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ARTIFICIAL AIRWAYS

by

Kevin T. Martin BVE, RRT, RCP

V7115 HC 05

RC Educational Consulting Services, Inc. P.O. Box 1930, Brockton, MA 02303-1930 (800) 441-LUNG / (877) 367-NURS www.RCECS.com

ARTIFICIAL AIRWAYS
BEHAVIORAL OBJECTIVES UPON COMPLETION OF THE READING MATERIAL, THE PRACTITIONER WILL BE ABLE TO: 1. Identify the characteristics of the following artificial airways: Oropharyngeal Nasopharyngeal Endotracheal tubes Tracheostomy tubes Laryngeal Mask Airway (LMA) Esophageal-Tracheal Combitube Double Lumen Endotracheal Tubes (DLET) 2. Identify the medical indications specific to each of the above listed airways. 3. Identify the clinical contraindications for each of the above listed airways. 4. Identify the quantifiable advantages and disadvantages of the above listed airways. 5. Identify clinical cautions required in the use of the above listed airways. 6. Describe an endotracheal tube changer and describe its use. 7. Describe the clinical general steps in tracheal tube weaning. 8. Identify and describe three stoma maintenance devices. 9. Define and explain the effects of an artificial airway on a patients work of breathing. 10. List the specific quantifiable conditions that require airway management. 11. List the clinical conditions that may require emergency tracheal intubation. 12. Explain the proven care necessary to prevent complications associated with artificial airways. 13. Describe two scientific different methods of securing an endotracheal tube. 14. Describe two techniques to prevent excessive intra-cuff pressures. 15. Identify the three primary clinical emergencies the clinician may encounter when dealing with artificial airways. 16. List the medical criteria that are factors in a patient being at greater risk for re-intubation.
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ARTIFICIAL AIRWAYS
17. Identify five general recommendations for care of the artificial airway. 18. Using critical thinking skills and the information learned in this activity, complete a clinical practice exercise.

COPYRIGHT OCTOBER 1985 BY RC EDUCATIONAL CONSULTING SERVICES, INC. COPYRIGHT April 2000 BY RC Educational Consulting Services, Inc. (# TX 1 762 726)

AUTHORED 1985 BY KEVIN T. MARTIN, BVE, RRT, RCP REVISED 1988, 1991, 1993, 1996 BY KEVIN T. MARTIN, BVE, RRT, RCP REVISED 2001 BY MICHAEL R. CARR, BA, RRT, RCP REVISED 2003 BY SUSAN JETT LAWSON, RCP, RRT-NPS AND MICHAEL R. CARR, BA, RRT, RCP REVISED 2006 BY MICHAEL R. CARR, BA, RRT, RCP REVISED 2010 BY AIMEE STAGGENRORG, MA, BA, RRT ALL RIGHTS RESERVED

This course is for reference and education only. Every effort is made to ensure that the clinical principles, procedures and practices are based on current knowledge and state of the art information from acknowledged authorities, texts and journals. This information is not intended as a substitution for a diagnosis or treatment given in consultation with a qualified health care professional.

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ARTIFICIAL AIRWAYS
TABLE OF CONTENTS INTRODUCTION ...........................................................................................................................7 TYPES OF AIRWAYS....................................................................................................................7 Oropharyngeal Airways...........................................................................................................7 Nasopharyngeal Airways.........................................................................................................8 Endotracheal tubes (ETT)......................................................................................................10 Problems associated with orotracheal tubes .....................................................................14 Advantages of nasotracheal tubes over orotracheal tubes for long-term intubation .......14 Problems associated with nasotracheal tubes ...................................................................15 Tracheostomy tubes...............................................................................................................15 Purpose of design..............................................................................................................16 Inner Cannula ..............................................................................................................16 Obturator......................................................................................................................16 15mm connector ..........................................................................................................16 Neck plate or flange.....................................................................................................17 Cuffs ............................................................................................................................17 Pilot balloon.................................................................................................................17 Dimensions .......................................................................................................................17 Tracheostomy tube sizing and conversion........................................................................18 Metal tracheostomy tubes.................................................................................................20 Rusch tracheostomy tubes ................................................................................................20 Pediatric tracheostomy tubes ............................................................................................21 Speaking tracheostomy tubes ...........................................................................................21

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ARTIFICIAL AIRWAYS
Percutaneous dilational tracheostomy tubes (PDT)..........................................................22 Tracheal tube wedge.........................................................................................................23 ALTERNATIVE INVASIVE AIRWAYS ....................................................................................23 Laryngeal mask airway (LMA) .............................................................................................23 Advantages .......................................................................................................................25 Disadvantages...................................................................................................................25 Combitude ..........................................................................................................................26 Advantages .......................................................................................................................27 Disadvantages...................................................................................................................27 Contraindications..............................................................................................................27 Cuffed oropharyngeal mask airway (COPA) ........................................................................28 Placing and using the COPA ............................................................................................28 Lingual nerve injury after use of a cuffed oropharyngeal airway ....................................30 Pharyngeal-tracheal lumen airway (PtL)...............................................................................30 AIRWAY ADJUNCTS..................................................................................................................30 Tracheal tube changers ..........................................................................................................31 Stoma maintenance devices (trach buttons).......................................................................31 Olympic button, Kistner valve and Montgomery valve ...................................................32 Tracheostomy tube weaning........................................................................................32 GENERAL INFORMATION........................................................................................................32 INDICATIONS..............................................................................................................................33 Specific conditions that require airway management ...........................................................34 Conditions which may require emergency tracheal intubation ............................................34

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ARTIFICIAL AIRWAYS
CONTRAINDICATIONS .............................................................................................................35 COMPLICATIONS .......................................................................................................................35 Predisposing Factors..............................................................................................................35 Tracheal Damage...................................................................................................................35 Decrease in the effectiveness of the cough............................................................................36 Decrease in mucociliary activity ...........................................................................................36 Tracheal ulceration ................................................................................................................36 Stenosis..................................................................................................................................36 Glottis or subglottic edema....................................................................................................37 Infection.................................................................................................................................37 Swallowing dysfunction ........................................................................................................37 PREVENTION OF COMPLICATIONS.......................................................................................38 Intra-cuff pressure..................................................................................................................40 Minimal leak technique (MLT) .............................................................................................40 Minimum occluding volume (MOV) ....................................................................................41 PRECAUTIONS, HAZARDS, AND/OR COMPLICATION.......................................................42 EMERGENCIES............................................................................................................................42 Cuff leaks....................................................................................................................................42 Accidental extubation .................................................................................................................43 Obstructions................................................................................................................................44 Additional hazards or complications related to emergency airway management .....................45 Algorithm for a difficult airway .................................................................................................45 CARE OF THE ARTIFICIAL AIRWAY .....................................................................................47

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ARTIFICIAL AIRWAYS
SUMMARY...................................................................................................................................49 CLINICAL PRACTICE EXERCISE ............................................................................................49 PRACTICE EXERCISE DISCUSSION .......................................................................................52 SUGGESTED READING AND REFERENCES .........................................................................55

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ARTIFICIAL AIRWAYS
INTRODUCTION

he following material discusses types, indications, complications, emergencies and care of adult artificial airways. The majority of the paper is devoted to endotracheal and tracheostomy tubes as used in the acute care environment. Unless otherwise noted, airways for the adult patient population are discussed. Unique airways used in skilled nursing facilities, rehabilitation, and home care not discussed in this course. TYPES OF AIRWAYS OROPHARYNGEAL AIRWAYS

n oropharyngeal airway is used in an unconscious patient to reduce risk of obstructing the airway with the tongue, or to prevent potential laceration of the tongue if the incoherent patient has a seizure. These airways are commonly called oral airways. Oral airways are used to keep the tongue from occluding the airway and as a bite block. When properly inserted and positioned, the tongue is held up and out of the hypopharynx. The airway is reinforced so biting cannot crush it. Oral airways have a channel through the middle or along the sides to allow for suctioning of oral secretions. Guedel oral airways have a channel down the middle. Berman oral airways have an I-beam design with side channels. Oral airways come in sizes from 000 for neonates to 6 for adults.

Example of the Berman oral airways

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ARTIFICIAL AIRWAYS
ORAL AIRWAY

Oral airways are inserted upside down from the side or top of the mouth then twisted 180 degrees around so the distal tip is positioned in the inferior oropharynx. Care should be taken during insertion that the tongue is not inadvertently pushed down into the throat. A tongue depressor can aid insertion. To determine proper airway size, place the airway along the cheek and measure the distance from the corner of the mouth to the tragus of the ear (the cartilaginous point near the opening). Tubes too long can put pressure on the epiglottis and may obstruct the airway. A tube too short can push the tongue back and decrease ventilation. If the flange sticks out more than a few millimeters, select a smaller airway. Oropharyngeal airways are to be used only with the unconscious patient as they may cause vomiting and laryngospasm in the alert or semiconscious patient. NASOPHARYNGEAL AIRWAYS A nasopharyngeal airway is used to relieve upper airway obstruction caused by the tongue or soft palate falling against the posterior wall of the pharynx. These airways are commonly referred to as nasal airways or trumpets. They are inserted for repeated suctioning, bronchoscopies and as an airway for an intoxicated or semiconscious patient. They help guide catheters toward the trachea and prevent unnecessary irritation of the nasal mucosa. It may be possible to avoid intubation with frequent suctioning through a nasal airway in some patients. Nasal airways are made of red rubber or silicone. They have fixed or adjustable flanges on the proximal end, depending upon the manufacturer. One brand has an inflatable balloon at the end to ease passage through the nose. The balloon is deflated after insertion.

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ARTIFICIAL AIRWAYS
NASAL AIRWAY

Nasal airways are lubricated with a sterile water-soluble lubricant and inserted through the nare. Use a sterile 4 by 4 -inch gauze pad to smear the lubricant over the length of the airway. The bevel should face the midline during insertion. Once in place, the distal tip is located behind the base of the tongue like an oral airway. The length of the airway can be estimated by measuring the distance from the tip of the nose to the tragus of the ear plus one inch. The airway must be rotated periodically between the nares to prevent mucosal crusting. Nasopharyngeal airways should also be removed and cleaned at least once every 24 hours. Keep the nares clean and dry while in place. If a nasal airway is not available an un-cuffed ET tube can be used. The length of the tube can be cut to fit the patients nasopharynx. The tube connector will prevent the tube from slipping deeper into the nasal passage. This method does present a problem. The connectors internal diameter is smaller than the tube and may prevent suction catheter passage and limit gas flow rates during ventilation. Complications of using nasal airways are bleeding, sinusitis, otitis media, and nasal necrosis. You can avoid or decrease opportunity of these complications by using generous lubrication, and vasoconstrictive agents.

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ARTIFICIAL AIRWAYS
ENDOTRACHEAL TUBES (ETT) An endotracheal tube is indicated when a patients airway requires airway protection, tracheal suctioning or when ventilation is necessary. Endotracheal tubes can be inserted nasally or orally. Oral endotracheal (figure 1) tubes have a preformed curve at a 450 angle. Nasal endotracheal (figure 2) tubes have a preformed curve curved at a 600 angle. Once the selected tube is in place, the distal tip rests in the trachea just above the carina. Most have an opening (Murphys eye) in the wall near the distal tip. Should the tip be occluded, ventilation may still be possible through this opening. There also is an inflatable cuff attached near the distal end of adult tubes. Cuff inflation seals the airway so all ventilation must occur through the endotracheal tube. The cuff is inflated via a pilot balloon valve and line attached to the endotracheal tube. Infant tubes have no cuff. Endotracheal tubes less than sizes 5.0 are generally uncuffed. Some 5.0 tubes are manufactured with and without cuffs however.

