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^*

Most modern tracheostomy tubes are constructed of a hard polyvinyl chloride (PVC) plastic and have a high-volume, low-pressure cuff. Some specialty tubes are made of silver, rubber, or latex. The older, silver tubes may not have a cuff or the cuff may be removed. A syringe is needed to inflate the tube cuff. The practitioner should wear gloves and a mask when working with a patient’s tracheostomy tube and stoma.

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

The following are commonly seen examples of tracheostomy tube styles:

1. Standard tracheostomy tube

After the tracheostomy procedure is completed, the majority of patients have a standard tube placed into the stoma. Refer to Figure 12-13 for these features of a typical tracheostomy tube:

a. The cannula is the airway through which the patient breathes. The proximal end is outside of the patient’s stoma and attached to an adjustable flange. The angle of the flange can be adjusted so that the distal end of the cannula fits properly into the patient’s trachea. Soft, cloth tracheostomy tie strings are attached to the ends of the flange. The loose ends are tied behind the patient’s neck to hold the tube in place. The distal end of the cannula has a small area where radiopaque material is imbedded. As with an endotracheal tube, this allows the end of the cannula to be seen on a chest radiograph. The cuff is a high residual volume, low-pressure type. Air is inserted and withdrawn from the cuff by an inflation tube with a pilot balloon and one-way valve.

b. The obturator is slid into the outer cannula’s opening before it is inserted into the patient’s stoma. The obturator has a rounded end that protrudes from the end of the cannula. This prevents any tissue trauma during the insertion. The obturator is removed as soon as the cannula is in place.

c. An inner cannula is slid into the outer cannula’s opening and locked into place with a clockwise twist. This completes the airway. The proximal end has a standard 15-mm outer diameter (OD) adapter so that all respiratory care equipment fits onto it. The distal end is flush with the end of the outer cannula. Some practitioners believe that the inner cannula should be periodically removed and cleaned so that secretions do not accumulate. Other practitioners believe that this is unnecessary if the airway is properly humidified and suctioning is performed as needed.

Figure 12-13 Typical tracheostomy tube with its component parts and features.

2. Fenestrated tracheostomy tube

A fenestrated tube is often placed in a patient who can breathe spontaneously and who is being considered for a complete removal of the tracheostomy tube. If the patient does well with this tube, it can probably be removed safely. If the patient has difficulty, the plug can be removed, the inner cannula can be replaced, and the patient’s airway can be suctioned or mechanically ventilated.

Refer to Figure 12-14 when reviewing these features of the fenestrated tracheostomy tube:

a. The outer cannula has an opening called the fenestration (Dutch for window). The rest of the cannula, cuff, inflation tube, and flange are the same as already discussed.

b. The inner cannula functions as discussed earlier. When it is in place, the tube functions in the same manner as the standard model.

c. The outer cannula plug is used to prevent the patient from breathing through the proximal end of the tube. The plug does not cover the fenestration; therefore the patient is able to breathe through the upper airway. The patient can now talk and expectorate any secretions.

Figure 12-14 Fenestrated tracheostomy tube with its component parts and features.

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

Exam Hint 12-2 (ELE, WRE)

A standard tracheostomy tube should be replaced with a fenestrated tube when a patient is improving and can breathe spontaneously (off of the ventilator) for an extended time. Remove the inner cannula and deflate the cuff so that the patient can breathe through the upper airway. Replace the inner cannula and inflate the cuff when mechanical ventilation is resumed.

c. Troubleshoot any problems with the equipment

Before a tracheostomy (or endotracheal) tube is inserted into a patient, the cuff must be tested. Do this by attaching a syringe to the one-way valve and inflating the cuff. Remove the syringe. The cuff must stay inflated to show that it and the one-way valve work properly. Then reattach the syringe and deflate the cuff. Do not use a tube with a leaking cuff or leaking one-way valve. Make sure that the obturator, inner cannula, and plug all fit properly into the outer cannula. They all should easily snap into place and be easily removable. Check this before inserting the tube into the patient.

Secretions, blood, or foreign matter can plug the lumen of the tube. Suction to remove any obstruction. It is also possible for the cuff to herniate and cover the end of the tube. If the catheter cannot be inserted beyond the tube and the patient is having respiratory distress, the tube will have to be removed. Replace the defective tracheostomy tube with another as soon as possible.

Exam Hint 12-3 (ELE)

The following factors can contribute to obstruction of the lumen of the cannula: (1) secretions or foreign matter; (2) a cuff that has herniated or slipped over the end of the tube; (3) placement of the tip of the tube into the subcutaneous tissues. Initially, attempt to suction to remove any obstruction. If the catheter cannot be inserted beyond the tube and the patient is having respiratory distress, the tube must be removed and replaced.

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

The first step in assessing tube placement is knowing that it was properly inserted. With the cuff deflated and the obturator inserted into the cannula, the tube should be gently slid through the stoma. The natural curvature of the tube should result in the distal tip being placed within the trachea and the flange being against the neck of the patient. Forcing should be avoided as this may indicate that the tip of the tube is entering the surrounding tissues. Also, the proper size tube will not need to be forced through the stoma. Inflate the cuff. All of the patient’s breathing should pass through the tube. Auscultate for equal and bilateral breath sounds. No breath sounds should be heard over the patient’s stomach area. An exhaled carbon dioxide monitor can also be attached to the proximal end of the tube to measure the concentration of carbon dioxide being exhaled by the patient. Lastly, the physician may want to have an upper airway or chest radiograph taken. Ensure that the distal tip of the tube is within the center of the trachea.

4. Maintain the proper position and appropriate cuff inflation of a tracheostomy tube (Code: IIIB4d) [Difficulty: ELE: R, Ap; WRE: An]

After being assured that the tracheostomy tube is properly located, wrap the tie strings behind the patient’s neck and tie them with a bowknot or fasten the Velcro straps. Tying the strings should help to prevent the tube from being misplaced or pulled out. The cuff pressure should be measured on a regular basis to make sure that it is being kept at a safe level. In most patients, a safe cuff pressure is no more than 20 to 25 mm Hg (25 to 35 cm H₂O). (A more complete discussion of cuff pressure measurement follows in the discussion on endotracheal tubes.)

If the patient experiences a sudden partial or complete airway obstruction, it is possible that the tube has become twisted or partially pulled out and forced into the soft tissues around the trachea. However, first eliminate other possible causes. Quickly deflate the cuff to rule it out as a cause of the obstruction. If the obstruction is still present, attempt to pass a suction catheter. If it can be passed though the tube, perform suctioning to remove any mucous plug. If the tube has an inner cannula and the catheter cannot be passed, remove the inner cannula. If it is plugged with mucus, either remove the mucus or replace the inner cannula. If none of these procedures opens the patient’s airway, it is likely that the distal tip of the tracheostomy tube is misplaced into the soft tissues. Withdraw the tube and let the patient breathe through the stoma. As quickly as possible, replace the tube through the stoma and into the trachea. Inflate the cuff and check that the patient can breathe normally.

5. Change the tracheostomy tube (ELE code: IIIB7) [Difficulty: R, Ap, An]

A tracheostomy tube may have to be changed because of a ruptured cuff or because of another problem. In addition, patients with a permanent tracheostomy have the tube changed on a routine schedule as part of tracheostomy care. These two different situations are discussed separately.

a. Emergency tube change

Several factors can cause the clinical emergency of obstruction, such as the cuff herniating over the end of the tube, a mucous plug blocking the lumen, or the end of the tube being forced into the tracheal tissues. Unfortunately, these problems cannot be seen from the outside. If the patient is in acute respiratory distress and an obstruction is suspected, attempt to pass a suction catheter. Failure to pass it beyond the end of the tube confirms the obstruction. A rapid clinical decision has to be made to choose the best action. The tube should be removed if the obstruction is complete and the patient cannot breathe. A spontaneously breathing patient can continue to breathe through the stoma. An apneic patient must be temporarily ventilated with mouth-to-stoma breaths. As rapidly and carefully as possible another tracheostomy tube should be inserted. This usually results in a patent airway. If loose tracheal mucosa is blocking the airway, an endotracheal tube must be inserted past the tissue and deeper into the trachea. Call the physician as soon as possible to evaluate the patient’s condition.

b. Routine tube change

If possible, the tube should not be changed until 7 to 10 days after a fresh tracheostomy procedure. This allows time for the stoma site to form granulomatous tissue as it begins to heal. The site is then less likely to bleed as the tube is changed. When the tracheostomy tube is changed, it is usually part of tracheostomy wound care. The following are typical steps in changing the tracheostomy tube:

1. Gather the necessary equipment: a new tracheostomy tube of the same size and the next size smaller, its inner cannula, its obturator, tracheostomy tie strings to secure the tube in the patient (see Figure 12-10), a sterile tracheostomy dressing pad (4 × 4 inches for an adult), sterile scissors, a 10-mL syringe to inflate the cuff, sterile water-soluble lubricant, sterile gloves, and goggles. Make sure the cuff inflates and deflates properly.

