Airway Management Chapter 33

1
Airway ManagementChapter 33

• Melissa Dearing, BS, RRT-NPS, RCP

2
Introduction

• In the clinical environment, the RCP is
  responsible for establishing and maintaining a
  patients artificial airway.

3
Proficiency

• The RCP must be proficient in 3 broad areas in
  order to maintain a patients airway.
• AIRWAY CLEARANCE TECHNIQUES
• INSERT AND MAINTAIN ARTIFICIAL AIRWAYS
• ASSIST PHYSICIANS IN PERFORMING SPECIAL
  PROCEDURES IN AIRWAY MANAGMENT

4
AARC Guidelines for Establishing an Artificial
Airway

• On page 701-702 of Egan

5
Indications for an Artificial Airway

• Airway Compromise airway patency is in doubt or
  patient may be at risk of losing patency
• SEE INDICATIONS IN EGANS

6
Indications for an Artificial Airway

• Respiratory Failure
• Definition a condition in which the exchange of
  oxygen and or carbon dioxide between the alveoli
  and the pulmonary capillaries are inadequate.
• PaO2 lt60 mmHg and/or a PaCO2 gt50mmHg in an
  otherwise healthy individual

7
Indications for an Artificial Airway

• Need to Protect the Airway
• For some reason the patients ability to sneeze,
  gag or cough has been dulled and aspiration is
  possible.

8
Contraindications for Art. Airway

• When a pts desire to not be resuscitated has
  been expressed and is documented in the pts chart

9
Routes for Art. Airways

• 2 Types
• Pharyngeal Airways
• Tracheal Airways

10
Pharyngeal Airways

• Indicated by the need to restore patency in an
  unconscious patient.
• Pulls the tongue forward and away from the
  posterior pharynx
• Allows for easy suctioning of the patient

11
Pharyngeal Airways

• 2 Types of Pharyngeal Airways
• Oral Pharyngeal Airway inserted into the mouth
• Nasal Pharyngeal Airway inserted into the nose

12
Pharyngeal Airways

• Oral Pharyngeal Airway -

13
Oral Pharyngeal Airway

• 3 parts
• Flange
• Body
• Channel

14
Oral Pharyngeal Airway

• Accurate Measurement of Size
• Place the flange at
  the center of
• the lips and the tip
  of the curved
• body to the angle of
  the jaw.

15
Oral Pharyngeal Airway

• Hazards
• Gagging
• Vomiting
• Laryngeal spasm

16
Oral Pharyngeal Airway

• Contraindications
• Conscious patients
• Trauma to mouth or jaw area
• Lesions to this area

17
Oral Pharyngeal Airway

• Can be used as a bite block with artificial
  airways

18
Oral Pharyngeal Airway

• Inserted upside down with a 180 twist
• Flange remains outside teeth
• Never tape in place!!

19
Nasopharyngeal Airway

• Has a port, channel, body and beveled edge

20
Nasopharyngeal Airway

• Measured via placing the port at the nares and
  the bevel at the ear lobe.
• Commonly used for frequent suctioning

21
Nasopharyngeal Airway

• Link to insertion video
• http//youtube.com/watch?vBw5_Uvl7IQ0featurerel
  ated

22
Nasopharyngeal Airway

• Insertion
• Insert into the nostril with the bevel facing the
  septum
• Use water soluble lubricant (always)
• Do not force!
• Tilt head back

23
Nasopharyngeal Airway

• Hazards
• Nasal bleeding (epitaxis)
• Trauma to nose
• Otitis media

24
Nasopharyngeal Airway

• Contraindicated
• Nasal trauma
• Space occupying lesion
• Skull fracture
• Deformities of the nose
• Coagulation Disorders

25
Tracheal Airways

• 1. Endotracheal Tubes AKA ETT or ET
• Tube
• 2 types
• Oral ETT
• Nasotracheal Tube
• 2. Tracheostomy Tubes

26
Oral ETT

• Various sizes depending on patient age and weight
• Size is given by ID
• See Table 33-2 on page 707

