Artificial Airways
Lecture Hours:
Lab Hours:
Online Study Hours:
Credit Hours:
Reading assigned:
Suggested reading:
Fundamentals of Respiratory Care – Chapter 33
Essentials of Respiratory Care – Chapter 36, sections I – V, Chapter 38
Respiratory Care, Principles and Practice – Chapter 35, pp 665 – 683,
chapter 36
Foundations of Respiratory Care – Chapters 19 and 20
Course Description
The student will learn the various types of artificial airways, the function of each, and the proper
maintenance of each. The student will demonstrate proficiency in the use and maintenance of each
airway in the laboratory setting.
Educational Objectives
At the end of the course, the student will:
1. State the function of an oropharyngeal airway and list the steps for its insertion.
2. State the function of a nasopharyngeal airway and list the steps for its insertion.
3. Identify the equipment required for endotracheal intubation via the nasal passage and via the
mouth.
4. List the steps of endotracheal intubation via the nasal passage and via the mouth.
5. List the methods by which the position of endotracheal or nasotracheal airways may be
confirmed as being correct.
6. List the various types of endotracheal tubes and the indications for use.
7. List the indications, contraindications, and hazards associated with each of the above airways.
8. List the methods of maintaining an artificial airway.
9. Describe the indications and hazards associated with tracheostomy.
10. Describe the techniques for determining cuff pressure.
11. List the hazards associated with excessive and insufficient cuff pressure.
12. List the steps required for an effective cough.
13. List the indications for bronchial hygiene therapy, including:
a. Postural drainage.
b. Directed cough.
c. Positive expiratory pressure therapy.
d. High frequency oscillation.
e. Mobilization and exercise.
14. Describe the methods of determining effectiveness of therapy.
15. Describe the procedure for obtaining a sputum specimen.
16. List the alternative airway devices and the indications and hazards associated with each.
Performance Objectives
At the end of the course in a laboratory setting, the student will be able to successfully:
1.
2.
3.
4.
5.
Insert an oropharyngeal airway.
Insert a nasopharyngeal airway.
Perform endotracheal intubation.
Perform oropharyngeal suction using a Yankauer suction tip.
Perform tracheal suction using a catheter.
Lesson Plan
1. Effective cough.
a. Components.
A. Adequate vital capacity (VC > 15 mL/kg).
B. Abdominal contraction.
C. Glottic closure.
b. Phases.
A. Irritation of airway.
B. Inspiration of adequate volume.
C. Compression.
i.
Glottic closure.
ii.
Contraction of abdominal muscles.
iii.
Increase in intrathoracic pressure.
D. Expulsion.
i.
Opening of glottis.
ii.
Explosive expulsion of air and matter (flow up to 500 mph).
2. Ineffective cough.
a. Inadequate vital capacity (e.g., airway obstruction, decreased lung volume).
b. Inadequate compression.
A. Inadequate abdominal contraction (e.g., pain, muscle weakness).
B. Inability to close glottis (e.g., CVA, vocal cord paralysis).
3. Suctioning.
a. Indications.
A. Need to remove secretions from patient unable to remove them without help.
B. Need to maintain patency of airway.
C. Presence of atelectasis presumed to be caused by secretion retention.
D. Obtaining of a sputum specimen.
b. Hazards.
A. Trauma.
B. Hypoxia.
i.
Arrhythmias.
ii.
Inadequate cerebral oxygenation.
C. Infection.
D. Vagal stimulation – respiratory and/or cardiac arrest.
E. Atelectasis.
F. Bronchospasm.
G. Increase in intracranial pressure.
H. Gag reflex stimulation.
c. Equipment required.
A. Oral suctioning.
i.
Source of negative pressure.
ii.
Suction canister.
iii.
Connective tubing.
iv.
Yankauer (tonsil tip) suction tip.
v.
Distilled water or saline solution in container.
vi.
Gloves.
B. Nasal and tracheal suctioning.
i.
Source of negative pressure.
ii.
Suction canister.
iii.
Connective tubing.
iv.
Suction catheter.
v.
Water soluble gel (for nasal suction).
vi.
Distilled water or saline solution in container.
vii.
Gloves.
d. Suction catheters.
A. Types of catheters.
i.
Whistle tip.
ii.
Argyle.
iii.
Coude.
iv.
Closed catheter systems.
B. Size of catheter.
i.
Measured in French (French/3.14 = size in mm.).
ii.
