MANAGEMENT OF THE AIRWAY

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CHAPTER 4 MANAGEMENT OF THE AIRWAY

PRETEST QUESTIONS

Answer the pretest questions before studying the chapter. This will help you determine your strong and weak areas in the material covered.

1. A patient has just been intubated, and the CO₂ detector placed on the proximal end of the ET tube reads 1.5%. The respiratory therapist should suspect which of the following?

A. The tube is in the trachea.

B. The tube is in the right mainstem bronchus and should be withdrawn 4 cm.

C. The tube is in the esophagus.

D. The tube is at the level of the carina and should be withdrawn 2 cm.

2. Opening the patient’s airway using an oropharyngeal airway is most beneficial when which of the following causes the obstruction?

B. Foreign body

3. McGill forceps are used during which of the following procedures?

A. Nasotracheal intubation

B. Oral intubation

D. Insertion of an esophageal obturator airway (EOA)

4. The physician wants to begin weaning a patient from a tracheostomy tube. How may this best be accomplished?

A. Deflate the cuff every 2 h.

B. Change to a fenestrated tracheostomy tube.

C. Keep the cuff inflated and remove the inner cannula.

D. Change to a tracheostomy tube with a foam cuff.

5. You are called to a patient’s room because a ventilator alarm is sounding. You hear an audible leak around the patient’s ET tube during a ventilator breath and notice the exhaled volume reading is 150 mL less than the set VT. You check the cuff pressure and find that it is 12 mm Hg. Which of the following is the appropriate action to take?

A. Maintain the current cuff pressure and increase the patient’s VT to compensate for the leak.

B. Instill enough air to maintain a cuff pressure of 30 mm Hg.

C. While listening with a stethoscope at the larynx, instill air into the cuff until a slight leak is heard on inspiration.

D. Instill enough air until only a slight audible leak is heard.

6. You want to pass a suction catheter into the patient’s left lung to obtain a sputum specimen. What is the most appropriate method of accomplishing this?

A. Have the patient turn his or her head to the left.

B. Have the patient turn his or her head to the right.

C. Use a coudé suction catheter.

D. Use a catheter that is one half the internal diameter of the patient’s airway.

See answers and rationales at the back of the text.

REVIEW

I. UPPER AIRWAY OBSTRUCTION

CRT Exam Content Matrix: IB1a-b, 2b, 7d, IIIB1, III I1a-d

RRT Exam Content Matrix: IB1a-b, 2b, 7d, IIIB1, III I1a-c

A. Main Causes of Upper Airway Obstruction

1. Tongue falling back against the posterior wall of the pharynx, which is caused by unconsciousness or CNS abnormality; patients with macroglossia (enlarged tongue) are at greater risk

2. Edema, or postextubation inflammation and swelling, of the glottic area

5. Foreign substances

a. Foreign bodies

6. Laryngospasm

B. Signs of Partial Upper Airway Obstruction

1. Crowing, gasping sounds on inspiration

2. Inability to cough (with a slight obstruction, the patient may be able to cough)

3. Increasing respiratory difficulty

4. Good to poor air exchange (depending on the severity of the obstruction)

5. Exaggerated chest and abdominal movement without comparable air movement

6. Cyanosis (depending on the severity of the obstruction)

C. Signs of Complete Upper Airway Obstruction

1. Inability to talk

2. Increased respiratory difficulty with no air movement

4. Sternal, intercostal, and epigastric retractions

5. Use of accessory muscles of the neck and chest

6. Extreme panic

7. Unconsciousness and respiratory arrest if obstruction is not removed

D. Treatment of Airway Obstruction

1. If the patient is conscious and has a partial airway obstruction, the patient should be monitored closely and allowed to try to relieve the obstruction on his or her own.

2. If the patient is conscious and has a complete airway obstruction caused by food or a foreign object, abdominal thrusts must be performed until the object is dislodged. (See Chapter 6 on cardiopulmonary respiration [CPR].)

3. If the patient is unconscious and has a partial or complete airway obstruction that is most likely caused by the tongue, the head tilt and chin lift maneuver will help relieve the obstruction by moving the tongue forward.

II. ARTIFICIAL AIRWAYS

CRT Exam Content Matrix: IB1a-b, IB2b, IB4a, IB9c, IB10c, IC9, IIA7a-g, IIIB1-7, IIIE3d, IIIE4e, IIIE11, IIIF2g1, 5, IIIJ1,4

RRT Exam Content Matrix: IB1a-b, IB2b, IB4a, IB9c, IB10c, IC10, IIA3a-b, IIIB1-3d, IIIE3c, IIIE4b, IIIE9, IIIF2d1-2, IIIJ1, 4

A. Oropharyngeal Airway

FIGURE 4-1

1. This airway maintains a patent airway by lying between the base of the tongue and the posterior wall of the pharynx, preventing the tongue from falling back and occluding the airway.

2. This airway must only be used on the unconscious patient because a conscious patient would gag on the airway, which could potentially lead to aspiration.

3. This airway should never be taped in place because the airway must be easily removable to prevent vomiting and aspiration if the patient becomes conscious.