2. Put on the gloves and goggles.

3. Maintaining sterile technique, make sure the obturator easily fits into and can be withdrawn from the tracheostomy tube.

4. Open the tracheostomy dressing pad (it has a slit into the center of the gauze pad).

5. Apply some lubricant to the tip of the tracheostomy tube.

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

7. Remove the oxygen and/or aerosol from the patient.

8. Suction the patient’s trachea. Reoxygenate the patient.

9. Untie the tracheostomy strings or separate the Velcro straps.

10. Deflate the cuff.

11. Remove the current tracheostomy dressing pad.

12. Remove the tracheostomy tube by pulling it in a curved motion toward the patient’s chest.

13. Inspect the tracheostomy opening for signs of infection such as redness, pus, or swelling. Report signs of infection to the nurse or physician.

14. Carefully insert the new tracheostomy tube with obturator into the stoma. The motion should be opposite that used to remove the original tube. Make sure not to force the tube into the tissues of the trachea.

15. Remove the obturator and insert the inner cannula. Lock it in place.

16. Give the patient oxygen and/or aerosol as before the tube change.

17. Inflate the cuff to a safe pressure.

18. Listen for bilateral breath sounds.

19. Slide the new tracheostomy dressing pad around the tube so that the slit fits around it.

20. Tie the tracheostomy tie strings or fasten the Velcro straps behind the patient’s neck.

6. Independently perform tracheostomy care (Code: IIIF2g5) [Difficulty: ELE: R, Ap; WRE: An] (ELE code: IIIB6) [Difficulty: ELE: R, Ap, An]

Routine tracheostomy care generally includes the steps previously described, except the removal of the tracheostomy tube. While performing tracheostomy care, inspect the stoma for possible signs of infection, clean the stoma site, apply a topical antibiotic, if indicated, and replace the 4 × 4 inch tracheostomy dressing pad.

7. Extubate the patient

a. Recommend extubation (Code: IIIG1h) [Difficulty: ELE: R, Ap; WRE: An]

Extubation should only be performed after correction of the causes that led to insertion of the tracheostomy tube. If the patient has required mechanical ventilation, review the discussion in Chapter 15 that relates to weaning the patient and extubation.

b. Perform extubation (Code: IIIB9) [Difficulty: ELE: R, Ap; WRE: An]

Extubation should be performed only by trained personnel and under the proper conditions to ensure the patient’s safety. See Box 12-3 for a list of complications that can occur after extubation. The generally recommended steps in extubation include the following:

1. Evaluate the patient’s cardiopulmonary status. The reason(s) for the tube being placed should be corrected. The most recent blood gas results should be acceptable. Tracheal secretions should be minimal and not so thick that they cannot be expectorated by the patient. Bedside spirometry results should show an acceptable tidal volume, vital capacity, and maximal inspiratory pressure.

2. Inform the patient about the removal of the tube and the follow-up care that is needed.

3. The patient’s inspired oxygen percentage may be kept the same or increased before the extubation. If increased, it should be done at least 5 to 10 minutes before the tube is removed.

4. Suction the trachea until all secretions are removed.

5. Suction the oral pharynx to remove all saliva. Be prepared to suction additional oral secretions and mucus after extubation.

6. In rapid succession:

a. Give a deep sigh breath.

b. Deflate the cuff. Cut the inflation tube to the cuff to ensure its collapse.

c. Pull out the tube when the lungs are full.

Alternatively, in rapid succession:

a. Give a deep sigh breath.

b. Place a suction catheter through the tube into the trachea. This works best with a self-contained catheter and sheath system.

c. Deflate the cuff. Cut the inflation tube to the cuff to ensure its collapse.

d. Pull out the tube when the lungs are full.

e. Apply suction as the tube is withdrawn.

7. Have the patient cough vigorously to remove any secretions.

8. Depending on the physician’s order, do one of the following:

• Apply a bland aerosol by tracheostomy mask to the stoma site with the previous amount of oxygen.

• Cover the stoma site with a sterile 4 × 4 inch dressing. Tape it in place. Apply a bland aerosol by face mask with the previous amount of oxygen.

9. Monitor and evaluate the patient every 30 minutes for several hours. Encourage deep breathing and coughing. Check the vital signs and breath sounds. Be prepared to reintubate the patient if necessary. Measure pulse oximetry continuously or arterial blood gases after 10 to 20 minutes.

Routine stoma care to ensure healing usually includes the following each shift:

1. Remove the dressing. Inspect the stoma for signs of infection such as pus, redness, and swelling.

2. Clean the stoma site with hydrogen peroxide on a sterile gauze pad.

3. Apply antibiotic ointment to the stoma site, if indicated

4. Reapply a sterile dressing.

MODULE G

Tracheostomy buttons

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 tracheostomy button is a hard plastic tube that is placed into the patient’s stoma to keep it open after the tracheostomy tube has been removed (Figure 12-15). A button is inserted because the physician has determined that the stoma must be kept open in case the tracheostomy tube must be reinserted. Advantages of the button include the patient being able to eat, talk, and cough normally. Yet, in case the patient has difficulty or needs a breathing treatment, a secure airway can be quickly reestablished.

Figure 12-15 Typical tracheostomy button properly positioned in patient. The insert shows its component parts.

2. Manipulate a tracheostomy button by order or protocol (ELE code: IIA7c) [Difficulty: ELE: R, Ap, An]

a. Get the necessary equipment

In general, the patient sizes for tracheostomy buttons match the sizes for tracheostomy tubes listed in Table 12-1.

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

Refer to Figure 12-15 when reviewing these features of the tracheostomy button and accessories:

• The hollow outer cannula has a slightly flared pro-ximal end. This keeps the button from slipping entirely into the patient. The distal end is flanged and split into several flexible “grippers.”

• A closure plug fits into the outer cannula and snaps into the flexible grippers on the end of the outer cannula. This seals the button so that the patient breathes through the upper airway.

• A hollow inner cannula can be inserted into the outer cannula instead of the plug. This inner cannula has a standard 15-mm OD so that a T-piece/Briggs adapter or other respiratory care equipment can be attached if needed. The patient’s secretions can also be suctioned.

• Spacers of various widths are used to make sure that the inner cannula is placed at the right depth. The end of the tube should enter the trachea but not obstruct it. See the airway picture in Figure 12-15 for the proper position.

A one-way valve may be added to the button. This would be used for patients who must not inspire through their upper airway but may exhale through it. In patients with a very small tidal volume, inhaling through one of these valves reduces the patient’s upper airway anatomic dead space. Since expiration is through the upper airway, the patient can speak normally. Refer to Figure 12-16 when reviewing these features of the Kistner tracheostomy tube with an attached one-way valve:

• The hollow plastic cannula keeps the stoma open. The distal end is flanged so that it is not likely to be pulled out of the trachea accidentally.

• The proximal end of the cannula is capped with a one-way valve. The valve allows the patient to inhale room air or an oxygen- and aerosol-enriched gas source. Expiration is through the upper airway. The patient can talk, eat, and cough normally.

Figure 12-16 Kistner tracheostomy button.

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

c. Troubleshoot any problems with the equipment

Make sure that all component pieces of these tracheostomy buttons fit together properly and can be easily disconnected if necessary. The cannula must be kept clear of any secretions, blood, or foreign debris. A suction catheter should be passable through the hollow opening in the cannula. If the button is obstructed and the patient is having trouble breathing through the upper airway, the button should be removed and replaced with another button or a tracheostomy tube.

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

After the physician removes the tracheostomy tube, the depth of the stoma is measured. Based on that depth, spacers are added to the cannula to obtain the appropriate depth. Once the button is placed, the patient should not have any added resistance to breathing. If the button becomes misplaced and the patient has difficulty breathing, the button should be removed. A tracheostomy tube can then be inserted.

MODULE H

Speaking tubes and valves

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 speaking tracheostomy tube is indicated in a patient who requires support on a mechanical ventilator but is conscious and wishes to speak. Some speaking valves can be added to a standard tracheostomy tube in a ventilator-dependent patient. In this situation, the cuff must be deflated for the exhaled tidal volume gas to pass through the vocal cords for speaking. Remember to reset the ventilator’s exhaled low tidal volume alarm because no exhaled gas will return through the ventilator circuit.

Usually, a speaking valve is added to a tracheostomy button in a patient who is not ventilator-dependent. This patient cannot or should not be inhaling through the nose or mouth but can exhale through the natural upper airway. Commonly, these are patients with a neuromuscular disease. Their condition causes them to have a small tidal volume, which results in a large percentage of dead space ventilation. Placing a tracheostomy tube or button into these patients improves their dead space to tidal volume ratio and improves their blood gas values.

