Alternative Airways

Airway Management
Donna Kerner, MS, RN, CCRN October 1, 2006

Types
Oropharyangeal Nasopharyngeal Laryngeal Mask Airway
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Oropharyngeal Airway

Oropharyngeal Airway
Relieves airway obstruction caused by: tongue relaxation secretions seizures biting on tracheal tube Different sizes available Measure from ear lobe to corner of mouth for correct size
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Oropharyngeal Airway
Made of rigid plastic or rubber Semicircular Inserted upside down and rotated during insertion to fit the curvature of the oral cavity

Oropharyngeal Airway
Tip of oropharyngeal airway rests near the posterior pharyngeal wall For this reason, not recommended for alert patients May trigger gag reflex & induce vomiting

Oropharyngeal Airway

Oropharyngeal Airway Management

Frequent assessment of lips & tongue to prevent pressure areas Frequent removal of airway to provide oral care

Nasopharyngeal Airway

Nasopharyngeal Airway
Used in semiconscious patients and intoxicated patients Facilitate nasotracheal suctioning Soft rubber Sizes 26-35 FR Measure from ear lobe to nose AKA nasal trumpet

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Nasopharyngeal Airway
Water soluble gel applied to airway for insertion Gently inserted into nare with rotating motion Patency assessed by feeling airflow through airway

Nasopharyngeal Airway

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Nasopharyngeal Airway
Management
Frequent assessment for:
Pressure areas Dried secretions

Laryngeal Mask Airway (LMA)

Lubricate with water soluble gel prior to suctioning Monitor for complications
Sinusitis Erosion of mucus membranes
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Laryngeal Mask Airway

Uses anesthesia rescue airway fiberoptic conduit when intubation is difficult, hazardous or unsuccessful
Inflatable Mask

Laryngeal Mask Airway

Consists of an inflatable silicone mask & rubber connecting tube Inserted blindly into pharynx and advanced until resistance is felt

Pilot Balloon Adaptor

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Laryngeal Mask Airway

When cuff is inflated, mask is pushed up against tracheal opening, providing an effective seal and clear airway into trachea Permits gentle positive pressure ventilation

Placement of Laryngeal Mask Airway

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Laryngeal Mask Airway

Advantages Allows for rapid access Does not require laryngoscope Relaxants not needed Provides for spontaneous or controlled ventilation

Laryngeal Mask Airway

Disadvantages Does not fully protect against aspiration Standard LMA does not allow high positive pressure ventilation

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Bag-Mask Ventilation
Bag-mask devices (Ambu) consist of a bag and a non-rebreathing valve attached to a face mask Ambu bags can be used to ventilate intubated patients after removing face mask Adult BVMs have a volume of approximately 1600 ml Sufficient ventilations should be provided to produce visible chest expansion
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Bag-Mask Ventilation

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Bag-Mask Ventilation
Procedure If no neck injury, tilt patients head back Apply mask to face with one hand using the bridge of nose as a guide Place 3rd, 4th & 5th fingers along bony portion of mandible Place thumb & index fingers of same hand on mask Compress bag with other hand Observe chest to ensure that ventilation is adequate Deliver each breath over 2 seconds
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Artificial Airways

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Artificial Airways

Artificial Airway
Indications Elective
Patient receiving general anesthesia

Types Endotracheal tube Tracheostomy tube

Urgent
Protect airway Relieve airway obstruction Facilitate suctioning of tracheobronchial tree Facilitate mechanical ventilation
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Routes of Intubation

Cricothyroidotomy

Endotracheal Nasotracheal Tracheal

Tracheotomy-usually elective Cricothyroidotomy -urgent
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Cricothyroidotomy

Endotracheal Tube (ETT)

Description Balloon at distal end (cuff) Adaptor at proximal end fits ambu bag Size: the bigger the #, the bigger the tube Centimeter markings along side of tube used to estimate tube position
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Centimeter Markings

Cuff Pilot Balloon

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Endotracheal Tube (ETT)

Description The cuff is inflated with air using a 10 mL syringe The cuff is inflated with just enough air to create a seal

Intubation Tray
Laryngoscope
Handle Curved blade Straight blade Batteries Light bulb

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Intubation tray
Stylet:
Flexible wire Used to keep tube rigid during insertion Removed after intubation

Intubation Tray
Magill forceps
Used to remove foreign bodies Can be used during nasal intubation to advance tube down pharynx

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Intubation
The endotracheal tube (ETT) is inserted into the trachea via the nose or mouth The laryngoscope is used to visualize vocal cords The ETT is inserted into the trachea 2-4 cm above carina

Post Intubation
Confirmation of Proper Tube Placement Primary confirmation Equal chest expansion on inspiration Bilateral breath sounds Absence of gurgle in stomach Secondary confirmation CO2 detector Chest x-ray
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End-tidal CO2 Detector

Used to confirm tube placement after lung sounds & chest expansion have been verified Detects CO2 Dial changes color in the presence of CO2 Place between ambu bag and ETT

Portable CXR
A portable CXR will verify proper tube placement A radio-opaque marker along length of tube facilitates visualization of ETT on x-ray
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ETT in Right Main Stem Bronchus

Post Intubation
Tube is secured with fixation device to prevent movement
Commercial tube holder Tape

Centimeter markings are noted at lip line (nare line) Marking is checked & documented every shift
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Tracheostomy Tracheostomy
A surgical procedure where an incision is made just below the 2nd & 3rd tracheal ring, bypassing the epiglottis A tube is placed to establish an airway

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Indications for Tracheostomy