Diameter of catheter < ½ diameter of tube.
C. Murphy eye.
e. Pressure during suctioning.
A. Adult – -100 to -120 mmHg.
B. Child – -80 to -100 mmHg.
C. Infant – -60 to -80 mmHg.
f. Procedure.
A. Gather equipment, identify patient, introduce self, explain procedure, and wash
hands.
B. Don gloves, prepare equipment.
C. Hyperoxygenate the patient, as appropriate.
D. If suctioning nasally, lubricate the catheter.
E. Introduce the catheter into the airway, ensuring that no suction is applied during
introduction.
F. Advance the catheter until resistance is met.
G. Withdraw the catheter 1 to 2 cm.
H. Apply suction continuously, withdraw catheter, rotating catheter during
withdrawal (NOTE: apply suction for a maximum of 15 seconds).
I. Rinse the catheter in saline or distilled water.
J. Reassess the patient.
4. Artificial airways.
a. Oropharyngeal airway.
A. Used in unconscious patients only to avoid gag reflex.
B. Prevents tongue from occluding airway.
C. Prevents occlusion of endotracheal tube because of biting.
D. Allows passage of suction catheter through center or along the side of airway.
E. Insertion procedure.
i.
Airway is upside down as it is inserted into mouth.
ii.
Rotate sideways as airway passes over tongue.
iii.
Place in correct position once past tongue.
b. Nasopharyngeal airway.
A. Used in conscious patients requiring frequent suctioning.
B. Length of airway equals length from nostril to ear plus one inch.
C. Prevents tongue from occluding airway.
D. Change from nares to nares as required.
E. Insertion procedure.
i.
Lubricate airway with water soluble gel.
ii.
Examine nares; if available, choose nares with smaller opening.
iii.
Gently insert airway, avoiding forcing past obstructions.
iv.
Tip of airway should be visible just past uvula.
c. Endotracheal tubes.
A. General information.
i.
Specifications established by the American Society for Testing and
Materials (ASTM).
ii.
Markings.
a. I.T. – implant tested.
b. I.D. – inner diameter.
c. O.D. – outer diameter.
d. Z-79 – meets standards of that committee for non-toxicity.
e. Radiopaque line – determine position after placement.
f. Centimeter markings to indicate depth of placement.
B. Types of endotracheal tubes.
i.
Cuffed.
ii.
Uncuffed.
iii.
Double lumen.
iv.
Jet ventilation.
C.
Indications for endotracheal intubation.
i.
Maintain airway patency (e.g., facial or neck trauma, laryngospasm).
ii.
Prevent aspiration.
iii.
Cardiopulmonary arrest.
iv.
Establishment/maintenance of mechanical ventilation.
v.
Bronchial hygiene.
D.
Physiologic effects of endotracheal intubation.
i.
Decrease in VD (approximately by ½).
ii.
If tube is too small, may increase resistance and work of breathing.
E.
Equipment needed.
i.
Suction equipment.
ii.
Laryngoscope.
a. MacIntosh blade.
i.
Curved blade.
ii.
Tip placed in vallecula, anterior to epiglottis.
b. Miller blade.
i.
Straight blade.
ii.
Tip used to lift epiglottis.
iii.
Stylet – only used for oral intubation.
d.
iv.
Magill forceps – used for nasotracheal intubation.
v.
Oropharyngeal airway – used for oral intubation.
vi.
Syringe – to fill cuff with air after intubation.
vi.
Tape or other equipment to secure tube after intubation.
vii.
Topical anesthetics (Lidocaine, xylocaine) – may be required.
viii.
Paralyzing agents (Pavulon, Succinylcholine) – for combative patients.
ix.
Endotracheal tube – choice of sizes to meet unexpected conditions.
F.
Procedure.
i.
Assemble and check all equipment prior to beginning procedure.
ii.
Ensure patient is hyperoxygenated and hyperventilated, if possible.
iii.
Determine desired endotracheal tube size and lubricate with topical
anesthetic, if required; insert stylet for oral intubation.
iv.
Pre-oxygenate the patient.
v.
Position patient in “sniffing” position, if possible.
vi.
Administer paralyzing agent, if required
vii.
Insert laryngoscope.
viii.
Visualize the vocal cords.
ix.
Insert endotracheal tube between vocal cords.
x.
Inflate the cuff.
xi.
Check breath sounds; adjust position of endotracheal tube as needed.
xii.