2. Manipulate a speaking tube or valve by order or protocol (ELE code: IIA7d) [Difficulty: ELE: R, Ap, An]

a. Get the necessary equipment

Table 12-1 lists the standard sizes of tracheostomy tubes. A speaking tracheostomy tube should match the same size as the current tracheostomy tube or button, if it is available.

Speaking tracheostomy tubes are only available in adult sizes. See Figure 12-17 for the features of a speaking tracheostomy tube (Pitt and Vocalaid have versions). The cannula is the standard type except that an additional tube has been added to carry a compressed gas through a hole in the back of the cannula. This gas flows through the vocal cords and allows the patient to speak. The voice is not as strong as normal but should be understandable. Improved communication ability is a great help to the patient’s psychologic well-being. Patients can still be mechanically ventilated and have their secretions suctioned, and can eat and drink as usual.

Figure 12-17 Pitt tracheostomy tube permits the patient to speak. Note its special feature that directs outside gas flow past the vocal cords.

(From Wilkins RL, Stoller JK, Kacmarek, RM: Egan’s fundamentals of respiratory care, ed 9, St Louis, 2010, Mosby.)

Passy-Muir (Figure 12-18) and Kistner (see Figure 12-16) are common types of speaking valves that can be attached to a tracheostomy tube or tracheostomy button. All feature a one-way valve that opens when the patient inspires to allow room air or supplemental oxygen to be inhaled. When the patient exhales, the valve closes. This causes all of the exhaled tidal volume to pass through the vocal cords for speech. Aerosol therapy may be provided either by a tracheostomy mask over the valve or by a T-piece attached to it. (See Chapter 6 for a discussion of these aerosol/oxygen delivery systems.) As an alternative, the Trach-Talk combines an elbow adapter to the tracheostomy tube and a T-piece with a one-way valve (Figure 12-19). This device provides the patient with aerosol and/or oxygen with humidity through the one-way valve during inspiration. On exhalation, the valve closes and the patient exhales through the vocal cords for speech.

Figure 12-18 Photograph of a variety of speaking valves made by Passy-Muir. When the one-way valve is attached to a tracheostomy tube, the patient breaths in through the valve and exhales through the upper airway for speech.

(Courtesy Passy-Muir, Inc., Irvine, Calif.)

Figure 12-19 A patient with a tracheostomy tube and attached Olympic Trach-Talk speaking device. It features a one-way valve so that the patient breaths in through the valve and exhales through the upper airway for speech.

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

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

With a speaking tracheostomy tube, a Y-connector is added to the compressed gas tube. Usually about 4 to 6 L/min of compressed air or oxygen are set by a flowmeter to run to the Y. Closing off the other opening in the Y with a finger diverts the gas into the patient’s larynx for speaking. A little experimentation with flows helps the patient find the flow that works best for speaking (see Figure 12-17). If the patient cannot speak at all, check that the gas is turned on and that the tubing is properly connected.

All speaking valves are available in a standard size to fit onto a 15-mm-OD tracheostomy tube. Passy-Muir makes a variety of valves. Whether the patient is breathing spontaneously or is ventilator-dependent, the one-way valve directs the tidal volume into the patient. The valve closes on exhalation so that gas passes through the vocal cords for speaking. Be aware that for this system to work with a ventilator-dependent patient, the cuff must be deflated. This will result in some loss of delivered tidal volume. Make sure that the patient can tolerate this. Also adjust the ventilator’s alarm settings accordingly. If the patient is breathing spontaneously and needs low-flow supplemental oxygen, use the valve that includes a small-bore oxygen tubing nipple (see Figure 12-18).

c. Troubleshoot any problems with the equipment

For a speaking tracheostomy tube, see the preceding discussion on care of standard or fenestrated tracheostomy tubes. The same problems can occur with speaking tracheostomy tubes. Assess the patient’s ability to speak in an understandable way. Enough compressed gas must pass through the vocal cords for this to happen. Yet, too high a gas flow can cause some resistance to the patient’s tidal volume exhalation.

With a speaking valve, make sure that the one-way valve opens and closes properly. If a spontaneously breathing patient’s valve was to become plugged with secretions, the patient would have to inhale through the natural upper airway rather than the valve.

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

The assessment of the placement of a speaking tracheostomy tube would be the same as discussed previously with standard tracheostomy tubes.

MODULE I

Endotracheal tubes and intubation equipment

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 endotracheal tube is indicated when a secure, patent airway is required for endotracheal suctioning or mechanical ventilation. Aspiration is also prevented when the cuff is inflated. It is generally accepted that an endotracheal tube provides for a more secure airway than a laryngeal mask airway or Combitube. In most emergency situations an oral endotracheal tube is indicated over a nasal endotracheal tube because the oral route is faster and easier. A nasal endotracheal tube is indicated when the patient has oral trauma or when a cervical spine injury prevents the neck from being hyperextended for placing the oral tube.

2. Manipulate oral and nasal endotracheal tubes by order or protocol (ELE code: IIA7b) [Difficulty: ELE: R, Ap, An]

a. Get the necessary equipment

An endotracheal tube is the best emergency device for maintaining a secure airway. It also provides a direct suctioning route to the lungs and prevents aspiration. Mechanical ventilation can easily be provided through it. See Table 12-1 for a list of endotracheal tube sizes (this also applies to tracheostomy tubes and buttons) based upon the patient’s 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 male would be 8.0- or 8.5-mm ID.

An endotracheal tube is meant to be a temporary airway; however, it can stay in patients for weeks if necessary. Virtually all endotracheal tubes used clinically now are made of pliable plastic. Always select a tube that has a large residual volume and low-pressure cuff unless there is a specific contraindication. For the most part, oral and nasal endotracheal tubes can be used interchangeably. The nasal endotracheal tube is longer and more curved than an oral endotracheal tube. The greater curve of the nasal tube should result in less pressure on the nasal mucosa. An anesthesiologist requests a nasal tube if he or she is going to place it by the nasal route. Oral tubes are used in the majority of patients.

The tubes are available in sizes from 4-mm OD through 14-mm OD so that patients of all ages and sizes can be intubated. The OD size increments are 0.5 mm. The thickness of the outer wall of the tube varies from 0.5 to 1 mm, which results in a reduction of the inner diameter (ID) of the tube by about 1 to 2 mm. Table 12-1 lists the approximate ID of an endotracheal tube to place into a patient based on age. It is common practice to refer to the size of endotracheal tube (or tracheostomy tube) needed by its ID. Once the tube is properly placed into the patient, the excess tube, beyond 3 to 4 cm past the teeth, should be removed. This reduces the airway resistance and mechanical dead space.

Most endotracheal tubes have the standard features shown in Figure 12-20. There are a number of specialty endotracheal tubes that can be found in limited use. They all share the same characteristics except for some special feature. These tubes are worth considering if available.

Figure 12-20 Typical, modern endotracheal tube with its component parts. The insert shows important features found at the distal end of the tube.

1. Pediatric endotracheal tubes

Pediatric endotracheal tubes are available in two basic types. One type has a constant diameter. During intubation, the tube should be inserted until the black mark about 2 cm from the tip is at the vocal cords. The second type has a body with a relatively wide proximal part that narrows at the distal end. The design is supposed to allow the smaller diameter tip to be passed through the vocal cords but prevent the wide “shoulder” from passing into the trachea. The distal ends of both types of tube have a single opening with a bevel cut (Figure 12-21). It is recommended that children less than 8 years of age have a tube without a cuff.

Figure 12-21 Comparison of the two different types of pediatric endotracheal tubes. The top type of tube is made by several manufacturers and has a uniform diameter. The bottom tube is made by Cole and features a narrowing of the distal tip to pass through the vocal cords. Note that neither has a cuff.

(From Burgess WR, Chernick V: Respiratory therapy in newborn infants and children, ed 2, New York, 1986, Thieme.)

2. Wire-reinforced tubes

Wire-reinforced (also called armored) tubes have a steel spring coiled through them (Figure 12-22). An advantage of these tubes over regular tubes is that they are more resistant to collapse if the patient bites on them. Furthermore, the tube may be bent for shape and does not kink if the patient’s head is turned at an angle that might kink an ordinary tube.

Figure 12-22 Photograph of a spiral wire–reinforced (also called an armored) endotracheal tube.

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

3. Preformed tubes

Preformed tubes have been preshaped for surgical procedures on the head and neck. One style has a forward bend so that the tube can be taped to the chin (Figure 12-23). This shape keeps the tube and anesthesia circuit away from the patient’s nose, eyes, and top of the head. There are also tubes with a backward bend so that it can be taped to the forehead (Figure 12-24). This shape keeps the tube and anesthesia circuit away from the patient’s throat area.

