Airway Management

Primary Indications for tracheal suctioning
-Need to maintain patency and integrity of the artificial airway
-Need to remove accumlated pulmonary secretions as evidenced by one of the following:
1. Sawtooth pattern on the flow-volume loop on the monitor screen of the ventilator or the presence of coarse crackles over the trachea-both are strong indicators of retained pulmonary secretions
2. Increased peak inspiratory pressure on volume-control ventilation or decreased tidal volume on pressure control ventilation.
3. Deterioration of O2 saturation or blood gas values
4. Visible secretions in the airway.
5. Inability of patient to generate an effective cough.
6. Acute respiratory distress
7. Suspected aspiration of gastric or upper airway secretions.
-Need to obtain a sputum specimen to rule out or identify pneumonia or other pulmonary infection or for sputum cytology

Most common complications of suctioning
-Decrease in dynamic lung compliance and FRC
-Hypoxia or hypoxemia
-Tissue Trauma to the tracheal or bronchial mucosa
-Bronchoconstriction or bronchospasm
-Increased microbial colonization of lower airway
-Changes in cerebral blood flow and increased intercranial pressure
-Cardiac dysrhythmias
-Routine use of normal saline instillation may be assoicated with the following adverse events:
1. Excessive coughing
2. Decreased O2 saturation
3. Bronchospasm
4. Dislodgement of the bacterial bioflim that colonizes the endotracheal tube into the lower airway
5. Pain, anxiety, dyspnea
6. Tachycardia
7. Increased intercranial pressure

How often should patients be suction?
A patient should generally never be set on a preset schedule but should be assessed to see if there is a need.

The normal range of negative pressure to use when suctioning an adult patient is?
100-150 mmHg

The normal range of negative pressure to use when suctioning a pediatric patient?
100-120 mmHg

The normal range of negative pressure to use when suctioning a infant?
80-100 mmHg

The normal range of negative pressure to use when suctioning a neonate?
60-80 mmHg

To estimate the proper size of suction catheter when a patient has an trach tube.
1. Multiply the tubes inner diameter by 2. 6mm tube= 2 X 6= 12
2. Use next smallest size catheter Use a 10F catheter

To prevent hypoxemia when suctioning a patient, how should we prepare the patient?
Deliver 100% O2 for 30-60 seconds to peds & adults
Increase O2 concentration by 10% for neonates

Indications for use of closed suctioning tecnique
-PEEP >/= 10 CWP
-Mean airway pressure >/= 20CWP
-Inspiratory time >/= 1.5 seconds
-FiO2 >/= 0.60
-Frequent suctioning (>/= 6 times/day)
-Hemodynamic instability associated with ventilator disconnection
-Respiratory infections requiring airborne or droplet precautions
-Inhaled agents that cannot be interrupted by ventilator disconnection (e.g., nitric oxide, helium/O2 mixture)

Total application for endotracheal suction in adults should not exceed how many seconds?
15 seconds

What methods can help to reduce the likelihood of atelectasis due to tracheal suctioning?
1. Limit the amount of negative pressure used
2. Keeping the duration of suctioning as short as possible
3. Using the appropriate size suction catheter
4. Avoiding disconnection from the ventilator

What can help to minimize the likelihood of mucosal trauma during suctioning?
Limit the amount of negative pressure used and always rotate the catheter while withdrawing

The absolute contraindications for nasotracheal suctioning are?
Epiglottis or croup

Equipment needed for suctioning
-Vacuum source
-Calibrated adjustable regulator
-Collection bottle and connection tubing
-Disposable gloves: sterile (Open suction) or clean (closed suction)
-Sterile suction catheter
-Sterile water and cup (open suction)
-Goggles, mask, and other appropriate equipment for standard precautions
-O2 source with a calibrated flowmeter (open suction) or ventilator (closed suction)
-Pulse oximeter
-Manual resuscitation bag equipped with O2 enrichment device for emergency back up use

Nasopharyngeal Airway
-Use with a patient who requires frequent nasotracheal suctioning to minimize damage to the nasal mucosa that can be caused by suctioning catheter
-May also be placed in a recently extubated patient with facial surgery to help maintain patent airway despite swelling

