Airway Management

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12 Airway Management

Note 1: This book is written to cover every item listed as testable on the Entry Level Examination (ELE), Written Registry Examination (WRE), and Clinical Simulation Examination (CSE).

The listed code for each item is taken from the National Board for Respiratory Care’s (NBRC) Summary Content Outline for CRT (Certified Respiratory Therapist) and Written RRT (Registered Respiratory Therapist) Examinations (http://evolve.elsevier.com/Sills/resptherapist/). For example, if an item is testable on both the ELE and the WRE, it will simply be shown as: (Code: …). If an item is only testable on the ELE, it will be shown as: (ELE code: …). If an item is only testable on the WRE, it will be shown as: (WRE code: …).

Following each item’s code will be the difficulty level of the questions on that item on the ELE and WRE. (See the Introduction for a full explanation of the three question difficulty levels.) Recall [R] level questions typically expect the exam taker to recall factual information. Application [Ap] level questions are harder because the exam taker may have to apply factual information to a clinical situation. Analysis [An] level questions are the most challenging because the exam taker may have to use critical thinking to evaluate patient data to make a clinical decision.

Note 2: A review of the most recent Entry Level Examinations (ELE) has shown an average of 9 questions (out of 140), or 7% of the exam, that cover airway management. A review of the most recent Written Registry Examinations (WRE) has shown an average of 6 questions (out of 100), or 6% of the exam, that cover airway management. The Clinical Simulation Examination is comprehensive and may include everything that should be known by an advanced level respiratory therapist.

MODULE A

General airway management topics

1. Assess the patient’s airway by inspection

a. Inspect the patient’s face to identify the presence of macroglossia (Code: IB1b) [Difficulty: ELE: R, Ap; WRE: An]

Macroglossia is an excessively large tongue that is often seen to protrude out of the mouth (Figure 12-1). It can partially obstruct the neonate’s upper airway and may be associated with inspiratory stridor. Macroglossia is associated with Down syndrome, Beckwith-Wiedemann syndrome, and several metabolic disorders. Immediate treatment may require (1) manually moving the mandible forward to pull the large tongue out of the airway, (2) inserting an oropharyngeal airway or nasopharyngeal airway, (3) placing the infant in the prone position. If the infant has life-threatening airway obstruction that is not corrected by these procedures, an endotracheal tube or tracheostomy tube must be inserted. Long-term management may require a tracheostomy or corrective facial surgery.

Figure 12-1 Close-up photograph of an infant with macroglossia. Note the larger than normal tongue that can obstruct the upper airway.

(From Zitelli and Davis, 1992; courtesy Dr. Christine L. Williams, New York Medical College.)

b. Assess for limits in neck range of motion (Code: IB1b) [Difficulty: ELE: R, Ap; WRE: An]

It is standard practice for emergency medical personnel to place a neck brace on a trauma victim (for example, an automobile crash) to prevent a cervical spine injury. In some cases, the patient is strapped on a body board in addition to wearing a neck brace. Usually the neck brace is not removed until after neck radiographs are taken and a physical exam is performed to disprove a cervical spine injury.

Other people with limited neck range of motion include a patient who has recently had cervical spine surgery and is being weaned from a neck brace or a patient with kyphoscoliosis who is wearing a supportive brace. If a patient wearing a neck brace has an upper airway obstruction, it may be possible to insert an oropharyngeal airway or nasopharyngeal airway to push the tongue forward to ease breathing. If these devices are not effective, and the neck cannot be hyperextended to open the airway, an emergency airway is needed. It is possible that a laryngeal mask airway (LMA) or Combitube could be inserted by an emergency medical technician, paramedic, or respiratory therapist. If these devices are not able to provide a secure airway, a physician will need to perform nasotracheal intubation or a tracheostomy (see Chapter 18).

2. Properly position the patient

a. Recommend a change in the patient’s position (Code: IIIG2a) [Difficulty: ELE: R, Ap; WRE: An]

A patient who is hypoxic may have oxygenation improved by a change in position that better matches ventilation and perfusion. A patient with unilateral lung disease is usually placed flat in bed and rolled onto the side of the unaffected lung. It has been found that some patients with acute respiratory distress syndrome (ARDS) have improved oxygenation when placed in the prone position. The Trendelenburg position should not be used in a patient with head trauma and increased intracranial pressure. Lowering the patient’s head could increase the pressure on the brain.

b. Properly position the patient to maintain a patent airway (Code: IIIB1) [Difficulty: ELE: R, Ap; WRE: An]

Positioning of the head to open the airway is discussed in Chapter 11. Briefly, use the head tilt-chin lift maneuver to hyperextend the neck of an adult, and slightly extend the neck of a child to open the airway. You can place a small pad behind the neck and head to put the patient in the “sniff position.” Always keep the head in line with the body. If the patient has a known or suspected cervical spine injury, the neck cannot be hyperextended. Instead, open the airway with the jaw-thrust maneuver. Keep the head in line with the body.