Figure 1

Figure 2 There are many types of endotracheal tubes used for specific purposes. Double Lumen Endotracheal Tubes (DLET) are special tubes that provide selective endobronchial intubation, and independent lung ventilation. One lumen is advanced into a main stem bronchus, the other lumen remains in the trachea for selective endobronchial intubation. Carlens tubes are used for the left main stem bronchus and White tubes are used for the right main stem. The distal tip is curved to enter the bronchus and there is a carinal hook to hold it in place. The Robertshaw tube is used for either main stem bronchus and has no carinal hook.

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ARTIFICIAL AIRWAYS

Carlen double-lumen endotracheal tube, with carinal hook in position.

White double-lumen endotracheal tube, with carinal hook in position.

Indications for the use of DLET: Isolation of one lung from another due to infection and/or hemorrhage Control of distribution of ventilation as in bronchopleural fistula

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Surgical opening of a major conducting airway in the cases of a large unilateral bulla or cyst or a tracheobronchial tree disruption Unilateral bronchopleural lavage as a treatment for pulmonary alveolar proteinosis Surgical exposure to perform a pneumonectomy or upper lobe resection Independent lung ventilation

Contraindications of a DLET include: Full stomach (risk of aspiration) Difficult placement due to abnormal airways or lesions Patients who would not tolerate being off mechanical ventilation or PEEP

Points to remember 28: These tubes are more rigid and bulkier than standard tubes Must be rotated during insertion to gain proper alignment with the proper bronchus Fiberoptic bronchoscopy should be performed to ensure the proper placement The resistance to flow through each tube will be increased since each lumen is smaller than the same size single lumen tubes A longer suction catheter will be needed to access the bronchial tube

Armored tubes (Figure 4) have steel wire wound through the walls. An advantage of the armored tubes over regular ones is that they will not collapse if the patient should bite down. They are used for surgery so the tube can be bent without kinking, also. The armored tube is the most appropriate airway for head trauma victims and patients with frequent seizure activity. RAE (Ring-Adair-Elwin) tubes are used for the same purpose, but they are preformed and have no steel wire. Stainless steel tubes are used for laser surgery so the light will bounce harmlessly off its walls.

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ARTIFICIAL AIRWAYS

Figure 4 Preformed tubes have been preshaped for better patient comfort or security. One style has a forward bend so that the tube can be taped to the chin. There is also a pediatric tube with a bend for taping it to the forehead. Guidable trigger tubes make it easier to intubate a patient with anterior larynx or to perform a blind nasal intubation.

Figure 5 Mallinckrodt Critical Care makes several specialized tubes. The Endotrol (Figure 5) has a loop on the proximal end. The user can pull on the loop to control the direction of the distal tip to aid intubation. The Hi-Lo Jet tube is used for high-frequency jet ventilation. It has an extra lumen for monitoring and irrigation. Other manufacturers make additional tubes for specialized functions. Experimental ultra thin-walled ETTs have been produced for use with infants. These specially manufactured tubes have a wall thickness of only 0.2 mm. This gives a much larger inner diameter (ID) for the lumen. The result is a tremendous decrease in airway resistance to breathing. Conventional 2.5 mm I.D. tubes have a wall thickness of 0.6 mm and 4.5 mm I.D. tubes a 0.85 mm thickness. Ultra thin-walled tubes can lower resistance by as much as three
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times. These tubes are not commercially available at this time; they have been bench-tested only. Problems Associated With Orotracheal Tubes 28 They are poorly tolerated in conscious and semiconscious patients They are difficulty to stabilize and may be easily dislodged Inadvertent extubation is common A bite block may be necessary to prevent biting of tube Vagal stimulation may cause bradycardia and hypotension. Oral hygiene is difficult They require a laryngoscopy during insertion Patients are unable to mouth words Lips may be lacerated There is a potential for laryngeal pathology The tip of the tube moves when the patients head position changes (1) Extension of the head moves the tip toward the oropharynx (possible extubation) (2) Flexion of the head moves the tip toward the carina (possible right endobronchial intubation) Oral feeding is difficult

Advantages of Nasotracheal Tubes over Orotracheal Tubes for Long-Term Intubation 28 Easier to stabilize May be better tolerated by some patients May be inserted blindly (laryngoscopy is unnecessary in most cases) Oral hygiene is easily accomplished

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ARTIFICIAL AIRWAYS
The patient is able to mouth words Attachment of equipment is easier and safer; there is less torque on the trachea Problems Associated With Nasotracheal Tubes 28 The tip of the tube moves when the patients head position changes Pressure necrosis in area of the alae nasi may occur Sinus drainage may be obstructed, and acute sinusitis may result Eustachian tube drainage may be obstructed, and otitis media may result The incidence of vocal cord damage after 3 to 7 days (also seen with oral ETTs) increases Vagal stimulation is possible, but it occurs less frequently than with the oral ETT Skilled personnel are necessary for placement The nasal passage limits the tube size; a tube at least 0.5 mm ID smaller than the oral route is required (1) Men: 7.5 to 8.5 mm ID (2) Women: 6.5 to 7.5 mm ID The angle of curvature is acute; the resistance to gas flow is increased; there is difficulty in suctioning; and the work of breathing is increased when compared with an orotracheal tube in the same patient There is a potential for laryngeal pathology

A tracheostomy tube is indicated for long-term airway management or when facial trauma or surgery prevents the use of an oral or nasal endotracheal tube. TRACHEOSTOMY TUBES Tracheostomy tubes also are inserted in the trachea, but insertion is through a tracheal stoma. They are similar to an endotracheal tube but much shorter and more rigid. Most tracheostomy tubes have an inner and outer cannula, obturator, and inflatable cuff. Some have no inner cannula or cuff. The obturator provides a smooth surface to ease insertion and prevent tissue and blood debre from entering the tube during insertion. The obturator is removed when the airway is in place. Inner cannulas can be removed and cleaned periodically. Some inner cannulas are
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disposable. Most tubes also come with a decannulation plug. The variation in tracheostomy tubes is endless. Sizes, materials, style and specific applications differ. The practitioner must learn the basic theory of operation of tracheostomy tubes and the wide array that exists. Basically, each tracheotomy tube consists of a neck flange, tube body and cuff.

Low Pressure Cuffed Tracheostomy Tubes


Courtesy of Shiley - Nellcor

PURPOSE OF DESIGN Inner Cannula This device can be removed to clean secretions and blood from the interior surface without removing the entire tube. Shiley manufactures tracheostomy tubes with disposable inner cannulas. Obturator The obturator prevents blood or mucus from entering the tube as it is being inserted and provides a smoothly tapered surface to facilitate introduction of the tube into the airway and is removed when the tube is in the proper position. 15mm Connector This is the standard connector, which allows connection to resuscitation bags and other respiratory equipment.

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ARTIFICIAL AIRWAYS
Neck Plate or Flange This enables the tube to be secured around the patients neck with ties or collar. Some surgeons initially suture the flange to the patients neck. These sutures are removed in approximately 3-5 days by the surgeon or respiratory therapist. They are replaced with the standard tracheostomy ties or alternative commercially available ties. Cuffs Cuffs seal the airway to allow positive pressure ventilation and minimize the risk of aspiration of stomach contents into the lungs. They do not eliminate aspiration; even the best cuffs have microscopic air leakage. Aspiration of pharyngeal secretions commonly occurs with cuffed artificial airways. Tubes that remain connected to continuous suction can suction above the cuff and lower the risk of aspirated secretions, but these systems have not gained wide use since their introduction and cost may be a factor. Knowing these facts, we cannot emphasize enough the importance of oral care, oral suction and proper procedures prior to and during deflation of cuffs. Pilot Balloon The cuff is inflated (not foam cuffs) using a syringe. A spring-loaded one-way valve on the pilot balloon maintains cuff inflation when the syringe is removed. The pilot balloon functions to show an inflated, or not inflated, condition of the cuff. It is impossible to judge the pressure within the cuff by squeezing the pilot balloon. The best practice is to use MLT (Minimal leak technique) or MOT (minimal occlusion technique) to determine the lowest amount of air aspirated in to seal the cuff. DIMENSIONS Anatomic variations of neck length, location and diameter of the tracheostomy incision are factors that affect tube sizing for patients. Surgeons hope to limit the damaged area by avoiding large stoma sites and excessively large tubes. Generally, a 10 mm OD (7 mm ID) tube is optimal for women and 11 mm OD (8 mm ID) tube for men. French sizing is based on the circumference of the outer surface of the tube. Conversion to French formula: Maximum diameter (Fr) = ID (mm) x 3. Roughly the size of the trach or ETT should be 2/3 the internal diameter of the trachea. Tube length has been standardized, but extra long and adjustable tubes are available which are helpful in the morbidly obese patient. The intratracheal part of the tube should be straight and somewhat flexible. A desirable tube has a smooth curvature with a small radius between intratracheal and extratracheal limbs. This permits an entrance of close to 90 degrees, lessening pressure on the longitudinal aspect of the tracheal stoma. Once in the trachea, the tube sides or tip should not produce pressure points on the tracheal wall. In addition to the tracheal wall, the esophagus and major blood vessels are at risk for erosion. The flange should emit gentle yet firm fixation of the tube. Excessive movement of the tube increases the potential for lesions especially at the stoma level. This is the rationale for securing the ventilator circuits with a Velcro wrap during mechanical ventilation and using tracheostomy collars instead of T adapters when a precise FIO2 is not required with aerosol therapy. Some tubes have adjustable flanges to change the extratracheal dimension.
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TRACHEOSTOMY TUBE SIZING AND CONVERSION French Size 13 15 16.5 18 21 24 27 30 33 36 39 42 45 48 Jackson Trach Size Tube Size ETT Size 00 00 2.5 0 00-0 3.0 1 2 3 4 5 6 7 8 9 10 11 12 0-1 1-2 2-3 4 4 5 5 6 3.5 4.0 4.5-5.0 5.5 6.0-6.5 7.0 7.5-8.0 8.5 9.0-9.5 10.0 10.5-11.0 11.5 mm OD 4.3 5.0 5.5 6.0 7.0 8.0 9.0 10.0 11.0 12.0 13.0 14.0 15.0 16.0 mm ID 2.5 3.0 3.5 4.0 4.5-5.0 5.5 6.0-6.5 7.0 7.5-8.0 8.5 9.0-9.5 10.0 10.5-11.0 11.5 Patient age <30 weeks 30-35 weeks/newborn 6 months 1 year 2-4 years 6 years 8-10 years 12 years 14 years-adult female Adult male

Fenestrated tracheostomy tubes have an opening in their posterior (cephalad) wall above the cuff. The inner cannula seals the opening when inserted. Fenestrated tubes may be used in weaning patients from the trach tube and to allow the patient to talk. This procedure is done as follows: the inner cannula is removed, the cuff deflated, and the inlet plugged, which forces air through the upper airway. These trach tubes should only be utilized for patients who have good control of their airway and adequate spontaneous ventilation. If a patient requires ventilation or has aspiration issues, the inner cannula must be reinserted and the cuff inflated. Many ENT specialists do not use fenestrated tracheostomy tubes to wean patients from their trach because only 50% of patients have an anatomic structure that can be accommodated with standard tubes. This means that the channel is blocked in the other 50% of patients-generally by tissue or granulations.