Oropharyngeal Airway
-Inserted into the mouth and over the tongue.
-Be restricted to unconscious patient to avoid gagging and regurgitation.
-Help maintain a patent airway when the tongue would otherwise obstruct the oropharynx.
-Can also be used as a bite-block for patients with oral tubes

What are the general conditions that require airway management?
1. Airway compromise
2. Respiratory Failure
3. Need to protect the airway

What conditions require emergency tracheal intubation
-Persistent apnea
-Traumatic upper airway obstruction
-Accidental extubation of a patient unable to maintain adequate spontaneous ventilation
-Obstructive angioedema
-Massive uncontrolled upper airway bleeding
-Infection-related upper airway obstruction (partial or complete)
1. Epiglottitis in children or adults
2. Acute uvular edema
3. Tonsillopharyngitis or retropharyngeal absecess
4.Suppurative parotitis
-Coma with potential for Increased ICP
-Neonatal or pediatric specific conditions
1. Perinatal asphyxia
2. Severe adenotonsillar hypertrophy
3. Severe laryngomalacia
4. Bacterial tracheitis
5.Neonatal epignathus
6. Obstruction from abnormal laryngeal closure owing to artyenoid masses
7. Mediastinal tumors
8. Congenital diaphragmatic hernia
9. Presence of thick or particulate meconium in amniotic fluid
10. Absence of airway protective reflexes
11. Cardiopulmonary arrest
12. Massive hemoptysis

What types of artifical airways are inserted through the larynx?

Advantages of Oral Intubation
-Insertion is faster, easier, less traumatic, and more comfortable
-Larger tube is tolerated
-Easier suctioning
-Less airflow resisitance
-Decreased work of breathing
-Easier passage of bronchoscope
-Reduced risk of tube kinking
-Avodiance of nasal and paranasal complications, including epistaxis and sinusitis

Disadvantages of Oral Intubation
-Esthetically displeasing, espeically long term
-Greater risk of self- extubation or inadvertent extubation
-Greater risk of main stem intubation
-Risk of tube occlusion by biting or trismus
-Risk of injury to lips, teeth, tongue, palate, and oral soft tissue
-May require additional use of oral airway
-Great risk of retching, vomiting and aspiration
-Pain discomfort, especially with inadequate preparation

Advantages of Nasal Intubation
-Less Retching and gagging
-Greater comfort in long term use
-Less salivation
-Improved ability to swallow oral secretions
-Improved communication
-Improved mouth care and oral hygiene
-Avoidance of oral route complications
-Easier nursing care
-Avoidance of oral route complications
-Less posterior laryngeal ulceration
-Better tube anchoring, less chance of inadvertent extubation
-Reduced risk of main stem intubation
-Some patients can swallow liquids, providing a means of nutritional support
-Blind nasal intubation does not require muscle relaxants or sedatives
May avert “crash” oral intubation

Disadvantages of Nasal Intubation
-Nasal and paranasal complications, including epistaxis, sinusitis, otitis
-More difficult to perform
-Spontaneous breathing required for blind nasal intubation
-Smaller tube is necessary
-Greater suction difficulty
-Increased airflow resistance
-Increased work of breathing
-Difficulty passing bronchoscope
-Smaller risk of transient bacteremia

Advantages of Tracheotomy
-Avoidence of laryngeal and upper airway compliacations of translaryngeal intubation
-Greater comfort
-Aids feeding, oral care, suctioning and speech
-Psychologic benefit (improved motivation)
-Easier passage of fiberoptic bronchoscope
-Easier reinsertion
-Estheically less objectionable
-Facilitation of weaning from ventilator
-Elimination of risk of main stem intubation
-Reduced work of breathing
-Better anchoring (reduced risk of decannulation)
-Improved ability to place curve tipped suction catheter in left bronchus
-Improved mobility (transer out of ICU to ward or extended care facility_

Disadvantages of Tracheotomy
-Greater expense
– Requirement for use of operating room in most cases
-Need for general anesthesia in most cases
– Permanent scar
– More severe complications
-Greater mortaility rate
– Delayed decannulation
– Increased frequency of aspiration
– Greater bacterial colonization rate
– Persistent open stoma after decannulation, reducing cough efficiency

