Airway Management / Equipment

Responsibilities for RT’s
Perform airway clearance techniques on
both artificial and natural airways (e.g.
suctioning)
Insert and maintain artificial airways in
patients whose natural airway are
inadequate (e.g. oral pharyngeal insertion)
Assist physicians in performing special
procedures related to airway management
(e.g. bronchoscopy)
Indications for Artificial Airways
Restore Patent Airway / To Relieve Airway
Obstruction
To Facilitate Removal of Secretions
To Protect the Lower Airways from Aspiration
To Facilitate Application of Positive Pressure
Ventilation
Provide an Alternate Route for the
Administration of Emergency Drugs
Relieving Airway Obstruction
Upper airway vs Lower airway
Partial vs Complete Obstruction
Causes
Trauma, Edema, Tumors, Tongue,
Secretions, Foreign Bodies, Laryngospasm
Artificial Airways Bypass Upper Airway
Obstruction
Signs of Partial Airway Obstruction
Crowing, gasping sounds on inspiration
Difficulty in coughing
Increased respiratory distress
Good to poor exchange (depends on severity)
Exaggerated chest and abdominal movement
Cyanosis (depends on severity)
Signs of Complete Airway
Obstruction
Inability to talk
Increased respiratory difficulty with no air
movement
Cyanosis
Sternal, intercostal and epigastric retractions
Extreme panic
Unconsciousness and resp. arrest if obstruction
is not removed
Secretion Removal
Artificial Airways Provide More Direct
Access for Removal of Secretions
Retained Secretions Lead to
Hypoxemia
Hypercapnia
Increased Work of Breathing
Ideal Medium for Bacterial Growth
Four Reflexes Help Prevent Aspiration
Pharyngeal (Gag and Swallowing Response)
Laryngeal ( Glottic Closure)
Tracheal (Cough Response)
Carinal (Cough Response)
Protecting the Airway
Four Reflexes Help Prevent Aspiration
CNS Depression Decreases Reflex Response
Airway Cuff Protects Lower Airway (Trachea /
Lung)
Positive Pressure Ventilation
Continuous Positive Pressure Ventilation
Requires a Closed – Sealed System
If System is Open – Gas Will Follow the
Pathway of Least Resistance and Flow
Out the Upper Airway Instead of
Ventilating the Lungs
The Artificial Airway Cuff Provides This
Seal
What does continuous positive pressure ventilation require:
Closed – Sealed System
If you have an open system what will happen:
If System is Open – Gas Will Follow the
Pathway of Least Resistance and Flow
Out the Upper Airway Instead of
Ventilating the Lungs
What provides the seal?
The cuff
Two Types of Artificial Airways
Pharyngeal
Tracheal
Pharyngeal Artificial Airway
Oral pharyngeal
Nasal pharyngeal
Tracheal Artificial Airway
Endotracheal (Translaryngeal)
Oral endotracheal
Nasal endotracheal
Tracheostomy
Endotracheal (Translaryngeal)
Oral endotracheal
Nasal endotracheal
Indications of Pharyngeal Airways
Establish or restore airway patency
Facilitate suctioning
What do Pharyngeal Airways seperate
the tongue
from the posterior pharyngeal wall
Types of Pharyngeal Airways
Oral pharyngeal
Nasal pharyngeal
Oral Pharyngeal Airway Sizes
very from person to person
Adult, childrenMeasure from corner of mouth to angle of the jaw
Place flange even with mouth follow curvature to jaw
An Oral Pharyngeal Airway is only to be used on:
Patients who are unconscious
Two Basic Types of Oral Pharyngeal Airways
Berman: hard plastic with two parallel side
channels
Guedel: softer plastic with a single center
channel
Berman:
hard plastic with two parallel side
channels
Guedel
softer plastic with a single center
channel
Components of an Oral Pharyngeal Airway
Flange
Body
Tip
Air Channel
Contraindications of Oral Pharyngeal Airway
Conscious and semi-conscious patients since
they may provoke a gag reflex, vomiting or
laryngospasm
Trauma to oral cavity, mandibular or maxillary
areas of the skull
Space occupying lesion or foreign body which
obstructs the oral cavity or pharynx
Placement of Oral Pharyngeal Airway
Insert right side up. Displace tongue away from the
roof of the mouth with tongue depressor. Advance
airway over the tongue following the curve of the oral
cavity
Insert upside down. Rotate 180 degrees before
insertion, Advance airway separating tongue from
roof of mouth, turn 180 degrees (right side up) as the
tip reaches the back of tongue.