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ARTIFICIAL AIRWAYS

Fenestrated Tracheostomy Tube


Courtesy of Mallinckrodt - Nellcor

Schematic Fenestrated cuffless Model 304


15mm connector of inner cannula

Neck plate, moving around 2 axis Fenestration of outer cannula Outer cannula

Decannulation plug blue Fenestration of inner cannula Outer diameter of inner cannula Inner diameter of inner cannula

Courtesy of Kapitex Healthcare Lanz tubes have pressure controlling pilot balloons, which are easily recognized by the presence of a large floppy PVC cover over the pilot balloon. The compliance of the pilot balloon limits the pressure in the cuff to 20-25 mmHg. Kamen-Wilkinson or Bivona Fome Cuff tubes (following picture) have cuffs that contain polyurethane foam that expands when the pilot tube is open to the atmosphere. It operates opposite to other cuffs. For insertion, the cuff is actively deflated by use of a syringe to remove the air. After insertion, the pilot tube, is opened, and the cuff expands until it contacts the tracheal wall. As the cuff expands, the pressure it exerts on the trachea decreases. This means that the smaller the tube with respect to the airway, the less pressure is exerted on the airway wall. There

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is no pilot balloon and the pilot tube should never be plugged.
Obturator Inflation Line Connector Flange

Tube Ties Fome-Cuff Side-Port Connector

Courtesy of: Portex Limited, Hythe, Kent CT216JL.uk Metal Tracheostomy Tubes Bausch and Lomb continue to carry stainless steel and sterling silver tracheostomy, speaking and laryngectomy tubes. The advantages of these tubes is that the tissue growth into the cannula is reduced, thin wall construction minimizes bulk, which makes concealment easier and is more comfortable to the patient, and precise mating of tube and cannula eliminates the space where secretions can build up. The disadvantages include granuloma formation, tracheal wall erosion and tube occlusion against the tracheal wall. Steel or Silver tubes can not be used if mechanical ventilation is required. Rusch Tracheostomy Tubes Tracheoflex tracheostomy tubes are PVC siliconized and stainless steel spiral reinforced. The flange and neckband are adjustable. It is X-ray opaque and has a low volume cuff. Rusch also offers Laryngoflex reinforced tubes for laryngectomy. The significance of knowing the composition of these tubes is that you cannot take these patients for a MRI without changing their tracheostomy tube!

Tracheoflex
Courtesy of Rusch, Inc. 20
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ARTIFICIAL AIRWAYS
Pediatric Tracheotomy Tubes Tracheostomy tubes began their most prevalent use with pediatric patients during the diphtheria epidemic in the early 1800s for upper airway obstruction. In 1932, a tracheotomy was performed for those with poliomyelitis for prophylactic and therapeutic indications, not just obstruction of the upper airway. After years of evolution and now increased need due to improved neonatal outcomes, pediatric tracheostomy tubes are available in many sizes, lengths, materials and configurations. These smaller tracheostomy tubes are usually a single-cannula tube without an inner cannula or a cuff. There are tight to shaft (TTS) cuffed tubes made by Bivona which are instilled with sterile water used for children who can be off their ventilator periodically. Older children who require ventilation probably need cuffed tracheostomy tubes to achieve an adequate seal. Children who do not require mechanical ventilation should have tracheostomy tubes that allow airflow around the tube in order to reduce the chances of tracheal wall damage. Fenestrated tubes are not recommended for pediatric use as the opening may be obstructed with granulated tissue.

Pediatric And Neonatal Tracheostomy Tubes


Courtesy of Shiley - Nellcor

Speaking Tracheostomy Tubes These tubes, such as the Pitt Speaking Tube, have a separate pilot tube that directs compressed gas to an exit point just above the cuff that passes through the vocal cords. This allows the patient, with practice, to coordinate speech. Laryngectomy tubes are shorter than standard tracheostomy tubes from the outer neck skin to the trachea. Removal of the larynx obviates the need for a cuff on these tubes. They are generally rigid in design and have three pieces. It is important to keep in mind that those having had a laryngectomy have had the connection between the upper and lower air severed, and emergency
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responses must be directly to the stoma and not the nose and mouth. Several manufacturers produce talking tracheostomy tubes or devices to allow vocalization. Talking trach tubes have an additional line similar to the pilot balloon line. When the line is attached to a gas source, flow is released above the cuff. This produces flow through the vocal cords even when the cuff is inflated. The patient can therefore communicate even though the airway is sealed. The Passy-Muir Trach Speaking Valve and Olympic Trach-Talk are one-way valves attached to a tracheostomy tube. They allow flow on inspiration through the tube but force expiratory flow through the vocal cords. The cuff must be deflated for these devices and should not be used if the patient is asleep.

PMV 007 (Aqua) PMV 005 (White) PMV 2000 (Clear) with the PMV Secure-It PMV 2020 (Clear) with the PMA 2020-S Adapter

PMV 2001 (Purple) with the PMA 2000 Oxygen Adapter

Passy-Muir Tracheostomy and Ventilator Speaking Valves


Courtesy of Passy-Muir

Percutaneous Dilational Tracheostomy Tubes (PDT) 28 Advantages when performed properly as compared with surgical tracheostomy are: No operating room required No need to move high-risk patients General anesthesia not required Decreased incidence of pneumothorax, bleeding, and stenosis Stoma closes quickly after decannulation with less scar tissue formed

Disadvantages are: If inadvertent decannulation occurs before maturation of tracheostomy tract (2 weeks), reinsertion may lead to complications such as bleeding and tracheal trauma. Oral intubation is recommended in this case.

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Should not be performed on patients who are morbidly obese, have burns to the neck, have bleeding disorders, have anatomic abnormalities of the trachea or cervical region, or had a previous tracheostomy.

Product Features Tapered distal tip and inverted cuff shoulder provide easy insertion Cylindrical cuff provides low-pressure seal to help protect sensitive tracheal tissue Integral snap-lock connector facilitates changing the inner cannula Swivel neck flange affords greater comfort and easier cleaning while buffering movement

Tracheal Tube Wedge Used to detach respiratory equipment and prevent needless tugging and pulling to disconnect trachs and other respiratory equipment. ALTERNATIVE INVASIVE AIRWAYS

he Laryngeal Mask Airway (LMA) is sometimes called mask on a tube. An inflated cuff forms a low-pressure seal in the laryngeal inlet. ACLS 2003 guidelines have deemed the LMA as an additional technique for invasive airway control and ventilation.

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There are several LMA products including the LMA-Classic, LAM-Flexible, LMAUnique, a single-use LMA, the LMA-Fastrach, and an LMA designed to facilitate endotracheal intubation. These devices are latex-fee. LMA Size 1 1 2 2 3 4 5 Patient Size Neonates and infants up to 5 kg. Infants between 5-10 kg. Infants and children between 10-20 kg. Children between 20-30 kg. Children over 30 kg. and small adults Normal and large adults Large adults

The standard insertion technique is to hold the LMA like a pen with the mask aperture facing forward and the black line on the airway tube oriented anteriorly toward the upper lip of the patient. The tip of the cuff is then pressed upward against the hard palate, flattening the cuff against it. The position of the mask is then verified and your index finger inserts the tube further into the mouth. The jaw may be pushed downwards with your middle finger. The LMA is advanced without force into the hypopharynx until a definite resistance is felt. Before removing the hand that inserted the LMA, the other hand is brought from behind the patients head to press
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ARTIFICIAL AIRWAYS
down on the LMA to prevent displacement of the tube. The cuff is inflated with the volume specific to the LMA size used.

Laryngeal Advantages Provides a clear airway leaving hands free Designed for blind insertion Alternative for difficult or impossible intubations Eliminates need for use of neuromuscular blocking agents for laryngoscopy Can be left in place in recovery room until protective reflexes have returned Can be heat sterilized for repeated use No need for proper positioning of the airway for alignment or landmarks Better choice than an ETT for patient with possible unstable neck injuries or access to the airway/patient is difficult The possibility of fatal errors with the LMA is much lower than with ETT

Disadvantages The laryngeal mask does not prevent regurgitation or aspiration Laryngeal spasm may occur if the patient is too lightly anesthetized during surgical

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ARTIFICIAL AIRWAYS
stimulation Bronchial secretions may irritate the vocal cords and provoke laryngeal spasm during recovery from anesthesia Cost for reusable LMAs are in excess of $200.00 Obstruction may occur if: The Laryngeal mask is inserted incorrectly The Laryngeal mask is dislodged The epiglottis is pushed down during insertion The cuff is deflated before protective reflexes return Laryngeal spasm occurs as a result of too light anesthesia or from Mucosal irritation from secretions Combitube (Figure 6) As the name of this airway implies, it is a combination tube: a combination of an endotracheal tube and an esophageal tube. Remember the esophageal obturator airway (EOA)? The Combitube is a modification and advancement of that device. The Combitube has two separate, clear, polyvinyl chloride (PVC) tubes, fused together longitudinally. One tube is patent while the other is blind. The blind tube is longer than the patent tube and is color-coded blue on its more proximal end as its pilot balloon. Two inflatable balloons are located on the tube; one proximal latex 100 ml balloon that functions as the oropharyngeal balloon, and a more distal conventional 15 ml PVC balloon. Between the balloons, on the blind-ended tube, are eight small perforations. Each tube has a standard 15 mm connector on its proximal end for connection to a breathing circuit. Like the laryngeal-mask airway, the Combitube is placed blindly. It can be lubricated prior to insertion with avoidance of occluding the perforations, however, this is not mandatory. The use of this airway has both a low reported rate of complications and few published evaluations. The Esophageal-Tracheal Combitube is another device that was recommended as a Class IIb advanced airway device in the 2003 ACLS Provider Manual. There are two sizes available: 37 Fr for patients between 4-5.5 feet tall (SA-small adult) and 41 Fr for patients over 5 feet tall (A-adult). Either may be used for 5-5.5 feet tall individuals.

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ARTIFICIAL AIRWAYS

Combitube Figure 6 Advantages Blind placement without laryngoscope Unique design provides patent airway esophageal or tracheal placement Reduces risk of aspiration of gastric contents. Requires no restraining devices.

Disadvantages Its not considered a secure airway Does not guard against pulmonary aspiration ACLS medications cannot be administered unless the trachea itself is intubated

Contraindications Do not use in patients with: An intact gag reflex Known esophageal disease History of ingestion of caustic material Presence of upper airway obstruction

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Cuffed Oropharyngeal Mask Airway (COPA)

Figure 7: Cuffed Oropharyngeal Mask Figure 7: Cuffed Oropharyngeal MaskAirway Airway (COPA)
(COPA)

Both the LMA and Combitube suffer from limitations regarding cost and training. The use of more simple, recognizable airway adjuncts may overcome some of these problems. The recently introduced cuffed oropharyngeal airway (COPA) (Figure 7) is a simple modification of a Guedel airway and goes a long way to fulfilling these goals. The device is inserted like a standard oral airway with the addition of an inflatable pharyngeal cuff and universal connector. While it was originally developed for use during spontaneously breathing subjects under general anaesthesia, the COPA does allow positive pressure ventilation to occur provided lung compliance is good and airway pressures are not high. Initial work has suggested practitioners can easily insert the device and ventilation is possible in nearly every case. There appears to be a leak in a number of patients but this rarely impairs the ability to effectively ventilate the lungs. A larger size COPA, than standard Guedel airway, also appears to be more effective. Further work has suggested that the COPA, while conferring no advantage to patients if bag and mask ventilation is being done well, does allow good ventilation if the bag and mask system is proving ineffective. Thus, while the device confers no protection of the airway against regurgitation and aspiration, it does appear to have some advantages over simple bag and mask ventilation if this is not being performed well. If we accept that training all healthcare staff in the use of the LMA and Combitube is a practical impossibility, then the COPA may represent an important intermediary between bag and mask and more sophisticated airway devices. Placing and Using the COPA The COPA currently comes in four sizes (8 - green, 9 - yellow, 10 - red, 11 - light green). Selecting the right size is one of the most important steps of using the COPA. As a guide to choosing the right size, a COPA held next to the patients head should result in the bite block just above the teeth with the tip of airway at angle of mandible. This is usually one size larger than the corresponding oral airway that would be used in that patient. Choosing the right size is important, as the airway is designed to lock into place behind the base of the tongue. Once the right size is chosen, the device should be prepared for use by lubricating it, placing the included strap behind the patients head, testing the cuff, completely deflating the cuff and pre-oxygenating