27
Nasotracheal Tube

• More difficult than orotracheal intubation.
• Is the route of choice in special situations such
  as when the oral route is unavailable.
• Maxillofacial injuries
• Recent oral surgery

28
Tracheostomy Tube

• AKA trach

29
Orotracheal Intubation Procedure

• Check and Assemble Equipment (Box 33-3 page 707)

30
Orotracheal Intubation Procedure

• 2. Position your patient into the sniffing
  position

31
Orotracheal Intubation Procedure

• Preoxygenate with 100 oxygen to provide apneic
  or distressed patient with reserve while
  attempting to intubate.
• Do not allow more than 30 seconds to any
  intubation attempt.
• If intubation is unsuccessful, ventilate with
  100 oxygen for 3-5 minutes before a reattempt.

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Orotracheal Intubation Procedure

• Insert Laryngoscope

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34
Miller vs. MacIntosh Blades
35
Orotracheal Intubation Procedure

• After displacing the epiglottis insert the ETT.
  Depth of tube is on chart (Table 30-2).
• The depth of the tube for a male patient on
  average is 21-23 cm at teeth
• The depth of the tube on average for a female
  patient is 19-21 at teeth.

36
Orotracheal Intubation Procedure

• Confirm tube position
• By auscultation of the chest
• Bilateral chest rise
• Tube location at teeth
• CO2 detector (esophageal detection device)
• e) Laryngoscopy not always available

37
Orotracheal Intubation Procedure

• Stabilize the ETT

38
Complications of Oral ETT Placement

• Physical Damage teeth, gums, lips, tongue,
  pharynx, larynx, and esophagus
• Physiological Hazards acute hypoxemia and
  hypercapnea leading to bradycardia and cardiac
  arrest
• Complications can be minimized by effective
  ventilation, oxygenation, sedation and anesthesia

39

• Advantages and Disadvantages of Oral ETT Table
  33-1 page 704

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Video on Intubation

• http//youtube.com/watch?veRkleyIJi9Ufeaturerel
  ated
• http//youtube.com/watch?v5ueZ9YO2sRM
• http//youtube.com/watch?vN3rTV2GdCWE

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Nasotracheal Intubation

• Direct Visualization- pt. is not breathing
• Blind Intubation- pt. is spontaneously breathing
• With both of the above methods, a nasal spray of
  2 lidocaine and 0.25 racemic epinephrine
  provide local anesthesia and vasoconstriction
  (bleeding).

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Nasotracheal Intubation

• Direct Visualization
• 1. Check your equipment
• 2. Hyperoxygenate your patient
• 3. Pass the ETT with the bevel toward the
  septum and advance it until the trip is in the
  oropharynx. Open the mouth and insert the
  laryngoscope with your left hand to visualize the
  glottis.
• 4. With your R hand grasp the tube with the
  forceps and direct it between the vocal cords.
• 5. Average insertion is 28 cm for adult males
• 26 cm for adult females
• 6. Confirm your placement and stabilize tube.

43
Direct Visualization
44
Nasotracheal Intubation

• Blind Insertion
• Put patient in supine or sitting position
• Insert ETT through the nose and listen for air
  movement
• The movement of air becomes louder as you enter
  the pharynx
• If the sounds disappear, you have entered the
  esophagus

45
Complications of NT Intubation

• Physical Damage nasal system, pharynx, larynx,
  and trachea
• Physiologic hazards - acute hypoxemia and
  hypercapnea leading to bradycardia and cardiac
  arrest
• Complications can also include
• Nasal curvature at nasopharynx
• Sinusitis
• ?Raw and WOB

46
Advantages and Disadvantages of NT Intubation

• Page 704 Table 33-1 in Egans

47
Tracheotomy

• Indications
• Long term care for patient of neuromuscular
  disease
• Route for overcoming upper airway obstruction
• Trauma
• Prolonged intubation period

48
Tracheostomy Algorithm
49
Tracheotomy

• Consider intubation time
• Performed by surgeon
• Can be performed in an OR or at the bedside.