The patient may be supine during the airway-opening procedures just mentioned. Frequently, however, the patient is positioned with the head and body elevated. An unconscious patient is less likely to vomit and aspirate in either Fowler’s or semi-Fowler’s position. The combination of either of these body positions with the head and neck hyperextended into the sniff position will probably keep the airway open and minimize the risk of aspiration of vomitus. Turning the patient’s head to one side may also reduce the risk of aspiration. Placing the patient into either Fowler’s or semi-Fowler’s position will also minimize the patient’s work of breathing (WOB) and help to reduce hypoxemia.

3. Recommend the insertion of an artificial airway or a change in the type of artificial airway (Code: IIIG1f) [Difficulty: ELE: R, Ap; WRE: An]

An artificial airway is indicated in any patient who cannot protect his or her airway. The patient may be at risk of upper airway obstruction from the tongue falling back, may have facial trauma or be undergoing surgery, may be at risk of vomiting and aspirating, or may need mechanical ventilation for assisted breathing. A number of possible airways are available; select the best one based on the patient’s needs. These airways are presented in the remainder of this chapter.

Exam Hint 12-1 (ELE, WRE)

Identify that the patient has an airway problem. Know the uses, advantages, and disadvantages of the various airway devices. Be prepared to make a recommendation for which device to use or when to change to a different airway device, as necessary.

4. Humidify an artificial airway

a. Maintain adequate humidification to the patient’s airway (ELE code: IIIB8) [Difficulty: ELE: R, Ap, An]

b. Independently change the type of humidification equipment (ELE code: IIIF2g1) [Difficulty: ELE: R, Ap, An]

Patients with an oropharyngeal or nasopharyngeal airway may also be given supplemental humidity by a simple aerosol mask to help prevent drying of secretions. If a patient is given more than 4 L/min of oxygen, supple-mental humidity should be provided. Patients with an endotracheal or tracheostomy tube in place should ideally be provided 100% relative humidity at body temperature. If not, secretions in the airway may dry and result in mucous plugs. Depending on the patient situation, a heat-moisture exchanger (HME) or heated humidifier may be used. However, it may be necessary to change from a heat-moisture exchanger to a cascade-type or wick-type humidifier if the patient has thick secretions that are difficult to remove by coughing or suctioning. Humidification is discussed with the various oxygen delivery systems.

See Chapter 8 for a complete discussion of humidity and aerosol therapy and administrative devices.

MODULE B

Oropharyngeal airways

1. Recommend the insertion of an artificial airway or a change in the type of artificial airway (Code: IIIG1f) [Difficulty: ELE: R, Ap; WRE: An]

An oropharyngeal airway is typically used in one of the three following situations: (1) in an unconscious patient at risk of obstructing the airway with his or her tongue; (2) in an unconscious seizure patient who may bite his or her tongue during another seizure; (3) in an orally intubated patient to prevent the endotracheal tube from being bitten. An oropharyngeal airway should not be used in a conscious patient because it may cause gagging.

2. Manipulate oropharyngeal airways by order or protocol (ELE code: IIA7a) [Difficulty: ELE: R, Ap, An]

a. Get the necessary equipment

The oropharyngeal airway (or bite block) is made of plastic that is hard enough to withstand any patient’s biting force. A properly sized and placed oropharyngeal airway lifts the tongue forward from the posterior portion of the oropharynx to keep a patent airway and make suctioning oral secretions easier. An oropharyngeal airway is poorly tolerated in a conscious patient and can cause gagging and even vomiting. Oropharyngeal airways are available in a variety of sizes that fit infants or adults. The proper size is found by holding the airway against the patient’s face with the flange against the lips. The end of the airway should reach the angle of the jaw (Figure 12-2). Too large an airway can block the oropharynx by extending past the tongue. An airway that is too small can push the tongue back into the oropharynx rather than pulling the tongue forward, as intended. Figure 12-3 shows a properly placed and sized oropharyngeal airway.