Prolonged intubation with endotracheal tube
Trach usually performed 7-10 days (in general) if unable to wean off ventilator
Improves patient comfort due to absence of ET tube Enables eating, speaking, increased mobility due to tube security

Indications for Tracheostomy

Permit long-term positive pressure ventilation
Massive chest wall trauma Respiratory failure High lesion spinal cord injury Prolonged coma Neuromuscular disease

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Types of Tracheostomy Tubes

Metal (Jackson) Plastic (Shiley, Portex) Single or double cannula Cuffed or cuffless Fenestrated (for speaking) Non-fenestrated Disposable or permanent Long-term and short-term
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Tracheostomy Tube
Parts of trach tube: Flange: holds ties, prevents pressure points & movement Inner cannula: sleeve which fits inside trach tube Cuff: inflated with just enough air to create seal Pilot balloon: port to inflate cuff
Shiley Trach

Flange

Outer Cannula

Pilot Balloon

Inner Cannula

Cuff
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Tracheostomy Tubes

Tracheostomy Tubes

Portex Trach

Double Cuff Trach

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Extra Length Flexible Trach

Adjustable Neck Flange Trach

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Jackson Trach

Cuffless Trach

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Fenestrated Trach
Hole in trach tube to allow air passage for speaking. Used to enhance air flow in and out of the trachea Trach tube is below larynx, making speech with a cuffed nonfenestrated tube impossible.
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Tracheostomy Tube
Obturator
Guides tube into position without causing trauma to tissues. Removed once tube is in place

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Passy-Muir Valve
Passy-Muir one way speaking valve is used with trach patients with or without mechanical ventilation

Passy-Muir Valve
Criteria for use:
Patient awake & oriented Motivated to vocalize Fenestrated trach is preferred but may not be required if airflow is adequate Able to tolerate extended periods of cuff deflation Able to tolerate any volume loss from around cuff during inspiration Have ability to protect airway Patent upper airway in order for patient to exhale
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Passy-Muir Valve
Valve should be removed during hours of sleep or at daytime rest Should only be used for times patient is fully awake and needing to talk

Passy-Muir Valve

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Passy-Muir Valve

Accidental Extubation
Keep an extra trach tube of same size and an obturator at the bedside If tube becomes dislodged obtain medical help immediately ! Be prepared to initiate artificial respiration

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Cuff Pressure Measurement

Cuff Pressure Measurement

An endotracheal or tracheostomy cuff provides a closed system for mechanical ventilation Allows volume to be delivered to the patients lungs To function properly, the cuff must exert enough pressure on the tracheal wall to seal the airway without compromising the blood supply to the tracheal mucosa
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Minimal Leak Technique (ML)

Suction patient (tracheal & oral) Deflate cuff Inject air back into cuff in 0.5 to 1 mL increments while listening with stethoscope until no leak is heard Then withdraw air until a small leak is heard on inspiration Record amount of air instilled

Minimal Leak Technique

Problems: Maintaining peep Aspiration around cuff Increased movement of tube

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Minimal Occlusive Volume (MOL)

Suction patient Deflate cuff Inject air in 0.5 -1 ml increments while listening over larynx with a stethoscope Continue inflation until air leak disappears Withdraw air until a small leak is heard on inspiration Add more air until no leak is heard on inspiration Record amount of air instilled
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Minimal Occlusive Volume

Problems: Higher cuff pressure than minimal leak technique Use only if patient needs a seal to provide adequate ventilation and/or is at high risk for aspiration

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Cuffalator

Cuffalator
Used to inflate/deflate cuff & measure cuff pressure Goal is to inflate cuff with just enough pressure to prevent air leak & decrease risk of aspiration

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Cuffalator
Green zone
14-24 cm H2O Acceptable pressure

Cuffalator
Bulb: used to inflate cuff Red button: deflates cuff Port: attaches to cuff inflation port

Red Zone
Too high Unacceptable pressure

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Monitoring Cuff Pressure

Important because:
Excessive pressure will decrease blood flow to the tissue resulting in tracheal necrosis Insufficient cuff pressure predisposes patient to aspiration. Establishes a baseline for evaluation of change in pressure

Monitoring Cuff Pressure

Cuff pressure should be monitored at least once a shift Can be measured by nurse or respiratory therapist

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Suctioning
Clinical indications for suctioning:
High pressure alarm Respiratory distress Coughing Audible airway noise

Suctioning
Sterile technique Suction pressure not greater than 120 mm Hg Hyperventilate with 100% O2 prior to suctioning Suction 10-15 seconds while withdrawing catheter

Suction only as needed, not on set schedule

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Suctioning
Regular suction catheter:
Size should not exceed one-half the diameter of the airway
This increases the possibility of suction induced hypoxia and atelectasis

Suctioning
Closed suction system:
Use clean gloves Apply continuous suction while withdrawing catheter straight back Lock suction valve when suctioning is completed

Use sterile gloves and appropriate PPE Apply intermittent suction while slowly withdrawing catheter

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Suctioning
Precautions:
Always hyperoxygenate prior to and during suctioning Maintain sterile technique Never use same catheter to suction the trachea after it has been used in the nose or mouth

Suctioning
Use of saline installations for loosening secretions has been controversial and recent research shows that in fact it is detrimental and poses a grater risk of pneumonia

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Suctioning
Related care:
Include strategies to move secretions through peripheral airways;
Appropriate hydration Adequate humidification of inspired gases Coughing and deep breathing Frequent position changes Use of pulmonary bed Chest PT Use of bronchodilating agents
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Suctioning
Monitor patient during suctioning for dysrhythmias aggravated by suctioninduced hypoxemia and irritation of vagal receptors within the respiratory tract

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