Tracheostomy tubes require daily care
Assemble and check equipment
PPE; masks, goggles, gown, gloves
Suction equipment
Oxygen, manual resuscitator
Tracheostomy cleaning kit

32. Care of the Tracheostomy Tube
Tracheostomy tubes require daily care
Suction the patient
Clean the inner cannula
Remove the inner cannula and place in the basin with hydrogen peroxide to soak
Insert a disposable inner cannula if on mechanical ventilator
Clean inside and outside of cannula with a brush and rinse with sterile water
Allow to dry

33. Care of the Tracheostomy Tube
Tracheostomy tubes require daily care
Clean the stoma site
Remove the patient’s gauze dressing and discard in a biohazard container
Using cotton-tipped applicators, or sterile gaze dipped in a hydrogen-sterile water solution to clean under the flange and around the stoma
Using a sterile gauze dipped only in sterile water, rinse stoma site

34. Care of the Tracheostomy Tube
Tracheostomy tubes require daily care
Clean the stoma site (cont.)
Place a clean gaze under the flange
Do not cut gauze for this purpose as fibers may loosen and become caught in the stoma
Use precut gauze or folded 4 x 4 gauze pads
Change ties
Replace clean inner cannula

35. Extubation / Decannulation
For most patients, tracheal intubation is a temporary measure
The process of removing an artificial tracheal airway is called extubation

36. Assessing Readiness to Extubate
Original need to for the artificial airway no longer exists
Able to protect airway
Presence of a gag reflex
Able to manage secretions
Cough strength
Quantify and thickness of secretions
Patency of the upper airway

37. Orotracheal / Nasotracheal Tubes
Procedure
Assemble Equipment
Suction apparatus
O2 / Lg. volume nebulizer
Resuscitator/mask
SVN with racemic epinephrine and NSS
Intubation tray

38. Orotracheal / Nasotracheal Tubes
Procedure
Suction ETT and pharynx to above the cuff
After use, prepare rigid tonsillar (yankauer) suction tip
Oxygenate the patient well after suctioning
Give 100% oxygen for 1 – 2 minutes
Deflate the cuff

39. Orotracheal / Nasotracheal Tubes
Procedure
Remove the tube
Method 1
Give a large breath with manual resuscitator and remove tube at peak inspiration
Method 2
Ask the patient to take a deep breath and cough, pull the tube during the expulsive expiratory phase

40. Orotracheal / Nasotracheal Tubes
Procedure
Apply appropriate oxygen and humidity
Patients who have been receiving mechanical ventilation may still require oxygen therapy, usually a higher FIO2
If humidity therapy is indicated, most clinicians suggest a cool mist aerosol, which helps reduce the swelling that normally occurs after extubation
Encourage the patient to cough

41. Orotracheal / Nasotracheal Tubes
Procedure
Assess/Reassess the patient
Air movement
Auscultate and listen for good air movement; stridor or decreased air movement after extubation indicates upper airway problems
RR, HR, BP, SpO2
ABG as needed

42. Orotracheal / Nasotracheal Tubes
Complications
The most common problems after extubation are hoarseness, sore throat, and cough – these are benign and will resolve with time
Laryngospasm, a rare but serious complication associated with extubation, is usually transient and treatable with high FiO2 and application of positive pressure. If it persists, a neuromuscular blocking agent may have to be given, which will necessitate manual ventilation or reintubation

43. Tracheostomy Tube Removal
There are several approaches to removing tracheostomy tubes (“decannulation”) – the method used will be depend on the patient’s needs
Abrupt - removed in one step
Weaning
Fenestrated tubes
Progressively smaller tubes
Tracheostomy buttons

44. Fenestrated Tracheostomy Tube
The fenestrated tracheostomy tube has a removable inner cannula. However, the outer cannula has a hole in its posterior wall - a fenestration
With the inner cannula removed and the cuff deflated, the patient may breathe through the upper airway, via the fenestration - allowing for increasing use of the upper airway

45. Fenestrated Tracheostomy Tube
In the event mechanical ventilation is required, the cuff can be inflated and inner cannula replaced; in this configuration, the tube performs like a regular cuffed tracheostomy tube

46. Progressively Smaller Tubes
A second airway weaning technique is to use progressively smaller and smaller tracheostomy tubes
Indicated in patients who airway is too small for a fenestrated tube
May facilitate better healing of the stoma
Problems
Increases in airway resistance
May impair coughing
Smaller tubes may result in the curve of the tube impacting the posterior tracheal wall

47. Tracheostomy Button
Used to maintain a tracheal stoma

48. Tracheostomy Button
Fits from the skin to just inside the anterior wall of the trachea
Avoids added resistance to the airway
Use:
Relieving airway obstruction
Removing secretions

49. Tracheostomy Button
Has an adaptor for provision of IPPB or mechanical ventilation
An optional one-way valve on the external end of the button allows for speech

50. Assessment After Decannulation
Vocal cord evaluation
Abnormalities can result in aspiration or acute airway obstruction
Symptoms
Stridor
Retractions
Inability to feel airflow through the upper airway
Have a replacement tracheostomy tube and suctioning equipment available