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ARTIFICIAL AIRWAYS
the patient. Insertion is facilitated with a dose of Propofol. This dose approximates the usual induction dose. The technique for insertion is the same as insertion of oral airway - either the reverse Guedel technique or the direct Guedel technique may be used. Since most people are already familiar with these techniques, which are already easy to learn, the learning curve for use of this device is not steep. Once inserted, the device should be strapped into place before any manipulation. This ensures that the COPA will not pop out of position with subsequent airway maneuvers. When strapping the COPA in place, make sure that the device is in the midline. If the proper size has been chosen, the colored bite block should transition at the teeth. After strapping the device in place, do a jaw thrust/chin lift. Then inflate the cuff with the proper amount of air: Size 8 - 25 cc Size 9 - 30 cc Size 10 - 35 cc Size 11 - 40 cc

Once in place, the following steps should be taken: Connect the circuit Gentle positive pressure Allow return of spontaneous ventilation Use airway maintenance techniques if needed

Some of the Airway Maintenance Techniques suggested by the company to ensure that the COPA works easily are: Increased or decreased head tilt Turn head to one side Support the shoulders Gentle chin lift may be needed early in case Positive airway pressure up to 10 cm H2O

When the anesthetic is complete, removal of the airway is easy as well. First, allow emergence from anesthesia while leaving the patient relatively undisturbed. Watch for return of airway reflexes - signs of this includes, swallowing, phonation, etc. Do not deflate the cuff; rather
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ARTIFICIAL AIRWAYS
remove the device intact. Any secretions and such will be carried with the inflated cuff upon removal. Once removed, verify good spontaneous ventilation and airway patency of the patient. Lingual Nerve Injury after Use of a Cuffed Oropharyngeal Airway Gentle airway manipulation with the use of the cuffed oropharyngeal airway is recommend, this will help with the avoidance of excessive cuff inflation and early recognition of such a complication if it occurs. Pharyngeal-Tracheal Lumen Airway (PtL)

Courtesy Of: Alliance Medical Inc.

The PtL (Pharyngeal-tracheal Lumen) Airway is a double lumen adjunct that can deliver effective ventilation to a patient whether the device is placed in the trachea or esophagus. Unique design requires no syringes to inflate the airway balloons and has an integrated bite block design to aid in keeping an airway patent. AIRWAY ADJUNCTS

N

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ote that the following airways have been determined as class indeterminate recommendation in the 2000 ACLS guidelines which means that there is evidence lacking for the inclusion of these devices in the guidelines:

Esophageal obturator airway (EOA) Esophageal pharyngeal airway Pharyngotracheal lumen airway Berman intubating-pharyngeal airway (BIPA)
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ARTIFICIAL AIRWAYS
Tracheal-esophageal airway Tracheal tube changers are slender, flexible tubes inserted in existing ETTs to aid re-intubation. They are similar to the guide-wires used for changing intravascular catheters. The changer is placed in the existing ETT and the ETT removed, leaving the changer in place. The new ETT is then slid over the changer and advanced into the trachea. They can be used for changing ETTs due to cuff leaks or other problems. They also can be used on a patient where there is doubt as to whether they will tolerate extubation. The changer can be left in place for several hours following extubation and then removed if re-intubation is not necessary. Stoma maintenance devices (trach buttons) are used for weaning patients from trach tubes and for those in whom periodic suctioning or ventilation is needed. Trach buttons are short, straight tubes that maintain the stoma without impinging on the airway lumen. They can be plugged so the patient must breathe through the upper airway.

spacer plug cannula

Tracheal Button Courtesy of Aarons Home Page

Features Of The Tracheostomy Button: 1. The hollow outer cannula has a slightly flared proximal end, which keeps it from slipping all the way into the patient. The distal end is flanged and split into several flexible grippers. 2. A closure plug fits into the outer cannula and snaps into the flexible grippers on the end of the outer cannula. This seals the button so that the patient breathes through the upper airway. 3. A hollow inner cannula can be inserted into the outer cannula instead of the plug. This inner cannula has a standard 15-mm OD so that a Briggs adapter or other respiratory care equipment can be attached if needed. The patient can also be suctioned. 4. Spacers of various widths are used to make sure that the inner cannula is placed in the

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patient to the right depth. The end of the tube should enter the trachea but not obstruct it. The Olympic button, Kistner Valve and Montgomery valve are examples of these related devices. They extend through the anterior neck to the tracheal wall. The purpose is to prevent stoma closure and allow access to the trachea for suctioning and emergency resuscitation. Unites are generally composed of rigid Teflon or flexible silicone rubber. The valve type has a one-way valve to allow inspiration through the tube, permitting vocalization and exhalation. Sizing requires measurement of distances from the neck to the posterior stoma. Note that not all these devices can be attached to a standard 15mm adapter used for resuscitation. Of course, prior to insertion of any of these less commonly used devices, the manufacturer instructions should be reviewed carefully. Tracheostomy Tube Weaning: Prior to weaning the patient from a tracheostomy tube, preweaning criteria such as laboratory values within acceptable limits, must be met. In addition, a thorough assessment of the patient and their ability to breathe, expel secretions and prevent aspiration needs to be made. There are various weaning procedures. In the past, using a fenestrated tracheostomy tube to wean has been popular, but the recommendation now is to progress to a smaller tracheostomy tube (not less than 4 O.D.), then to plugging, then extubation or a tracheostomy button. To acquire more information on this specific topic, we refer you to our courses Passy-Muir Tracheal and Ventilator Speaking Valves and Tracheostomy. The remaining material in this course applies strictly to endotracheal and tracheostomy tubes. GENERAL INFORMATION nsertion of an endotracheal tube (ETT) or tracheostomy tube alters the geometry of the upper airway and changes airway resistance, work of breathing (WOB), dead space (VD) volume, and the potential for airway obstruction. The changes in resistance, WOB, and VD are related to the type of airway used, its internal diameter, and fluid mechanics. All artificial airways increase resistance to breathing. Airway resistance increases about three times with the insertion of an artificial airway. Obviously, WOB increases proportionally. The patient must generate a higher-pressure gradient on each breath to achieve the same minute volume. The increase in resistance through tracheostomy tubes and ETTs is similar. (The expected decrease in resistance due to the short length of a tracheostomy tube is offset by its greater curvature). Bypassing the normal airway, even with a large artificial airway, significantly decreases airway diameter and increases resistance. The cross-sectional area of an 8 mm internal diameter ETT is 50 mm2. (Cross-sectional area of the trachea is 150-300 mm2 and the oropharynx is 600 mm2). This decrease in total cross-sectional area significantly increases resistance and WOB, the smaller the artificial airway, the greater the impact on airway resistance. The newest generations of ventilators often have a tube compensation feature which does decrease some of the resistance

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ARTIFICIAL AIRWAYS
caused by an artificial airway. The relationship between resistance and tube diameter is exponential. Resistance varies inversely with tube radius to the fourth power under laminar flow conditions and to the fifth power under turbulent flow conditions. This means that minute changes in tube diameter cause huge changes in resistance. For example, a decrease in tube diameter by one half doesnt merely double resistance. Instead, resistance is increased by 2 X 2 X 2 X 2 or 16 times! Therefore, WOB increases exponentially with insertion of an artificial airway. This becomes increasingly critical as tube diameter decreases or patient minute volume increases. In healthy adults, there is little clinical difference in WOB in ETTs between 7-9 mm ID at minute volumes less than 8 lpm. However, when ID is less than 7 mm or minute volume exceeds 8 lpm, the increase in WOB is significant. It may be too great for some patients. The factors of fluid mechanics influencing resistance and WOB refer to the flow pattern of the gas. (Fluid density and viscosity also affect resistance but they can generally be ignored). Laminar flow exists when gas molecules are traveling parallel to each other in a straight line. Because of friction between the wall of the tube/airway and the molecules against the wall, gas molecules in the center of the tube/airway travel faster than those further out. This gives a slightly pointed or parabolic velocity profile to the column of gas. (Those molecules in the center move ahead of those near the wall). Laminar flow exists at low flow rates in straight tubes. Therefore, it rarely exists in clinical situations. Turbulent flow is the norm in clinical situations. All artificial airways curve to enter the trachea and have rough internal surfaces from moisture and secretions. The higher velocity gas molecules in the center of the gas column impact at the point of curvature and are deflected randomly. Gas molecules near the edges impact on moisture and secretion particles and are likewise deflected randomly. The result is turbulent flow and an increase in resistance. Intubation is extremely uncomfortable and even painful for many patients. The most common complaints of patients following extubation are ETT pain or discomfort, a sense of choking or gagging, and an inability to breathe adequately. Other common complaints are difficulty communicating, eating, and moving around. The clinician should remember these complaints when caring for intubated patients. INDICATIONS he indications for the insertion of an artificial airway directly into the trachea are numerous. The first is to maintain patency of the airway. Secretions, edema, foreign bodies, localized trauma, or anatomical malformations may obstruct the airway. Often, an airway is placed because the patient is unable to clear secretions. Chronic care of secretions is therefore a second indication. Secretions accumulate because the patient has an ineffective cough or the volume and tenacity of the secretions have overloaded normal clearance mechanisms. With an airway in place, not only will suctioning be possible, but also aerosol therapy may be delivered more effectively to thin out the mucus. Lavage with normal saline or a mucolytic through an

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artificial airway also can be used to liquefy secretions. Relief of an upper airway obstruction is a third indication. Aspirated objects can easily obstruct the throat or larynx. The patient may aspirate particles of food, suffer from glottic edema, or have epiglottitis. An airway is necessary until the acute problem is resolved. Some congenital anomalies of the upper airway require artificial airways in children. An artificial airway may be placed to protect the airway from aspiration of stomach contents. Patients who have ineffective glottic, laryngeal, or tracheal reflexes are in danger of aspiration. The possibility of aspiration is decreased by the inflation of the cuff around the tube. Cuffed tubes prevent massive aspiration. However, most patients aspirate small amounts of oral secretions in spite of an inflated cuff. A final indication for an artificial airway is to provide mechanical ventilation. The patient may have apnea associated with cardiac arrest. Hypoxemia, hypercarbia, and/or acidemia may exist determined by ABG analysis, oximetry, or exhaled gas analysis. The patient may also be experiencing respiratory distress. In the acute care setting, these are probably the most common reason we find people with an ET tube in place. Some of these patients are difficult to extubate and require an ET tube long after their need for mechanical ventilation is resolved.

