Transcript Egan Ch 33 Airway Management

Chapter 33
Airway Management
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Learning Objectives
● Describe how to safely perform endotracheal
and nasotracheal suctioning.
● Describe how to properly obtain sputum
samples.
● Assess the need for and select an artificial
airway.
● Identify the complications and hazards
associated with insertion of artificial airways.
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2
Learning Objectives (cont.)
● Describe how to perform orotracheal and
nasotracheal intubation of an adult.
● Assess and confirm proper endotracheal tube
placement.
● Describe the rationale and the methods for
performing a tracheotomy.
● Identify the types of damage artificial airways
can cause.
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3
Learning Objectives (cont.)
● Describe how to properly maintain and
troubleshoot artificial airways.
● Describe techniques for measuring and
adjusting tracheal tube cuff pressures.
● Identify when and how to extubate or
decannulate a patient.
● Describe how to use alternative airway devices.
● Describe how to assist a physician in setting up
and performing bronchoscopy.
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Suctioning


Application of negative pressure to airways
through collecting tube
Suctioning of trachea & bronchi is usually
done through endotracheal tube or
tracheostomy tube
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5
Suctioning (cont.)
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Suctioning (cont.)

Selecting Suction Catheter Size



External diameter (ED)of suction catheter should
be no more than ½ internal diameter (ID) of
artificial airway
Formulas to estimate proper catheter size:
• ID x 3/2 (then use next larger Fr size)
• ID x 2 (then use next smallest Fr size)
Example: Size 8.0 ETT x 3 = 24 / 2 = 12
Next larger =14 Fr
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Suctioning (cont.)

Vacuum Pressure



Adults -100 to -120 mm Hg
Children -80 to -100 mm Hg
Infants -60 to -80 mm Hg
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Endotracheal Suctioning

Two techniques for endotracheal suctioning:


Open, sterile technique requires disconnecting
patient from ventilator
Closed technique uses sterile, closed, in line
suction catheter which is attached to ventilator
circuit
• suction catheter can be advanced into patient’s
endotracheal airway without patient-ventilator
disconnection
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Endotracheal Suctioning (cont.)
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Endotracheal Suctioning

Step 1: Assess patient for indications


Patient should never be suctioned according to
preset schedule
Abnormal breath sounds (e.g., coarse crackles)
suggest that suctioning is needed
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Endotracheal Suctioning (cont.)


Step 2: Assemble & check equipment
Step 3: Hyperoxygenate patient



Step 4: Insert catheter
Step 5: Apply suction/clear catheter



Use 100% oxygen.
Total suction time should be <15 seconds
Step 6: Reoxygenate patient
Step 7: Monitor patient & assess outcomes
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Endotracheal Suctioning (cont.)

Minimizing complications & adverse
responses

Preoxygenation helps minimize incidence of
hypoxemia
 Avoid atelectasis by limiting amount of negative
pressure used, keeping duration of suctioning as
short as possible, using appropriate size suction
catheter, & avoiding disconnection from ventilator
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Endotracheal Suctioning (cont.)

Minimizing complications & adverse
responses (cont.)


Use sterile technique during suctioning & manually
ventilating patient to minimize bacterial
colonization
Do not routinely instill sterile normal saline into
artificial airway prior to suctioning unless
necessary to help mobilize thick secretions
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Nasotracheal Suctioning



Indicated for patients who retain secretions
but do not have artificial airway in place
Placing catheter in larynx & trachea is
facilitated by having patient assume “sniffing
position”
Procedure may cause patient to gag or
regurgitate; avoid suctioning immediately
after meals

Prepare to reposition patient & suction oropharynx
if this occurs
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Nasotracheal Suctioning (cont.)
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Procedures that minimize the complications of
suctioning include all of the following, except:
A. preoxygenation
B. limiting negative pressure
C. using septic technique
D. limiting suction time
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Sputum Sampling



