Airway Management Part III

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Airway ManagementPart III

• RET 2275
• Respiratory Care Theory 2

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Tracheostomy Tubes

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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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)

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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

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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

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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

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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

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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

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Providing for Patient Communication

• Communication Board

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Talking Tracheostomy Tube

• Provides a separate inlet for compressed gas,
  which escapes above the tube allowing phonations

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Passy-Muir Speaking Valves
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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)

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Passy-Muir Valve

• Candidates for PMV
• Awake and alert tracheostomized (ventilator or
  non-ventilator dependent patients) adult,
  pediatric and neonatal

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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

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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

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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

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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

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Ensuring Adequate Humidity

• Heated humidification
• Large volume nebulizer
• Heat and moisture exchanger (HME)

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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

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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

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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

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Care of the Tracheostomy Tube

• Tracheostomy tubes require daily care
• Clean the stoma site
• Remove the patients 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

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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

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Extubation / Decannulation

• For most patients, tracheal intubation is a
  temporary measure
• The process of removing an artificial tracheal
  airway is called extubation

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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

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Orotracheal / Nasotracheal Tubes

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

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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

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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

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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

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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

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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

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Tracheostomy Tube Removal

• There are several approaches to removing
  tracheostomy tubes (decannulation) the method
  used will be depend on the patients needs
• Abrupt - removed in one step
• Weaning
• Fenestrated tubes
• Progressively smaller tubes
• Tracheostomy buttons

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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

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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

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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

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Tracheostomy Button

• Used to maintain a tracheal stoma

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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

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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

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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