SPECIFIC CONDITIONS THAT REQUIRE AIRWAY MANAGEMENT: Airway emergency prior to endotracheal intubation Artificial airway obstruction Apnea Acute traumatic coma Penetrating neck trauma Cardiopulmonary arrest and unstable dysrhythmias Severe bronchospasm Self-extubation Pulmonary edema Sedative/narcotic drug effect Epiglottitis Severe allergic reactions with cardiopulmonary compromise Foreign body obstruction Choanal atresia in neonates Aspiration/risk of aspiration Severe laryngospasm

CONDITIONS WHICH MAY REQUIRE EMERGENCY TRACHEAL INTUBATION INCLUDE, BUT ARE NOT LIMITED TO: Accidental extubation of mechanically ventilated patient Traumatic upper airway obstruction Obstructive angioedema Massive hemoptysis Upper airway or laryngeal edema Loss of protective reflexes Cardiopulmonary arrest Infection-related upper airway bleeding Massive upper airway bleeding Coma with increased ICP Persistent apnea

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Neonatal or pediatric-specific, e.g., meconium aspiration CONTRAINDICATIONS Use of an artificial airway may be contraindicated when a patient has positively expressed and legally documented in their medical record and/or other valid document that they do not which to have any ambitious airway management or resuscitation. COMPLICATIONS

here are many complications to artificial airways and many predisposing factors to those complications. They begin with the characteristics of the tube itself. The external diameter is crucial. Too large and the vocal cords may be damaged. Too small and the cuff may require tremendous pressure to provide an effective seal. Cuff size and shape also is a consideration. Cuff size is obviously determined by tube size. Too small of a tube leaves too much space between the tube and tracheal wall. This requires the cuff to be over inflated to provide an effective seal. Cuff pressure will therefore be very high. Cuff shape should be symmetrical and rectangular rather than curved. Curved cuffs apply pressure within a small area to get an effective seal. A rectangular shape distributes the pressure over a wide area of the wall. This makes it possible to get an effective seal at a lower pressure and minimize complications. Intracuff pressure should always be kept as low as possible. Should intracuff pressure exceed the tracheal wall blood pressure, necrosis will develop. The construction material of the tube and cuff also should be considered. Some material is more irritating than others for a given patient and some materials are more compliant than others. The more compliant the material, the easier it is to inflate the cuff and get an effective seal with a low pressure. Another predisposing factor to note is the presence of an NG tube. An NG tube speeds erosion of the tracheal-esophageal wall at the site of the airway cuff, the esophagus is normally collapsed except when swallowing. An NG tube keeps the esophagus patent and expanded at all times. This causes a constant pressure to be exerted on the wall at the site of the cuff. Movement of the tube influences the amount of mucosal sloughing at points of contact. The tube should be secured and no tension placed upon it during routine patient movements. Duration of intubation also should be minimized. The longer the tube remains in place, the greater the possibility of tracheal damage or infection. The patients overall state of health also can affect the degree of tracheal damage. The debilitated, undernourished patient is at high risk for complications. The patient who already has an infection, particularly of the upper airway, is more prone to problems. Patients receiving steroids are at particular risk for the development of infections. Hydration status plays a key role in developing complications. Over hydration favors the development of congestion and edema. Under hydration favors mucociliary problems, such as an
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increase in mucus viscosity and decreased ciliary movement. Blood pressure is a final predisposing factor to be considered. Hypotension causes airway wall blood flow to be decreased at much lower cuff pressures than normal. Normally, intra-cuff pressures below 25 mm Hg are considered safe. This may be too high in the hypotensive patient. All the above predispose the patient to certain complications from artificial airways. However, complications related to artificial airways can occur during their insertion (intubation), while in place, or during their removal (extubation). Broken teeth occur in 1-2% of oral intubations. Nosebleeds occur in 54% of nasal intubations. Aspiration occurs in 8% of the patients. The right main stem is accidentally intubated 9% of the time. Arrhythmias occur in 32% of the patients. Retropharyngeal or hypopharyngeal perforation can occur during intubation or after prolonged pressure from the tube on the mucosa. Vocal cord, glottic, laryngeal, and tracheal damage can occur at any point. Damage can take the form of edema, irritation, necrosis, stenosis, or dilatation. Often these complications are not evident until extubation or even several months later. Inadequate nutrition occurs in many due to inadequate oral intake. Inadequate communication (due to inability to talk with the tube in place) produces anxiety, fear, frustration, and depression in many patients. Many complications occur with suctioning. The possibilities here are numerous. They include: hypoxemia, atelectasis, infection, and mucosal trauma. Suctioning complications are related to many factors, such as, the catheter design, catheter size, duration of suction, use of aseptic technique, pre and post hyperoxygenation, and many others. Please refer to a review of suctioning procedures for further discussion. There is a decrease in the effectiveness of the cough immediately upon placing an airway. The normal cough requires the glottis to seal so that pressure may build up within the thoracic cavity. The rapid opening of the glottis and release of this pressure is what expels mucus. With an airway in place, there is no way to seal the lungs for this pressure build-up. In addition, the decreased diameter of the tube impedes the expulsion of mucus. There is a decrease in mucociliary activity within 2 hours of insertion of an artificial airway. This is compounded if the inspired gas is not warmed and humidified properly. Inadequate humidity causes the mucus to increase in tenacity. In addition, the mere presence of the tube causes mucus volume to increase. Mucus movement is further impaired because the cilia cannot move mucus through the tube. Sloughing of the mucosa is common and generally not serious. Sloughing may lead to tracheal ulceration or tracheo-esophageal fistula, but these are more commonly associated with cuff pressures that are too high. If the tube impinges on the airway at one point, or the cuff pressure shuts off blood flow in the airway wall, ulceration, ischemia, malacia, or fistula may develop. Areas around the tip of the tube and the cuff are the most likely sites of damage. High cuff pressures or inadequate tube size are the cause of tracheal dilatation. This leads to stenosis upon extubation.

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Also upon extubation vocal cord paralysis, ulceration, granulomas, or polyps may be discovered. These are generally related to damage during intubation. However, they also can be the result of too big of a tube, excessive movement of the tube, repeated coughing or allergic reactions. The patient also may develop glottic or subglottic edema after removal of an airway. Glottic edema develops within a few hours and may increase up to 24 hours. Subglottic edema is particularly dangerous in children because the cricoid cartilage limits the outward expansion of the trachea. Edema that develops in a child therefore narrows their airway lumen. Neither glottic nor subglottic edema is major concerns until the patient is extubated. As long as the airway is in place, neither causes significant problems. Because edema may get worse up to 24 hours post extubation, the patient with stridor must be monitored closely. A cuff-leak test has been proposed as a predictor of the patient at greatest risk of post extubation airway obstruction. Prior to extubation, the cuff is deflated and the patient evaluated for the amount of leak around the tube. Patients with a leak have little danger of airway obstruction due to edema. The absence of a leak does not guarantee post extubation difficulty, but these patients should be observed closely.

BOLUS OF FOOD

TRACHEA

Cuff inflation impedes passage of substances through the esophagus

ESOPHAGUS

Contamination of the lower airway occurs with an airway in place. Virtually all patients who have an airway are colonized. Hopefully, contamination will not progress to infection. Infection is considerably more serious than mere contamination. Infection is present when there is evidence of bacteria within white blood cells. This indicates phagocytosis has taken place. Infection increases the incidence of other complications, such as, tracheal irritation, mucosal sloughing and necrosis. There is some swallowing dysfunction if the inflation of the cuff impedes the passage of substances through the esophagus. Normally, the esophagus expands into the trachea at the site of

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a bolus. This is disrupted at the cuff site and interferes with adequate oral intake. PREVENTION OF COMPLICATIONS ow that we know the complications and predisposing factors to those complications, preventing them becomes a matter of simple common sense. First, the airway must be secured in place to prevent its accidental movement or extubation. The endotracheal tube can be secured with adhesive tape. Apply tincture of benzoin to the patients cheeks to hold adhesive tape more securely without tearing the skin. The centimeter markings located on the endotracheal tube are used to identify the distance the tube is in the trachea. The average adults distance from the mid-trachea to teeth is about 23 to 25 cm. Check and record the centimeter mark at the patients teeth or gums after securing the tube. The practitioner can tell if the tube has been accidentally pulled out some or pushed farther into the patient by looking at the current centimeter mark. If the tube is intentionally adjusted, the new centimeter mark should be checked and recorded. There are manufactured devices available to secure the endotracheal tube. Proper sizing can with these devices can present some problems. When turning the patient, securing circuits and attached devices care should be taken to prevent pulling on the artificial airway. All tubing attached to the airway should be supported so as not to put a strain on the tube, particularly during patient movement. Before any patient movement, make sure there is enough slack in tubing connected to the airway to accommodate the movement. Otherwise, the airway scrapes along the airway wall or extubation may occur. Aseptic technique needs to be carefully adhered to when doing any procedure with the tube. Adequate humidity and temperature of the inspired gas must be maintained to prevent mucosal crusting and maintain proper ciliary action. As the mucociliary mechanism becomes impaired, the possibility of infection rises proportionally. The fluid status should be monitored and maintained to keep the secretions mobile. Selecting the proper tube size is crucial. 2.0 mm ETT are now being re-manufactured due to the increase in resuscitation of micro-premies. Approximate ETT (Endotreacheal) and tracheostomy tube sizes are: AGE < 30 weeks 30-35 weeks Newborn 6 months 1 year ETT SIZE (ID) 2.5 mm 3.0 mm 3.0 mm 3.5 mm 4.0 mm TRACHEOSTOMY TUBE SIZE 00 00-0 00-0 0-1 1-2

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ARTIFICIAL AIRWAYS
AGE 2 years 4 years 6 years 8 years 10 years 12 years 14 years Adult (female) Adult (male) ETT SIZE (ID) 4.5 mm 5.0 mm 5.5 mm 6.0 mm 6.5 mm 7.0 mm 7.5 mm 8.0-8.5 mm 8.5-9.5 mm TRACHEOSTOMY TUBE SIZE 2 3 4 4 4 5 5 5 6

Also crucial is using tubes that have a high volume, low pressure (HVLP) cuff. As mentioned earlier, too large of a tube causes vocal cord problems and too small of a tube requires high intracuff pressures to achieve an effective seal. HVLP cuffs are very compliant and are designed to provide a seal at very low inflation pressures. This brings us to the very important point of intra-cuff pressures. Intra-cuff pressure (IP) should be maintained at the lowest possible level to get the job done. This varies depending upon why the patient has the airway in the first place. For example, the cuff only needs to be inflated in the case of mechanical ventilation or protection of the airway. If the airway is just being used for suctioning, the cuff need not be inflated continuously.

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INTRACUFF PRESSURE

P R E S S U R E

B A
VOLUME

B
From point A to B there are small incremental increases in intracuff pressure. From point B on, small increases in cuff volume produce large increases in intracuff pressure.

IP rises slowly until the cuff actually touches the tracheal wall at which point it rises rapidly with even small increases in volume. When IP exceeds tracheal wall arterial pressure, ischemia develops rapidly. Systolic blood pressure in the trachea wall is approximately 20-25 mm Hg (2430 cm H2O) so IP should not exceed this amount. When the pressure on the wall exceeds 5 mm Hg lymph flow is decreased and edema develops. If wall pressure exceeds 18 mm Hg, venous flow is impeded and congestion develops. Many institutions do not monitor IP but rather use one of the following procedures to minimize pressure on the tracheal wall. Minimal Leak Technique (MLT) consists of inflating the cuff to the point where there is a very slight leak at the end of inspiration (mechanically ventilated patients). To determine this point, suction the trachea and oropharynx then deflate the cuff completely. Re-inflate the cuff on inspiration to the point where a slight leak may be auscultated at the neck at end-inspiration. The patient should not lose more than 50-100 ml of VT. You may wish to increase VT to compensate for this minimal leak. The rationale of MLT is that the airway is mechanically dilated the most at end-inspiration. If gas can leak around the tube at this point, tracheal wall pressure is minimal. Therefore, blood and lymph flow are not impeded.

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ARTIFICIAL AIRWAYS
MINIMAL LEAK TECHNIQUE

Slight leak at endinspriration prevents tracheal ischemia.