4. Proper insertion of the oropharyngeal airway

FIGURE 4-2

a. Measure the airway from the corner of the lip to the angle of the jaw to ensure proper length.

b. Remove foreign substances from the mouth.

c. Hyperextend the neck.

d. Using the cross-finger technique, open the patient’s mouth and insert the airway with the tip pointing toward the roof of the mouth.

e. Observe the airway passing the uvula, and rotate the airway 180 degrees.

5. Hazards of oropharyngeal airways

a. The patient may gag or fight the airway; if this occurs, remove the airway immediately.

b. If the airway is inserted improperly, the base of the tongue may be pushed into the back of the throat, obstructing the airway.

c. If the airway is too large, the epiglottis may be pushed into the laryngeal area.

d. If the airway is too small, it may be aspirated or ineffective in relieving obstruction.

6. Important points concerning oropharyngeal airways

a. Oropharyngeal airways may be used in the unconscious, orally intubated patient to prevent the patient from biting the ET tube.

b. Berman airways are made of hard plastic and have a groove down either side to guide a suction catheter to the glottic area.

c. Guedel airways are made of a soft, pliable material, which has an opening through the middle to allow the passing of a suction catheter into the glottic area.

B. Nasopharyngeal Airway

FIGURE 4-3

1. This airway maintains a patent airway by lying between the base of the tongue and the posterior wall of the pharynx.

2. This airway is constructed of soft pliable rubber; it is inserted as follows:

a. Select the proper size by measuring the airway from the tip of the nose to the earlobe. The outside diameter of the airway should be equal to the inside diameter of the patient’s internal nares.

b. Lubricate the airway with a water-soluble gel and insert into the patient’s nostril.

c. The flanged end should rest against the nose, and the distal tip should rest behind the uvula.

d. Place tape around the flanged end to secure the airway in place. (A safety pin may be inserted through the flange and the pin taped to the face.)

3. This airway is tolerated by the conscious patient.

4. This airway is most commonly used to facilitate nasotracheal suctioning.

5. Hazards of nasopharyngeal airways

a. An airway that is too small may be aspirated.

b. Nasal irritation may result. To prevent nasal irritation, alternate nostrils daily.

C. Laryngeal Mask Airway

FIGURE 4-4 Laryngeal mask airway.

Courtesy LMA North America, Inc.

1. The laryngeal mask airway (LMA) is designed to be used as an alternative to a face mask for achieving and maintaining control of the airway during surgery when tracheal intubation is not necessary or in emergencies when ET intubation cannot be accomplished after several attempts.

2. For the airway to be inserted successfully, the patient must be anesthetized so that the upper airway reflexes are obtunded; otherwise, laryngospasm may occur.

3. The LMA consists of a tube that is fused to an elliptical, spoon-shaped mask. When inserted, the tube protrudes from the patient’s mouth and is connected to a manual resuscitator via a standard 15-mm adapter.

4. The mask resembles a miniature face mask and has an inflatable rim that is filled with air via a pilot valve–balloon system.

5. The tube opens into the middle of the mask through three vertical slits that prevent the tip of the epiglottis from falling back and blocking the lumen of the tube.

6. The LMA is inserted through the mouth and into the pharynx after being lubricated with a water-soluble gel. The device is advanced until resistance is met. Then the mask is inflated, providing a low-pressure seal around the laryngeal inlet. The posterior aspect of the tube is marked with a black line, which should be seen midline against the patient’s upper lip when the airway is placed properly (see Figure 4-5).

7. LMAs are available in all sizes and can be used in patients of all ages, from neonates to adults.

8. Indications for LMA

a. Difficult face mask fit

b. Unsuccessful intubation and difficulty ventilating with bag-mask

c. Unavailability of personnel trained in ET intubation

d. Elective surgical procedures

9. Contraindications for LMA

a. Health care provider not trained in the use of the LMA

b. If risk of aspiration exists

10. Advantages of the LMA

a. This airway can be quickly inserted to provide ventilation when bag-mask ventilation is not adequate and ET intubation cannot be accomplished.

b. Tidal volume delivered may be greater when the LMA is used as opposed to bag-mask ventilation.

c. There is less gastric insufflation than with bag-mask ventilation.

d. The LMA ventilates equally as well as an ET tube.

e. Training is simpler than for ET intubation.

f. There is no risk of esophageal or bronchial intubation.

g. There is less risk of trauma to the airway than with ET intubation.

h. There is less coughing, laryngospasm, sore throat, and hoarseness than with ET intubation.

11. Disadvantages of LMA

a. Does not provide protection against aspiration of gastric contents

b. Cannot be used if the mouth cannot be opened more than 0.6 inches (1.5 cm)

c. May not be effective when airway anatomy is abnormal

d. May be difficult to provide adequate ventilation if high airway pressures are required

12. Insertion technique

a. Using the index finger, advance the LMA until resistance is met. The tip of the LMA should rest against the upper esophageal sphincter in the hypopharynx. The cuff should be inflated until no leak is heard. To determine proper position, auscultate the lungs bilaterally. Capnography may also be used to confirm an adequate airway.

b. To determine whether mild laryngospasm is present as a result of light anesthesia, auscultate the anterolateral neck for the presence of wheezing.

c. Because the LMA does not protect the airway from regurgitation, the patient must not eat for several hours before insertion.