Collected to identify organisms affecting
airway
Patients with strong enough cough can
provide ample sputum specimen by
expectorating in sterile cup
Sterile technique must be maintained when
touching connection points on sterile/Luken’s
trap
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Sputum Sampling (cont.)
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Establishing an Artificial Airway

Routes



Pharyngeal airways extend only into pharynx
Artificial airways placed through mouth & nose into
trachea are called endotracheal tubes
Intubation: process of placing artificial airway into
trachea
• Orotracheal intubation is when tube is passed through
mouth on its way into trachea
• Nasotracheal intubation is when endotracheal tube is
passed through nose first
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Pharyngeal Airways

Nasal pharyngeal airway is most often placed
to facilitate frequent nasotracheal suctioning


Minimizes damage to nasal mucosa caused by
suction catheter
Oral pharyngeal airway should be restricted
to unconscious patient to avoid gagging &
regurgitation


Maintains patient airway by preventing tongue
from obstructing oropharynx
Can be used as bite block for patients with oral
tubes
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Pharyngeal Airways
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Tracheal Airways

Two basic types


Endotracheal tubes are inserted through either
mouth or nose, through larynx, & into trachea
Tracheostomy tubes are inserted through
surgically created opening in neck directly into
trachea
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Tracheal Airways
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Establishing an Artificial Airway

Procedures



Orotracheal Intubation
Nasotracheal Intubation
Tracheotomy
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Orotracheal Intubation






Step 1: Assemble & check equipment
Step 2: Position patient
Step 3: Preoxygenate & ventilate patient
Step 4: Insert laryngoscope
Step 5: Visualize glottis
Step 6: Displace epiglottis
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Orotracheal Intubation (cont.)


Step 7: Insert tube
Step 8: Assess tube position


Tip of tube should be about 3-6 cm above carina
Step 9: Stabilize tube/confirm placement

Listen for equal & bilateral breath sounds as
patient is being ventilated
 Observe chest wall for adequate & equal chest
expansion
 If ET tube in airway, chest CO2 levels begin to
rise; seen on capnogram
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Orotracheal Intubation (cont.)
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Orotracheal Intubation (cont.)
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Orotracheal Intubation (cont.)
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Nasotracheal Intubation


More difficult than orotracheal intubation
Performed either blindly or with visualization


Direct visualization requires either standard or
fiberoptic laryngoscope
Steps for nasotracheal intubation are similar
to those of orotracheal intubation
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Nasotracheal Intubation (cont.)
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Tracheotomy

Procedure of establishing access to trachea via
neck incision




Either traditional surgical tracheotomy or
percutaneous dilatational tracheotomy can be
performed
Opening in neck is called “tracheostomy”
Procedure is best performed by physician or
surgeon in surgical setting after patient’s airway
is stabilized
Selection of tracheostomy tubes depend on
patient’s age, height, weight, & airway anatomy
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Tracheotomy
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The primary indications for an artificial tracheal
airway include all of the following, except:
A. facilitate secretion removal
B. relieve airway obstruction
C. protect against aspiration
D. provide negative pressure ventilation
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Airway Trauma Associated With
Tracheal Tubes

Laryngeal lesions


Most common injuries to larynx are:
• Glottic edema
• Vocal cord inflammation
• Laryngeal/vocal cord ulcerations
• Vocal cord polyps or granulomas
Less common but more serious injuries include
vocal cord paralysis & stenosis
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Airway Trauma Associated With
Tracheal Tubes (cont.)

Tracheal lesions




Granulomas
Tracheomalacia
Tracheal stenosis
Tracheoesophageal & tracheoinominate artery
fistula
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Airway Trauma Associated With
Tracheal Tubes (cont.)
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Airway Trauma Associated With
Tracheal Tubes (cont.)

Treatment




Depends on severity, especially length &
circumference of damage
Laser therapy may be useful for small lesions
Resection & end-to-end anastomosis may be
indicated when damage involves less than three
tracheal rings
Staged repair & stents may be required for more
involved damages
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Airway Trauma Associated With
Tracheal Tubes (cont.)