Minimum Occluding Volume (MOV) consists of taking the MLT a step further. It is used when MLT does not provide an effective seal. This is usually a patient requiring high (greater than 30-40 cm H2O) ventilating pressures or a patient in danger of aspiration. The same suctioning and inflation procedure is followed, but continue inflating the cuff to the point where there is no leak at end-inspiration. Once the cuff meets the tracheal wall and seals it, no more volume is introduced into the cuff. This minimum occluding volume should produce a minimum of pressure on the tracheal wall. Whether the MOV or MLT techniques are used, care must also be taken when deflating the cuff to capture the secretions which are not in the tube or in the mouth, but which are resting on top of the inflated cuff. There are several techniques to accomplish this. One is to suction the mouth with a tonsil-tip device, then perform ETS. Prior to removing the catheter, while it is at the fully distal end of the ETT, apply suction while deflating the cuff. The secretions resting on top of the cuff will fall and be suctioned. Another technique is to perform ETS, then oral suction with the tonsil tip. The tonsil tip device is left in the patients mouth and a positive pressure breath is given. The secretions sitting on top of the cuff are blown up into the oral cavity where suctioned with the tonsil tip. Another monitoring tool for cuffs is the comparison of the cuff diameter to tracheal air column ratio on the chest X-ray. It has been noted that tracheal complications, such as, dilatation and stenosis, are preceded by a change in this ratio. When the cuff diameter exceeds the tracheal air column by a ratio of 1.5/1.0, problems arise. If the ratio is observed increasing on serial chest X-rays, it is an indication to place a larger tube in, change the cuff location, or go to a different style of cuff.

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The longer a tube is in place, the greater the chance of a serious complication. For this reason, extubation parameters should be monitored on a regular basis and extubation performed as soon as possible. A careful evaluation should be done on all patients who have an endotracheal tube in place for 3 days. If it is decided that extubation will not be possible within the next several weeks then the patient should have a tracheotomy performed. According to the National Association of Medical Directors for Respiratory Care (NAMDRC) guidelines, a tracheostomy tube is preferred over an endotracheal tube if the need for an artificial airway is anticipated being over 21 days. This prevents many of the laryngeal complications associated with an endotracheal tube and it improves the swallowing mechanism. However, the tracheotomy procedure and stoma results in many other possible complications. With advances in tube technology and monitoring of cuff pressures, many patients can remain orally or nasally intubated for up to 30 days without serious complications. It should be noted that a tracheostomy tube reduces anatomic dead space by onehalf, thereby increasing alveolar ventilation. PRECAUTIONS, HAZARDS, AND/OR COMPLICATION EMERGENCIES

here are 3 common emergencies the clinician may be confronted with in dealing with artificial airways. They are: cuff leaks, accidental extubation, and obstructions.

Cuff leaks Cuff leaks are evidenced by your patients ability to make sounds or speak, decreasing exhaled volumes, low-pressure alarms, having to refill the cuff often, or the leak may be heard if it is large enough. Initially, VT (inspiratory flowrate) can be increased to compensate for minor leaks. Later, it is necessary to replace the tube by trained personnel at the earliest possible moment. If the leak is massive, it may be necessary to extubate the patient and maintain ventilation with a bag and mask until they can be reintubated. Placement of an ETT changer before extubation will aid reintubation. Proper placement of the ETT should be confirmed before diagnosing an actual cuff leak. Movement of the tube can result in the cuff being above the vocal cords. For adult males, an ETT should be around 23 cm at the anterior incisors. For adult females, they should be around the 21 cm mark. On chest X-ray the tip of an ETT or trach tube should be between T2 to T4 or 3-7 cm above the carina. If the tube is positioned properly try simply reinflating the cuff to stop a leak. A temporary technique that can be used if the patient has a tracheostomy tube in place, with a cuff leak is; completely deflate the cuff and place a smaller diameter ET tube inside the tracheostomy tube, after that institute bag/mask ventilation. Remember this may be possible as a temporary measure only. This is almost impossible with most trach tubes since their lumen prevents a cuffed ET tube from going through. However, it may be possible to insert an uncuffed infant tube for temporary ventilation. A defective one-way valve or severed cuff-inflating tube line may not necessarily lead to
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immediate reintubation. If the cuff is leaking due to a faulty pilot valve, it may be possible to place a 3-way stopcock into the valve to seal it. If the pilot valve has accidentally been cut off, then insert a large bore needle and syringe with stopcock attached into the pilot line. This can be used to inflate and seal the cuff until the tube is replaced. A 20-gauge Teflon angiocath also can be inserted into the pilot line. Use the steel needle for insertion then withdraw it to prevent puncturing the line. Accidental Extubation Accidental extubation is always a possibility, particularly in the mobile or disoriented patient. The solution here is obvious; the patient must be reintubated at the earliest possible moment. This is assuming the patient still needs intubation. Many patients seem to know better than the staff when its time to be extubated. The clinician may wish to monitor the patient and provide adequate oxygen therapy for a time before reintubation. The patient is high-risk for reintubation if they have four or more of the following: 40% FIO2 or greater 7 lpm mechanical minute volume or higher pH > 7.45 just before accidental extubation PaO2/FIO2 < 250 mm just before accidental extubation Peak heart rate > 120 in 24 hours before accidental extubation Coexisting disease (at least three of the following) COPD history Heart failure history Renal dysfunction Liver dysfunction Stroke, seizure, coma history Current use of antibiotics Electrolyte abnormality Non- alert mental status Reason for intubation was for acute respiratory failure Reason for intubation was for airway protection Approximately 35-40% of self-extubations do not need reintubation. A pre-extubation FIO2 < 40% and ventilator delivered minute volume < 7 lpm have a lower incidence of reintubation. This may help distinguish patients requiring immediate reintubation. Most who require reintubation do so within one hour of extubation. Few require reintubation if more than 15 hours have passed since extubation. For those requiring reintubation, ventilation and oxygenation needs to be maintained with a bag and mask. The cause of the accidental extubation should be identified and appropriate measures taken to prevent its reoccurrence.
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Risk factors for self-extubation are associated with the presence and severity of agitation and delirium. Both agitation and delirium predispose to self-extubation. However, the majority of patients who extubate themselves are oriented but restless. Many may due to the feelings of discomfort, difficulty breathing, and gagging experience this restlessness. Self-extubation may just be a protective response from the patient. Approximately 10% of extubations in the critical care unit are unplanned. They are a result of self-extubation or accidental extubation during movement or a procedure. To prevent accidental extubation: Secure airway placement Maximize patient acceptance of the airway Control delirium and agitation Apply physical restraints when necessary

Obstructions Obstructions are the result of many things: mucus plugs, kinked tubes, herniated, slipped, or over inflated cuffs, or the bevel of the tube resting against the tracheal wall. The first step is to suction the patient. If the catheter cannot be passed, manipulate and reposition the tube or patient. If the obstruction remains, deflate the cuff and attempt ventilation. If none of the above are successful, extubation may be necessary. Ventilation and oxygenation must be maintained until another tube can be placed.

Movement of the tube can cause obstructions, leaks, or lead to tracheal erosion

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Additional possible hazards or complications related to emergency airway management itself include: Failure to establish a patent airway, to intubate the trachea, or recognize esophageal intubation Trauma to nose, mouth, tongue, pharynx, vocal cords, trachea, esophagus, spine, eyes, teeth Aspiration and/ or infection (pneumonia, sinusitis, otitis media) ET tube problems (cuffs, pilot tubes, kinking, occlusion, extubation) Autonomic or protective neural responses (hypo/hypertension, brady/tachycardia, dysrhythmias, laryngospasm, bronchospasm) Bleeding, hematoma formation, stoma stenosis, innominate artery erosion

Algorithm for a Difficult Airway 25 The American Society of Anesthesiologist (ASA) Task Force on Management of the Difficult Airway has described a difficult airway as one that a conventionally trained anesthesiologist cannot manage without systemic oxygen desaturation despite increased inspired oxygen tension and without signs of hypercapnia, including hypertension, tachycardia, and other secondary evidence of ventilatory inadequacy. The incidence of difficult direct laryngoscopy and intubation is reported to be 1.5% to 15%, and impossible intubation during anesthesia has been reported in less than 1% of patients studied.26 27

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Difficult Airway Recognized Unrecognized

Uncooperative Patient

Proper Preparation

General Anesthesia + Paralysis

Mask Ventilation

No Emergency Pathway

LMA, Combitube, TTJV

Yes Non-Emergency Pathway

Awaken

Surgical Airway

Awake Intubation Choices

Fail

Regional Anesthesia

Intubation Choices

Intubation Choices

Succeed

Surgical Airway

Cancel Case, Regroup

Fail

Succeed

Awaken

Surgical Airway

Confirm

Anesthesia with Mask Ventilation

Extubate Over Jet Styler

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CARE OF THE ARTIFICIAL AIRWAY any of the routine procedures associated with airways have already been discussed. Once the complications, predisposing factors and emergencies are known, the care of artificial airways becomes quite simple. Care varies slightly from one institution to another so the appropriate departmental procedure manual should always be consulted. What follows are general guidelines that are used in the absence of specific institutional guidelines. Every 8 hours it is advisable to resecure the tube. Because of patient movement or secretions, the tape, ET tube holder, or trach ties can become loose. It may be advisable to reposition an oral tube to the other side of the mouth at this time to prevent and/or minimize tissue break down. Be careful to prevent the ET tube from slipping down the trachea during this procedure. A piece of tape placed on the tube at the level of the lip makes any movement during the procedure obvious. Those with excessive oral secretions may need the tube resecured more often than every 8 hours. The ideal technique for securing the ETT allows for minimal tube movement, maximum patient comfort, permits adequate oral hygiene, maintains skin integrity, and requires minimal time to maintain. Adhesive tape works best for most patients. Those with facial hair, oral/facial trauma, skin disorders, excessive oral secretions or those who have no teeth may need a commercial tube holder. In fact, the 2003 ACLS guidelines recommend use of a commercial endotracheal tube holder. Another method noted for those difficult to tape patients, is to use a 20-30 inch, inch thick tracheostomy tie formed into a clove-hitch knot, which is slipped over the ETT, and the balance tied around the patients head. In addition, many clinicians adhere to the practice of avoiding taping around the neck for any neurological patients. Regardless of technique, the tube should move less than 1 cm when properly secured. It is of interest that approximately 81% of unplanned extubations are considered adequately secured by the caregiver before extubation. Suctioning should be carried out PRN. Suctioning should not be done merely because its time to do it. Serious complications result from suctioning if no secretions are present. Tracheal instillation of normal saline or a mucolytic may be used to thin out or loosen secretions. A few drops are used for neonates, 1-3 ml for adults. Overzealous use of lavage is not suggested as it has been noted to wash out natural surfactant. The other issue, which has remained controversial for years, is whether or not to lavage at all. There are studies that site lavage as causing nosocomial infections. Instill the lavage solution, hyperexpand the lungs several times to distribute the liquid, and then suction the patient. Many believe tracheal lavage is unnecessary if the fluid status is acceptable and proper humidity has been provided. Proper temperature (35-37O C), proper humidity (100% relative body humidity), and proper FIO2 should always be maintained. If not, the trachea may be burned, mucociliary activity decreased, secretions may become more tenacious, or ABGs are altered. FIO2 should be measured with an O2 analyzer at least once a shift and whenever it is adjusted. Temperature should be monitored continuously. 35-37O C has been advocated for years as proper temperature. Many authors now advocate lower temperatures than this to prevent heat damage to the trachea and cilia. All authors readily agree that the body temperature of 37O should never be exceeded.

