Initiation and Modification of
Therapeutic Procedures
Maintain a Patent Airway Including the Care of
Artificial Airways
Maintaining a patent airway and caring for artificial
airways are critical components of good respiratory
care.
You must be
Familiar with many types of artificial airways and
how to properly place, maintain, and remove these
devices
Proficient in proper humidification of the airway
Patient Positioning
Positioning is an essential component of
 emergency airway management
 Preventing ventilator-associated pneumonia
 Managing conditions that cause hypoxemia or
abnormally increase the production of respiratory tract
secretions
Insert Oro- and Nasopharyngeal
Airways
 Oropharyngeal Airways
 Used during resuscitation to prevent upper airway
obstruction when providing bag-mask ventilation
 Used as a bite-block in unconscious / heavily sedated
intubated patients
 May be indicated
 In patients who are having a seizure
 When a comatose patient develops upper airway
occlusion
 You must be able to
 Select an appropriate sized oropharyngeal airway
 Insert and secure the airway
 Troubleshoot the airway
Insert Oro- and Nasopharyngeal
Airways
 Nasopharyngeal airways are used
 In resuscitation, most often when an oropharyngeal airway is
contraindicated
 When a patient exhibits acute upper airway obstruction and
is having severe seizures that prevent opening the mouth
 To prevent trauma in patients requiring frequent
nasotracheal suctioning
 You must be able to
 Select an appropriate sized nasopharyngeal airway
 Insert and secure the airway
 Troubleshoot the airway
 Know the hazards and complications
Endotracheal Intubation
In the NBRC Hospital, respiratory therapists must be skilled in
endotracheal intubation.
This section focuses on you performing the procedure
independently.
 Gather and confirm function of necessary equipment
 Know the basic steps in orotracheal intubation
 Nasotracheal intubation is discouraged because
 The incidence of VAP and other infections is higher
 Smaller/longer ET tubes are required, increasing airway
resistance
 Necrosis of the nasal septum and external meatus may
occur
Tracheotomy
The most common indications for tracheotomy are the need
for long-term positive pressure ventilation or the need for a
permanent artificial airway.
A trach tube’s OD needs to be no more than two-thirds to
three-quarters of the internal diameter of the trachea.
The NBRC expects that you
Be skilled in basic tracheostomy care (equipment / supplies
needed, and basic procedure)
Be skilled in changing these tubes in patients with established
stomas
Specialized Tracheostomy Airways
 Fenestrated tracheostomy tube
 Facilitates weaning from a trach tube
 Supports patients needing intermittent (e.g. nocturnal)
ventilatory support
 Always make sure that the cuff is fully deflated before
plugging the tube
 Attach a warning tag to the tube cap plug
 Tracheostomy button
 Small tube used to maintain an open stoma after the
tracheostomy tube is removed
 Maintain patency by regularly passing a suction catheter
through the tube
Tracheal Airway Cuff Management
Goal is to achieve an adequate seal at the lowest possible
pressure (no higher than 20 – 25 mmHg)
Most manometers used for cuff pressure management are
calibrated in cm H2O
 20 – 25 mmHg (ischemia pressure) equals 27 – 34 cm H2O
 Most hospitals and the NBRC set 25 cm H2O as the “high-end”
pressure
Always adjust pressure to the desired level, never just
measure it
Cuff pressures exceeding 20 – 25 mm Hg may occur when
 Using high peak pressures
 The tracheal tube is too small for the patient’s airway
Tracheal Airway Cuff Management
 Procedures most often used
 Minimal leak technique (MLT)
 Defined by most protocols as being less than 10% of
delivered volume
 Minimal occluding volume (MOV)
 Alternative cuff designs
 Lanz tube – external pressure-regulating valve and control
reservoir designed to automatically maintain cuff pressure at
approximately 30 cm H2O
 Kamen-Wilkinson tube – foam cuff that seals the trachea at
atmospheric pressure
Troubleshooting Tracheal Airways
 Cuff leaks
 Most common serious problem with tracheal airways
 Differentiate between small-leaks vs large leaks (“blown
cuff”)
 Signs of partial extubation are essentially the same as those
observed with a blown cuff, do not recommend
reintubation until you confirm that a cuff leak is the real
problem
Troubleshooting Tracheal Airways
Accidental Extubation
 Can be minimized by attention to the following:
 The integrity of the securing tube tape or ties
 The avoidance of traction on the tube connector
 The adequacy of sedation
 The appropriate use of restraints
Troubleshooting Tracheal Airways
Dealing with an obstructed airway
When a patient receiving ventilatory support exhibits severe
signs of respiratory distress the first step is always to remove
the patient form the ventilator, bag them manually with