Figure 12-2 Procedure for measuring the proper size of the oropharyngeal airway.

(From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.)

Figure 12-3 Three different possible procedures for inserting an oropharyngeal airway. A, Airway is placed with the tip pointing toward the palate. Then it is rotated 180 degrees to support the tongue. B, A tongue depressor is used to move the tongue toward the jaw. The airway is then slid behind the tongue to support it, and the tongue depressor is removed. C, A cheek is gently pulled aside to make room to place the airway behind the tongue.

(From Shilling A, Durbin CG: Airway management devices. In Cairo JM, Pilbeam SP, editors: Mosby’s respiratory care equipment, ed 8, St Louis, 2010, Mosby, Inc.)

A number of manufacturers make oropharyngeal airways, which fall into two basic types: hollow center and I-beam (Figure 12-4).

Figure 12-4 Close-ups of hollow and I-beam types of oropharyngeal airways.

d. Insert the correct oropharyngeal airway (ELE Code: IIIB2) [Difficulty: ELE: R, Ap, An]

There are three widely used methods to insert an oropharyngeal airway.

1. First method

a. Open the patient’s mouth with the cross-finger technique. Insert the airway upside down into the patient’s mouth until it reaches the palate. Some authors recommend inserting it past the uvula.

b. Twist the airway 180 degrees, and insert it the rest of the way until the tongue is supported by the curved body.

c. The flange should rest at the lips (Figure 12-3, A).

2. Second method

a. Insert a tongue blade into the mouth and push the tongue toward the jaw.

b. The curved body of the airway is directed into the mouth to support the tongue.

c. The flange should rest at the lips (Figure 12-3, B).

3. Third method

a. Open the patient’s mouth with the cross-finger technique. Insert the airway into the mouth with the curved body rotated toward a cheek.

b. Twist the airway 90 degrees, and insert it the rest of the way so that the tongue is supported by the curved body.

c. The flange should rest at the lips (Figure 12-3, C).

MODULE C

Nasopharyngeal airways

1. Recommend the insertion of an artificial airway or a change in the type of artificial airway (Code: IIIG1f) [Difficulty: ELE: R, Ap; WRE: An]

A nasopharyngeal airway has three indications. First, it is used to keep the tongue from blocking the airway when an oropharyngeal airway cannot be used. This would include conscious supine patients or patients with oral trauma or jaw surgery. Second, it is also used as a guide to pass a catheter for tracheal suctioning or to pass a flexible fiberoptic bronchoscope. The nasopharyngeal airway protects the patient’s mucous membranes from the trauma of repeatedly passed catheters. Third, a nasopharyngeal airway is used in a patient currently seizuring with a tightly closed jaw. In this case, an oropharyngeal airway cannot be used. The nasopharyngeal airway can be passed into the patient’s oropharynx to push the tongue forward and maintain an airway. The nasopharyngeal airway is probably not as effective in keeping the tongue forward as the oropharyngeal airway. However, it is better tolerated in a semiconscious or alert patient.

2. Manipulate nasopharyngeal airways by order or protocol (ELE code: IIA7a) [Difficulty: ELE: R, Ap, An]

a. Get the necessary equipment

Nasopharyngeal airways (also known as nasal airways, nasal trumpets, or nasal stents) are made of a relatively soft and pliable plastic or rubber. This decreases the chances of damaging the delicate mucous membranes of the nasal turbinate opening as it passes through the nasopharynx.

Several manufacturers make the two basic types of nasopharyngeal airways—the blunt tip and the beveled tip. The beveled-tip types are available with right-sided and left-sided cut bevels. If possible, open the airway with the bevel cut opening toward the patient’s oropharynx (toward the nasal septum). For example, if the airway is going to be inserted into the left naris, the bevel should be cut on the right side of the tube so that it is open to the patient’s oropharynx. If you were inserting the tube into the right nostril, you would want the bevel cut on the left side of the tube.

See Figure 12-5 for a close-up of a nasopharyngeal airway. All nasopharyngeal airways have a flange that fits close to the patient’s nostril. This prevents the entire tube from being pushed into the patient. All nasopharyngeal airways have a cannula with a channel for breathing or suctioning. Nasopharyngeal airways are available in a variety of sizes for adults. They can be properly sized by measuring from the tip of the nose to the tragus of the ear and adding 2 to 3 cm (Figure 12-6).