What is the standard size for endotracheal or tracheostomy tube adaptors?
15 mm external diameter

What is the purpose of the additional side port (Murphy’s eye) on most modern endotracheal tubes?
Ensures gas flow if the main port should become obstructed

What is the purpose of a cuff and pilot balloon on an artificial tracheal airway?
Inflation of the cuff seals off the lower airway either for protection from gross aspiration or to provide positive pressure ventilation. A small filling tube leads from the cuff to a pilot balloon used to monitor cuff status and pressure when the tube is in place. A spring loaded valve with a standard connector for a syringe allows inflation and deflation of the cuff.

What features are incorporated into most modern endotracheal tubes assist in verifying proper tube placement?
Radiopaque indicator that is embedded in the distal end of the tube body

The purpose of the removable inner cannula commonly incorporated into modern trachestomy tubes serves to?
Can be removed for cleaning and if it becomes obstructed.

What is the purpose of the tracheostomy tube obturator?
It has a rounded tip used for tube insertion to minimize mucosal trauma during insertion

Why is orotracheal intubation the preferred route for establishing an emergency tracheal airway?
The oral passage is the quickest and easiest route in most cases

Equipment needed for endotracheal intubation
-O2 flowmeter and tubing
– Suction apparatus
– Flexible sterile suction catheters
– Sterile gloves for endotracheal suctioning
– Yankauer (Tonsillar) tip suction
– Manual resuscitation bag and mask
– Colorimetric CO2 detector
– Oropharyngeal airways
– Laryngoscope (2) with assorted blades (size 2-3 for adults, size 1-2 for children size 0-1 for infants)
– Endotracheal tubes (3 appropraite sizes)
– Tongue depressor
– Stylet
– Stethoscope
– Tape or endotracheal tube holder
– 10-ml or 12-ml syringe
– Water- soluble lubricating gel
– Magill forceps
– Local anesthetic (spray)
– Towels (for positioning)
– CDC barrier precautions ( gloves, mask, gowns, goggles or face shields)

Guidelines for infant, pediatric and adult tracheostomy tube sizes
Premature <2kg = 2.5 cuffless neonatal Infant = 3.0-3.5 cuffless neonatal 6-18 mos = 3.5-4.0 neonatal or pediatric 18 mo to 4-5 yrs = 4.0-4.5 pediatric 4-5yrs to 10 yrs = 4.5-6.0 pediatric 10-14 yrs = 5.0-6.5 pediatric or adult 14 yrs to adult = 6.0-9.0 adult The difference between the same size (ID) neonatal and pediatric tube or pediatric and adult tube is the length; that is , the adult tube is longer than the pediatric tube and the pediatric tube is longer than the neonatal tube

What is the purpose of an endotracheal tube stylet?
Add Rigidity and maintain shape during insertion of tube

Estimation of ET tube size (Changs)
Neonate (<1000 grams) 2.5mm ID Neonate (1000 to 2000 grams) 3.0mm ID Neonate (2000 to 3000 grams) 3.5mm ID Neonate (>3000 grams) 4.0 mm ID
Child (1-2 yrs) 4.5mm ID
Child (2-12 yrs) 4.5+ mm ID
Adult female 7.0 or 7.5 mm ID
Adult male 7.5 or 8.0 mm ID

What should be the maximum time devoted to any intubation attempt?
30 seconds

During oral intubation of an adult, the endotracheal tube should be advanced into the trachea about how far?
3-6 cm above the carina