50
Tracheostomy Tubes

• Tracheotomy surgical procedure that creates a
  tracheostomy (surgical opening in the trachea).
• Video http//video.google.com/videoplay?docid7135
  207193183107526qtracheotomytotal60start0num
  10so0typesearchplindex5

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Traditional Tracheotomy Procedure

• A local anesthetic is used in addition to mild
  sedation of the pt.
• The ETT is not removed until just before the
  trach is placed.
• An incision is made in the neck over the second
  or third tracheal ring.
• After removal of tissue and incision of the
  thyroid isthmus, he enters the trachea through a
  horizontal incision between the rings.
• A trach tube is inserted into the trachea.

52
Vertical Tracheotomy
53
Tracheotomy Procedure Video

• http//video.google.com/videoplay?docid-418914376
  185249199qtracheotomytotal60start0num10so
  0typesearchplindex0

54
Percutaneous Tracheostomy

• An incision is made into the anterior wall of the
  trachea
• A needle and a sheath is inserted into the
  trachea b/t the cricoid and 1st ring or the first
  and second tracheal rings.
• A guide wire is then inserted through the sheath
  and the sheath is removed.
• A dilator is then passed over the guide wire.
• Larger and larger dilators are passed over the
  guide wire until the stoma is large enough for
  the trach tube to be inserted.

55
Percutaneous Tracheotomy Video

• http//video.google.com/videoplay?docid-418914376
  185249199qtracheotomytotal60start0num10so
  0typesearchplindex0

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Percutaneous Tracheostomy From Inside the Lung

• http//video.google.com/videoplay?docid4189143761
  85249199qtracheotomytotal60start0num10so
  0typesearchplindex0

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Trach Tube SizesTable 30-4

• PREEMIE 00
• Birth to 6 months 0
• 6-18 months 1
• 18 months to 5 years 1-2
• 5 years to 10 years 2-3
• 10-14 years 3-5
• 14 years to adult 5-9

58
Post Trach Tube Insertion

• Inflate the cuff
• Secure with trach ties
• Secure enough to prevent movement of the tube but
  loose enough so insert one finger under the tie.

59
Tracheotomy Advantages and Disadvantages

• Table 33-1 page 704 in Egans

60
Complications of TracheostomyBranson p.130

• Early Complications
• Hemorrhage
• Apnea
• Cardiac Arrest
• Hypotension
• Obstruction or displaced tube
• Subcutaneous emphysema
• Pneumothorax
• Aspiration and atelectasis
• Laryngeal nerve damage
• Tracheoesophageal fistula

61
Complications of TracheostomyBranson p.130

• Late Complications
• Hemorrhage
• Obstruction
• Tracheitis
• Pneumonia
• Wound Infection
• Subglottic Edema
• Tracheal stenosis
• Dysphagia
• TE fistula
• Persistent tracheocutaneous fistula
• Difficult decannulation
• Scar

62
Decannulated Stoma
63
Blockage of Trach by Foreign Object
64
Complications
65
Airway Trauma

• Ischemia and ulceration
• Friction Injuries
• Allergic Reactions
• Structural Damage
• Laryngeal Dysfunction

66
Post Tube Removal

• Airway must be evaluated for damage after removal
  of the tube.
• This may be done by a combination of any of the
  following methods
• Physical exam
• Air tomography
• Fluoroscopy
• Laryngoscopy
• Bronchoscopy
• MRI
• PFTs

67
Airway Trauma Laryngeal Lesions

• Most common
• Glottic edema
• Vocal cord inflammation
• Laryngeal or vocal cord ulceration
• Vocal cord polyps
• Less common
• Vocal cord paralysis
• Laryngeal stenosis

68
Video on Vocal Cord Paralysis

• http//video.google.com/videoplay?docid5768781314
  993002026qvocalcordparalysistotal5start0n
  um10so0typesearchplindex1

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Vocal Cord Polyp

• http//video.google.com/videoplay?docid8113560708
  014264669qvocalcordpolypstotal4start0num
  10so0typesearchplindex0

70
Glottic Edema and Vocal Cord Inflammation

• Due to pressure of the ETT or intubation trauma
• Problem occurs after extubation
• Symptoms
• Hoarseness
• Stridor