Prevention

Tube movement is primary cause of injury
 Sedation can help avoid self-extubation
 Nasotracheal tubes are easier to stabilize
 Swivel adapter can reduce tube traction
 Selection of correct airway size is important
 Maintain pressures of 25-35 cm H2O to reduce
tracheal wall injury
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Airway Trauma Associated With
Tracheal Tubes (cont.)

Alternative cuff designs


Lanz tub incorporates external pressure regulating
valve & control reservoir
• Designed to limit cuff pressure between 16 & 18 mm Hg
Foam cuff designed to seal trachea with
atmospheric pressure in cuff
• Not commonly used except in patients who have already
developed tracheal injury
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Airway Trauma Associated With
Tracheal Tubes (cont.)

Alternative cuff designs (cont.)

Tight-to-shaft cuff is low-volume, high pressure
cuff design that maximizes airflow around tube
when deflated
• Can only be inflated with sterile water; not air since it is
made of porous silicone material
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Airway Maintenance

Role of RTs

Secure tube & maintain placement
 Provide for patient communication
 Ensure adequate humidification
 Minimize possibility of infection
 Aide in secretion clearance
 Provide appropriate cuff care
 Troubleshoot airway-related problems
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Airway Maintenance (cont.)

Tracheostomy care

Step 1: Assemble & check equipment
 Step 2: Explain procedure to patient
 Step 3: Suction patient
 Step 4: Remove & clean inner cannula
 Step 5: Clean & examine stoma site
 Step 6: Change ties/holder
 Step 7: Replace clean inner cannula (if present)
 Step 8: Reassess patient
• Check for adequate breath sounds, check vital signs &
oxygenation, as well as confirm no adverse effects
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Serious complications of emergency airway
management include all of the following, except:
A. acute hypoxemia
B. hypocapnia
C. bradycardia
D. cardiac arrest
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Troubleshooting Airway Emergencies

Tube obstruction

Kinking or biting tube
• Obstruction is reversed by moving patient’s head & neck
or repositioning tube

Herniation of cuff over tip
• Deflate cuff
• If deflating cuff fails to overcome obstruction, try to pass
suction catheter through tube

Obstruction of tube orifice against tracheal wall
 Mucus plugging
• Suction tube if instillation of sterile normal saline is not
necessary
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Troubleshooting Airway Emergencies
(cont.)
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Troubleshooting Airway Emergencies
(cont.)

Cuff leaks

Primarily problem for patients receiving mechanical
ventilation
 Will cause reduced delivery of tidal volume
 If pilot tube or valve is leaking, tube needs to be
changed as soon as possible
• Pilot valve repair kit offers safe & effective alternative by
permitting insertion of replacement valve into pilot tubing

Ruptured cuff requires extubation & re-intubation or
using endotracheal tube exchanger
• Endotracheal tube exchanger is semi-rigid guide, over
which damaged tube can be removed & new tube inserted
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Troubleshooting Airway Emergencies
(cont.)
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Troubleshooting Airway Emergencies
(cont.)

Accidental extubation


Partial displacement of airway out of trachea can
be detected by:
• Decreased breath sounds
• Decreased airflow through tube
• Decreased ability to pass catheter past end of tube
With positive pressure ventilation, airflow through
mouth & nose or into stomach may be heard
• Completely remove tube & provide ventilatory support by
manual resuscitator & mask as needed until patient can
be reintubated or tracheostomy tube reinserted
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Extubation/Decannulation



Extubation: Process of removing oral or nasal
endotracheal airway
Decannulation: Process of removing
tracheostomy tube
Assess patient readiness for extubation or
decannulation





Original problem is no longer present
Quantity & thickness of secretions
Upper airway patency
Presence of intact gag reflex
Ability to clear airway secretions
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Steps of Extubation




Step 1: Assemble needed equipment
Step 2: Suction endotracheal tube & pharynx
above cuff
Step 3: Oxygenate patient
Step 4: Deflate cuff
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Steps of Extubation (cont.)


