Airway Management – Comprehensive Study Notes

Compromised Airway Assessment

• Complete obstruction – Signs: absent breath sounds, extreme distress, inability to ventilate.
• Partial obstruction – Signs: stridor, gurgling, visible respiratory effort.
• Assessment priorities

  • Level of consciousness (↓ LOC = ↑ risk of airway loss).

  • Breath sounds (bilateral comparison).

  • Skin & mucous‐membrane colour (cyanosis = late hypoxia).

  • Rapid decision-making: determine need for adjuncts or definitive airway.

Oropharyngeal Airways (OPA)

• Purpose: prevents posterior displacement of the tongue, maintaining upper-airway patency.
• Sizing

  • Measure from corner of mouth to earlobe or angle of mandible (\approx anatomic length of oropharynx).
    • Insertion technique

  • Insert upside-down, advance past hard palate, rotate 180^{\circ} so flange rests on lips/teeth.

  • Confirm that tip lies in posterior pharynx, tongue held forward, airway patent.
    • Key advantages

  • Rapid, non-invasive, minimal equipment.
    • Limitations & risks

  • Gag reflex stimulation – contraindicated in semi-conscious pts; may induce vomiting/aspiration.

  • If too small/large, can worsen obstruction.

  • Prolonged pressure → mucosal necrosis; reassess frequently.
    • Variants: Berman OPA (rigid sides, open centre allowing suction/catheters).

Nasopharyngeal Airway (NPA)

• Indications

  • Oral trauma, trismus, intact gag reflex where OPA not tolerated.
    • Technique & considerations

  • Select diameter \approx pt’s smallest nostril; length: tip of nose to earlobe.

  • Lubricate with water-soluble gel (e.g., Surgilube).

  • Insert bevel toward septum following floor of nose.
    • Benefits

  • Better tolerated by semi-conscious pts.

  • Allows simultaneous suctioning of pharyngeal secretions.
    • Risks

  • Epistaxis, turbinate injury.

  • Contraindicated with mid-face / basilar skull # (risk of intracranial placement, CSF leak).

Manual Resuscitation Bag (AMBU)

• Components: self-inflating bag, non-rebreather valve, mask, O2 reservoir.
• Technique

  • "E-C" clamp: thumb-index form “C” on mask, other fingers lift mandible (“E”).

  • Deliver tidal volume \sim 6–7\,mL\,kg^{-1} at rate 10–12\,min^{-1} (adult).

  • With O2 reservoir & >15\,L\,min^{-1} flow → FiO_2 \approx 1.0.
    • Pitfalls: inadequate seal, gastric insufflation, hyperventilation → ↓ cerebral perfusion.

Endotracheal Tubes (ETT)

Indications

• Bypass upper-airway obstruction, protect against aspiration, enable mechanical ventilation & secretion clearance.

Anatomy

• Poly-vinyl-chloride tube with radiopaque line for CXR confirmation.
• 15-mm universal adapter connects to circuits.
• Inflatable cuff seals trachea; pilot balloon indicates pressure.

Sizing

• Typical adult sizes: internal diameter 6.5–8.5\,mm (female \sim7.0, male \sim8.0). Larger diameter ↓ resistance.

Intubation steps

  1. Preparation – position (sniff), pre-oxygenate 100\% O2, assemble laryngoscope, stylet, suction.

  2. Visualization – displace tongue, expose cords within <30\,s (ideal <15\,s per attempt).

  3. Insertion – advance ETT through cords until cuff just beyond.

  4. Cuff inflation – minimal-leak or minimal-occlusive volume technique.

  5. Immediate confirmation

    • End-tidal CO_2 (colorimetric/quantitative).

    • Bilateral breath sounds, absent epigastric sounds.

    • Symmetric chest rise.

  6. Secure at measured depth (e.g., 22–24\,cm at incisors).

  7. Post-confirmation – portable CXR: tip 3–5\,cm above carina.

Types

• Oral ETT: first-line in emergencies – easier, larger, superior suctioning.
• Nasal ETT: more stable, permits swallowing/speech, better long-term comfort but ↑ sinusitis, smaller diameter.

Troubleshooting ↓ gas exchange ("DOPES")

• Displacement, Obstruction (secretions/kink), Pneumothorax, Equipment failure, Stacked breaths.
• Evaluate if confusion/agitation → possible unplanned extubation; secure & sedate as needed.