FIGURE 4-5 LMA Insertion.

Courtesy LMA North America, Inc.

FIGURE 4-6 LMA Insertion.

Courtesy LMA North America, Inc.

FIGURE 4-7 LMA Insertion.

Courtesy LMA North America, Inc.

D. Esophageal–Tracheal Combitube

FIGURE 4-8 The Combitube is inserted with the head in the neutral position (A) and both cuffs inflated (B). The two possible locations of the distal lumen are the usual esophageal location (C), in rare cases, the trachea (D).

From Cairo J, Pilbeam S: Mosby’s respiratory care equipment, ed 8, St Louis, 2010, Mosby.

1. The esophageal–tracheal combitube (ETC) is similar to an EOA but is a double-lumen tube. The tubes run parallel to each other.

2. Once the tube is inserted, a pharyngeal balloon that occludes the pharynx is inflated to prevent air from leaking out the nose or mouth. Because of this, a mask is not necessary. A cuff is located on the distal end of the tube.

3. Once the airway is advanced beyond the pharynx, it enters into either the trachea or the esophagus. It makes no difference which structure it enters.

4. A balloon at the distal end of the tube is inflated and will seal off either the trachea or the esophagus. If the tube rests in the trachea, that lumen is used to ventilate the patient just like an endotracheal tube. If the tube rests in the esophagus, the patient is ventilated through holes in the upper part of the tube below the pharyngeal cuff, like those on the EOA.

5. To determine which tube to ventilate through, attach the resuscitator bag to tube No. 1 (esophageal tube) and begin bagging. If the chest rises, breath sounds are auscultated over the lungs and no air is heard over the epigastric region; the ETC is in the esophagus, and ventilation is occurring through the holes above the distal cuff. The use of a CO₂ detector is very helpful in determining tube placement.

6. If the chest does not rise or sounds are only heard over the epigastrium, the resuscitator bag should be attached to the other tube (No. 2) and ventilation started. If the ETC is in the trachea, the chest should rise. Confirm the placement by auscultating over the epigastrium and the chest. The use of CO₂ detector is very helpful.

7. Indications for the ETC

a. Difficult face mask fit

b. Unsuccessful intubation and difficulty ventilating with bag-mask

c. No one available that has been trained in endotracheal intubation

8. Contraindications for the ETC

a. Patient with an intact gag reflex

b. Patient with known or suspected esophageal disease

c. Patient known to have ingested a caustic substance

d. Suspected upper airway obstruction because of laryngeal foreign body or pathology

e. Patient less than 4 feet tall

9. Advantages of the ETC

a. Minimal training and retraining required

b. Visualization of the upper airway or use of special equipment not required for insertion

c. May be useful for patients with suspected neck injury because the head does not need to be hyperextended

d. Face mask not needed because of the oropharyngeal balloon

e. Can provide a patent airway with either tracheal or esophageal placement

f. If placed in the esophagus, allows suctioning of gastric contents without interruption of ventilation

g. Reduces the risk of aspiration of stomach contents

10. Disadvantages of the ETC

a. Proximal port may be occluded with secretions

b. Difficulty in determining proper tube location resulting in ventilation through wrong tube

c. Soft tissue trauma because of rigidity of the tube

d. Cannot suction the trachea if the tube is in the esophagus

e. Esophageal trauma from poor insertion technique

E. ET Tubes

1. Indications for ET Tubes

a. Relief of upper airway obstruction resulting from laryngospasm, epiglottitis, or glottic edema

b. Protection of the airway. The airway has four protective reflexes:

(1) Pharyngeal reflex: gag and swallowing

(2) Laryngeal reflex: laryngospasm

(3) Tracheal reflex: coughing when trachea is irritated

(4) Carinal reflex: coughing when carina is irritated

When these reflexes are obtunded or knocked out, the airway must be protected with an ET tube. Paralysis, drugs, loss of consciousness, or neuromuscular disease may obtund these reflexes.

As these reflexes become obtunded, they are lost in progression from the pharyngeal to the carinal. As they are recovered, they come back in progression from the carinal to the pharyngeal.

c. Facilitation of tracheal suctioning

d. Assistance in manual or mechanical ventilation

2. Hazards of ET tubes

a. Contamination of the tracheobronchial tree

b. Cough mechanism reduced

c. Damage to the vocal cords

d. Laryngeal or tracheal edema

e. Mucosal damage leading to tracheal stenosis

f. Tube occlusion with inspissated secretions

g. Loss of patient’s dignity

h. Loss of patient’s ability to talk

3. Steps to perform ET intubation

FIGURE 4-9

a. Select a laryngoscope with a Miller (straight) blade or a McIntosh (curved) blade. Make sure the lightbulb is tight because it will not light if it is loose. If the light source is dim or is yellowish in color, the batteries are weak and should be replaced.

b. Place the patient in the “sniffing position” (head above shoulder level).

c. Select the proper size of ET tube, insert air into the cuff to make sure it holds air, and then deflate the cuff.

d. Insert a stylet into the ET tube to make the tube more rigid for easier insertion. Make sure the stylet doesn’t extend past the end of the tube.

e. Insert the laryngoscope blade into the right side of the mouth and move the tongue to the left.

f. Advance the blade forward.