Figure 12-23 Photograph of cuffed and uncuffed SAE endotracheal tubes with an anterior bend to allow access to the upper part of the patient’s face and head.

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

Figure 12-24 Photograph of cuffed SAE endotracheal tubes with a posterior bend to allow access to the patient’s neck area.

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

4. Guidable (trigger) tubes

Guidable tubes have a string embedded within the wall of the tube (Figure 12-25). When the ring at the proximal end is pulled, the distal tip is flexed up to shorten the radius of the curve. This allows the tube to be directed into the anterior trachea. Guidable trigger tubes make it easier to intubate a patient with an anterior larynx or to perform a blind nasal intubation.

Figure 12-25 Photograph of an Endotrol guidable (trigger) endotracheal tube. A wire is embedded within the wall of the tube. When the ring at the proximal end is pulled, the distal tip is flexed up to shorten the radius of the curve. This allows the tube to be directed into the anterior trachea.

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

5. Double-lumen endotracheal tubes

Double-lumen endotracheal tubes are used to allow independent lung ventilation. A double-lumen tube is also used during special procedures performed on one lung such as bronchoscopy, bronchoalveolar lavage, lobectomy, and pneumonectomy. The other lung may be mechanically ventilated to maintain the patient’s blood gas values (Figure 12-26). An adapter can be added to join the two proximal ends of the channels so that a single ventilator can be used to ventilate both lungs. The Carlens tube is used to preferentially intubate the left bronchus. The White tube is used to preferentially intubate the right bronchus (see Figure 12-27 for both). Robertshaw makes tubes for either right or left bronchial intubation.

Figure 12-26 Double-lumen endotracheal tube properly positioned in patient so that both lungs can be independently ventilated or suctioned, or have special procedures performed.

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

Figure 12-27 Two types of double-lumen endotracheal tubes. A, Carlens tube; its distal end enters the left mainstem bronchus. B, White tube; its distal end enters the right mainstem bronchus. Note how both tubes have a cuff that seals the trachea and a cuff that seals a bronchus. Each has its own inflation tube, pilot balloon, and one-way valve.

(From Miller RD, editor: Anesthesia, New York, 1981, Churchill Livingstone.)

Several limitations are inherent in all double-lumen tubes. First, they can be used only on adults because the smallest size is 8-mm OD. Second, the small internal diameter of the two lumens results in a high airway resistance. Third, a much smaller than normal suction catheter must be used to remove any tracheal secretions.

6. Tubes for high-frequency jet ventilation

These special purpose tubes have a main lumen for a standard ventilator and an additional lumen to which a jet ventilator is attached. See Chapter 15 for more discussion and a photograph.

7. Oropharyngeal suctioning tubes

In response to the concern about oropharyngeal secretions leaking around the endotracheal tube cuff and causing ventilator-associated pneumonia, an endotracheal tube with a built-in suctioning catheter has been invented (Figure 12-28). The catheter runs down the outer curve of the tube to just above the cuff. When vacuum is applied to the catheter, any secretions that have accumulated above the cuff are suctioned out of the area. It functions like a standard, cuffed endotracheal tube in all other aspects.

Figure 12-28 Photographs of a Hi-Low Evac endotracheal tube that has an added channel to suction oral secretions from the subglottic area. The removal of these secretions should help to reduce the possibility of the patient developing ventilator-associated pneumonia.

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

Exam Hint 12-4 (ELE)

Know the proper size of endotracheal or tracheostomy tube to use with an adult man or woman (about 8-mm ID) and a small neonate (about 3-mm ID).

Exam Hint 12-5 (ELE)

Know the indications, features, and any uses for the various types of endotracheal tubes.

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

Refer to Figure 12-20 for these components of a standard endotracheal tube:

• The hollow curved body is the main part of the tube through which the patient can breathe, or a suction catheter can be placed. The OD and ID sizes are printed on the side of the tube. Make sure that the central channel is not plugged by dried secretions, blood, or foreign debris.

• The proximal end is left outside of the patient’s nose or mouth. An adapter with a 15-mm-OD equipment connector is inserted into the tube. The other end of the adapter narrows and is individually sized to fit snugly into the ID of the endotracheal tube. The adapters cannot be cross-fitted to different sizes of endotracheal tubes.

• The distal end is inserted into the patient’s trachea. The tip is cut with either a right- or left-sided bevel. The bevel cut creates an oval-shaped opening that is less likely to become plugged with secretions than is a round opening. An extra hole (the Murphy eye) is cut in the tube on the opposite side of the bevel.

• A line of radiopaque material is imbedded in the tube from the tip back to the cuff. It is seen as a white line on the chest radiograph, showing the location of the tube’s tip in the trachea (see the insert in Figure 12-20).

• A cuff (balloon) is located a few centimeters from the tip of the tube. It is inflated with air to seal the trachea so that mechanical ventilation can be performed and aspiration is prevented. Most modern tubes have a large residual volume, low-pressure cuff.

• Note: Most tubes that are 4.0-mm ID/6.0-mm OD or larger have cuffs. However, there are cuffless tubes larger than this for pediatric patients. Pediatric and neonatal tubes smaller than 4.0-mm ID/6.0-mm OD will not have a cuff.

• A cuff-filling inflation tube is connected about halfway down the tube. The proximal end is left out of the patient’s mouth, and the distal end goes to the cuff so that it can be inflated and deflated. A pilot balloon that inflates and deflates with the cuff is found in the middle of the capillary tube or connected with the one-way valve at the distal end. The one-way valve has an end that connects to any syringe. When the syringe is disconnected, the one-way valve seals to prevent the air in the cuff from escaping.

• With a double-lumen endotracheal tube, each lumen has its own 15-mm adapter, cuff, one-way valve, pilot balloon, and inflation tube to inflate the cuff. As with traditional endotracheal tubes, both cuffs should be test-inflated. They should hold the air without a leak and then be easily deflated. One additional piece of equipment, a plastic Y, can be used with a double-lumen tube. The plastic Y can be used to connect the proximal ends of both tubes. Both 15-mm adapters are removed and one branch of the Y is inserted into each of the proximal ends of the tubes. The open end of the Y has a 15-mm adapter so that it can be connected to a ventilator or oxygen source.

c. Troubleshoot any problems with the equipment

The cuff(s) should be inflated and the syringe should be disconnected from the one-way valve before the tube is placed in the patient. This ensures that the system works properly. The cuff(s) should hold the air. Do not use any tube with a leaking cuff or leaking one-way valve. Deflate the cuff before placing the tube into the patient.

3. Manipulate intubation equipment: laryngoscope and blades, by order or protocol (WRE Code: IIA7d) [Difficulty: An]

a. Get the necessary equipment

The laryngoscope is made up of two basic parts: a handle and a blade. The most commonly seen handle is made of stainless steel; some newer units are made of plastic. The handle contains two C-cell batteries to power the light source in the blade. They all have a common base with a hooking bar so that the blades can be attached (Figures 12-29 and 12-30).

Figure 12-29 Laryngoscope handle with a MacIntosh (curved) blade attached. A Miller (straight) blade is shown below for comparison. Note component parts and features.

Figure 12-30 Motions to attach a laryngoscope to a handle.

Blades are available in a variety of sizes from pediatric to adult. They all have a common hook so that they can be snapped and locked in place on the handle. The stainless-steel handles use stainless-steel blades. The newer plastic handles use plastic blades. The two different sets of handles and blades are not interchangeable. The blades are available in two different shapes. The Miller blades are straight and the MacIntosh blades are curved (see Figure 12-30). The person performing the intubation may specify a particular style of blade as well as blade size.

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

See Figure 12-29 for the steps in fastening the blade to the handle:

1. Hold the handle in the left hand and the blade in the right hand.

2. Place the hook on the blade over the hooking bar on the base of the handle.

3. Pull the blade down so that it snaps into place on the handle. The handle and blade should fit together at a 90-degree angle.

4. Make sure that the light bulb in the stainless-steel blade is tight.

c. Troubleshoot any problems with the equipment

The light source shines when the handle and blade are properly connected because an electrical circuit has been completed. Failure of the light source to shine may result from any of the following problems:

• The handle and blade are not properly connected and snapped into place. Disconnect them by performing the opposite motions and reconnect them properly.

• There are cross-connected stainless-steel and plastic components. Stainless-steel handles go only with stainless-steel blades, and plastic handles go with plastic blades.

• The batteries are low, as shown by the bulb failing to glow or glowing with a yellow instead of a white light. Unscrew the cap from the handle. Replace the old batteries with two new C-cell batteries. When reassembled, the bulb should glow with a white light.

• The batteries are not placed properly. It does not matter if a positive or negative pole touches the base of the handle. Be sure that a positive pole touches a negative pole or vice versa so that electrical current will flow properly. When reassembled, the bulb should glow with a white light.