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Stridor (Emergency)

• http//video.google.com/videoplay?docid-679466807
  1682595240qstridortotal26start0num10so0
  typesearchplindex1

72
Vocal Cord and Laryngeal Ulcerations

• Cause hoarseness
• Symptom usually resolve soon after extubation.
• No trx is indicated

73
Vocal Cord Polyps and Granulomas

• Develop slowly take weeks to months to form
• Symptoms
• Difficulty swallowing
• Hoarseness
• Stridor

74
Vocal Cord Paralysis

• Likely in extubated pts with hoarseness and
  stridor that does not resolve over time.
• Paralysis may be temporary post extubation and
  return to normal after several days.
• If the problem becomes obstructive then
  tracheostomy is performed

75
Laryngeal Stenosis

• Scar tissue formation on the larynx
• Causes stricture and reduces mobility
• Symptoms
• Stridor
• Hoarseness

76
Tracheal Lesions

• Can occur with any tracheal airway
• Most common
• Granulomas
• Tracheomalacia
• Tracheal stenosis
• Less common
• Tracheoesophageal fistula
• Tracheoinnominate fistula

77
Tracheoinnominate Fistula

• Occurs when the trach tube erodes a hole through
  the innominate artery.
• Causes massive hemorrhage and death
• Rare complication

78
Tracheoesophageal Fistula

• Direct opening between the trachea and esophagus
• Rare complication of ETT or trach
• Can be caused by sepsis
• Malnutrition
• Tracheal erosion from the cuff or tube
• Esophageal erosion from NG tube

79
Tracheoesophageal Fistula Diagnosis

• Symptoms
• Frequent aspiration
• Abdominal distention during mech ventilation
• Diagnosis
• Direct visualization of the defect by endoscopic
  exam

80
Tracheoesophageal Fistula
81
Tracheomalacia

• Softening of the cartilage rings causing collapse
  of the trachea on inspiration.
• Video http//video.google.com/videoplay?docid601
  1250625294348515qtracheomalaciatotal2start0
  num10so0typesearchplindex0

82
Tracheal Stenosis

• Narrowing of the trachea due to scarring
• Usually at the site of
• ETT cuff
• ETT tip
• Stoma site
• Video of a tracheal stenosis repair
  http//video.google.com/videoplay?docid-455143974
  0720697250qtrachealstenosistotal4start0num
  10so0typesearchplindex2

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Symptoms of Tracheal Damage

• Prior to Extubation
• Difficulty sealing the cuff
• Tracheal dilatation on the CXR
• Post Extubation
• Difficulty with expectoration
• Dyspnea
• stridor

84
PFT Diagnosis

• Tracheomalacia will appear as a variable
  obstruction
• Tracheal Stenosis will appear as a fixed
  obstruction

85
Prevention of Airway Trauma

• Limit tube movement
• Select correct size of airway
• Limit cuff pressures or dont inflate
• Practice good trach care

86
Airway Maintenance Suctioning

• Retained Secretions cause problems such as
• ? RAW
• ? WOB
• Hypoxemia
• Hypercapnia
• Atelectasis
• Infection

87
Removal of Secretions

• By way of
• Mechanical aspiration
• Suctioning can be performed in the upper or
  lower airway

88
Oropharynx

• Upper airway secretions are removed by a rigid
  tonsillar or Yankauer suction tip.

89
Lower Airway Suction

• Via a flexible suction catheter through the nose
  or artificial airway.

90
Endotracheal Suctioning

• AARC Guidelines page 696 Egans

91
NT Suctioning

• P. 699 AARC Guidelines

92
NT Equipment

• In addition to suction equipment used in ETT
  suction you will need
• Water soluble jelly
• Can use a nasopharyngeal airway if requiring long
  term suctioning

93
Procedure

• Lubricate catheter and insert gently into nostril
  directing it toward the septum and floor of the
  nasal cavity.
• Have pt assume a sniffing position
• Advance the catheter until the pt coughs or
  resistance is felt in the lower airway