FIGURE 4-10

(1) The curved blade (McIntosh) should be inserted between the epiglottis and the base of the tongue (vallecula). With a forward and upward motion, raise the epiglottis to expose the glottis and vocal cords.

(2) The straight blade (Miller) should be placed under the epiglottis and lifted upward and forward to expose the cords.

FIGURE 4-11 View of the larynx through the laryngoscope.

Never exceed 15 to 20 s per intubation attempt. The blade and tube in the back of the throat may stimulate the vagus nerve, which may lead to bradycardia. Remove the blade and tube and use bag-mask ventilation until cardiac status has stabilized.

g. As the cords are observed, advance the ET tube approximately 2 cm past the cords.

Exam Note

If the tube is inserted too far, it will enter the right mainstem bronchus.

h. Inflate the cuff and listen for equal and bilateral breath sounds. If louder sounds are heard on the right than the left, then the tube probably is in the right mainstem. Deflate the cuff and withdraw the tube until equal breath sounds are heard.

i. Another method to determine whether the tube is in the airway is by exhaled CO₂ analysis, or capnometry. If the ET tube is in the airway, CO₂ levels begin to rise, as seen on the capnogram. End-tidal CO₂ levels are generally around 6%. If the tube is in the esophagus, the end-tidal CO₂ reading remains near zero.

j. An easier and less expensive method of monitoring exhaled CO₂ levels is with the use of a disposable colorimetric CO₂ detector on the proximal end of the ET tube. The indicator on the detector changes colors when exposed to different CO₂ levels.

Exam Note

During resuscitative procedures when cardiac output and blood pressure are low, gas exchange is reduced and the CO₂ detector may read near zero even when the ET tube is in the trachea.

Exam Note

The average distance from the teeth to the carina is 27 cm. Note that the ET tube has markings in centimeters indicating the distance to the end of the tube from that point. Therefore, taping the tube at the 23- to 25-cm mark at the teeth will most likely place the tube in a proper position.

Table 4-1 Appropriate Endotracheal Tube Sizes

Newborns (by body weight)
Less than 1 kg	2.5 mm
1 to 2 kg	3.0 mm
2 to 3 kg	3.5 mm
More than 3 kg	4.0 mm
Children (by age)
6 mo	3.0-4.0 mm
18 mo	3.5-4.5 mm
2 yr	4.0-5.0 mm
3 to 5 yr	4.5-5.5 mm
6 yr	5.5-6.0 mm
8 yr	6.0-6.5 mm
12 yr	6.0-7.0 mm
16 yr	6.5-7.5 mm
Adults (by gender)
Women	7.5-9.0 mm
Men	8.0-9.5 mm

FIGURE 4-12 A Disposable colorimetric device for detecting the presence of CO₂ in expired gas.

Courtesy Nellcor Puritan Bennett, Pleasanton, Calif. part of Covidien.

k. Tape the tube in place and obtain a stat chest x-ray film to ensure proper tube placement. The end of the tube should rest 2 to 5 cm above the carina. The carina is seen on radiographs at the fourth rib or the fourth thoracic vertebra.

4. Parts of the ET tube

FIGURE 4-13

5. ET tube markings

a. IT (implantation tested): indicates the material in the tube is nontoxic and does not cause tissue reaction when implanted in rabbit tissue.

Polyvinylchoride is the most common material used in ET tubes.

b. Z-79: the Z-79 Committee for Anesthesia Equipment for the American National Standards Institute. This committee ensures that the tube manufacturer is using material that is not toxic to tissues.

c. ID: internal diameter of the tube in millimeters. This is how the tubes are designated by size.

d. OD: outside diameter of the tube in millimeters. Also measured in French (Fr) units.

e. Numbers and marks indicate the distance in centimeters from that mark to the distal tip of the tube.

6. Complications of ET tubes

a. Poorly tolerated by conscious or semiconscious patients

b. Difficult to stabilize because of the movement of the tube

c. Stimulates oral secretions

d. Gagging caused by tube irritation

e. More difficult to pass suction catheter as a result of the curvature of the tube and poor stabilization

f. Harder for the patient to communicate

g. Harder to attach equipment to a poorly stabilized ET tube

h. Patient may bite the tube, occluding air flow and setting off the ventilator high-pressure alarm, which ends inspiration prematurely.

i. Erodes corners of patient’s mouth

7. Nasotracheal tubes

a. These are considered nonemergent tubes.

b. Nasotracheal intubation

(1) Nose should be anesthetized with lidocaine or cocaine spray. A vasoconstrictor, such as phenylephrine hydrochloride (Neo-Synephrine) drops, are used to shrink nasal mucosal blood vessels for easier tube insertion.

(2) Lubricate the tube with water-soluble gel and insert through a patent nostril.