100% O2, and reassess the situation
Alternative Emergency Airways
 Laryngeal Mask Airway (LMA)
 Used primarily by anesthesiologists as an alternative to
endotracheal intubation during surgery
 Use for emergency airway management of unconscious
patients in whom tracheal intubation cannot be performed or
fails
 Avoid using to establish an airway in patients who are
conscious, who have intact gag reflexes, or who resist insertion
 Avoid using in patients who will need tracheobronchial
suctioning
 Should not be inserted in patients with trauma to or obstructive
lesions of the mouth or pharynx
Alternative Emergency Airways
 Esophageal-tracheal Combitube
 Used as an alternative to endotracheal intubation for
emergency ventilatory support and airway control
 Designed to be inserted blindly
 Should not be inserted in conscious patients or those with
intact gag reflexes
 Contraindicated for infants, small children, patients with
esophageal trauma or disease
 The majority of blind intubations with the ECT end up in the
esophagus
 The initial attempt at ventilation should always be via the
longer (blue) #1 pharyngeal tube
Maintaining Adequate Humidification
Humidity therapy is indicated
 Either to humidify dry medical gases or to overcome the
humidity deficit when bypassing the upper airway
 Facilitate mobilization of secretions
 Heated humidification can be used to treat hypothermia
and bronchospasm associated with inhaling cold air
The use of unheated active humidifiers is contraindicated in
patients with bypassed upper airways.
Maintaining Adequate Humidification
Selecting a Humidification Strategy
 Whether or not the patient has an artificial tracheal
airway
 The thickness of the secretions
 The gas flow
 The need for and duration of mechanical ventilation
 The presence of contraindications against using an HME
Maintaining Adequate Humidification
Patients Requiring Ventilatory Support
You can begin with an HME unless it is contraindicated
 The HME must meet or exceed the 30 mg/L standard for
humidification of gases delivered to the trachea
 Contraindications include




Thick and bloody secretions
Hypothermia (<32oC)
Large tidal volumes (> 1000 ml)
Large system leaks
 If the HME needs frequent changing you should switch to a
heated humidifier
Maintaining Adequate Humidification
 HME’s
 Increase deadspace by 30 – 70 ml
 Increase flow resistance through the breathing circuit by
about 1 – 3 cm H2O/L/sec
 Heated passover humidifiers
 Can be used in conjunction with heated-wire circuits
 Will always cause condensation in the circuit in the absence
of heated wires
Peform Extubation
Should be considered only in patients who
 Can maintain adequate oxygenation and ventilation
without ventilatory support (spontaneous breathing trial)
 Are at minimal risk for upper airway obstruction (check by
performing a cuff-leak test)
 Have adequate airway protection and are at minimal risk
for aspiration (positive gag and the ability of the patient to
raise their head off the bed)
 Can adequately clear pulmonary secretions on their own
(patient alert and coughs deeply on suctioning; can
generate MEP greater than 60 cm H2O)
Common Errors to Avoid on the Exam
 Never place or keep an oropharyngeal airway in a
conscious patient
 Never use McGill forceps during intubation without direct
visualization
 Never tie tracheostomy ties with a bow; instead use a
square knot
 Never force the inner cannula of a tracheostomy tube
during insertion, nor pull on or rock it when attaching
equipment
More Common Errors to Avoid on the
Exam
 Never just measure cuff pressure; always adjust the
pressure if it is not correct
 Never use more than 60 cm H2O to inflate an LMA cuff
 Never cover a heated-wire breathing circuit with towels,
drapes, or linens
 Never extubate a patient without being prepared to
reintubate
Exam Sure Bets
 Always be sure a nasopharyngeal airway is well
lubricated before insertion
 Always keep an obturator and unopened tubes in the
same size and one size smaller at the bedside of patients
with tracheostomies
 Always use the lowest cuff inflation pressures need to
protect the airway and provide for adequate ventilation
 Always suction the patient’s oropharynx before you
measure cuff pressure or extubate
More Exam Sure Bets
 Always provide 100% O2 to patients prior to suctioning
and before/after extubation
 Always pass a suction catheter through artificial
tracheal airways regularly to ensure patency
 Always make sure that the cuff of a fenestrated trach
tube is fully deflated before plugging it
 Always provide all patients receiving ventilatory support
via an artificial tracheal airway at least 30 mg/L water
vapor (equivalent to 100% relative humidity at 32-35oC)
Reference:
Certified Respiratory Therapist Exam Review Guide, Craig
Scanlon, Albert Heuer, and Louis Sinopoli
Jones and Bartlett Publishers