• The light bulb in the stainless-steel blade is loose or defective. Tighten the light bulb by turning it clockwise. It should glow if it was just loose. Unscrew and throw away a defective light bulb. Replace it with a light bulb of the same size. When reassembled, the bulb should glow with a white light. The newer plastic laryngoscopes use a fiberoptic bundle as the light source. There is no light bulb to tighten or replace.

Besides the laryngoscope handle and blades, there are a number of additional items that are typically needed to ensure a smooth, safe intubation procedure. These are listed in Box 12-4.

Exam Hint 12-6 (ELE)

Know how to troubleshoot and repair a malfunctioning laryngoscope and blade.

4. Manipulate intubation equipment: fiberoptic devices, by order or protocol (ELE code: IIA7e) [Difficulty: ELE: R, Ap, An]

a. Get the necessary equipment

A physician may use a fiberoptic laryngoscope (Figure 12-31) or bronchoscope (see Figure 18-3) to visualize the larynx and trachea during a difficult intubation. Either can be used during a nasal or oral endotracheal intubation procedure.

Figure 12-31 A fiberoptic laryngoscope that is being used to insert an endotracheal tube through the nasal passage.

(From Wilkins RL, Stoller JK, Kacmarek RM: Egan’s fundamentals of respiratory care, ed 9, St Louis, 2010, Mosby.)

A fiberoptic lighted stylet or lightwand (Figure 12-32) can be placed through the lumen of the endotracheal tube so that the lighted distal tip is at the end of the tube. When the room is darkened and the tube enters the trachea, a bright light will shine though the tissues over the throat.

Figure 12-32 Photograph of a lightwand inserted through the lumen of an endotracheal tube. The lightwand’s light will shine through the laryngeal structures to show that the tip of the tube has entered the patient’s trachea.

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

Recently, a closed-circuit system has been developed that employs a laryngoscope handle and blade with a tiny camera at the tip of the blade. A fiberoptic bundle carries the image of the patient’s larynx from the blade to a monitor for viewing. This could be used to replace direct visualization of the larynx by the person performing the intubation.

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

See the following section.

c. Troubleshoot any problems with the equipment

Review the discussion on bronchoscopy in Chapter 18 for the details on the equipment. The fiberoptic tube should be lubricated so that it will easily slide through the lumen of the endotracheal tube (see Figure 12-31). After the physician has confirmed that the distal end of the fiberoptic tube has entered the trachea, the endotracheal tube is gently pushed into the trachea. The fiberoptic tube is then withdrawn, the cuff is inflated, and the endotracheal tube is secured. If the endotracheal tube will not slide into the patient’s trachea, it is either too large or there is not enough lubricant on the fiberoptic tube. It may be necessary to withdraw them, correct the problem, and start over again.

The lightwand needs functioning batteries in the proximal handle in order to glow. Replace any nonfunctioning batteries. The unit should have a water-soluble lubricant added so that it easily passes in and out of the endotracheal tube’s channel.

The closed-circuit laryngoscope handle and monitor need to plugged into an electrical outlet and properly assembled. Each laryngoscope blade is disposed of after single-patient use.

MODULE J

Endotracheal intubation and tube management

1. Perform endotracheal intubation (Code: IIIB3) [Difficulty: ELE: R, Ap; WRE: An]

Oral endotracheal intubation is the recommended procedure for securing the airway during an emergency such as a CPR attempt. In uncomplicated cases, the patient can be quickly intubated with an apneic period of no more than 20 seconds. This procedure is explained for a team of two respiratory therapists. It is difficult, if not impossible, for a single therapist to perform this important task without placing the patient at great risk. Usually the therapist who intubates is considered the leader and the other therapist acts as the assistant. Therapists must feel comfortable in both roles. See Box 12-5 for a list of indications and contraindications for oral intubation and Box 12-6 for a list of complications.

Steps in an emergency oral endotracheal intubation include the following:

1. Prepare the patient. The assistant should:

a. Place the head and neck in the sniff position.

b. Ventilate the patient’s lungs with 100% oxygen by a face mask and manual resuscitator or demand valve.

2. The intubator should put on a surgical mask, goggles, and clean gloves on both hands, and then perform the following.

3. Prepare the endotracheal tube.

a. Select the proper endotracheal tube. (See Table 12-1 for the recommended tube sizes based on the patient’s age. It is common practice to select the tube size based on its inner diameter [ID]. For example, a premature neonate would need a 2.5-mm-ID tube.) If time permits, the next smaller and larger tube sizes should also be selected.

b. Inflate the cuff using a 10- or 20-mL syringe. Remove the syringe from the one-way valve. Make sure that it holds the air and then deflate the cuff completely.

c. Lubricate the last few centimeters of the endotracheal tube with a water-soluble lubricant.

d. (Optional step) Lubricate a stylet with the sterile water-soluble lubricant. Place the stylet into the tube so that the natural curve of the tube is maintained. The tip of the stylet should not go past the end of the tube (Figure 12-33). Some practitioners may prefer not to use a stylet. Many believe that the stylet offers the advantage of being able to bend the tube to match the patient’s anatomy if a second attempt is needed.

4. Prepare the laryngoscope and blade.

a. Select a laryngoscope handle.

b. Select a laryngoscope blade. The blades are available in several sizes from pediatric to adult. There are two main classes of blades: straight and curved (see Figure 12-29). The straight blades (Miller is a common brand) are designed to lift the epiglottis to expose the tracheal opening. The curved blades (MacIntosh is a common brand) are designed to fit into the vallecula (between the base of the tongue and the epiglottis). As the blade is lifted, the epiglottis is raised and the tracheal opening can be seen. Personal experience and training leads the practitioner to select between the two styles.

c. Attach the blade to the handle (see Figure 12-30). Make sure that the light bulb shines brightly.

5. The intubator should tell the assistant to stop ventilating the patient and stand clear so that an intubation can be attempted. The assistant should check his or her watch to silently count off 20 seconds. The intubator should be told when 20 seconds has passed so that the patient can be reventilated if the intubation is proving to be difficult.

6. Open the victim’s mouth as widely as possible without using force. Remove any dentures or foreign material. Suction any saliva, blood, or vomitus.

7. Grasp the laryngoscope handle in the left hand. Carefully advance the blade between the teeth or gums along the right side of the mouth. Move the tongue to the left side of the mouth to allow a clear view of the oropharynx (Figure 12-34). Advance the blade along the base of the tongue until the epiglottis is seen.

8. With a straight blade:

a. Advance the blade so that it barely passes the epiglottis.

b. Do not advance the blade too far or it will enter the esophagus or trachea.

Figure 12-33 Stylet with stopper properly placed in standard endotracheal tube to maintain its curved shape.

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

Figure 12-34 Proper placement of the laryngoscope blade to move the patient’s tongue. A, Proper placement of the laryngoscope blade to the right of the patient’s tongue to move it to the left. This should give a clear view of the glottis. B, Tongue partially obstructs the view if it is not moved to the left.

(From Shapiro BA et al: Clinical application of respiratory care, ed 4, St Louis, 1991, Mosby.)

With a curved blade:

a. Advance the blade tip into the vallecula.

b. Lift the blade tip into this space.

9. With either blade, lift the laryngoscope handle and blade toward the patient’s chest at a 45-degree angle (Figure 12-35). The straight blade lifts the epiglottis. The curved blade lifts the soft tissues of the vallecula and the epiglottis lifts with them. Do not pull back on the patient’s upper teeth.

10. The vocal cords and glottis should be clearly seen (Figure 12-36). If needed, tell the assistant to put gentle, downward pressure on the patient’s larynx. This may help to bring the glottis into better view.

11. Tell the assistant to place the endotracheal tube into your right hand.

12. Place the tube into the right side of the patient’s mouth and direct it into the trachea. (The assistant may feel over the larynx as the tube enters the trachea. If necessary, the assistant may need to apply gentle pressure over the larynx to move it more posterior.) In the adult, advance the tube until the proximal end of the cuff is 3 to 4 cm past the vocal cords (Figure 12-37). In children less than 6 months of age, with an uncuffed endotracheal tube, advance the tube until the tip is about 1 cm past the vocal cords.

13. Hold the tube in place.

14. Withdraw the laryngoscope blade.

15. Tell the assistant to inflate the cuff. Place about 10 mL of air into the cuff (of an adult’s tube; less in a pediatric tube) so that some resistance can be felt. The cuff pressure can be measured and adjusted later.

16. Pull out the stylet (if used).

17. The assistant should ventilate the patient’s lungs with the manual resuscitator bag or a demand valve.

18. The intubator should listen to both lung fields in the upper lobes and bases. Bilateral breath sounds should be heard.