(3) If the patient is alert and breathing spontaneously, try advancing the tube as the patient takes a deep breath or coughs. This is called “blind nasal intubation.”

(4) If the patient is not cooperative or is unconscious, visualize the tube in the mouth, grasp by Magill forceps, and guide through the vocal cords by means of direct visualization with a laryngoscope.

(5) Tape the tube in place when proper placement is assured.

c. Advantages of nasotracheal tubes (vs. oral tubes)

(1) Easier to stabilize

(2) Better tolerated by the patient because gagging is not as likely

(3) Less potential for inadvertent extubation

(4) Easier to attach equipment

(5) Easier to pass suction catheter

(6) Easier for patient to eat or drink

d. Complications of nasotracheal tubes

(1) Pressure necrosis of the nasal tissue

(2) Sinus obstruction, leading to sinusitis

(3) Obstruction of eustachian tube, resulting in middle-ear infections

(4) Septal deviation

(5) Bleeding during intubation or extubation

8. High-Lo Evac Tube

FIGURE 4-14 The Hi-Low Evac tube has a portal for suctioning subglottic secretions and is used as part of a program to reduce the incidence of ventilator-associated pneumonia in intubated patients.

From Cairo J, Pilbeam S: Mosby’s respiratory care equipment, ed 8, St Louis, 2010, Mosby.

a. This tube has a port to allow for continuous or intermittent suctioning of subglottic secretions. These secretions, if not removed, may drain down past the ET tube cuff to the lower airway, increasing the incidence of infection.

b. These tubes are being used to help prevent ventilator-associated pneumonia (VAP).

F. Tracheostomy Tubes

FIGURE 4-15

1. Insert tracheostomy tubes through an incision (stoma) made between the second and third tracheal rings.

2. Always insert the obturator into the outer cannula when advancing the tube into the stoma.

3. Once the tube is properly positioned, remove the obturator and insert the inner cannula.

4. Then inflate the cuff and secure the tube with tracheostomy ties.

5. Some tubes use foam cuffs (Mikity-Wilson Fome Cuff, Bivona Fome Cuf, and Kamen Fome Cuff), which are deflated during insertion; when the tube is in place, the cuff is allowed to resume its normal foam shape, which provides an effective seal against the tracheal wall. (This type of cuff exerts about 20 mm Hg pressure on the tracheal wall.)

6. Indications for tracheostomies

a. To bypass upper airway obstruction

b. To prevent problems posed by oral or nasal ET tubes

c. To allow patient to swallow and receive nourishment

d. For long-term airway care (ET tubes should be left in no longer than 3 to 4 wk.)

7. Immediate complications of tracheostomy tubes occurring within the first 24 h and associated with the tracheotomy procedure:

a. Pneumothorax

c. Air embolism from tearing of pleural vein

d. Subcutaneous emphysema

8. Late complications of tracheostomy tubes occurring more than 2 days after the tracheotomy:

c. Airway obstruction

d. Tracheoesophageal fistula

e. Interference with swallowing

f. Rupture of innominate artery

g. Stomal stenosis

Changing a tracheostomy tube within 48 h of the tracheotomy is not advisable and should only be done by a surgeon, if it is done at all, because the tracheal rings may recede when the tube is removed, making reintubation difficult.

9. Tracheal Stoma Care

a. Stoma care involves both the cleaning of the stoma site and the application of clean tracheostomy ties and dressing. This is a sterile procedure, so care must be taken to wear sterile gloves and perform the task as aseptically as possible.

b. The tracheostomy tube should be stabilized with one hand while the old dressing is removed. The old ties should be cut and then removed. Continuing to stabilize the tube at this point is essential to prevent accidental decannulation caused by coughing or sudden movement. Always have a spare tracheostomy tube at the bedside during this procedure.

c. The stoma area may be cleaned with 4- by 4-inch gauze pads soaked with hydrogen peroxide. After cleaning, discard the pads in a dirty area away from the sterile field. The stoma should be assessed for swelling, redness, or pulsation of the tube.

d. Cotton-tipped applicators may be dipped in peroxide to do more detailed cleaning around the stoma site and flanges of the tracheostomy tube.

e. After the stoma site is cleansed, rinse the site using gauze pads dipped in sterile water. Gently dry the area by patting with sterile gauze pads.

f. Apply a sterile 4- by 4-inch gauze pad dressing supplied with the tracheostomy care kit. Never make a dressing by cutting the gauze pad to the proper size. Cotton filaments from the gauze pad may be absorbed into the stoma and may result in an abscess.

g. The new ties may then be applied. The ties should be cut to the proper size before beginning stoma care so that the tube may be stabilized throughout the procedure. Use a square knot to secure the tube. Never use a bow, which can be easily untied.

h. The chest should be auscultated immediately after the procedure to ensure that the tube has been maintained in the proper position. If the patient exhibits respiratory distress, determine whether ventilation is adequate. If there is doubt about proper tube placement, remove the tube, cover the stoma with a sterile 4- by 4-inch gauze pad, and ventilate the patient’s lungs by mouth or with bag-mask ventilation.

