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Responsibilities for RT's

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Perform airway clearance techniques on both artificial and natural airways (e.g. suctioning) Insert and maintain artificial airways in patients whose natural airway are inadequate (e.g. oral pharyngeal insertion) Assist physicians in performing special procedures related to airway management (e.g. bronchoscopy)

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Indications for Artificial Airways

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Restore Patent Airway / To Relieve Airway Obstruction To Facilitate Removal of Secretions To Protect the Lower Airways from Aspiration To Facilitate Application of Positive Pressure Ventilation Provide an Alternate Route for the Administration of Emergency Drugs

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Relieving Airway Obstruction

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Upper airway vs Lower airway Partial vs Complete Obstruction Causes Trauma, Edema, Tumors, Tongue, Secretions, Foreign Bodies, Laryngospasm Artificial Airways Bypass Upper Airway Obstruction

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Signs of Partial Airway Obstruction

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Crowing, gasping sounds on inspiration Difficulty in coughing Increased respiratory distress Good to poor exchange (depends on severity) Exaggerated chest and abdominal movement Cyanosis (depends on severity)

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Signs of Complete Airway Obstruction

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Inability to talk Increased respiratory difficulty with no air movement Cyanosis Sternal, intercostal and epigastric retractions Extreme panic Unconsciousness and resp. arrest if obstruction is not removed

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Secretion Removal

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Artificial Airways Provide More Direct Access for Removal of Secretions

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Retained Secretions Lead to

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Hypoxemia Hypercapnia Increased Work of Breathing Ideal Medium for Bacterial Growth

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Four Reflexes Help Prevent Aspiration

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Pharyngeal (Gag and Swallowing Response) Laryngeal ( Glottic Closure) Tracheal (Cough Response) Carinal (Cough Response)

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Protecting the Airway

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Four Reflexes Help Prevent Aspiration CNS Depression Decreases Reflex Response Airway Cuff Protects Lower Airway (Trachea / Lung)

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Positive Pressure Ventilation

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Continuous Positive Pressure Ventilation Requires a Closed - Sealed System If System is Open - Gas Will Follow the Pathway of Least Resistance and Flow Out the Upper Airway Instead of Ventilating the Lungs The Artificial Airway Cuff Provides This Seal

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What does continuous positive pressure ventilation require:

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Closed - Sealed System

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If you have an open system what will happen:

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If System is Open - Gas Will Follow the Pathway of Least Resistance and Flow Out the Upper Airway Instead of Ventilating the Lungs

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What provides the seal?

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The cuff

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Two Types of Artificial Airways

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Pharyngeal Tracheal

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Pharyngeal Artificial Airway

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Oral pharyngeal Nasal pharyngeal

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Tracheal Artificial Airway

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Endotracheal (Translaryngeal) Oral endotracheal Nasal endotracheal Tracheostomy

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Endotracheal (Translaryngeal)

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Oral endotracheal Nasal endotracheal

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Indications of Pharyngeal Airways

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Establish or restore airway patency Facilitate suctioning

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What do Pharyngeal Airways seperate

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the tongue from the posterior pharyngeal wall

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Types of Pharyngeal Airways

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Oral pharyngeal Nasal pharyngeal

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Oral Pharyngeal Airway Sizes

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very from person to person Adult, childrenMeasure from corner of mouth to angle of the jaw Place flange even with mouth follow curvature to jaw

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An Oral Pharyngeal Airway is only to be used on:

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Patients who are unconscious

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Two Basic Types of Oral Pharyngeal Airways

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Berman: hard plastic with two parallel side channels Guedel: softer plastic with a single center channel

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Berman:

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hard plastic with two parallel side channels

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Guedel

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softer plastic with a single center channel

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Components of an Oral Pharyngeal Airway

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Flange Body Tip Air Channel

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Contraindications of Oral Pharyngeal Airway

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Conscious and semi-conscious patients since they may provoke a gag reflex, vomiting or laryngospasm Trauma to oral cavity, mandibular or maxillary areas of the skull Space occupying lesion or foreign body which obstructs the oral cavity or pharynx

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Placement of Oral Pharyngeal Airway

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Insert right side up. Displace tongue away from the roof of the mouth with tongue depressor. Advance airway over the tongue following the curve of the oral cavity Insert upside down. Rotate 180 degrees before insertion, Advance airway separating tongue from roof of mouth, turn 180 degrees (right side up) as the tip reaches the back of tongue.