Figure 12-5 Typical nasopharyngeal airway.

Figure 12-6 Procedure for measuring the proper size of the nasopharyngeal airway.

(From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.)

b. Put the equipment together and make sure that it works properly

All nasopharyngeal airways are made up of a single piece. There is nothing to assemble.

c. Troubleshoot any problems with the equipment

Make sure that the tube is not plugged by dried secretions, blood, or a foreign body. If plugged, the patient cannot breathe through it, and a suction catheter cannot be passed through it. Remove a plugged nasopharyngeal airway.

d. Insert the correct nasopharyngeal airway (ELE Code: IIIB2) [Difficulty: ELE: R, Ap, An]

The following steps are taken to insert a nasopharyngeal airway:

1. Select the most patent nostril. Check the patient’s chart for a history of a broken nose, deviated septum, or current head cold. Interview the conscious patient to determine whether one nostril is more open than the other. Place your finger in front of the patient’s nostrils to feel which one has greater airflow. Avoid forcing the airway into a nostril and nasal passage that may be damaged by the procedure.

2. Lubricate the properly sized airway with a sterile, water-soluble lubricant such as K-Y jelly. Place the lubricant on a sterile, 4 × 4 inch gauze pad, and then smear it over the length of the airway.

3. Tell the patient what you are going to do.

4. Gently place the airway into the nostril. It should be directed straight back parallel to the hard palate. Stop if you feel any resistance. Try a different angle if resistance is felt. Do not force the airway. Try the other nostril if necessary.

5. Secure the airway by sticking a safety pin through the flange and taping the pin to the bridge of the patient’s nose or cheek (see Figure 12-7). This helps prevent the airway from being accidentally dislodged or inserted further.

6. Rotate the airway to the other nostril, if possible, on a regular basis. This helps prevent ulceration of the mucous membrane. Some authors recommend rotation at least every 48 hours, whereas others recommend rotation at much shorter time intervals.

Figure 12-7 Proper position of the nasopharyngeal airway behind the tongue can be determined by looking into the mouth. The tube is also secured by placing a safety pin through the flange and taping it to the cheek.

e. Assess the nasopharyngeal tube placement (ELE code: IIIB5) [Difficulty: ELE: R, Ap, An]

Check the placement by looking into the patient’s mouth with a flashlight and tongue depressor. A properly placed nasopharyngeal airway can be seen in the oropharynx and extends behind the tongue (Figures 12-7 and 12-8). The placement should be checked each time a tube is replaced or moved from one nostril to the other. If a nasopharyngeal tube is inserted too deeply, it can block the glottis opening into the trachea.

Figure 12-8 Cross section of the head showing the proper position of the nasopharyngeal airway.

(From Ellis PD, Billings DM: Cardiopulmonary resuscitation: procedures for basic and advanced life support, St Louis, 1980, Mosby.)

MODULE D

Laryngeal mask airways

1. Recommend the insertion of an artificial airway or a change in the type of artificial airway (Code: IIIG1f) [Difficulty: ELE: R, Ap; WRE: An]

A laryngeal mask airway (LMA) is composed of a modified endotracheal tube with a standard 15-mm-outer diameter (OD) adapter (for attaching a resuscitation bag or ventilator circuit) at the proximal end and a silicone laryngeal mask at the distal end. The mask is inflated by attaching a syringe to the one-way valve and pilot balloon on an inflation tube, in the same manner as an endotracheal tube cuff (Figure 12-9). When the mask is inflated it surrounds and seals the larynx. LMAs were first used in the operating room by anesthesiologists. Their use has been expanded; today, emergency medical personnel and respiratory therapists use LMAs as an alternative to endotracheal tubes or Combitubes in patients with a difficult airway or during a CPR effort. Experience has shown that an LMA can be easily and quickly inserted without any additional equipment. Patients with asthma or irritable airways will have less coughing or bronchospasm than if an endotracheal tube were inserted. It has been shown that ventilating a patient with a resuscitation bag to an LMA is as effective or better than bag-mask ventilation. See Box 12-1 for indications, contraindications, and limits to an LMA.

Figure 12-9 Laryngeal mask airway (LMA). It features an inflatable mask that creates a seal around the patient’s larynx. A syringe is attached to the one-way valve to deflate and inflate the mask. The proximal end of the tube can be connected to a resuscitation bag, anesthesia machine, or mechanical ventilator.