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The inner cannulas of tracheostomy tubes should be removed and cleaned, every 4-8 hours. The area around the stoma also should be cleaned with sterile cotton-tipped applicators and sterile gauze at the same time. Apply a sterile dry dressing and antibiotic ointment to the stoma every 8 hours, or more often if needed. If there is evidence of infection, it should be cultured. Always keep another sterile tracheostomy tube at the bedside for emergency situations. Support all tubing attached to the airway and change the tubing as hospital policy dictates. Many institutions have changed to a 48-hour instead of 24-hour schedule for circuit changes. Hospital policy should be observed in this respect. Heated wire circuits and the use of hygroscopic condenser humidifiers have made it possible to change circuits much less frequently than in past years. Cuff pressure should be maintained at the lowest possible amount. There are several ways to do this; measuring the IP, MLT, and MOV are the most common. Whichever is used, it should be performed every 4-8 hours. Measurement of the intra-cuff pressure should be used when the patient is hypotensive. MLT is used when ventilating pressures are less than 30-40 cm H2O. MOV is used when ventilating pressures are greater than 30-40 cm H2O. A minimal leak of 50-100 ml is considered acceptable with MLT. Increasing VT slightly may compensate for this. It should be remembered that with this technique the airway is open at end-inspiration so aspiration is possible. When the cuff leak is excessive; or the danger of aspiration high, MOV is recommended. The clinician may wish to increase cuff inflation slightly during and after feedings to minimize aspiration. In the past, it was recommended that endotracheal tubes be maintained for 3-7 days before a tracheotomy performed. This has been expanded considerably in recent years to up to 21 days. It is recommended to change trach tubes every 7 days. The physician who performed the surgery should do the first change. Trained allied health personnel can do later changes. (Some do not recommend changing trach tubes on a regular basis, only when there is a problem). Extubation parameters should be performed every 8-24 hours, depending upon the patients condition. There are far too many extubation parameters to be discussed here, so the interested reader is referred to other papers on the subject. The goal should always be to extubate as soon as possible. Frequently orient patients to time and place and remind them of the purpose and importance of the ETT. Patients who perceive the tube as a threat or source of discomfort are less tolerant of intubation. Inform them before any manipulation of the tube or tubing. Provide meticulous oral hygiene and be careful when applying or removing tape. All of the above improves patient acceptance of the tube. Control delirium and agitation. First identify the cause of any agitation if possible. Exclude movement of the ETT or severe hypoxia as the cause. The tip of the tube may be resting on the carina or in a main stem bronchus. Movement of the head from flexion to extension moves the ETT an average of 3.8 cm. This gives intermittent symptoms. If there is no obvious cause of agitation consider sedatives or psychotropics. Haloperidol and benzodiazepines are commonly

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given. Apply appropriate physical restraints. Use arm and chest restraints on patients who are confused, agitated, or on those whom accidental extubation would be critical. Most patients receiving > 40% O2 or > 7 lpm mechanical minute volume who are accidentally extubated require reintubation and should be restrained. A combination of arm and chest restraints is more effective than arm restraints alone. High-risk patients should be identified and have follow-up evaluations for airway problems every 1-3 months for one year post extubation. Scar tissue may be slow to build up and stenosis may not be apparent for some time. SUMMARY

his course has focused on the care, complications, and emergencies of the endotracheal and tracheostomy tube. Complications include: suctioning complications, decreased cough effectiveness and mucociliary activity, swallowing dysfunction, sloughing, ulceration, ischemia of the mucosa, tracheal dilatation, stenosis, or malacia, TE fistula, edema of the upper airway, infection, and vocal cord paralysis, or ulceration.

Predisposing factors to these complications are: the general health of the patient, their hydration status and blood pressure, characteristics of the tube, movement of the patient or tube, the duration of intubation, the presence of infection, and the use of steroids. Preventing these problems consists of: securing the tube in place, supporting all tubing to prevent strain, smooth patient movements, use of aseptic techniques, maintenance of temperature, humidity, FIO2, and fluid status, selection of the proper tube, monitoring and minimizing intracuff pressure, and extubation as soon as possible. The emergencies encountered with artificial airways are cuff leaks, accidental extubation, and obstructions. These can be treated with tube replacement, repositioning, or suctioning. Ventilation and oxygenation need to be maintained in the meantime. Care of endotracheal and tracheostomy tubes consist of: properly securing them in place, suctioning PRN, maintaining proper temperature, humidity, and FIO2, cleaning the stoma and inner cannula on trach tubes, placing sterile dressings on the stoma, replacing all circuit tubing regularly, monitoring and maintaining cuff pressure at the lowest effective amount, and extubating ASAP. CLINICAL PRACTICE EXERCISE The following clinical practice exercises are discussed at the end of the course. Several answers and options may be correct based upon personal experience and institutional procedures. Case 1 1. You are called to the emergency room to attend to a 40 year old, male, trauma victim. The patient has been severely beaten about the head with a blunt instrument. There are multiple

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lacerations and hematomas on the head. The cheekbones and mandible are broken. There are gurgling noises on inspiration and the airway appears obstructed. An artificial airway is necessary. What type of airway do you suggest and why? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2. The airway is now in place and copious amounts of blood and edema fluid have been suctioned from the airway. What additional procedures need to be done regarding the artificial airway? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3. One hour later the patient is transported to the critical care unit. Shortly after his transfer from the gurney to the bed you notice inspiratory retractions, decreased bilateral breath sounds, and the patient is slightly cyanotic. What are possible causes of these and what can be done to correct them? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Case 2 1. A 22-year-old man suffers second and third degree burns to 50% of his body in a motor vehicle crash. On the 5th post-burn day, he is scheduled for wound debridement to face and arms. Discuss the potential airway implications for burn patients. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

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2. What ominous signs and symptoms would indicate that early intubation is necessary? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3. Which airway would be your choice and how would it be secured? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 4. After the patient was admitted you noticed that he continued to have a depressed level of consciousness and hypoxemia. What might be the explanation of his condition? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Case 3 Ordinary Cuff Leak Following a successful difficult intubation (in the first two attempts the ETT went into the esophagus), a leak is found after the therapist injected the usual (for that hospital) 5 ml of air. (Alternately, the leak may occur in the middle of the case). List some causes of such a leak and how one might deal with them. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

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PRACTICE EXERCISE DISCUSSION Case 1 1. Due to the extensive facial trauma, intubation would be difficult if not impossible. An emergency tracheotomy is necessary with insertion of a tracheostomy tube. The patient needs an artificial airway that seals the airway and prevents further aspiration of foreign material. The patient should be monitored for the effectiveness of normal glottic reflexes. He may be severely obtunded from head trauma and not be able to protect his airway. 2. Assuming that a tracheostomy tube is in place, it must be secured properly. Cuff pressure, MLT, or MOV should be performed. Since the danger of aspiration is high in this patient, MLT is not recommended. Warmed, humidified gas should be provided and suctioning PRN. 3. Since the patient has recently been moved, there is a strong possibility that the tube has shifted and is obstructed. Attempt to pass a suction catheter and reposition the tube. Support the attached tubing so it is not pulling on the tracheostomy tube. Case 2 1. Burn patients present many potential airway problems. Acutely, the findings of singed nasal hairs, facial burns and/or pharyngeal burns may signify an inhalation injury and a need for early intubation before airway edema becomes a problem. 2. Hoarseness and stridor are especially ominous signs. 3. With facial burns it may not be possible to tape the ETT to the face. Options include wiring the ETT to the teeth and the use of special ETT securing devices. The laryngeal mask airway may be useful in this context. 4. Patients with very high carboxyhemoglobin levels may have depressed consciousness. Patients unable to protect their airways and patients with severe hypoxemia generally require intubation. Case 3 Causes of cuff leaks: (1) Under inflation of cuff (2) ETT out too far (3) damaged inflation valve (4) damaged inflation line (5) damage to cuff itself. One approach to the problem is a follows: 1. First, see if the leak can be remedied simply by adding more air (be sure to measure cuff pressures once things are settled). 2. Second, consider that the ETT cuff may be situated at the level of the cords rather than below the cords. If this is the case, adding more air will not help. Laryngoscopy may help identify this

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situation, but that is not always possible. A view using the FOB may be more illuminating, but this involves a lot of trouble. If the centimeter mark at the teeth seems to be too low (e.g. 19 cm in an adult) be very suspicious of this situation. Some clinicians recommend blindly advancing the ETT with the cuff deflated to 2 - 4 cm. See if this resolves the problem, but if you do this, double check the air entry to make sure the ETT hasnt gone endobronchial. 3. Third, consider the possibility of damage to the ETT inflation valve, with a resultant leak. Using a three-way stopcock jammed into the cuff inflation port and inflating through it may just do the job. 4. Next, consider that there could be a leak or cut in the cuff inflation line. If one can be identified, cutting out the damaged position and using a dulled #20 needle with three-way stopcock to cannulate the remaining portion of the cuff inflation line may help. 5. Of course, if the patient was easy to intubate, it might be easier to reintubate using a new ETT. If there is a cuff tear and the patient is easy to reintubate, this is your best choice. If reintubation would be difficult and the procedure is of short duration, insertion of a throat pack may do in some cases, but may end up putting air in the stomach with PPV. This will be less of a problem if you can let the patient breathe spontaneously. ETT cuff leaks may present serious clinical problems both intraoperatively and postoperatively. However, in many cases reintubation can be avoided, at least for a while; this can be highly desirable where reintubation is exceedingly dangerous (e.g. jaw wired shut, edematous airway, unstable cervical spine). In many cases reinflating the ETT cuff will suffice to reestablish the airway for an extensive period. As well, for small leaks it may be sufficient to increase the tidal volume of the ventilator to compensate for the leak, but this could conceivably lead to gas entering the stomach. Even if the ETT cuff must be reinflated every few hours, this may be preferable to reintubating the patient under suboptimal conditions. These and other temporizing measures may be especially valuable in the middle of the night, when help may not be readily available. Facilities for establishing a surgical airway (e.g. TTJV, cricothyroidotomy) should be nearby should reintubation attempts be unsuccessful. Many ETT cuff leaks are due to failure of the ETT cuff inflation valve. Should this occur, it may be helpful to insert a stopcock into the cuff inflation valve, and then inflating the cuff with a syringe located at the other end of the stopcock, and then closing the stopcock. When a three-way stopcock is used, the sidearm may be used to connect an ETT cuff pressure monitor. When an ETT cuff leak is due to a cut cuff inflation line, reintubation can still be avoided by employing the following method: Take a #20 gauge needle, dull it, insert it into the remaining end of the cuff inflation line, attach a stopcock to the needle and inflate with a syringe. When the problem is due to a tear in the cuff itself, the only remaining remedies other than reintubation are to switch to spontaneous ventilation (where clinically appropriate) and/or to

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insert a throat pack. Obviously the deflated cuff poses an additional problem in that it no longer protects the airway against aspiration. Sometimes an ETT leak is due to malpositioning of the ETT (i.e. ETT cuff situated at the level of the cords instead of being beyond the cords) rather than due to loss of gas from the ETT cuff. This situation should be suspected when a leak occurs despite high cuff pressures and/or when the ETT does not appear to be inserted far enough into the patient (usually we seek to have the ETT markings at the teeth approximately as follows: average adult males 24 cm; average adult females 22 cm).