Step 5: Remove tube
Step 6: Apply appropriate oxygen & humidity
therapy


Oxygen with cool mist
Step 7: Assess/reassess patient

Check for good air movement by auscultation
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During extubation, the ET tube should be
withdrawn at what point of the breathing cycle?
A. beginning of inspiration
B. peak inspiration
C. beginning of exhalation
D. during exhalation
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Decannulation


Removal of tracheostomy tube
Weaning process:

Fenestrated tubes
• Double cannulated tube that has opening in posterior
wall of outer cannula above cuff


Progressively smaller tubes
Tracheostomy buttons
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Decannulation (cont.)
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Alternative Airway Devices

Laryngeal mask airway (LMA)

Consists of short tube & small mask that is
inserted deep into oropharynx
 Open surface of mask faces laryngeal opening
 Ventilation is directed to lungs.
 LMAs range in sizes from size 5 for adults to 1 for
infants
 Disadvantages:
• Cannot be used in conscious or semi-comatose patients
due to stimulation of gag reflex
• If ventilation pressure greater than 20 cm H2O is needed,
gastric distention may occur
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Alternative Airway Devices (cont.)
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Alternative Airway Devices (cont.)
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Alternative Airway Devices (cont.)

Double-lumen airway




Also called Combitube
Inserted blindly through oropharynx & into trachea
or esophagus
Has two external openings, two 15-mm adapters,
two lumens, & two cuffs
One cuff seals oropharyx & second seals trachea
or esophagus
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Alternative Airway Devices (cont.)
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Bronchoscopy


Insertion of visualization instrument endoscope
into bronchi
Purpose:

Inspect airways
 Collect samples
 Remove foreign objects
 Place devices into airway

Two different bronchoscopic techniques:


Rigid tube bronchoscopy
Flexible bronchoscopy
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Bronchoscopy (cont.)

Rigid tube bronchoscopy



Open metal tube with distal light source & port for
attaching oxygen or ventilating equipment
Used most often by otorhinolaryngologists &
thoracic surgeons
Disadvantages:
• Very uncomfortable for conscious patients
• Usually requires assistance of anesthesiologist & use of
operating room
• Cannot assess smaller airways
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Bronchoscopy (cont.)

Flexible fiberoptic bronchoscopy


Gained popularity because it allows access to
small airways
Typical scope has three channels
• Light transmission channel
• Visualization channel
• Multipurpose open channel

Used to give oxygen, take tissue samples, & suction
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Bronchoscopy (cont.)
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Bronchoscopy (cont.)

Premedication




Sedatives reduce anxiety
Anticholinergic agent dry patient’s airway
Narcotic analgesics may also be given to reduce
pain
Equipment preparation

RTs are often responsible for preparing
equipment, & thoroughly checking for function,
tight connections, & integrity
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Bronchoscopy (cont.)

Airway preparation




Goal is to prevent bleeding, coughing, gagging, &
pain
Topical vasoconstrictors such as
pseudoephedrine or dilute epinephrine may be
used to prevent bleeding
Airway anesthesia is achieved by topical
anesthetics or nerve block
Monitoring

RTs have active role in monitoring SpO2, ECG,
vital signs
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Bronchoscopy (cont.)

Complications


Hypoxemia
• Minimized by providing oxygen before & after procedure
Hemodynamic changes
• Heart rate, blood pressure, & cardiac output vary depending
on technique & medications used

Bronchospasm
• Premedicate with albuterol & ipratropium bromide
• Meperidine & fentanyl are better for asthma patients
 RT should be present during procedure to adjust
ventilator & monitor oxygen saturation & exhaled
volumes
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Complications of bronchoscopy include all of the
following, except:
A. hypoxemia
B. arrhythmias
C. bronchospasm
D. hypertension
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