(From Intavent International SA, Henley-on-Thames, England.)

BOX 12-1 Indications, Contraindications, and Limits of a Laryngeal Mask Airway

INDICATIONS

Patient has undergone CPR effort or has a difficult airway and cannot have an endotracheal tube or Combitube.

Patient needs a patent airway and cannot have his/her neck hyperextended for endotracheal intubation.

A channel is needed through which to pass an endotracheal tube into the trachea.

CONTRAINDICATIONS

Patient is conscious or resists placement of the LMA.

Patient is known to have or might have food in the stomach.

Patient will require high pressure to ventilate (because of low lung compliance and/or high airway resistance).

Patient has severe gastroesophageal reflux disease (GERD).

LIMITS

Aspiration is possible if the patient’s stomach is not empty or has GERD.

There is tidal volume leakage out of the mouth or into stomach if the ventilating pressure is >20 cm H₂O.

Remember that an LMA does not provide as secure an airway as an endotracheal tube. There are two limitations to using an LMA. First, the LMA does not absolutely protect against aspiration. Second, tidal volume gas can leak if mechanical ventilation pressures are greater than 20 cm H₂O. This can lead to a smaller than desired tidal volume and/or gas being forced into the stomach. Excessive air in the stomach can cause vomiting. If either of these possibilities is of paramount clinical concern, the patient should have an endotracheal tube inserted rather than an LMA.

2. Manipulate laryngeal mask airways by order or protocol (Code: IIA7f) [Difficulty: ELE: R, Ap; WRE: An]

a. Get the necessary equipment

The LMA is available in eight sizes for insertion into patients ranging in weight from a small child to a large adult. Selected sizes include mask size 1 for a neonate or child up to 5 kg (up to 11 pounds); mask size 2½ for children weighing between 20 and 30 kg (44 and 66 pounds); mask size 4 for adults weighing 50 to 70 kg (110 to 154 pounds); and mask size 5 for large adults weighing 70 to 100 kg (154 to 220 pounds). Other mask sizes are available for patients within these weight ranges or for very large adults.

Several manufacturers make standard LMAs like that shown in Figure 12-9. In addition, there are two commonly seen modifications. The first is an LMA that facilitates tracheal intubation by easily allowing an endotracheal tube to slide through its lumen. The second is an LMA that includes a port for gastric suction to vent any air in the stomach. Adjunct supplies include a watersoluble lubricant for the laryngeal mask, syringe to inflate the mask, and protective gear for the practitioner, such as a face mask and gloves.

b. Put the equipment together and make sure that it works properly

Make sure that the proximal end has a 15-mm-OD adapter attached. Check the laryngeal mask to be sure it is functioning. Inflate the cuff with a syringe, disconnect the syringe to make sure the one-way valve works, reattach the syringe, and deflate the mask.

c. Troubleshoot any problems with the equipment

Do not use an LMA that does not have a proximal adapter or if the mask will not inflate properly.

3. Assess the placement of the LMA (ELE code: IIIB5) [Difficulty: ELE: R, Ap, An]

While the NBRC does not list the insertion of an LMA as a testable item, proper placement is needed to ensure that it can be correctly maintained in the airway. Figure 12-10 shows the procedure for inserting an LMA and how the inflated mask covers the laryngeal inlet (glottis opening into the trachea). When the properly sized LMA is being placed, it is gently advanced until resistance is felt. (If the LMA is too small, no resistance will be felt since it will slide into the esophagus.) The distal tip of the mask will stop at the upper esophageal sphincter. The cuff is then inflated to cover the tracheal opening and seal off the esophagus. (Later, the cuff pressure can be measured; it should not exceed 60 cm H₂O.) Manually ventilate the patient’s lungs with a resuscitation bag. The following steps should be taken to ensure that the LMA is properly placed to cover the opening to the trachea: (1) when the LMA mask is inflated, the tube will move out of the mouth about 1 to 2 cm; (2) auscultate for equal, bilateral breath sounds; (3) auscultate for the absence of sounds over the stomach; (4) an end-tidal carbon dioxide monitor should show exhaled CO₂.

Figure 12-10 Steps to insert an LMA to make sure that it seals the patient’s larynx. A, The lubricated mask is deflated and manually inserted into the mouth. B, The mask should easily slide behind the tongue into the oral pharynx. C, The mask is gently advanced until resistance is felt as the mask lodges at the opening of the larynx. D, The syringe is attached to the one-way valve and air is pumped into the mask to seal the larynx. Attach a resuscitation bag to the proximal end of the tube and inflate the patient’s lungs. Listen for bilateral breath sounds. See the inset for the anatomic structures related to the larynx, glottis, and esophagus.