94
Endotracheal Suctioning

• Assess the pt for indications
• Assemble and check equipment
• See Box 30-1 for equipment on page 655
• Hyperoxygenate your patient
• Insert the Catheter
• Apply Suction
• Reoxygenate your patient
• Monitor

95
Suction Pressures

• Check suction pressures
• Adults pressure -100 to -120 mm Hg
• Children -80 to -100 mm Hg
• Infants -60 to 80 mm Hg

96
Suction Catheters

• Various Sizes
• Side port to reduce mucosal damage
• 22 inches long
• Sized in French units

97
Coude Tip Catheter

• Used to suction L main stem bronchi

98
Catheter Size

• Never use a catheter that is gt ½ the ID of the
  ETT or trach tube.
• ROT
• Proper size suction catheter
• Multiply tube size by 2
• Use the next size smaller catheter

99
Closed System Catheter

• Incorporated into the vent circuit
• Patient is not disconnected from the vent for
  suctioning
• Can be used continuously for 24 to 48 hours
• Allows maintenance of high PEEP and high FiO2
• Less chance of cross contamination

100
Indications for Use of Closed Catheter Systems

• High vent requirements
• PEEP gt10 cm H20
• MAP gt 20 cm H20
• I time gt 1.5 seconds
• FiO2 gt 60
• Patients requiring suctioning gt 6 X per day
• Hemodynamically instable during vent disconnect
• Ventilated pts with active TB
• Pts receiving inhaled gases that will be
  interrupted with vent disconnection
• Nitric oxide
• heliox

101
Saline Use

• Controversial Saline irrigation is a common
  practice to aid in removal of secretions during
  suctioning.
• Egans says Increases incidence of nosocomial
  pneumonia by displacing bacteria from the wall of
  the airways
• If secretions are tenacious acetylcysteine may
  be used with a physicians order.
• Can cause bronchospasm use with care!

102
Preoxygenate

• Use BVM to hyperinflate the pt
• Provide 100 O2 for at least 30 seconds
• COPD patient beware of increasing the O2 just
  hyperinflate if possible

103
Catheter Insertion and Suction

• Insert the catheter until it can go no further
• Apply suction while withdrawing the catheter
• Total suction time lt 15 seconds
• Clear the catheter with saline to prevent drying
  of secretions

104
Reoxygenate and Hyperinflate

• Apply oxygen and Hyperoxygenate the patient for
  at least one minute post suctioning.

105
Monitor

• After suctioning always monitor your pts. VS and
  response to suctioning.
• You may need to apply suction repeatedly to
  remove the retained secretions.
• Remember to assess the outcome of the suctioning
  and always reassess your pt.

106
Minimize Complications

• You may be able to hyperoxygenate your pt. with
  their ventilator instead of removing them from
  their vent.
• Helpful with pts on high levels of PEEP (gt10).

107
Cardiac Arrhythmias

• Stimulation of the airway can cause a cardiac
  arrhythmia
• Vagal stimulation can cause bradycardia or
  asystole.
• Tachycardia occurs with a hypoxic or agitated pt.

108
Hypotension

• Can occur during suctioning, coughing, or a
  cardiac arrhythmia.
• Due to decreased venous return from any of these
  complications

109
Atelectasis

• Due to removal of too much air during suctioning.
• Limit the amount of suction used
• Keep the duration short
• Provide hyperinflation before and after procedure

110
Mucosal Trauma

• Occurs when the catheter adheres to the wall of
  the airway during suctioning.
• Watch suction pressures
• Rotation of the catheter while withdrawing may
  help

111
? ICP

• Transient ICP usually returns to normal within
  one minute
• Problem with a pt. with already high ICP
• Can give aerosolized topical anesthesia 15
  minutes prior to suctioning

112
Minimize Complications

• Be ready for vomit in case it happens.
• Dont suction too soon after a meal
• Turn the pt to the side and suction the mouth
• Avoid using too much force when advancing the
  catheter
• Lubricate the catheter
• Use sterile technique
• Assess pt for wheezing post suctioning

113
Sputum Sampling

• Used to identify organisms infecting the airway
• A specimen container is necessary in addition to
  usual suction equipment