Tracheostomy

Indications

• Need for mechanical ventilation > 21\,days.
• Upper-airway obstruction above cords, failed intubation, chronic secretion burden.

Surgical anatomy

• Incision between 2^{nd}–3^{rd} tracheal rings; stoma created anteriorly.

Tube components

• Outer cannula (airway patency), inner cannula (removable cleaning), cuff (inflatable), obturator (guides insertion).

Sizing guide

• Pediatric: inner diameter 5.0–7.0\,mm (size 2–3).
• Small adult: 7.0–8.5\,mm (size 4–6).
• Average adult: 8.5–10.0\,mm (size 6–8).
• Large adult: 10.0–11.0\,mm (size 8–10).

Routine assessment (Box 26.10)

• Respiratory rate/pattern vs baseline; tachypnea may signal hypoxia, dyspnea = retained secretions.
• Cyanosis, pulse oximetry.
• Verify O2 delivery & humidification settings.
• Inspect stoma & secretions (colour, amount, consistency); assess sutures or tie integrity.
• Evaluate peri-stomal skin breakdown/pressure areas.
• Cuff pressure < 25\,cm\,H_2O (collab with RT).
• Auscultate lungs; ensure spare trach & obturator at bedside.

Tracheostomy care best practice (Box 26.11)

  1. Gather sterile supplies, don PPE.

  2. Suction first if indicated (↓ aspiration risk).

  3. Remove dressings, set up sterile field.

  4. Clean inner cannula (½-strength H2O2 then sterile saline) or replace disposable.

  5. Clean stoma & plate; prevent solution entering airway.

  6. Change ties if soiled; secure new before removing old, leave 1 finger breadth slack, square knot lateral.

  7. Document secretion characteristics, tissue integrity, pt tolerance.

Suctioning artificial airway (Box 26.13)

• Pre-suction assessment; don eyewear; pressure 80–120\,mmHg.
• Pre-oxygenate 100\% for 30\,s–3\,min (≥3 breaths).
• Insert catheter sterile, no suction, until resistance; withdraw 0.4–0.8\,in then continuous suction with twirl 10–15\,s max.
• Re-oxygenate 1–5\,min; limit total passes to \le 3.

Advantages vs disadvantages

• Advantages: improved oral hygiene, speech possible (fenestrated/speaking valve), ↓ WOB, easier suctioning/re-insertion, secure.
• Disadvantages: surgical procedure, early displacement difficult to reinsert, ↑ complications, specialised care, body-image issues.

Potential complications

• Hemorrhage – innominate artery erosion (life-threatening).
• Infection – cellulitis, abscess, subcutaneous emphysema.
• Tube issues – obstruction (dried secretions), displacement.
• Long-term – tracheal stenosis, tracheomalacia.

Nursing considerations

• Frequent assessment, sterile suction, scheduled trach care, nutrition support (protein, kcal for wound healing), plan for gradual decannulation when feasible.

Pulmonary & Oral Hygiene

• Positioning: turn q 1–2\,h, early ambulation/OOB.
• Pulmonary toilet: incentive spirometry, deep-breathing, chest percussion, postural drainage.
• Oral care: avoid alcohol-based rinses, examine for ulcers; keep mucosa moist (saline, swabs).

Communication Strategies

• Cuffless/fenestrated tubes allow vocal cords to vibrate.
• One-way (Passy-Muir) speaking valves: cuff must be deflated first.
• Alternative methods: writing boards, picture charts, yes/no signalling.

Home-care Transition

• Teach pt/caregiver suction, cleaning, cuff checks, emergency tube replacement (keep spare same size & one size smaller).
• Supply planning: sterile saline, suction catheters, humidification system, backup O2, batteries for equipment.
• Emergency plan: what to do if tube decannulates/obstructs; when to call EMS.
• Follow-up with ENT/RT for stoma evaluation, weaning progress.

Ethical & Practical Considerations

• Airway control vs patient autonomy: sedation & restraints for extubation risk must be balanced with dignity & communication.
• Body-image & psychosocial impact of tracheostomy – early counselling, speech-language involvement.
• Infection-control stewardship: judicious suctioning (no routine saline instillation), cuff pressure monitoring to prevent mucosal injury.