19. If the breath sounds are equal and bilateral, the assistant can secure the tube in place with tape or a tube holder. If the breath sounds are unequal or absent on one side, the tube has been placed into a bronchus (usually the right mainstem). The cuff should be deflated and the tube then withdrawn 1 to 2 cm in an adult, less in a child. The cuff should be reinflated and breath sounds assessed again. When the breath sounds are equal, the tube can be secured.

20. If no breath sounds are heard, listen over the stomach area. If air is heard bubbling into the stomach, the tube has been placed into the esophagus. Immediately remove the tube. Ventilate the patient’s lungs and prepare to attempt reintubation with a new endotracheal tube.

Figure 12-35 Proper use of the laryngoscope blade to expose the larynx by lifting the glottic structures. Note how the lifting is at a 45-degree angle toward the patient’s chest. Never pull back on the blade against the teeth. A, A straight blade is used to lift the epiglottis to expose the trachea. B, A curved blade is used to lift soft tissues of the vallecula to expose the trachea.

(From Shapiro BA et al: Clinical application of respiratory care, ed 4, St Louis, 1991, Mosby.)

Figure 12-36 Major anatomic features that can be seen when epiglottis is lifted. Opening to trachea can be seen between vocal cords.

(From Shapiro BA et al: Clinical application of respiratory care, ed 4, St Louis, 1991, Mosby.)

Figure 12-37 Oral endotracheal tube properly positioned within the trachea.

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

The practitioner should only perform those procedures for which he or she has been trained. If the patient cannot be intubated with the standard equipment and procedure, an anesthesiologist or trained physician should be requested. Be prepared to assist as necessary.

2. Assess the placement of an endotracheal tube (ELE code: IIIB5) [Difficulty: ELE: R, Ap, An]

Clinical experience has shown that there is no single foolproof procedure that can confirm that the endotracheal tube is within the trachea. Current guidelines recommend that several of the following procedures be done to confirm proper tube placement within the trachea.

3. Palpate the patient to determine asymmetric chest movements, crepitus, and/or tracheal deviation (Code: IB2b) [Difficulty: ELE: R, Ap; WRE: An]

As discussed previously, the first step to confirm tube placement during the intubation procedure is to palpate it passing through the larynx and entering the trachea. Most often the endotracheal tube can be palpated in an infant as it is being inserted. This is because the laryngeal structures are so pliable. Feeling the tube being inserted through the larynx indicates that it is properly located within the trachea. If the tube cannot be palpated through the larynx, it has probably been inserted into the esophagus. It is more difficult to use this technique with confidence in adults because their laryngeal structures are stiffer.

If the tube is advanced and cannot be palpated within the trachea, there are two other possible locations. First, the endotracheal tube could have been placed into the esophagus. Breath sounds will be heard over the epigastric area rather than the lungs. Deflate the cuff, withdraw the tube, and bag-mask ventilate the patient’s lungs. Second, the tube could have entered the trachea but deviated through the tracheal wall to enter one or the other lung field. Assess the patient for a possible pneumothorax, including findings of asymmetric chest movements, crepitus, and/or tracheal deviation. Withdraw the tube and begin bag-mask ventilation. Call a physician for help.

4. Auscultate the patient’s breath sounds and interpret any changes (Code: IB4a) [Difficulty: ELE: R, Ap; WRE: An]

Respiratory efforts without breath sounds indicate that a complete obstruction exists in the patient’s airway. Inspiratory stridor or wheezing indicates that a partial obstruction exists in the patient’s airway. Listen for stridor over the larynx and wheezing over the major airways. The restoration of the normal airway should result in the return of normal breath sounds over all areas of both lung fields (unless there is another, unrelated problem).

After intubation, deliver a breath and listen over the epigastric area to rule out tube placement in the esophagus. After ruling out esophageal placement, check for bilateral breath sounds. Confirm equal bilateral breath sounds by first listening over the apical areas and then the lateral areas. If the tube has been inserted too far, it usually enters the right mainstem bronchus because it separates from the trachea at a less acute angle than the left mainstem bronchus. No breath sounds will be heard over the left lung field. If both lung fields cannot be auscultated, at least listen to the right apical area. This one site can be checked because the segmental bronchus to the right upper lobe separates from the right mainstem bronchus in such a way that if the right mainstem bronchus is intubated, the upper lobe segmental bronchus will be blocked.

While listening to the patient’s breath sounds, look at the endotracheal tube. The condensation of moisture on the inside of the tube during exhalation would also confirm that the tube is in the trachea (or a bronchus) instead of the esophagus.

a. Esophageal detection device

The esophageal detection device (EDD) is able to show that the endotracheal tube has been placed within an airway by pulling a small sample of gas from the patient’s lungs. If the endotracheal tube has been accidentally put into the esophagus, the deflated bulb will stay collapsed (Figure 12-38). A limitation of the EDD is that it inflates whether the endotracheal tube is placed into the trachea or either mainstem bronchus. Remember to auscultate for bilateral breath sounds.

Figure 12-38 Esophageal detection device (EDD). This squeeze bulb device is attached to the proximal end of the patient’s endotracheal tube and air is squeezed out. A, Shows reinflation of bulb with air from patient’s lungs when the endotracheal tube has been properly placed. B, Shows that the bulb fails to reinflate when the endotracheal tube has been accidentally placed into the patient’s esophagus.

(From Scanlan C, Simmons K: Airway management. In Scanlan CL, Wilkins RL, Stoller JK, editors: Egan’s fundamentals of respiratory care, ed 7, St Louis, 1999, Mosby.)

5. Detect exhaled carbon dioxide

a. Recommend capnography to obtain additional data (Code: IC10) [Difficulty: ELE: R, Ap; WRE: An]

It is now common clinical practice to check for the presence of exhaled carbon dioxide to confirm endotracheal intubation. In the operating room the anesthesiologist will attach a capnography system to a patient’s endotracheal tube or add one into a ventilator circuit. In most other intubation situations, a simple, inexpensive colorimeter device is used. With either device, if the patient is not in cardiopulmonary arrest and the tube is within the trachea or a major bronchus, exhaled CO₂ will be found. If none is detected, the tube has been placed into the esophagus. Deflate the cuff, remove the tube, and begin bag-mask ventilation. Both units are discussed in the following sections.

b. Manipulate intubation equipment: exhaled carbon dioxide detectors, by order or protocol (ELE code: IIA7e) [Difficulty: ELE: R, Ap, An]

1. Get the necessary equipment

Most exhaled carbon dioxide detectors are inexpensive, single-patient use, disposable devices. They are called colorimetric units because they change color when exhaled carbon dioxide passes through the sensitive material within the capsule (Figure 12-39). The units are placed onto an endotracheal tube’s 15-mm-OD adapter to monitor the proper placement of the endotracheal tube. This is often done if a patient is being transported and there is a possibility that the tube could be dislodged. Exhaled carbon dioxide detectors are also used during CPR attempts to help determine if resuscitation attempts are being performed on a viable patient. If the patient is not producing exhaled CO₂, there is no metabolic activity. The physician may then decide to stop CPR efforts.

Figure 12-39 Easy Cap E_Tco₂ detector. This disposable device is available in adult and pediatric sizes and is able to detect exhaled carbon dioxide. Color change from dark purple to yellow indicates exhaled CO₂ to confirm tracheal placement of endotracheal tube or effective efforts at cardiopulmonary resuscitation.

(Courtesy Nellcor Puritan Bennett, Pleasanton Calif, part of Covidien [formerly Tyco Healthcare].)

Currently available disposable units include the Easy Cap, the A.C.E. STAT-Check CO₂ Indicator, and the unit produced by Resuscitation ACE Inc. The Easy Cap end-tidal CO₂ detector (Figure 12-39) is the original unit and quite widely used. It is available in a neonatal/pediatric size for infants weighing less than 15 kg and in a standard size for larger children and adults. Its carbon dioxide indicator changes color from dark purple to yellow when CO₂ is exhaled through it. The other two disposable units also indicate the presence of exhaled CO₂ by an indicator turning purple.

One choice for an intubation capnograph is the MiniCAP III CO₂ detector. It is a reusable item that has a mainstream type of infrared carbon dioxide detector. The unit is powered by a battery pack. Its light-emitting diode signals the presence of carbon dioxide with each exhalation. A capnograph should be selected if it is necessary to obtain a more accurate CO₂ reading. Remember that capnography cannot confirm that the tube is properly placed in the trachea rather than a bronchus. Check for equal, bilateral breath sounds. See Chapter 5 for a full discussion on capnometry.