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SUGGESTED READINGS AND REFERENCES 1. American Association For Respiratory Care: Clinical Practice Guideline. MANAGEMENT OF AIRWAY EMERGENCIES 2. American Heart Association. ACLS PROVIDER MANUAL. (2001). 3. Barnes, T. (Editor) RESPIRATORY CARE PRACTICE, 1988, Yearbook Medical Publishers, Inc., pp 195-198 4. Branson R, Hess D, Chatburn A. RESPIRATORY CARE EQUIPMENT, 1995, (1999), J.B. Lippincott Co., pp 118-137 5. Burton G, Hodgkin J. RESPIRATORY CARE: A GUIDE TO CLINICAL PRACTICE, 2nd ed., 1984, (1997), J. B. Lippincott Co, pp 493-522 6. Cairo, J.M. and Pilbeam, Susan, MOSBYS RESPIRATORY CARE EQUIPMENT, 6th edition, 1999, Mosby Year-Book Inc., pp 144-148 7. Colice G., Stukel T., Dain B. LARYNGEAL COMPLICATIONS OF PROLONGED INTUBATION, Chest, October 1989, Vol. 96, #4, pp 877-883 8. Hess, Dean R., MANAGING THE ARTIFICIAL AIRWAY, Respiratory Care, July 1999, vol. 44, # 7, pp 759-767 9. Ho A, Contardi L. WHAT TO DO WHEN AN ETT CUFF LEAKS, Journal of Trauma, 1996, Vol. 40, #3, pp 486-487 10. LMA North America LARYNGEAL MASK AIRWAY INSTRUCTION MANUAL. San Diego, CA 92121 August 1998. 11. Marik P. THE CUFF-LEAK TEST AS A PREDICTOR OF POSTEXTUBATION STRIDOR, Respiratory Care, June 96, Vol. 41, #6 pp 509-511 12. Marino P. THE ICU BOOK, 1991, Lea and Febiger, pp 383-390 13. May, Harold, M.D. Editor. (1984). Emergency Medicine. New York: John Wiley & Sons. 14. McPherson S. RESPIRATORY THERAPY EQUIPMENT, 3rd Ed, 1985, C.V. Mosby Co., pp 163-173 15. Murray J, Nadel J. TEXTBOOK OF RESPIRATORY MEDICINE, 1988, W. B. Saunders Co

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16. Neff T, Clifford D. A NEW MONITORING TOOL - THE RATIO OF TRACHEOSTOMY TUBE CUFF DIAMETER TO THE TRACHEAL AIR COLUMN RATIO, Respiratory Care, October 1983, Vol 28, #10, pp 1287-1290 17. Okhuysen R. et al, EVALUATION OF A NEW THIN-WALLED ETT FOR USE IN CHILDREN, Chest, May 96, Vol. 109, #5, pp 1335-1338 18. Scanlan C, Spearman C, Sheldon L. EGANS FUNDAMENTALS OF RC, 6th edition, 1995, (1999), Mosby Year-Book Inc., pp 548-574 19. Sessler C, Glass C, Grap M. TECHNIQUES FOR PREVENTING AND MANAGING UNPLANNED EXTUBATIONS, Journal of Critical Illness, June 94, Vol. 9, #6 pp 609- 619 20. Shapiro B, Harrison R, Trout C. CLINICAL APPLICATION OF RESPIRATORY CARE, 2nd ed., 1979, Yearbook Medical Publishers, Inc. pp 235-295 21. Sharar S. THE EFFECTS OF ARTIFICIAL AIRWAYS ON AIRFLOW AND VENTILATORY MECHANICS, Respiratory Care, Mar 95, Vol 40, #3, pp 257-261 22. Sills, J. (1995). Respiratory Care Registry Guide. St. Louis: Mosby. 23. Whelan J, Simpson S, Levy H. UNPLANNED EXTUBATION, Chest, June 94, Vol. 105, #6, pp 1808-1812 24. White, G. (1998). Basic Clinical Lab Competencies for Respiratory Care. (3rd Ed.). Albany: Delmar ITP. 25. American Society of Anesthesiology, Task Force on Management of the Difficult Airway. Practice guidelines or management of the difficult airway. Anesthesiology 1993; 78:597-602. 26. Williamson JA, Webb RK, Szekely S, et al. The Australian Incident Monitoring Study: difficult intubation: an analysis of 2000 incident reports. Anesth Intensive Care 1993; 78:597602. 27. Wilson ME. Spiegelhalter D, Robertson JA, et al. Predicting difficult intubation. Br J Anaesth 1988;61:211-216. 28. Scanlan C, Spearman C, Sheldon L. EGANS FUNDAMENTALS OF RC, 8th edition, 2003, Mosby Year-Book Inc., pp 665-666 29. Kacmarek RM, Dimas S., Mack CW, THE ESSENTIALS of RESPIRATORY CARE, 8th edition, 2005, Mosby Year-Book Inc., page

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30. Brady. Emergency Medical Responder (Second Canadian Version). 2006. pp. 9297

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POST TEST DIRECTIONS: Use the FasTrax answer sheet enclosed with your order to respond to all the test questions that follow. Leave the remaining answer circles on the FasTrax answer sheet blank. Be sure to fill in circles completely using blue or black ink. The FasTrax grading system will not read pencil. If you make an error, you may use correction fluid (such as White Out) to correct it. FasTrax answer sheets are preprinted with your name and address and the course title. If you are completing more than one course, be sure to record your answers on the correct corresponding answer sheet. RETURN TO: RCECS, P.O. Box 1930, Brockton, MA 02303-1930 or FAX TO: (508)-894-0172. 1. Armored and RAE tubes are no longer in use. a. True b. False 2. A 16 year-old conscious male patient is brought into the emergency department from a motorcycle accident. He has facial lacerations including a broken nose and jaw. The heavy bleeding into his mouth has caused him to have difficulty with his breathing. Which of the following would you recommend ensuring the safest, most effective airway? a. b. c. d. Place an oral airway Place a tracheostomy tube Place a nasopharyngeal airway Place a nasal endotracheal tube

3. Your patient has a convulsive disorder and is having unpredictable seizure activity. What oral endotracheal tube would you suggest be placed to provide a secure airway? a. b. c. d. e. Standard Double - lumen Preformed Armored Guidable

4. Lanz tubes: a. b. c. d. Have a PVC cover over the pilot balloon Have a channel to permit use of the natural airway Have a cuff made of polyurethane foam Are shorter than regular tracheostomy tubes

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ARTIFICIAL AIRWAYS
5. All of the following are advantages of the Laryngeal Mask Airway (LMA) EXCEPT: a. b. c. d. Can be gas sterilized for repeated use Provides a clear airway Designed for blind insertion Can be left in place in recovery room

6. What is the maximum intra-cuff pressure that can be tolerated in the patient with a normal BP? a. b. c. d. 10-15 mm Hg. 15-20 mm Hg. 20-25 mm Hg. 20 mm Hg.

7. Which of the following is a description of Minimum Occulsive Volume (MOV)? a. Inflation of the cuff to 20 mm Hg. b. Inflation of the cuff until there is a minimal leak at end-inspiration. c. Inflation of the cuff to the point where cuff diameter is 1.5 times the diameter of the trachea. d. Inflation of the cuff just to the point where the airway is sealed. 8. Why is the Minimum Leak Technique (MLT) used? a. b. c. d. To prevent tracheal ischemia. To prevent hypoxemia from suctioning. To minimize the danger of aspiration. None of the above.

9. All of the following are indications for artificial airways EXCEPT: a. b. c. d. Mechanical ventilation. Protection of the airway. Chronic care of secretions. Improve the cough mechanism.

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10. Which of the following are complications of an endotracheal tube? 1. 2. 3. 4. a. b. c. d. Glottic edema. Tracheal ulceration. Increase in dead space. Tracheal stenosis.

1, 3. 1, 2, 4. 2, 3. 1, 2, 3.

11. How long does it take to develop glottic edema? a. b. c. d. Immediately postextubation. From 7 days up to 2 years post-extubation. Within a few hours, but may increase up to 24 hours post-extubation. Within 24 hours of intubation.

12. How often should cuff pressures be monitored? a. b. c. d. Q24 hours. Q8 hours. Q7 days. Only when indicated.

13. Which of the following are possible emergency situations that could arise with an artificial airway in place? 1. 2. 3. 4. a. b. c. d. 1, 2, 3. 2, 3, 4. 3, 4. 1, 4. Glottic edema. Cuff leaks. Extubation. Obstructions.

14. How does the presence of an NG tube affect the intubated patient? a. b. c. d. It will speed erosion of the tracheal-esophageal wall at the site of the cuff. It will increase the possibility of aspiration. It is irrelevant. It will aid secretion removal.

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ARTIFICIAL AIRWAYS
15. How is mucociliary clearance of mucus affected by the insertion of an artificial airway? a. Increased. b. Decreased. c. No change. 16. Oropharyngeal airways should NOT be used in which type of patient? a. b. c. d. e. Conscious Semi-conscious Unconscious a&b b&c

17. Which of the following tracheostomy tubes have a cuff made of polyurethane foam? a. b. c. d. e. Lanz Kamen-Wilkinson Bivona a&b b&c

18. At 1800 you are called to the recovery room to assess an eight-year-old, 28 kg. girl in respiratory distress. She is post-op appendectomy. The anesthesiologist is in the middle of another case that he cannot leave. When you arrive, the patient has just stopped breathing. You oxygenate and ventilate the girl with a bag-valve- mask device, but it is difficult to keep an effective seal and achieve good chest expansion. You decide to intubate her. What size ETT would be MOST appropriate? a. b. c. d. 5.0 mm 6.0 mm 8.0 mm None of the above

19. Referring to patient in question 18, you are unable to place the ETT. There is no other skilled professional in house. After ventilating and oxygenating the child again, you take the option of using a LMA. What size is MOST appropriate for this patient? a. b. c. d. 1-2 2 3-4 5

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20. Of the following airways, which one is NOT recommended for use in the most recent ACLS guidelines? a. Endotracheal tube b. LMA c. EOA d. Combitube 21. The anesthesiologist on-call in your medical center arrives in response to an airway emergency situation. Your patient is a 9-year-old male. Although the LMA is an excellent choice in this situation, he decides that a tracheotomy must be performed. What size tracheotomy tube, that is not a Jackson tube, is MOST appropriate for this patient? a. b. c. d. d. 1 2 3 4 5

22. A patient may be at high risk for re-intubation if they have: I. II. III. IV. a. b. c. d. COPD Fractured femur An electrolyte abnormality Renal dysfunction

I, II & III I, II & IV I & IV only I, III & IV

23. Three PRIMARY emergencies which clinician may be confronted with in dealing with artificial airways include: I. II. III. IV. a. b. c. d. Inappropriate size Cuff leaks Accidental extubation Artificial airway obstruction

I, II & III II, III & IV I & II only III & IV only

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24. The Combitube can be used for ventilation and oxygenation if placed in the Trachea. a. True b. False

25. The indications for a Double Lumen Endotracheal Tube (DLET) include: I. Difficult placement of a regular ETT II. Unilateral Bronchopleural Lavage III. Control of distribution of ventilation IV. Isolation of one lung a. b. c. d. I, II & III II, III & IV I & II only III & IV only

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COURSE EVALUATION RC Educational Consulting Services, Inc. wishes to provide our customers with the highest quality continuing education materials possible. Your honest feedback will help us to continually improve our courses and meet state regulations. Responses to the following evaluation questions should be recorded in the far right hand column of the FasTrax answer sheet, in the section marked Evaluation. Mark A for Yes and B for No. Thank you.

YES

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1. Were the objectives of the course met? 2. Was the material presented in a clear and understandable manner? 3. Was the material well-organized? 4. Was the content presented without bias of any commercial product or drug? 5. Was the material relevant to your job? 6. Did you learn something new? 7. Was the material interesting? 8. Were the illustrations, if any, helpful? 9. Would you recommend this course to a friend?

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