(Redrawn from Gensia Automedics, San Diego, Calif. In Cairo JM, Pilbeam SP, editors: Mosby’s respiratory care equipment, ed 8, St Louis, 2010, Mosby, Inc.)

4. Maintain the proper position and appropriate cuff inflation of a laryngeal mask airway (Code: IIIB4a) [Difficulty: ELE: R, Ap; WRE: An]

Once the LMA is properly located, it needs to be stabilized. This is usually done by taping the tube to the patient’s upper lip or using a manufactured tube-holding device. Observe that the black line that runs the length of the tube, and marks its center, is not twisted. If the tube is twisted, the tracheal mask may not cover the glottis. This would cause a leak and loss of tidal volume. A standard cuff measuring device (like the Cufflator) can be used to measure the mask pressure. It should not be greater than 60 cm H₂O to seal the airway. (See the later discussion on managing an endotracheal tube for more information on securing the tube and measuring cuff pressure.)

MODULE E

Esophageal obturator airway: Combitube

1. Recommend the insertion of an artificial airway or a change in the type of artificial airway (Code: IIIG1f) [Difficulty: ELE: R, Ap; WRE: An]

The Combitube (also known as the esophageal-tracheal Combitube or ETC) is a double-lumen tube that can be used to ventilate a patient whether the tube is placed into the esophagus (as intended) or trachea (Figure 12-11). The Combitube is one version of a series of tubes called esophageal obturator airways (EOAs) that are designed to be placed into the esophagus of an unconscious adult patient. Clinical experience has shown that a Combitube provides a reasonably secure airway in emergency situations, such as when performing CPR. It can be used as an alternative to an LMA. At the time this book was being published, there were five different types of EOA that provide the same two functions: ensure a stable airway for artificial ventilation and prevent vomiting and aspiration. Clinical experience with the various types of esophageal obturator airways is highly recommended because they do not appear or operate like standard endotracheal tubes. See Box 12-2 for a comparison of a Combitube with an endotracheal tube.

Figure 12-11 Combitube with its component features. Note that the Combitube has two lumens and two cuffs. The lumen with the distal cuff is inserted into the patient’s esophagus (or occasionally the trachea). The proximal cuff is inserted into the patient’s pharynx. Each cuff has its own inflating tube with one-way valve. There are perforations in the esophageal tube between the two cuffs that allow ventilation through the esophageal port. The proximal end of both tubes has a standard 15-mm-OD adapter for attachment of a resuscitation bag. Depending on the placement of the Combitube in the esophagus (as intended) or trachea, the patient’s lungs can be ventilated through the esophageal or tracheal port when both cuffs are inflated.

(From Blosser SA, Stauffer JL: Clin Chest Med 17:355-378, 1996.)

BOX 12-2 Indications, Contraindications, Advantages, and Disadvantages of the Combitube

GENERAL INDICATIONS

Emergency personnel are not trained in endotracheal intubation.

Attempted endotracheal intubation has not been successful.

Patient is apneic, without reflexes, and unconscious.

GENERAL CONTRAINDICATIONS

Endotracheal intubation can be performed.

Patient is responsive with an intact gag reflex.

Patient is too small for the Combitube.

Esophageal obturator device would be needed for more than 1 to 2 hours.

Patient is known to have esophageal trauma, pathology, or to have ingested a corrosive substance.

DISADVANTAGES

Accidental and unrecognized tracheal intubation is possible.

The possibility of upper airway tear and hemorrhage during tube insertion exists.

Incomplete cuff seals result in air leak during ventilation.

The airway cannot be reliably kept open.

2. Manipulate a Combitube by order or protocol (Code: IIA7g) [Difficulty: ELE: R, Ap; WRE: An]

a. Get the necessary equipment

The Combitube is available in two sizes. The longer, larger size (41Fr) version is used for patients who are more than 16 years old and more than 60 inches (5 feet) in height. The Combitube SA is smaller (37Fr) and intended for smaller patients. Neither size is intended for small pediatric patients. Both Combitube types are included in a kit with a 140-mL syringe to inflate the larger, proximal cuff in the patient’s oral pharynx and a 20-mL syringe to inflate the smaller, distal cuff in the patient’s esophagus (or trachea). The practitioner should have protective gear such as a face mask and gloves.

b. Put the equipment together and make sure that it works properly

Before placing either Combitube version into the patient, check that each cuff will inflate, hold air, and deflate properly. Each of the tubes should have a standard 15-mm-OD ventilator adapter inserted into its proximal end.

c. Troubleshoot any problems with the equipment

Do use a unit that has a defective cuff(s) or missing adapters. If a cuff should fail during patient use, the Combitube should be removed. It can be replaced by another unit, another type of secure airway can be inserted, or bag-mask ventilation can be performed.