Exam Note

If after changing a tracheostomy tube, you observe subcutaneous emphysema and respiratory distress and can auscultate little or no air movement, the tube is malpositioned and must be removed immediately; ventilate the patient’s lungs by bag-mask.

10. Special tracheostomy tubes

a. Fenestrated tracheostomy tube

FIGURE 4-16

(1) This tube is used to aid in weaning the patient from a tracheostomy tube and to allow the patient to talk.

(2) With the inner cannula removed, air may pass through the hole (fenestration) in the outer cannula, which allows for weaning from the tracheostomy tube and enables speech.

(3) The outer cannula may be plugged with the cap on the proximal end of the tube. With the cuff deflated, air flows through the tube, out the fenestration, and through the patient’s upper airway.

(4) If ventilation is necessary, the inner cannula may be reinserted and the cuff reinflated.

b. Tracheostomy button

FIGURE 4-17

(1) This airway consists of a short, hollow tube that is used to replace the tracheostomy tube but can still maintain a patent stoma, in case problems arise.

(2) The patient has complete use of the upper airway.

c. Kistner tracheostomy tube

FIGURE 4-18

(1) This airway is used to wean patients from tracheostomy tubes while maintaining a patent stoma.

(2) Kistner tubes are much like tracheostomy buttons, except they have a one-way valve on the proximal end of the tube.

(3) Air enters through the one-way valve and the tube during inspiration. As the patient exhales, the valve closes and the air flows up through the vocal cords and out the nose and mouth.

d. Speaking tracheostomy tubes

FIGURE 4-19 Passy-Muir valve in-line during mechanical ventilation.

(1) A constant gas flow is available above the cuff and around the vocal cords to allow speech.

(2) The cuff remains inflated.

e. Passy-Muir speaking valve

FIGURE 4-20 Passy-Muir speaking valves.

Courtesy Passy-Muir, Irvine, Calif.

(1) The Passy-Muir valve is a commonly used tracheostomy speaking valve that is placed on the proximal end of the tracheostomy tube (15-mm adapter).

(2) The cuff must be deflated. The patient’s inspired air passes through the valve, but on exhalation the valve closes and directs the air up through the upper airway and vocal cords to allow the patient to talk.

(3) The patient should be suctioned with the cuff deflated before the valve is attached so that secretions that have pooled above the cuff will not be aspirated into the airway.

(4) The valves may be used on spontaneously breathing patients or ventilator patients. If the valve is attached to a ventilator patient, the tidal volume must be increased to compensate for gas loss through the upper airway.

III. MAINTENANCE OF ARTIFICIAL AIRWAYS

CRT Exam Content Matrix: IB9p, IB10p, IIA8, IIA19, IIIB9, IIIC1b-c, IIIC2, IIIF2g3-4, IIIF2h1-4, IIIG1h

RRT Exam Content Matrix: IB9q, IB10q, IIIB4, IIIC1b-c, IIIC2, IIIG1h

A. Cuff Care

1. Tubes should employ high-volume, low-pressure cuffs only because less occlusion to tracheal blood flow occurs as a result of the application of less pressure. They are also called floppy cuffs. If excessive air is placed in the cuff, it acts as a high-pressure cuff.

2. To ensure that the cuff is exerting the least amount of pressure on the tracheal wall and is still providing an adequate seal, use the minimal leak technique or minimal occluding volume technique.

a. Minimal leak technique: With the stethoscope beside the larynx, listen for airflow as the cuff is inflated. Inflate the cuff until no airflow is heard, then withdraw air slowly until a slight leak is heard.

b. Minimal occluding volume technique: This is accomplished the same way as the minimal leak technique, except the cuff is slowly inflated just to the point where no leak is heard.

Exam Note

If the peak inspiratory pressure (PIP) on the ventilator decreases after the minimal leak has been determined, the leak technique should be redone at the lower pressure. For example, the minimal leak test is done when the PIP is 40 cm H₂O, the patient is suctioned, and the PIP decreases to 30 cm H₂O. Because the cuff was inflated to create a slight leak at 40 cm H₂O and the PIP has decreased to 30 cm H₂O, there is now excessive air in the ET tube cuff. There should no longer be a leak at this lower PIP; therefore, the minimal leak technique should be determined again at 30 cm H₂O.

c. Cuff pressures should be maintained between 20 and 25 mm Hg (25-34 cm H₂O) to prevent tracheal wall damage. Tracheal mucosal capillary perfusion pressure is approximately 25 to 30 mm Hg. Pressures higher than this range will cut off blood flow to the mucosa, resulting in tracheal tissue damage. Always use the lowest cuff pressure—one that will produce only a slight leak when heard with a stethoscope at peak inspiration.

Exam Note

The exam questions regarding cuff pressure may indicate the pressure in either mm Hg or cm H₂O. Pay close attention to the units so that you do not select the wrong pressure. Remember, maximum cuff pressure is 25 mm Hg or 34 cm H₂O.

d. If the cuff is inflated above 25 mm Hg (34 cm H₂O) and a leak is still heard, continue inflating the cuff using the minimal leak or occluding volume technique. It may be that the ET tube is too small and needs to take more air into the cuff to adequately seal the airway. In this case, the cuff pressure does not relate to the pressure on the tracheal wall. To be safe, replace the ET tube with a larger one.