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

The Easy Cap is a single unit within a sealed foil container. Remove the unit from the container and compare the initial purple color of the indicator with the purple color labeled CHECK on the product dome. Do not use an Easy Cap unit whose color is not the same or darker than that on the product dome. Attach the Easy Cap to the patient’s endotracheal tube by its 15-mm-ID connector port. The Easy Cap’s 15-mm-OD circuit end is connected to the manual resuscitator to ventilate the patient’s lungs. If a heat and moisture exchanger is used, it should be placed between the patient’s endotracheal tube and the Easy Cap and manual resuscitator. The Easy Cap should not be used with a heated humidifier or nebulizer because too much humidity affects its accuracy. The unit is not intended to be used for more than 2 hours because the color change will fade.

The MiniCAP III has a disposable adapter that connects the mainstream CO₂ detector to the patient’s endotracheal tube. The adapter has a 15-mm-ID end for attachment to the endotracheal tube and a 15-mm-OD end to which the manual resuscitator can be attached. The assembly and operation of a capnograph are discussed in Chapter 5. Review this material if necessary.

3. Troubleshoot any problems with the equipment

Because the Easy Cap is a self-contained single-piece unit, there is nothing to repair. The following items can contaminate the Easy Cap and cause a patchy yellow or white discoloration of the indicator: stomach contents, mucus, pulmonary edema fluid, and intratracheal epinephrine. If the color does not change with the breathing cycle, the Easy Cap unit should be discarded. The 15-mm-ID patient connector port fits only over the endotracheal tube adapter. The 15-mm-OD circuit connector port fits only into the manual resuscitator or demand-valve adapter.

The adapter is the only removable part in the MiniCAP III. It fits only in one direction into the CO₂ detection unit. The other end of the adapter fits only into a manual resuscitator outlet. Some limitations exist in the use of an Easy Cap carbon dioxide detector. It should not be used during mouth-to-mouth resuscitation, to detect right mainstem bronchus intubation, to detect hypercarbia, or to determine the placement of an esophageal obturator airway.

Troubleshooting with a capnograph was presented in Chapter 5.

6. Recommend a chest radiograph to help determine the patient’s condition and review the chest radiograph (Code: IC2 and IIIE1) [Difficulty: ELE: R, Ap; WRE: An]

A chest radiograph should always be taken to confirm the location of a newly placed endotracheal or tracheostomy tube. The chest radiograph should be repeated if there has been a significant change in the patient’s condition or if the tube has been pulled back or pushed deeper into the trachea. Ideally the tip of the tube is in the middle of the trachea. In the adult this would be several centimeters above the carina.

A chest radiograph also confirms the presence and location of an opaque foreign body in the airway. Metallic objects, stones, and coins can be clearly seen. Less radiopaque objects can be barely seen, if at all. The chest radiograph also detects a pneumothorax related to the tracheostomy procedure or other pulmonary conditions. If needed, an upper airway radiographic examination can be performed to look for a foreign body or to check the position of the tracheostomy tube.

7. Review the upper airway or chest radiograph to see the position of the endotracheal or tracheostomy tube (Code: IB7b) [Difficulty: ELE: R, Ap; WRE: An]

All modern endotracheal and tracheostomy tubes contain a strip of radiopaque material near the distal tip of the tube. This is easily noticed as the white line s een on the chest radiograph and confirms the location of the tip of the tube in the airway (see Figure 12-20). The ideal location of the tip of the endotracheal tube is the middle third of the trachea. When the tube is positioned properly, it is less likely for the tip to be pushed into the carina when the patient bends his or her head forward or for the cuff to hit the vocal cords if the patient’s head is bent back. Both endotracheal and tracheostomy tubes should be positioned midline within the trachea. They should not be twisted laterally because the tip can cause damage to the tracheal wall.

Exam Hint 12-7 (ELE)

Be prepared to determine the proper placement of the endotracheal tube by any of the following: (1) palpation of the larynx and neck, (2) auscultation of bilateral breath sounds, (3) determination of moisture condensation within the tube during exhalation, (4) detection of exhaled carbon dioxide, (5) observation of bilateral symmetric chest movement on inspiration, (6) visualization of the tip of the tube on a chest radiograph, or (7) observation that the 24-cm mark on the tube will be at an adult’s front teeth (incisors).

8. Maintain the proper position of an endotracheal tube (Code: IIIB4c) [Difficulty: ELE: R, Ap; WRE: An]

As mentioned earlier, an endotracheal tube is ideally located within the middle third of the trachea. Check the chest radiograph for positioning. If the tube is too high within the trachea, it may be pulled up through the vocal cords if the patient’s head is hyperextended. An air leak may be heard at the larynx if the patient is using a mechanical ventilator. In this case, the cuff should be deflated and the tube inserted deeper into the trachea.

Conversely, if the tip of the tube is inserted too deeply into the trachea, it may be pushed into a mainstem bronchus if the patient’s head is moved toward the chest. In this situation no breath sounds would be heard in the opposite lung (usually the left). The cuff should be deflated and the tube pulled up into the middle third of the trachea. Reinflate the cuff after the tube is repositioned. A chest radiograph should be taken to confirm the tube’s position after it has been moved.

The endotracheal tube body has centimeter marks inscribed on it, starting at the distal end and finishing at the proximal end. Check and record the centimeter mark present at the patient’s teeth or gums. The average adult’s distance from the midtrachea to the teeth is about 23 to 25 cm. The practitioner can determine if the tube has been accidentally pulled out a little or pushed further into the patient by looking at the current centimeter mark. If the tube is intentionally adjusted, the new centimeter mark should be checked and recorded.

A wide variety of handmade, as well as manufactured, devices are available to secure the endotracheal tube in the correct position. Figure 12-40 shows one way to make a tube holder from adhesive tape. This is flexible when the patient moves and is inexpensive. Tincture of benzoin can be applied to the patient’s cheeks to make the tape hold more securely without tearing the skin. An oropharyngeal airway may or may not be needed.

Figure 12-40 Taping the endotracheal tube to secure it in the airway.

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

The manufactured tube holders are made of plastic with cloth ties and usually include a built-in bite block. Make sure that it is sized properly to the patient’s mouth. Too large a bite block can injure the tongue, lips, and mouth. Watch for a gag reflex. This type of holder is useful in the patient who is prone to seizures.

A tracheostomy tube should be positioned so that the flange is snug against the base of the neck and the outer cannula is within the trachea. If pulled out too far, the cuff may be seen at the stoma. An air leak may be heard or secretions may be seen to bubble out of the stoma. Correct the problem by deflating the cuff, inserting the tube so that the flange is against the base of the neck, and reinflating the cuff.

Exam Hint 12-8 (ELE, WRE)

There is usually a question that addresses understanding that the lack of breath sounds over the left lung indicates that the endotracheal tube has been placed into the right mainstem bronchus. Deflate the cuff and withdraw the tube into the trachea. Note the 24-cm mark on the tube is at the adult patient’s front teeth (incisors).

9. Maintain the appropriate cuff inflation of an endotracheal tube or tracheostomy tube (Code: IIIB4c, 4d) [Difficulty: ELE: R, Ap; WRE: An]

All of the adult and larger pediatric endotracheal and tracheostomy tubes have a cuff for sealing the airway. Most brands of modern tubes have cuffs that are designed to have a relatively large reservoir volume that fills at a relatively low pressure. The soft, flexible balloon seals the airway by having a large surface area that conforms to the shape of the trachea.

a. Determine tracheal tube cuff pressure and/or volume (Code: IB9r) [Difficulty: ELE: R, Ap; WRE: An]

There are two slightly different ways to inflate the cuff and maintain a safe cuff pressure. Both methods can be used only with patients on a positive-pressure ventilator.

1. Minimal leak

1. Connect the cuff pressure measuring device (see next discussion) to the one-way valve on the cuff inflating tube.

2. Listen with a stethoscope over the patient’s larynx.

3. Inflate or deflate the cuff as necessary while listening for an air leak.

4. Stop changing the air volume when a minimal leak is heard at the peak airway pressure in the breathing cycle. The tidal volume should still be delivered except for this minor leak.

5. Note the cuff pressure when the minimal leak was heard. Note the cuff volume, if possible.

6. Disconnect the cuff pressure measuring device.

7. It may be necessary to add more volume and pressure to the cuff if the leak gets worse when the peak airway pressure increases.

2. Minimal occluding volume

The purpose is to find the cuff pressure that results in no leak at the cuff when the patient’s airway pressure is greatest. The following are the steps in the procedure:

1. Connect the cuff pressure measuring device (see next discussion) to the one-way valve on the cuff inflating tube.

2. Listen with a stethoscope over the patient’s larynx.

3. Inflate or deflate the cuff as necessary while listening for an air leak.

4. Stop changing the air volume when no leak is heard at the peak airway pressure in the breathing cycle.

5. Note the cuff pressure when the seal was heard. Note the cuff volume, if possible.

6. Disconnect the cuff pressure measuring device.

7. It may be necessary to add more volume and pressure to the cuff if a leak results when the peak airway pressure increases.