3. Assess the placement of the Combitube (ELE code: IIIB5) [Difficulty: ELE: R, Ap, An]

While the NBRC does not list the insertion of the Combitube as a testable item, proper placement is needed to ensure that it can be correctly maintained in the airway. Figure 12-12 shows the procedure for inserting a Combitube. When the tube enters the esophagus as intended, both cuffs are inflated, and the patient is ventilated through the longer, colored tube, bilateral breath sounds will be heard (see Figure 12-12, C). Continue to ventilate the patient’s lungs and tape the tube in place. If breath sounds are not heard, the tube has accidentally entered the patient’s trachea. Now, ventilate through the shorter, clear tube and listen for bilateral breath sounds. If they are heard, continue to ventilate and tape the tube in place (see Figure 12-12, D).

Figure 12-12 Steps in the insertion of a Combitube to make sure that it seals the patient’s airway. A, One hand is used to grasp the jaw and pull it forward. With both cuffs deflated and the patient’s head in a neutral position, the Combitube is inserted into the center of the mouth. B, Outer view of the Combitube after it has been gently inserted until the black rings on the tube are at the teeth. C, Inner view of the usual location of the tube in the patient’s esophagus. Both cuffs are inflated. The resuscitation bag is attached to the longer, colored esophageal tube and the patient’s lungs are ventilated. Listen for bilateral breath sounds. D, Inner view of the occasional location of the tube in the patient’s trachea. Both cuffs are inflated. The resuscitation bag is attached to the shorter, clear tracheal tube and the patient’s lungs are ventilated. Listen for bilateral breath sounds.

(From Cairo JM, Pilbeam SP: Mosby’s respiratory care equipment, ed 8, St Louis, 2010, Mosby, Inc.)

4. Maintain the proper position and appropriate cuff inflation of a Combitube (Code: IIIB4b) [Difficulty: ELE: R, Ap; WRE: An]

Tape can be used to secure the tube to the patient’s upper lip. Follow the manufacturer’s recommendation for cuff volumes. With the original Combitube, the large, pharyngeal cuff is designed to hold 100 mL of air; the smaller cuff is designed to hold 15 mL of air. Use enough air in the cuffs so that there is no air leak when manual resuscitation is performed.

MODULE F

Tracheostomy tubes

1. Recommend the insertion of an artificial airway or a change in the type of artificial airway (Code: IIIG1f) [Difficulty: ELE: R, Ap; WRE: An]

The tracheostomy tube offers the same uses as the endotracheal tube, such as maintaining a secure airway, providing a direct suctioning route to the lungs, preventing aspiration, and assuring a safe route to provide mechanical ventilation. In addition, it is placed in the patient who has an upper airway obstruction or facial trauma that makes intubation impossible. A tracheostomy tube is often placed in a patient who requires long-term mechanical ventilation. Some patients with a permanent neurologic problem that limits their breathing will have a tracheostomy performed. By not breathing through the upper airway, their anatomic dead space is reduced. In the long term, a tracheostomy is said to be more comfortable than an endotracheal tube, even though it requires a surgical procedure for its placement. An additional advantage of a tracheostomy tube over an endotracheal tube is that it allows the patient to eat and drink.

2. Manipulate standard and fenestrated tracheostomy tubes by order or protocol (ELE code: IIA7c) [Difficulty: ELE: R. Ap, An]

a. Get the necessary equipment

These tubes are available in a variety of sizes for patients of all ages from neonate to adult. See Table 12-1 for tracheostomy tube sizes (this also applies to tracheostomy buttons and endotracheal tubes) based on patient age. It is common practice to refer to the needed tube size by its inner diameter (ID). For example, a tracheostomy tube for an adult female would be 7.5- or 8.0-mm ID.

TABLE 12-1 Endotracheal and Tracheostomy Tube Sizes Based on Patient Age^*