Note and record centimeter mark at the teeth.
xiii.
Secure the endotracheal tube.
xiv.
Insert oropharyngeal airway.
xv.
Obtain chest X-ray to ensure proper tube placement.
xvi.
Check cuff pressure.
G.
Hazards associated with endotracheal intubation.
i.
Intubation of the esophagus.
ii.
Trauma to the vocal cords or trachea.
iii.
Tracheal malacia, necrosis, T-E fistula.
iv.
Aspiration.
v.
Fracture of teeth.
Tracheostomy tubes.
A.
Indications for tracheotomy.
i.
Long term ventilation.
ii.
Provide patent airway when upper airway is impassable.
B.
Hazards associated with tracheotomy.
i.
Trauma – laryngeal lesions, tracheal lesions.
ii.
Hemorrhage.
iii.
Subcutaneous emphysema.
iv.
Infection.
v.
Tracheal malacia, necrosis, T-E fistula.
C.
Types of tracheostomy tubes.
i.
Portex / Shiley.
ii.
Jackson.
iii.
Kamen-Wilkensen.
iv.
Fenestrated.
D.
Care of the tracheostomy tube.
i.
Performed as needed according to hospital protocol.
ii.
Assemble and check equipment.
a. Gloves and other protective gear.
b. Suction equipment.
c. Hydrogen peroxide.
d. Sterile water.
e. Cotton-tipped applicators.
f. Pre-cut gauze or 4 x 4 gauze pad.
g. Tracheostomy tube ties.
iii.
Suction the patient.
iv.
Remove and clean the inner cannula.
v.
Clean the stoma site.
vi.
Change the tracheostomy tube ties.
vii.
Re-insert the inner cannula.
viii.
Assess the patient.
E.
Changing of the tracheostomy tube.
i.
Performed as needed – perforated cuff, mucus plug, change in size of
tube.
ii.
Assemble and check equipment.
a. Gloves and other protective gear.
b. New tracheostomy tube.
c. Suction equipment.
d. Tracheostomy tube ties.
e. Resuscitation bag.
iii.
Pre-oxygenate the patient.
iv.
Suction the patient.
v.
Remove the tracheostomy tube.
vi.
Insert the new tube.
vii.
Secure the tracheostomy tube with the ties.
viii.
Assess the patient.
e.
Management of the cuff.
A.
Pressure should be kept between 20 and 25 mmHg.
B.
Techniques for maintaining cuff pressure.
i.
Minimal occluding volume.
ii.
Minimal leak technique.
iii.
Direct measurement of cuff pressure by manometer.
5. Alternative airways.
a. Laryngeal mask airway (LMA).
A. Advantages.
i.
Ease and speed of insertion.
ii.
Avoidance of laryngeal and tracheal trauma.
iii.
Intubation possible without removing LMA.
B. Disadvantages.
i.
Short term use only.
ii.
Cannot provide high ventilation pressures.
iii.
Potential for esophageal injury.
iv.
Aspiration may still occur, although risk is decreased.
C. Placement.
i.
Lubricate posterior surface of the mask.
ii.
iii.
Fully deflate cuff.
Using index finger, guide the insertion along the palate and into the
oropharynx.
iv.
Inflate cuff to maximum of 60 cmH2O.
b. Combitube (double lumen airway).
A. Advantages.
i.
Little skill required for insertion.
ii.
Protects against aspiration.
iii.
Aids in positive pressure ventilation.
B. Disadvantages.
i.
Short term use only.
ii.
Aspiration may occur during removal.
iii.
If placed in esophageal position, cannot suction airway.
iv.
Potential for esophageal injury.
v.
Difficulty in distinguishing between esophageal and tracheal intubation.
C. Placement.
i.
Insert tube blindly through the oropharynx into the trachea or
esophagus.
ii.
Inflate the cuffs.
iii.
Assess placement of the tube.
iv.
Ventilate through the appropriate external adapter.
c. Tracheal buttons.
A. Used to maintain a tracheal stoma.
B. Advantages.
i.
Removes the airway resistance of a tracheostomy tube.
ii.
Aids in the removal of secretions by allowing continued access when cap
is removed.
iii.
Allows patient to communicate verbally, when able.
C. Disadvantages.
i.
Will not allow attachment of mechanical ventilators.
ii.
Must be removed and replaced with tracheostomy tube in emergency
situations.
D. Placement of the button – fits through the skin to just inside the anterior wall of
the trachea.