B. Suctioning the Airway

1. Technique of suctioning

a. Hyperoxygenate and hyperinflate the patient’s lungs. This is done to help prevent hypoxemia, which may lead to tachycardia.

b. Instill 3 to 5 mL of normal saline to help thin secretions; in infants, use 0.3 to 0.5 mL.

Exam Note

Although studies indicate that instilling saline down the ET tube may result in higher incidences of oxygen desaturation and microorganisms being washed into the lower airway, the exam considers it an appropriate procedure to aid in the mobilization of secretions. Another alternative to saline lavage is to instill acetylcysteine (Mucomyst) or sodium bicarbonate (2%) down the airway. Although this may require a physician order, it appears to be more beneficial than the use of saline.

c. Insert the catheter without applying suction and advance until an obstruction (the carina) is met. Do not jab with the catheter because this may cause carinal damage and bradycardia (vagal stimulation).

d. Withdraw the catheter approximately 1 to 2 cm and apply suction while rotating the catheter between the thumb and finger. (This decreases mucosal damage.)

e. Never leave the catheter in the airway for more than 15 s.

f. On removal of the catheter, reoxygenate and hyperinflate the patient’s lungs; wait 30 s to 1 min before entering the airway again.

Monitor the ECG and stop the procedure if complications occur; hyperoxygenate and ventilate the patient’s lungs (if the patient is using a ventilator).

g. Repeat the steps until the secretions are removed by suctioning and the airway sounds clear.

h. Then suction the nasal and oral pharynx; remember to never reenter the ET tube with this catheter.

When performing nasotracheal suctioning, follow the above steps in addition to performing the subsequent techniques:

(1) Lubricate the catheter with water-soluble gel.

(2) Instruct the patient to take a deep breath or cough as the catheter advances to the oropharynx. This aids in inserting the catheter through the glottic opening.

2. Selecting the proper size of catheter

a. The suction catheter should not occupy more than one half of the internal diameter of the tube. (Suction catheters are sized by Fr units.)

Exam Note

Using a catheter that occupies up to the inside diameter of the ET tube may be acceptable, but on the exam, never exceed of the inside diameter.

b. To estimate the proper catheter size, multiply the internal diameter of the ET tube by 2, then use the next smallest catheter size.

EXAMPLE:

What is the proper size of catheter to use when suctioning an 8.0-mm ET tube?

The next smallest size catheter is 14 Fr. (Suction catheters come in the following sizes: Fr, 8 Fr, 10 Fr, 12 Fr, 14 Fr, 16 Fr.)

3. Closed suction catheters

FIGURE 4-21 Closed suction catheter.

From Hess DR: Managing the artificial airway. Respir Care 44:759, 1999.

a. A closed suction catheter system is a suction catheter enclosed inside a clear plastic sleeve attached to the patient’s ET or tracheostomy tube; it allows for suctioning without removing the patient from the ventilator. This results in less potential for cardiac arrhythmias and desaturation during the suction procedure.

b. Because the catheter remains sterile inside the sleeve and gloves are not necessary when this system is used, there is less risk of contaminating the patient’s airway than when open suctioning with sterile gloves is used.

c. Potential problems with this system include the catheter being left in the ET tube after suctioning or the catheter migrating into the ET tube between suction procedures, which would result in increased airway resistance.

d. Although the manufacturers recommend changing the closed suction system daily, studies show that the system may be changed when the ventilator circuit is changed, about once per week.

4. Other types of catheters

a. Yankauer suction (tonsil): used to suction the oropharynx

FIGURE 4-22

b. Coudé suction catheter: angled-tip catheter used to suction the left mainstem bronchus

5. Indications for tracheal suctioning

a. To remove retained secretions that the patient cannot mobilize

b. To maintain patency of artificial airways

c. To obtain sputum for culture and sensitivity testing

6. Hazards of tracheal suctioning

a. Hypoxemia: caused by inadequate oxygen level during suctioning; increase FiO₂ to 1.0 before suctioning. (Some advocate increasing FiO₂ only 10% to15% on infants less than one month old to help prevent retinopathy of prematurity.)

b. Arrhythmias: caused by hypoxemia and vagal nerve stimulation. The vagus nerve is stimulated as the catheter irritates the oral or nasal mucosa, tracheal mucosa, and carina, causing bradycardia.

c. Hypotension: caused by bradycardia and prolonged coughing episodes.

d. Atelectasis: caused by using a suction catheter that is too large or excessive suction pressure.

e. Tissue trauma: caused by jabbing the catheter during insertion and improper lubrication during nasal suctioning.

Exam Note

Suctioning may suddenly stop as a result of a kinked suction catheter, a mucus plug lodged in the catheter, or a suction collection bottle that is full.