Procedure for Oral Intubation
1. Assemble and test supplies (e.g. check light source and ET tube for air leak)
2. Lubricate the deflated cuff with a water-soluble lubricant
3. Inform or explain procedure to patient
4. Bag-mask ventilate and preoxygenate patient with 100% oxygen
5. Tilt the head back and place in the sniffing position
6. Open mouth and apply anesthetic spray
7. Hold laryngoscope handle with left hand and insert blade into the right side of the opened mouth
8. Slide blade to the base of the tongue and sweep blade to the left
9. Maneuver the tip of the straight blade underneath the epiglottis (or the tip of curved blade at the vallecula)
10. Lift handle and blade anteriorly to displace the tongue and attached soft tissues
11. Locate the epiglottis (only with curve blade), larynx and vocal cords
12. Insert ET tube through the vocal cords under direct vision
13. For adults, the centimeter marking on the ET tube should initially be placed at the lips or incisors at 21 to 23 cm.
14. Inflate cuff and confirm endotracheal tube placement (eg, loss of phonation, rising SpO2, presence of bilateral breath sounds and expired CO2)
15. Verify proper depth of ET tube placement (1.5 inch above carina) with chest radiography

Ideally, the distal tip of a properly positioned endotracheal tube (in an adult man) should be positioned about how far above the carina?
3-6 cm

What bedside method can absolutely confirm proper endotracheal tube position in the trachea?
-Ausculation of chest and abdomen
-Observation of chest movement
-tube length (cm to teeth)
– esophageal detection device
– light wand
– capnometry
– colorimetry
– fiberoptic laryngoscopy or bronchscopy
– videolaryngoscopy

What is the average length of a properly positioned oral endotracheal tube.
males 23 and female 21

when using a bulb-type esophageal detection device (EDD) during an intubation attempt, how do you know that the endotrCheal tube is in the esophagus or in the trachea?
if the tube is correctly placed the bulb quickly reexpands on release because the tracheal lumen is held openby cartilaginous rings. if the tube is in the esophagus, it does not reinflTe because the more pliable esophagus collapses around the tip of the endotracheal tube preventing the blub from reinflating.

When using capnometry or colorimetry to differenate esophageal from tracheal placement of an endotracheal tube, what conditions can result in a false-negative finding (ie, no CO2 present even when the tube is in the trachea)?
In patients with cardiac arrest because of poor pulmonary blood flow

The most common complication of emergency airway management is tissue trauma. The most serious complications are acute hypoxemia, hypercapnia, bradycardia, and cardiac arrest. What can be done to minimize these complications.
Using proper technique
Providing adequate ventilation and oxygenation (before, during and after)
Adhering strictly to intubation time limits

What are the factors that should be considered when deciding to change from an endotracheal tube to a tracheostomy tube?
-Projected time the patient will need an artifical airway
-Patient’s tolerance of endotracheal tube
– Patient’s overall condition (including nutritional, cardiovascular, and infection status)
-Patient’s ability to tolerate a surgical procedure
– Relative risks of continued endotracheal intubation vs. tracheostomy

What are the primary indications for a tracheostomy?
-Upper airway obstruction or trauma
-Poor airway protective reflexes
-Prolonged period pf oral or nasal intubation

In a properly performed traditional surgical tracheotomy, entrance to the trachea is made through an incision that is made?
over the second or third tracheal ring

What is the most common sign associated with the transient glottic edema or vocal cord inflammation that follows extubation?
Hoarseness and stridor
Stridor is often treated with epinephrine via aerosol. If the stridor is marked then the patient should be reintubated

What techniques or procedures should be used to help minimize infection of a tracheotomy stoma?
Sterile techniques should be used when cleaning or suctioning trach tubes. Good trach care, including aseptic cleaning of the stoma with sterile normal saline or half-strength hydrogen peroxide, should be carried out routinely

When checking for proper placement of an endotracheal tube or trach tube on a CXR, how fair above the carina should the distal tip of the tube be positioned?
3-6 cm

An alert patient with a long-term need for a trach tube (because of recurrent aspiration) is having difficulty communicating with the ICU staff. What would you recommend to help this patient communicate better?
Speaking valve

To ensure adequate humidification for a patient with an artifical airway, inspired gas at the proximal airway should be 100% saturated with water vapor and at what temperature range?
32C and 35C

Why tracheal airways increase the incidence of pulmonary infection
-Bypassed upper airway filtration
-Increased aspiration of pharyngeal secretions
-Contaminated equipment or solutions
-Impaired mucociliary clearance in trachea
-Increased mucosal damage owing to tube or suctioning
-Ineffective clearance via cough