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Incorrect Placement of Oral Pharyngeal Airway

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The tongue may be pushed further back toward pharynx worsening the obstruction Incorrect size; too large or too small of an airway may lead to airway obstruction

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Correct Placement of Oral Pharyngeal Airway

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Tip lies at the base of the tongue above the epiglottis The flange portion extends outside the teeth

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Nasal Pharyngeal Airway

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Comes in a variety of sizes Also known as nasal airways or nasal trumpets Most common use is to facilitate nasotracheal suctioning Limited to use in adults since the child and infant have a very narrow nasal passage Provides passage from external nares to the base of the tongue Made of soft latex or polyethylene Adult sizes are in the 26 - 32 French range Sizing of Airway: measure from tip of nose to lobe of ear

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What is Nasal Pharyngeal Airway Also Known As:

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nasal airways or nasal trumpets

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What is Nasal Pharyngeal Airway most commonly used for:

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facilitaten nasotracheal suctioning

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Nasal Pharyngeal Airway is Limited in Children Because

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children and infants have very small/ narrow nasal passages

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Nasal Pharyngeal Airway Provides passage from:

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external nares to the base of the tongue

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Adult sizes range w/ Nasal Pharyngeal Airway

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26-32 French Range

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Sizing of Nasal Pharyngeal Airway:

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Measure from tip of nose to lobe of ear

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When is Nasal Pharyngeal Airway used:

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Used when oral placement is not possible

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Nasal Pharyngeal Airway is used:

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Conscious and semi-conscious patients requiring an airway Patients with oral cavity trauma or seizures when oral route is not accessible This type of airway is generally limited to adults

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Contraindications of Nasal Pharyngeal Airway

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Trauma to nasal region Space occupying lesion (nasal polyps) or presence of foreign body in nasal passage

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Placement of the airway (Nasal Pharyngeal Airway)

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Tilt head back slightly Lubricate with water soluble agent A mixture of a local anesthetic (4% Lidocaine) and a vasoconstrictor (phenylephrine) may be used Slowly advance through opening of the nose with the bevel facing toward the septum If slight resistance is felt during insertion, gently twist airway then advance If significant resistance is felt during insertion, then remove and try the other nostril Verify correct placement by visualizing tip of airway below the uvula If the airway cannot be inserted in either nares choose a smaller size tube When properly positioned, a nasopharyngeal airway is usually stabilized with its own flange

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Two Types of Tracheal Airways

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Endotracheal (Oral or Nasal) Tracheostomy (Trachea)

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Tracheal Airways

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Extend Beyond Pharynx into Trachea

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Endotracheal or translaryngeal tubes are inserted:

answer

through nose or mouth through larynx into trachea

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Tracheostomy tubes are inserted

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through a surgically created opening in the the trachea

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Endotubes are semi-rigid most often made from:

answer

polyvinylcholoride (PVC) or plastic polymers

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Tracheostomy tubes initially were metal most commonly made of silver. Brand name:

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Jackson. Some patients may still have these metal tubes Necessary to have special adapter for connection to manual resuscitator

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EndoTube Components:

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15mm external adapter / outside diameter (OD) Curved body of the tube Pilot filling tube Pilot balloon Tube cuff Spring loaded one way valve Angle of the bevel

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Tube Components / Markings :

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Murphy eye tip Radiopaque line Z-79 or IT designation Manufacturer's name Inside diameter (ID) in mm (Size of tube) Outside diameter (OD) in mm Type of tube (oral/nasal) Length of tube; markings in centimeters

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Tracheostomy Tube Components:

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Outer cannula Inner cannula Flange Pilot balloon Filling pilot tube Spring-loaded oneway valve Cuff Obturator 15 mm outside diameter adapter Cotton tape Radiopaque indicator

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Advantages of Oral Intubation:

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Airway of choice in an emergency Easier, faster, less traumatic and more comfortable to insert Larger tube can be tolerated Easier suctioning Less airflow resistance, decrease work of breathing Easier passage of bronchoscope Reduced risk of tube kinking Ideally used for short term intubation Avoidance of nasal and paranasal complication Epistaxis, sinusitis, otitis media

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Disadvantages of Nasal Intubation:

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Pain and discomfort with inadequate preparation Nasal and paranasal complications such as epistaxis, sinusitis, otitis media More difficult to perform Spontaneous breathing is required for blind nasal intubation Smaller tube necessary / increased resistance / increased work of breathing Greater suctioning difficulty Possible pressure necrosis in area of the alae nasi The nasal passage limits the tube size; a tube at least 0.5 mm ID smaller than the oral route is required

