Egan’s Chapter 33 Airway Management

Why suction?
To clear secretions due to thickness which can lead to increased airway resistance, WOB, hypercapnia, atelectasis, and infection.
How to select a catheter?
Choose a catheter ~22″ long to reach mainstream bronchi. multiply the tubes inner diameter by 2 and then use the next smallest size catheter.
What is the suction pressure for adults, children, and infants.
-120 to -150mmHg for adult.
-100 to -120 for children.
-80 to -100 for infants
What is suctioning and how is it done?
Application of negative pressure to airways through collecting tubing and is done through the trachea and bronchi with an endotracheal or tracheostomy tube.
What are reasons to use close suctioning?
•PEEP>10 • MAP>20 • FiO2 is >60% •I-time >1.5
How to determine if the patient needs suctioning?
If abnormal breath sounds are heard, increased pressure on the ventilator, lowered SpO2, ABG #s might get worse, and secretions can be seen in the ETT tube
Steps for Endotracheal Suctioning
1: Assess pt for indications.
2: Assemble and check equipment
3. Hyperoxygenate pt.
4. Insert Catheter
5. Apply suction/clear catheter which should last <15 seconds 6. Reoxygenate pt. 7. Monitor patient and assess outcomes
Complications to suctioning
Hypotension, hypertension, cough, bronchospasm, and trauma
How to minimize complications and adverse responses?
Preoxygenation helps to minimize incidence of hypoxemia, avoiding atelectasis by using negative pressure, use sterol technique and manually ventilate pt to reduce bacterial colonization and use normal saline only if necessary to mobilize secretions
What is nasotracheal suctioning?
Indicated for patients who retain secretions but don’t have an artificial airway.
How do you perform nasotracheal suctioning?
Placing the catheter in larynx and trachea is facilitated by having pt assume the sniffing position.
What is sputum sampling?
To collect and identify organisms affecting airway. Pts with cough can expectorate into sterile cup. 2-10ml of snot should be collected
Artificial airways placed through the mouth and nose and into the trachea are called what?
Endotracheal tubes
What is orotracheal intubation?
When the tube is passed through the mouth on its way to the trachea.
What is nasotracheal intubation?
When the endotracheal tube is passed through the nose first
What does the nasal pharyngeal airway do?
Often helps facilitate nasotracheal suctioning and minimizes damage to nasal mucosa caused by the catheter
What does the oral pharyngeal airway do?
Maintains airway by blocking the tongue.
Bedside assessment methods to confirm proper placement of endotracheal tube after intubation?
Auscultation of the chest/abdomen, observation of the chest, tube length cm to teeth, esophageal detection device, light wand, capnometry, colorimetry, fiberoptic laryngoscopy or bronchoscopy, and videolaryngoscopy
What are primary indications for an artificial tracheal airway?
To facilitate secretion removal, relieve airway obstruction, and protect against aspiration.
What trauma is associated with tracheal tubes?
Laryngeal and tracheal lesions.
What are common injuries to the larynx?
•Glottic edema
• vocal cord inflammation
• laryngeal/vocal cord ulcerations
• vocal cord polyps or granululomas
What are less common injuries to the larynx?
Vocal cord paralysis and stenosis(narrowing of airway)
Tracheal lesions include?
Granulomas, tracheomalacia, tracheal stenosis, tracheoesophageal and tracheoinominate artery fistula.
How are granulomas caused?
By the tracheostomy moving
What is tracheomalacia?
Softening of the airway
What is tracheoesophageal fistula?
A hole between the trach and esophagus. Life threatening very rare.
What is tracheoinominate artery fistula?
A hole between trach and artery. The trach will pulsate and you can look at it with PFT’s
How to prevent trauma caused by tracheal tubes?
• Avoid tube movement
• sedate self extubated pt
• use nasotracheal tubes for stability
• selection of correct size tubing help
• maintain cuff pressures of 20-25 mmHg to reduce tracheal wall injury
Role of Respiratory Therapist for airway maintenance
•Secure tube and placement
• provide pt w/communication
• use proper humidification
• aid in secretion clearance
• provide good cuff care
• troubleshoot any airway-related problems
Primarily problem for patients receiving mechanical ventilation?
Cuff leaks which will reduce delivery of Vt
Partial displacement of airway out of trachea can be detected by?
Decreased breath sounds, airflow through tube, and decreased ability to pass catheter past the end of the tube
Extubation
Process of removing oral or nasal endotracheal airway
Decannulation
Process of removing tracheostomy tube
What to assess patients readiness for extubation or decannulation?
• Original problem is no longer present
• Quantity and thickness of secretions
• upper airway patency
• presence of intact gag reflex
• Ability to clear airway secretions
During extubation, the ET tube should be withdrawn at what point of the breathing cycle?
Peak inspiration
Weaning process of trach tubes
Fenestrated tubes-progressively smaller tubes-tracheostomy buttons
What is a LMA?
Laryngeal Mask Airway that consists of a short tube &small mask that is inserted deep into the oropharnyx.
LMA sizes
Size 5 for adults and 1 for infants
What is a Combitube?
A double lumen airway that is inserted blindly through the oropharnyx & into the trachea or esophagus. It has 2 external openings, 2 15-mm adapters, 2 lumens, and 2 cuffs. One cuff seals the oropharnyx and 2nd seals trachea or esophagus
What is Bronchoscopy?
Insertion of visualization instrument endoscope into bronchi
What is the purpose of bronchoscopy?
To inspect airways, collect samples, remove foreign objects, and place devices into airway.
What are 2 different bronchoscopic techniques?
Rigid tube and flexible Bronchoscopy
Flexible fiberoptic Bronchoscopy
Allows access to small airways. Typical scope had 3 channels.
What is meds are given prior to a Bronchoscopy?
Sedatives to reduce anxiety, anticholinergic agent to dry patients airway, narcotic analgesics to reduce pain.