What is the maximum recommended range for trach tube cuff pressure?
Keep between 25CWP and 35CWP
Cuff pressure measurements should be done regularly to maintain the cuff pressure in the safe range to avoid tracheal wall injury and minimize risk of aspiration of oral secretions. (MOV=Minimal occluding volume; MLT= Minimal leak technique)

Pathogenesis of Tracheal CUff Site Injury
High Cuff Pressure = High lateral tracheal wall pressure, exceeding capillary perfusion pressure = Mucosal ischemia and inflammation = mucosal necrosis = Mucosal ulceration = (Extubation=healing process) (Continued Intubation=Destruction of tracheal cartilage=Loss of structural intergrity of tracheal wall= {Erosion into adjacent structures=Tracheovascular fistula/Tracheoesophgeal fistula}{Tracheal dilatation}{Tracheomalacia}

To minimize the problems assoicated with pharyngeal aspiration in intubated patients what is recommended?
1. Use of medications for stress ulcer prophylaxis, such as sucralfate, that maintain normal gastic pH
2. Positioning of patients with the head of the bed elevated 30 degrees or more to decrease reflux
3. Continuous aspiration of subglottic secretions

Obstruction of the tube is one of the most common causes of airway emergencies. Tube obstruction can be caused by?
1. Kinking of the tubing or the patient biting on the tube
2. Herniation of the cuff over the tube tip
3. Obstruction of the tube orifice against the tracheal wall
4. Mucus plugging

What is the purpose of tracheal buttons?
Maintain tracheal stoma

What is the purpose of fenestrated trach tube?
It a double cannulated tube that has an opening in the posterior wall of the outer cannula above the cuff. When the fenestration is opened it will allow air to pass through upper airway.

What is the purpose of progressively smaller tubes?
Airway weaning technique. It maintains the airway but still allows increasing use of upper airway.

Types of Oropharyngeal Airways
Berman airway has two external side channels and ranges from size 43mm for infants to size 110mm for extra large adults.
Guedel airway has one large internal channel and the cath-guide guedel has three internal channels. And range from sizes 55mm for infants and 120 mm for extra large adults

Double-lumen endobronchial tube
Has two separate lumens (tracheal and bronchial), two cuffs (tracheal and bronchial) and two pilot balloons (tracheal and bronchial) They are used for provide independent lung ventilation where isolation of the lungs is desirable in order to prevent lung to lung spillage of blood or pus. They are also used to provide one-lung ventilation so that the nonventilated lung may undergo surgical procedure.

Esophageal gastric tube airway (EGTA)
Has an opening at the distal end. The opening allows removal or aspiration of air and gastric contents from the stomach via a gastric tube.

Esophageal obturator airway (EOA)
Has a closed (blind=the far end of a tube with out an opening) distal end and it is inserted into the esophagus. Not to be used as an artifical airway for PPV

Esophageal-tracheal combitube
An airway that may be inserted into the esophagus or trachea. It is a combination of esophageal and endotracheal tube in one unit

Laryngeal mask airway (LMA)
Tube with a small cushioned mask on the distal end that provides a seal over the laryngeal opening.

Mactinosh blade
Curved larynogoscope blade. Its tip is placed at the vallecula and indirectly lifts the epiglottis for visualization of the vocal cords

Magill Forceps
Special forceps used to perform nasal intubation under direct vision

Mallampati Classification
A method to evaluate the degree of difficulty in intubation

Miller Blade
A straight larynogoscope blade. It lifts up the epiglottis for visualization of the vocal cords during endotracheal intubation

Pilot Balloon
The small balloon on the proximal end of an ET or Trach tube. It is used to regulate the volume of air in the cuff and to serve as an indicator of air volume in the cuff.

Sniffing Position
An ideal head position for ET intubation. It is done by tilting the forehead back slightly and moving the mandible anteriorly to the patient.

Speaking Valve
A one-way valve attachment to the trach tube that allows the user to talk

Radiopaque Marking
Impenetrable to xrays. It appears as a light area on the radiograph

Tracheostomy tube with high volume-low pressure cuff
Uses a silicone foam material to fill the cuff. Does not require manual inflation with a syringe

Rapid sequence intubation (RSI)
Intubation with an ET tube under controlled settings

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