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Specialized Endotracheal Tube:

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Double Lumen ET Tube

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Double Lumen ET Tube:

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The larger cuff seals the tracheal lumen and allows gas to flow into only one bronchus The smaller cuff seals the opposite bronchial lumen and allows gas to flow into the other lung

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Double Lumen ET Tube May be indicated for:

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unilateral lung disease where independent lung ventilation (ILV) is needed

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Double Lumen ET Tube parts:

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Two proximal ventilator connectors (15 mm adapter) Two inner lumens for gas flow Two cuffs and two filling (pilot) tubes Two distal opening

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Specialized ET Tubes / Sub Glottic Suction:

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A special tube with an attached sub-glottic suction port has been designed This port allows for suctioning secretions above the cuff This tube has a separate channel that attaches to a wall suction source The suction source provides a continuous - 20 to - 30 cmH2O of negative pressure

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Suction source for Specialized ET Tubes / Sub Glottic Suction:

answer

provides a continuous - 20 to - 30 cmH2O of negative pressure

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Specialized ET Tubes / Sub Glottic Suction important points:

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The aspirated material is collected and emptied on a regular basis Every 4 hours air should be injected into the port to ensure the tube is not clogged Use of the tube has been reported to decrease the incidence of ventilatorassociated pneumonia (VAP)

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Advantages of Tracheotomy:

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Airway of choice for long term use Best tolerated of all airways Avoidance of laryngeal and upper airway complications Greater comfort Aids feeding, oral care and speech Easiest airway to suction Aesthetically less of a problem, psychological benefit Easier passage of bronchoscope Easier reinsertion Eliminates risk of mainstem intubation

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The Tracheotomy helps:

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Facilitates weaning from ventilator, decreased work of breathing Better anchoring; reduced risk of decannulation With a mature stoma reinsertion is easy Easier to suction left bronchus with curved tip catheter Improved mobility (transfer out of ICU to ward or extended care facility Facilitate weaning from ventilator, decreased work of breathing

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During a mature Stoma reinsertion is:

answer

easy

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What is easier to suction the left bronchus:

answer

curved tip catheter

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Disadvantages of Tracheostomy

answer

Greater expense; usually requires the use of operating room and general anesthesia Permanent scar More severe complications Increased frequency of aspiration Greater mortality rate Delayed decannulation Greater bacterial colonization rate Persistent open stoma after decannulation, reducing cough efficiency

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Immediate Complications with Tracheostomy:

answer

Bleeding Pneumothorax Air embolism Subcutaneous and mediastinal emphysema

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Late Complications with Tracheostomy

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Infection of surgical wound Innominate artery erosion Passage into subcutaneous tissues Hemorrhage may occur Tracheal stenosis may occur

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Fenestrated Tracheostomy Tube:

answer

-Useful in assessing patients ability to be extubated or weaned from trach tube -Allows patient to talk when the tube is occluded and the cuff deflated -Fenestration is located in outer cannula only -The inner cannula is similar in design to the inner cannula of a normal tracheostomy tube

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Ability to extubate or wean from trach tube:

answer

The fenestration (hole) allows patient to breath through their upper airway and not through trach tube opening

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Fenestration hole is located:

answer

In outer cannula only

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Proper Use of Fenestrated Tracheostomy Tube:

answer

-Removal of inner cannula -Deflation of cuff -Corking or plugging of outer cannula -Patient now breathes through fenestration and upper airway

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Communi-Trach or Pitt Speaking Tube:

answer

-Designed to allow patient to talk when cuff is inflated -Functions by directing secondary gas flow through ports above the cuff, allowing gas to move past the vocal cords while maintaining ventilation via the airway -Internal diameter of airway smaller than standard tube of same size -Small tube with an opening above the cuff is connected to a 4 -6 L/min source of air or oxygen -Y connector for intermittent control -When the open port is occluded then gas is directed through the patient's larynx and the upper airway for vocalization

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How does the Communi-Trach or Pitt Speaking Tube Work?

answer

Functions by directing secondary gas flow through ports above the cuff, allowing gas to move past the vocal cords while maintaining ventilation via the airway

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Communi-Trach or Pitt Speaking Tube: When the open port is occluded then gas is directed through:

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The pts. larynx and upper airway for vocalization

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Communi-Trach or Pitt Speaking Tube is a small tube w/ opening above the cuff and is connected to:

answer

4-6 L/MIN source of air or oxygen

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Communi-Trach or Pitt Speaking Tube allows:

answer

Patient to talk/ "talking trach tube"

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