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Airway Management
Donna Kerner, MS, RN, CCRN October 1, 2006
Types
Oropharyangeal Nasopharyngeal Laryngeal Mask Airway
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Oropharyngeal Airway
Oropharyngeal Airway
Relieves airway obstruction caused by: tongue relaxation secretions seizures biting on tracheal tube Different sizes available Measure from ear lobe to corner of mouth for correct size
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Oropharyngeal Airway
Made of rigid plastic or rubber Semicircular Inserted upside down and rotated during insertion to fit the curvature of the oral cavity
Oropharyngeal Airway
Tip of oropharyngeal airway rests near the posterior pharyngeal wall For this reason, not recommended for alert patients May trigger gag reflex & induce vomiting
Oropharyngeal Airway
Nasopharyngeal Airway
Nasopharyngeal Airway
Used in semiconscious patients and intoxicated patients Facilitate nasotracheal suctioning Soft rubber Sizes 26-35 FR Measure from ear lobe to nose AKA nasal trumpet
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Nasopharyngeal Airway
Water soluble gel applied to airway for insertion Gently inserted into nare with rotating motion Patency assessed by feeling airflow through airway
Nasopharyngeal Airway
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Nasopharyngeal Airway
Management
Frequent assessment for:
Pressure areas Dried secretions
Lubricate with water soluble gel prior to suctioning Monitor for complications
Sinusitis Erosion of mucus membranes
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Bag-Mask Ventilation
Bag-mask devices (Ambu) consist of a bag and a non-rebreathing valve attached to a face mask Ambu bags can be used to ventilate intubated patients after removing face mask Adult BVMs have a volume of approximately 1600 ml Sufficient ventilations should be provided to produce visible chest expansion
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Bag-Mask Ventilation
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Bag-Mask Ventilation
Procedure If no neck injury, tilt patients head back Apply mask to face with one hand using the bridge of nose as a guide Place 3rd, 4th & 5th fingers along bony portion of mandible Place thumb & index fingers of same hand on mask Compress bag with other hand Observe chest to ensure that ventilation is adequate Deliver each breath over 2 seconds
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Artificial Airways
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Artificial Airways
Artificial Airway
Indications Elective
Patient receiving general anesthesia
Urgent
Protect airway Relieve airway obstruction Facilitate suctioning of tracheobronchial tree Facilitate mechanical ventilation
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Routes of Intubation
Cricothyroidotomy
Cricothyroidotomy
Centimeter Markings
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Intubation Tray
Laryngoscope
Handle Curved blade Straight blade Batteries Light bulb
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Intubation tray
Stylet:
Flexible wire Used to keep tube rigid during insertion Removed after intubation
Intubation Tray
Magill forceps
Used to remove foreign bodies Can be used during nasal intubation to advance tube down pharynx
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Intubation
The endotracheal tube (ETT) is inserted into the trachea via the nose or mouth The laryngoscope is used to visualize vocal cords The ETT is inserted into the trachea 2-4 cm above carina
Post Intubation
Confirmation of Proper Tube Placement Primary confirmation Equal chest expansion on inspiration Bilateral breath sounds Absence of gurgle in stomach Secondary confirmation CO2 detector Chest x-ray
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Portable CXR
A portable CXR will verify proper tube placement A radio-opaque marker along length of tube facilitates visualization of ETT on x-ray
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Post Intubation
Tube is secured with fixation device to prevent movement
Commercial tube holder Tape
Centimeter markings are noted at lip line (nare line) Marking is checked & documented every shift
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Tracheostomy Tracheostomy
A surgical procedure where an incision is made just below the 2nd & 3rd tracheal ring, bypassing the epiglottis A tube is placed to establish an airway
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Tracheostomy Tube
Parts of trach tube: Flange: holds ties, prevents pressure points & movement Inner cannula: sleeve which fits inside trach tube Cuff: inflated with just enough air to create seal Pilot balloon: port to inflate cuff
Shiley Trach
Flange
Outer Cannula
Pilot Balloon
Inner Cannula
Cuff
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Tracheostomy Tubes
Tracheostomy Tubes
Portex Trach
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Jackson Trach
Cuffless Trach
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Fenestrated Trach
Hole in trach tube to allow air passage for speaking. Used to enhance air flow in and out of the trachea Trach tube is below larynx, making speech with a cuffed nonfenestrated tube impossible.
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Tracheostomy Tube
Obturator
Guides tube into position without causing trauma to tissues. Removed once tube is in place
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Passy-Muir Valve
Passy-Muir one way speaking valve is used with trach patients with or without mechanical ventilation
Passy-Muir Valve
Criteria for use:
Patient awake & oriented Motivated to vocalize Fenestrated trach is preferred but may not be required if airflow is adequate Able to tolerate extended periods of cuff deflation Able to tolerate any volume loss from around cuff during inspiration Have ability to protect airway Patent upper airway in order for patient to exhale
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Passy-Muir Valve
Valve should be removed during hours of sleep or at daytime rest Should only be used for times patient is fully awake and needing to talk
Passy-Muir Valve
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Passy-Muir Valve
Accidental Extubation
Keep an extra trach tube of same size and an obturator at the bedside If tube becomes dislodged obtain medical help immediately ! Be prepared to initiate artificial respiration
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An endotracheal or tracheostomy cuff provides a closed system for mechanical ventilation Allows volume to be delivered to the patients lungs To function properly, the cuff must exert enough pressure on the tracheal wall to seal the airway without compromising the blood supply to the tracheal mucosa
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Cuffalator
Cuffalator
Used to inflate/deflate cuff & measure cuff pressure Goal is to inflate cuff with just enough pressure to prevent air leak & decrease risk of aspiration
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Cuffalator
Green zone
14-24 cm H2O Acceptable pressure
Cuffalator
Bulb: used to inflate cuff Red button: deflates cuff Port: attaches to cuff inflation port
Red Zone
Too high Unacceptable pressure
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Suctioning
Clinical indications for suctioning:
High pressure alarm Respiratory distress Coughing Audible airway noise
Suctioning
Sterile technique Suction pressure not greater than 120 mm Hg Hyperventilate with 100% O2 prior to suctioning Suction 10-15 seconds while withdrawing catheter
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Suctioning
Regular suction catheter:
Size should not exceed one-half the diameter of the airway
This increases the possibility of suction induced hypoxia and atelectasis
Suctioning
Closed suction system:
Use clean gloves Apply continuous suction while withdrawing catheter straight back Lock suction valve when suctioning is completed
Use sterile gloves and appropriate PPE Apply intermittent suction while slowly withdrawing catheter
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Suctioning
Precautions:
Always hyperoxygenate prior to and during suctioning Maintain sterile technique Never use same catheter to suction the trachea after it has been used in the nose or mouth
Suctioning
Use of saline installations for loosening secretions has been controversial and recent research shows that in fact it is detrimental and poses a grater risk of pneumonia
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Suctioning
Related care:
Include strategies to move secretions through peripheral airways;
Appropriate hydration Adequate humidification of inspired gases Coughing and deep breathing Frequent position changes Use of pulmonary bed Chest PT Use of bronchodilating agents
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Suctioning
Monitor patient during suctioning for dysrhythmias aggravated by suctioninduced hypoxemia and irritation of vagal receptors within the respiratory tract
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