This discussion relates only to those tubes that must be actively filled with air and have variable intracuff pressures. Several manufacturers have developed endotracheal and tracheostomy tubes that have built-in cuff pressure limitations. Follow the manufacturer’s guidelines when inflating these cuffs. This discussion would not be complete without mentioning the recent manufacture of systems designed to raise the cuff pressure to match the peak airway pressure of a patient using a mechanical ventilator. A tube connects the inspiratory circuit to the one-way valve on the cuff inflating tube. As a positive-pressure breath is delivered, the pressure in the circuit is also applied to the patient’s cuff. There should be no loss of tidal volume. When the patient exhales and the airway pressure drops to normal, the cuff pressure also drops back to its normal level.

3. Select a cuff pressure and/or volume measuring system

A cuff pressure manometer is needed to measure the air pressure within an endotracheal or tracheostomy tube cuff. When a tracheal tube is first inserted, the volume of air that is injected into the cuff should be measured and charted. The pressure within the cuff should also be noted. After that, if more air is inserted or any air is removed from the cuff it should be measured and recorded in the chart. The resulting final cuff pressure must also be recorded. A number of manufactured units are available for measuring cuff pressure. The Cufflator (Figure 12-41) is discussed here because it is widely used. This system consists of a pressure gauge calibrated in centimeters of water, a hand-pumped reservoir, an internal one-way valve, a pressure release valve, and an adapter to fit into the one-way valve on the cuff inflating tube. A three-way stopcock can be added to the one-way valve adapter. This can be used to prepressurize the system before attaching it to the patient’s one-way valve on the cuff inflating tube. The pressure in the cuff can be measured as air is added by squeezing the hand pump or as air is removed by the pressure release valve. The volume of air added or removed cannot be measured.

Figure 12-41 Cufflator device used to measure cuff pressure with its component parts.

A second system can be “homemade,” although it is also commercially available. It consists of a 5- to 10-mL syringe, a three-way stopcock, and a pressure gauge (either millimeters of mercury or centimeters of water). The syringe and pressure gauge are attached to two of the ports on the stopcock. The third port on the stopcock is connected to the one-way valve on the cuff inflating tube. When the stopcock handle is opened to all three ports, the pressures throughout the system and the cuff are the same. Air can be added or removed with the syringe. The pressure gauge shows the system and cuff pressure as the air volume is adjusted (Figure 12-42). One advantage of this system over the Cufflator is that the volume of air that is added or subtracted can be measured. This system can also be prepressurized so that its pressure matches the pressure anticipated in the cuff. With any of these systems, it is necessary to keep airtight connections. If the pressure drops unexpectedly, an air leak will be noticed. Tighten the connections to create a seal so that the pressure is maintained.

Figure 12-42 Cuff measuring device made from pressure manometer, three-way stopcock, and 10-mL syringe.

It is commonly recommended that the cuff pressure be monitored at least every 8 hours or whenever air is injected or withdrawn from the cuff.

b. Interpret the tracheal tube cuff volume and/or pressure (Code: IB10r) [Difficulty: ELE: R, Ap; WRE: An]

All manufacturers (except Kamen-Wilkenson) have designed cuffs that must be actively filled with air by way of a one-way valve and syringe. These cuffs have greater than atmospheric pressure within them. That pressure is placed against the wall of the trachea. The greater the pressure on the wall of the trachea, the greater the disruption of normal lymphatic and blood flow. Shapiro and colleagues (1991) stated that a patient with a normal blood pressure (120/80 mm Hg) has the following effects at these cuff pressures:

• Lymphatic flow blockage occurs at cuff pressures greater than 5 mm Hg (8 cm H₂O). Edema of the tracheal mucosa results.

• Capillary blood flow blockage occurs at cuff pressures greater than 18 mm Hg (24 cm H₂O). (Hess [1999] states that the capillary perfusion pressure ranges between 25 and 30 mm Hg.) Venous (and lymphatic) drainage stops as a result.

• Arterial blood flow blockage occurs at cuff pressures greater than 30 mm Hg (42 cm H₂O). Arterial (and lymphatic and capillary) flow stops as a result.

In general, the clinical goal is to keep the cuff pressure as low as possible to make sure that the circulation through the tracheal wall is normal. Based on the information from Shapiro and colleagues and Hess, it seems reasonable to try to keep the cuff pressure no greater than 20 to 25 mm Hg (25 to 35 cm H₂O). This is true for all normotensive patients. Hypertensive patients may be able to tolerate higher cuff pressures than normotensive patients before blood flow to the tracheal tissues is stopped. Hypotensive patients suffer from the loss of blood flow to the tracheal wall at lower cuff pressures than those previously listed.

c. Inflate and/or deflate the cuff (ELE code: IIIF2g4) [Difficulty: ELE: R, Ap, An]

A spontaneously breathing patient must have the cuff inflated to prevent the aspiration of oral secretions into the lungs. In general, keep the pressure at about 20 mm Hg (25 cm H₂O), as discussed earlier. It may be necessary to keep a higher cuff pressure in a mechanically ventilated patient. However, Shapiro and associates recommend that if the cuff pressure must be greater than 20 mm Hg, the endotracheal or tracheostomy tube is too small. Ideally, the tube should be replaced with a larger one. However, some patients are too unstable to tolerate reintubation of their airways and must simply have the cuff pressure increased temporarily.

It is clear that a cuff pressure greater than the patient’s mucosa capillary pressure prevents the flow of blood through the area covered by the cuff. Tissue ischemia (hypoxemia) results. If the ischemia is severe enough, tissue necrosis follows. The higher the cuff pressure and the longer the high cuff pressure is maintained, the greater the likelihood of tissue necrosis. If the necrosis is circumferential (all the way around) to the trachea, tracheal stenosis may occur. Tracheal stenosis is found when the diameter of the trachea is narrowed because of scar tissue buildup after the normal mucosa and underlying tissues have died. The patient’s airway is permanently narrowed and, if serious, must be surgically corrected. Another severe complication of high cuff pressures and tracheal necrosis is the development of a tracheoesophageal fistula. This is an opening between the trachea and esophagus. This is more likely when the patient also has a nasogastric tube in place. The fistula permits food to pass into the airway and lungs, causing pneumonia. Mechanical ventilation is more difficult because of the air leak from the lungs to the esophagus. Surgical repair of the fistula is required.

Exam Hint 12-9 (ELE, WRE)

There is usually a question that either addresses adjusting a cuff pressure to a safe level of no more than 20 to 25 mm Hg (25 to 35 cm H₂O) or involves recommending replacement of a tracheal tube that is too small and requires too high a cuff pressure with a larger tube. A small endotracheal tube should also be replaced with a larger one if a patient cannot wean from the ventilator because of the high airway resistance created by the smaller tube.

MODULE K

Endotracheal extubation

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]

There are usually only two reasons to replace a patient’s endotracheal tube. First, the tube should be changed if it is too small and the cuff must be overfilled to seal the airway. Excessive pressure results in damage to the tracheal wall as previously discussed.

Second, the tube should be replaced if the cuff is leaking or ruptured and the airway cannot be sealed. The patient may be reintubated by the procedure described earlier. Alternatively, a tube-changing stylet may be used (Figure 12-43). The stylet is a hollow, flexible plastic tube that can be bent and holds its shape. It has a center mark and 1-cm markings counting out to each end. These are to help keep the proper depth for inserting the replacement endotracheal tube. It can be used on an endotracheal tube that is at least 7.5-mm inner diameter. The procedure for changing the endotracheal tube with a tube-changing stylet includes the following:

1. Obtain the needed equipment: replacement endotracheal tube and one that is a size smaller, 10-mL syringe to inflate the cuff, sterile gloves, goggles, and sterile water-soluble lubricant. Make sure the cuff inflates and deflates properly.

2. Tell the patient what you are going to do. Put on the gloves, goggles, and mask.

3. Remove the patient’s oxygen equipment.

4. Suction the secretions from the patient’s trachea and oral pharynx.

5. Reoxygenate and ventilate the patient’s lungs.

6. Place some lubricant on the outside of the stylet.

7. Remove the oxygen equipment and pass the stylet through the endotracheal tube into the patient’s trachea.

8. Insert it to about the same depth as marked on the distal end of the endotracheal tube. For example, if the distal end of the endotracheal tube is 22 cm, insert the tube changer to 22 cm.

9. Deflate the cuff on the endotracheal tube.

10. While holding the distal tip of the tube changer in place, pull the defective endotracheal tube over the tube changer and out of the patient.

11. Advance the new endotracheal tube over the stylet. Hold the distal end of the stylet and push the new tube into the patient to the same depth mark on the stylet as the old tube had been positioned.

12. Hold the endotracheal tube in place and remove the stylet.