Incorrect Placement of Oral Pharyngeal Airway
The tongue may be pushed further back
toward pharynx worsening the obstruction
Incorrect size; too large or too small of an
airway may lead to airway obstruction
Correct Placement of Oral Pharyngeal Airway
Tip lies at the base of the tongue above the
epiglottis
The flange portion extends outside the teeth
Nasal Pharyngeal Airway
Comes in a variety of sizes
Also known as nasal airways or nasal trumpets
Most common use is to facilitate
nasotracheal suctioning
Limited to use in adults since the child and
infant have a very narrow nasal passage
Provides passage from external nares to the
base of the tongue
Made of soft latex or polyethylene
Adult sizes are in the 26 – 32 French range
Sizing of Airway: measure from tip of nose to
lobe of ear
What is Nasal Pharyngeal Airway Also Known As:
nasal airways or nasal trumpets
What is Nasal Pharyngeal Airway most commonly used for:
facilitaten nasotracheal suctioning
Nasal Pharyngeal Airway is Limited in Children Because
children and infants have very small/ narrow nasal passages
Nasal Pharyngeal Airway Provides passage from:
external nares to the base of the tongue
Adult sizes range w/ Nasal Pharyngeal Airway
26-32 French Range
Sizing of Nasal Pharyngeal Airway:
Measure from tip of nose to lobe of ear
When is Nasal Pharyngeal Airway used:
Used when oral placement is not possible
Nasal Pharyngeal Airway is used:
Conscious and semi-conscious patients requiring
an airway
Patients with oral cavity trauma or seizures when
oral route is not accessible
This type of airway is generally limited to adults
Contraindications of Nasal Pharyngeal Airway
Trauma to nasal region
Space occupying lesion (nasal polyps) or
presence of foreign body in nasal passage
Placement of the airway (Nasal Pharyngeal Airway)
Tilt head back slightly
Lubricate with water soluble agent
A mixture of a local anesthetic (4% Lidocaine)
and a vasoconstrictor (phenylephrine) may be
used
Slowly advance through opening of the nose with
the bevel facing toward the septum
If slight resistance is felt during insertion, gently
twist airway then advance
If significant resistance is felt during insertion,
then remove and try the other nostril
Verify correct placement by visualizing tip of
airway below the uvula
If the airway cannot be inserted in either nares
choose a smaller size tube
When properly positioned, a nasopharyngeal
airway is usually stabilized with its own flange
Two Types of Tracheal Airways
Endotracheal (Oral or Nasal)
Tracheostomy (Trachea)
Tracheal Airways
Extend Beyond Pharynx into Trachea
Endotracheal or translaryngeal tubes are
inserted:
through nose or mouth through larynx
into trachea
Tracheostomy tubes are inserted
through a
surgically created opening in the the trachea
Endotubes are semi-rigid most often made from:
polyvinylcholoride (PVC) or plastic polymers
Tracheostomy tubes initially were metal most
commonly made of silver. Brand name:
Jackson.
Some patients may still have these metal tubes
Necessary to have special adapter for connection
to manual resuscitator
EndoTube Components:
15mm external adapter / outside diameter (OD)
Curved body of the tube
Pilot filling tube
Pilot balloon
Tube cuff
Spring loaded one way valve
Angle of the bevel
Tube Components / Markings :
Murphy eye tip
Radiopaque line
Z-79 or IT designation
Manufacturer’s name
Inside diameter (ID) in mm (Size of tube)
Outside diameter (OD) in mm
Type of tube (oral/nasal)
Length of tube; markings in centimeters
Tracheostomy Tube Components:
Outer cannula
Inner cannula
Flange
Pilot balloon
Filling pilot tube
Spring-loaded oneway
valve
Cuff
Obturator
15 mm outside
diameter adapter
Cotton tape
Radiopaque indicator
Advantages of Oral Intubation:
Airway of choice in an emergency
Easier, faster, less traumatic and more comfortable to
insert
Larger tube can be tolerated
Easier suctioning
Less airflow resistance, decrease work of breathing
Easier passage of bronchoscope
Reduced risk of tube kinking
Ideally used for short term intubation
Avoidance of nasal and paranasal complication
Epistaxis, sinusitis, otitis media
Disadvantages of Nasal Intubation:
Pain and discomfort with inadequate preparation
Nasal and paranasal complications such as epistaxis,
sinusitis, otitis media
More difficult to perform
Spontaneous breathing is required for blind nasal
intubation
Smaller tube necessary / increased resistance /
increased work of breathing
Greater suctioning difficulty
Possible pressure necrosis in area of the alae nasi
The nasal passage limits the tube size; a tube at least
0.5 mm ID smaller than the oral route is required
Specialized Endotracheal Tube:
Double Lumen ET Tube
Double Lumen ET Tube:
The larger cuff seals the tracheal lumen and
allows gas to flow into only one bronchus
The smaller cuff seals the opposite bronchial
lumen and allows gas to flow into the other lung
Double Lumen ET Tube May be indicated for:
unilateral lung disease
where independent lung ventilation (ILV) is
needed
Double Lumen ET Tube parts:
Two proximal ventilator connectors (15 mm
adapter)
Two inner lumens for gas flow
Two cuffs and two filling (pilot) tubes
Two distal opening
Specialized ET Tubes / Sub Glottic Suction:
A special tube with an attached sub-glottic
suction port has been designed
This port allows for suctioning secretions
above the cuff
This tube has a separate channel that
attaches to a wall suction source
The suction source provides a continuous
– 20 to – 30 cmH2O of negative pressure
Suction source for Specialized ET Tubes / Sub Glottic Suction:
provides a continuous
– 20 to – 30 cmH2O of negative pressure
Specialized ET Tubes / Sub Glottic Suction important points:
The aspirated material is collected and
emptied on a regular basis
Every 4 hours air should be injected into
the port to ensure the tube is not clogged
Use of the tube has been reported to
decrease the incidence of ventilatorassociated
pneumonia (VAP)
Advantages of Tracheotomy:
Airway of choice for long term use
Best tolerated of all airways
Avoidance of laryngeal and upper airway complications
Greater comfort
Aids feeding, oral care and speech
Easiest airway to suction
Aesthetically less of a problem, psychological benefit
Easier passage of bronchoscope
Easier reinsertion
Eliminates risk of mainstem intubation
The Tracheotomy helps:
Facilitates weaning from ventilator, decreased
work of breathing
Better anchoring; reduced risk of decannulation
With a mature stoma reinsertion is easy
Easier to suction left bronchus with curved tip
catheter
Improved mobility (transfer out of ICU to ward or
extended care facility Facilitate weaning from ventilator, decreased
work of breathing
During a mature Stoma reinsertion is:
easy
What is easier to suction the left bronchus:
curved tip catheter
Disadvantages of Tracheostomy
Greater expense; usually requires the use of
operating room and general anesthesia
Permanent scar
More severe complications
Increased frequency of aspiration
Greater mortality rate
Delayed decannulation
Greater bacterial colonization rate
Persistent open stoma after decannulation, reducing
cough efficiency
Immediate Complications with Tracheostomy:
Bleeding
Pneumothorax
Air embolism
Subcutaneous and mediastinal
emphysema
Late Complications with Tracheostomy
Infection of surgical wound
Innominate artery erosion
Passage into subcutaneous tissues
Hemorrhage may occur
Tracheal stenosis may occur
Fenestrated Tracheostomy Tube:
-Useful in assessing patients ability to be
extubated or weaned from trach tube
-Allows patient to talk when the tube is occluded
and the cuff deflated
-Fenestration is located in outer cannula only
-The inner cannula is similar in design to the
inner cannula of a normal tracheostomy tube
Ability to extubate or wean from trach tube:
The fenestration (hole) allows patient to breath
through their upper airway and not through trach tube
opening
Fenestration hole is located:
In outer cannula only
Proper Use of Fenestrated Tracheostomy Tube:
-Removal of inner cannula
-Deflation of cuff
-Corking or plugging of outer cannula
-Patient now breathes through fenestration
and upper airway
Communi-Trach or Pitt Speaking Tube:
-Designed to allow patient to talk when cuff is inflated
-Functions by directing secondary gas flow through ports above the cuff, allowing gas to move past the vocal
cords while maintaining ventilation via the airway
-Internal diameter of airway smaller than standard tube of same size
-Small tube with an opening above the cuff is connected to a 4 -6 L/min source of air or oxygen
-Y connector for intermittent control
-When the open port is occluded then gas is directed
through the patient’s larynx and the upper airway for
vocalization
How does the Communi-Trach or Pitt Speaking Tube Work?
Functions by directing secondary gas flow through ports
above the cuff, allowing gas to move past the vocal
cords while maintaining ventilation via the airway
Communi-Trach or Pitt Speaking Tube: When the open port is occluded then gas is directed through:
The pts. larynx and upper airway for vocalization
Communi-Trach or Pitt Speaking Tube is a small tube w/ opening above the cuff and is connected to:
4-6 L/MIN source of air or oxygen
Communi-Trach or Pitt Speaking Tube allows:
Patient to talk/ “talking trach tube”