1. Artificial Airways & Airway Management

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 Murphy eye
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