Airway Care
I Use of Artificial Airways (Modified from AARC Clinical Practice Guideline: Management of Airway Emergencies, 1995)
1. Conditions requiring management of the airway generally are impending or actual
2. Specific conditions include but are not limited to
a. Airway emergency before endotracheal intubation
b. Obstruction of the artificial airway
f. Cardiopulmonary arrest and unstable dysrhythmia
h. Severe allergic reactions with cardiopulmonary compromise
j. Sedative or narcotic drug effect
k. Foreign body airway obstruction
3. Conditions requiring emergency tracheal intubation include, but are not limited to
b. Traumatic upper airway obstruction (partial or complete)
c. Accidental extubation of the patient unable to maintain adequate spontaneous ventilation
d. Obstructive angioedema (edema involving the deeper layers of the skin, subcutaneous tissue, and mucosa)
e. Massive uncontrolled upper airway bleeding
f. Coma with potential for increased intracranial pressure
g. Infection-related upper airway obstruction (partial or complete)
h. Epiglottitis in children or adults
4. Neonatal or pediatric specific
b. Severe adenotonsillar hypertrophy
f. Obstruction from abnormal laryngeal closure caused by arytenoid masses
h. Congenital diaphragmatic hernia
i. Presence of thick and/or particulate meconium in amniotic fluid
5. Conditions in which endotracheal intubation may not be possible and in which alternative techniques may be used include, but are not limited to
1. Failure to establish a patent airway
2. Failure to intubate the trachea
3. Failure to recognize esophageal intubation
4. Unrecognized bronchial intubation
5. Upper airway trauma, laryngeal and esophageal damage
12. Endotracheal tube (ETT) problems (e.g., cuff perforation, cuff herniation, pilot tube-valve incompetence, tube kinking during biting, tube occlusion, and inadvertent extubation)
17. Hypotension and bradycardia caused by vagal stimulation
18. Hypertension and tachycardia
22. Specific problems resulting from nasal intubation (e.g., nasal damage including epistaxis, tube kinking in the pharynx, sinusitis, and otitis media)
23. Tracheal damage (e.g., tracheoesophageal fistula, tracheal innominate fistula, tracheal stenosis, and tracheomalacia)
24. Laryngeal damage with consequent laryngeal stenosis, laryngeal ulcer, granuloma, polyps, or synechiae
25. Specific problems resulting from surgical cricothyrotomy or tracheostomy (e.g., stomal stenosis, innominate erosion)
26. Specific problems resulting from needle cricothyrotomy (e.g., bleeding at the insertion site with hematoma formation, subcutaneous and mediastinal emphysema, and esophageal perforation)
II General Classification of Artificial Airways
A Oropharyngeal airway (Figure 38-1)
1. Used to relieve upper airway obstruction by maintaining the base of the tongue off the posterior wall of the oral pharynx
2. Used to prevent inadvertent laceration of the tongue in the incoherent or seizuring patient
3. May be used as a bite block with oral ETTs
4. To insert the oropharyngeal airway, turn the airway 180 degrees from its normal position, insert it into the patient’s mouth, and when it is at the back of the tongue rotate it 180 degrees to its normal position so that the tip is behind the tongue and facing the larynx. A tongue depressor may be used to facilitate insertion of the airway.
5. Poorly tolerated in alert patient because of stimulation of gag reflex
1. It is used to relieve upper airway obstruction caused by the tongue or soft palate falling against the posterior wall of the pharynx.
2. To insert the nasal airway lubricate the outside of the nasal airway with water-soluble lubricant, insert it into the nares, and advance gently until the tip is behind the tongue just above the epiglottis.
3. Suctioning via this airway is less traumatic than nasal suctioning.
4. It is better tolerated than an oropharyngeal airway.
5. It should be alternated every 24 hours between right and left nares to minimize complications.
6. Sinusitis, otitis media, and nasal necrosis are possible complications of its use.
1. The LMA may be used to manage the airway during anesthesia or as an emergency airway when the airway is difficult to intubate.
2. The LMA is a tube with a small, inflatable mask at the distal end.
3. The LMA is inserted deep into the oropharynx with the tip of the mask just above the esophageal sphincter. After insertion the cuff of the mask is inflated. The opening in the mask should face the laryngeal opening when inserted properly (Figure 38-2).
4. Available in sizes 3, 4, and 5 for adults
1. Advantages when compared with nasotracheal tubes
a. It is easy to insert and is the airway of choice in an emergency.
b. A larger-diameter tube can be inserted orally than by the nasal route.
c. Sinusitis and otitis media are not problems.
d. The angle of curvature is less acute than with nasal tubes; it is easier to suction.
e. Generally there is less resistance to gas flow, and less work of breathing is imposed.
2. Problems associated with orotracheal tubes
a. They are poorly tolerated in conscious and semiconscious patients.
b. They are difficult to stabilize and may be easily dislodged.
c. Inadvertent extubation is common.
d. A bite block may be necessary to prevent biting of tube.
e. Vagal stimulation may cause bradycardia and hypotension.
g. They require a laryngoscopy during insertion.
h. Patients are unable to mouth words.
j. There is a potential for laryngeal pathology.
k. The tip of the tube moves when the patient’s head position changes.
1. Advantages over orotracheal tube for long-term intubation
b. May be better tolerated by some patients
c. May be inserted blindly (laryngoscopy is unnecessary in most cases)
d. Oral hygiene is easily accomplished.
e. The patient is able to mouth words.
f. Attachment of equipment is easier and safer; there is less torque on the trachea.
2. Problems associated with nasotracheal tubes
a. The tip of the tube moves when the patient’s head position changes.
b. Pressure necrosis in area of the alae nasi may occur.
c. Sinus drainage may be obstructed, and acute sinusitis may result.
d. Eustachian tube drainage may be obstructed, and otitis media may result.
e. The incidence of vocal cord damage after 3 to 7 days (also seen with oral ETTs) increases.
f. Vagal stimulation is possible, but it occurs less frequently than with the oral ETT.
g. Skilled personnel are necessary for placement.
h. The nasal passage limits the tube size; a tube at least 0.5 mm ID smaller than the oral route is required.
i. 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.
1. The size, length, and shape of a tracheostomy tube vary depending on the manufacturer and style of the tube.
2. Tracheostomy tube shapes are curved, angled, or extra long (Figure 38-3).
3. Careful consideration of the anatomy of each patient when choosing the brand and size of a tracheostomy tube may aid in preventing future complications.
4. Most tracheostomy tubes are sized according to ID in millimeters.
a. There are no complications with the upper airway or glottis.
d. The tracheostomy tube is the best tolerated of all airways.
e. The patient is able to mouth words, and talking or fenestrated tubes are available.
f. A speaking valve may be applied to either a fenestrated or a standard tracheostomy tube with the cuff deflated and the inner cannula removed (if present) so the patient can speak.