7. Vacuum systems and collection bottles

a. The suction catheter is attached to a connecting tube, which attaches to the outlet of a collection bottle. This bottle attaches to a Diameter Index Safety System (DISS) connection on the suction or vacuum regulator, which is either a portable pump or a 50-psi vacuum wall outlet at the bedside.

b. The vacuum regulator supplies the negative (subatmospheric) pressure necessary to suction the airway.

c. The secretion collection bottle is generally equipped with a system that interrupts suction when the bottle becomes full of secretions.

d. Most suction or vacuum systems provide up to −200 mm Hg pressure, but the desired vacuum level can be adjusted by occluding the suction regulator outlet and turning a vacuum control knob on the regulator. Most systems use locking mechanisms to prevent excessive suction pressures from being used.

e. Appropriate suction levels

Adults: −100 to −120 mm Hg

Children: −80 to −100 mm Hg

Infants: −60 to −80 mm Hg

IV. ET TUBE EXTUBATIONCRT Exam Content Matrix: IIIB9RRT Exam Content Matrix: IIIB4

A. Procedure of Extubation

1. Explain procedure to the patient.

2. Increase the FiO₂ level.

3. Suction down the ET tube.

4. Suction the mouth and back of throat.

5. Untape the ET tube, deflate the cuff, and instruct the patient to take a deep breath. At peak inspiration, withdraw the tube.

A resuscitator bag may be used to deliver the deep breath and to better ensure that the tube is removed at peak inspiration.

6. Place on aerosol mask with appropriate level of oxygen. It is permissible to withdraw the tube while suctioning because this clears the airway while extubating.

B. Complications of Extubation

1. Laryngospasm

a. Spasm of the vocal cords caused by irritation of the tube, resulting in airway obstruction. This is detected by observing respiratory difficulty immediately after extubation.

b. If laryngospasm occurs, administer a high FiO₂ concentration and, if it persists for more than 1 to 2 min, administer a bronchodilator via a handheld nebulizer.

2. Glottic edema (discussed later)

Intubation equipment should be readily available at the bedside during extubation in case reintubation becomes necessary.

V. LARYNGEAL AND TRACHEAL COMPLICATIONS OF ET TUBESCRT Exam Content Matrix: IIIF2gRRT Exam Content Matrix: IIIF2d

A. Sore Throat and Hoarseness

1. Are common results of tube irritation

2. Usually subside within 2 to 3 days

3. Are treated with cool aerosol

B. Glottic Edema

1. Inspiratory stridor is the major clinical sign.

a. Traumatic intubation

b. Insertion with oversized ET tube

c. Poor ET tube maintenance

d. Allergic response to material in the ET tube

3. Stridor should be treated with

a. Cool aerosol to decrease swelling

b. Vasoconstrictor, such as racemic epinephrine, via handheld nebulizer to constrict mucosal blood vessels and reduce swelling

c. Corticosteroids, such as dexamethasone (Decadron), to reduce swelling

C. Subglottic Edema

1. This edema occurs below the glottis at the level of the cricoid cartilage.

2. This is a serious complication after extubation, which may lead to reintubation.

3. If postextubation distress cannot be relieved, subglottic edema must be suspected.

D. Vocal Cord Ulceration

1. Suspected if hoarseness continues for more than 1 wk

a. Traumatic intubation

b. Tight-fitting tube

c. Allergic reaction to material in tube

d. Excessive movement of the tube

E. Tracheal Mucosal Ulceration

1. Is common after extubation

2. Occurs at the area of the cuff site

F. Vocal Cord Paralysis

1. Is caused by damage to the recurrent laryngeal nerve

2. Usually occurs secondary to upper chest or neck surgery

G. Laryngotracheal Web

1. Necrotic tissue at the glottic or subglottic level leads to fibrin formation, which combines with secretions and cellular debris to form a membrane, or web.

2. Stridor and acute airway obstruction generally occur.

3. The web should be suctioned from the airway immediately.

4. The web often occurs several days after extubation.

H. Tracheal Stenosis

1. This lesion is found at the cuff site or the level of the cricoid membrane.

2. As the lesion heals, it constricts, leading to a narrowing of the airway.

3. A narrowing of less than 50% of the diameter of the airway is not symptomatic.

4. To help prevent tracheal stenosis, maintain cuff pressure by use of the minimal leak technique.

I. Tracheal Malacia

1. Cartilaginous support of the trachea is lost.

2. After extubation, the trachea collapses, leading to respiratory distress.

POSTCHAPTER STUDY QUESTIONS

1. To prevent venous congestion on the trachea wall, the ET tube cuff should be maintained below what level of pressure?

2. Inspiratory stridor is a major clinical sign of what airway condition?

3. What is the name of the speaking valve that may be attached to a ventilator patient’s tracheostomy tube that allows the patient to talk?

4. Describe the purpose of an oropharyngeal airway.

5. What is the primary purpose of a fenestrated tracheostomy tube?

6. List the problems associated with the use of oral ET tubes.

7. How would you determine that an ET tube is resting in the right mainstem bronchus before a chest x-ray film is obtained?

8. What is a Yankauer suction device used for?

9. What is the maximum amount of suction pressure that may be used to suction an adult patient’s airway?

10. When extubating a patient, the ET tube should be withdrawn at what point in the breathing cycle?

See answers at the back of the text.

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