Lecture 9/1- Egans 37

Airway Management Fundamentals & Secretion Clearance Mechanics

• Cough Physiology and Artificial Airways:

  • Normal physiological coughing requires a sequence: deep inspiration, glottic closure, bearing down (Valsalva maneuver) to build intra-thoracic pressure, and sudden glottic release to project secretions outward.
  • An artificial airway (endotracheal tube or tracheostomy tube) passes directly through the glottis, preventing vocal cord closure and eliminating the ability to bear down or generate peak cough pressure.
  • Secretions may occasionally blow out of an endotracheal tube (ETT) or tracheostomy, but patient self-clearance is severely compromised, necessitating mechanical clearance assistance.

• Clinical Indications for Suctioning:

  • Inability of the patient to clear secretions independently.
  • Heavy sedation or neurological impairment causing loss of the protective cough reflex.
  • Copious, thick, or retained secretions blocking airway lumens.

Suctioning Overview, Route Classification, and Equipment

• Definition of Suctioning:

  • Suction is the application of negative pressure to the airways through a collecting catheter.

• Anatomical Classification:

  • Upper Airway (Oropharynx):
    • Target area: Mouth and pharynx down to the vocal cords.
    • Procedure classification: Clean procedure (not sterile) because upper airway passages naturally harbor bacteria.
    • Primary device: Yankauer suction catheter.
  • Lower Airway (Trachea and Bronchi):
    • Target area: Below the vocal cords, extending into the trachea and primary bronchi.
    • Procedure classification: Sterile procedure. Bypasses natural upper airway defense mechanisms (nasal filtration, mucociliary clearance, glottic closure), introducing high infection risks if non-sterile techniques are used.

• Oral Tracheal Suctioning Warning:

  • Directing a suction catheter down through the mouth into the lower trachea without an artificial airway should be avoided.
  • Triggers the gag reflex, inducing vomiting and high risk of aspiration in patients already unable to protect their airway.
  • Nasotracheal suctioning is the preferred non-artificial lower airway route.

• Yankauer Suction Catheter Details:

  • Types: Rigid (hard) Yankauers used during intubation and emergency airway clearance; soft Yankauers commonly included in oral care kits.
  • Thumb Control Valve Mechanics:
    • Air follows the path of least resistance. Vacuum pulling through the tubing will draw room air through an open thumb control hole rather than the catheter tip.
    • Occluding the thumb valve directs full negative pressure to the distal tip to remove secretions.
    • Thumb valve benefits: Allows selective application of suctioning to avoid constant tissue trauma.
    • Continuous (no valve) benefits: Ideal for rapid emergency suctioning during intubation where covering a hole manually might delay clearing heavy vomitus or blood. Continuous suction carries a risk of adhering to and damaging soft mucosal tissue (e.g., cheek/buccal mucosa).

Endotracheal Suction Techniques & Mathematical Sizing Rules

• Endotracheal Suction Techniques:

  • Open Suction Technique: A sterile technique requiring complete disconnection of the patient from the mechanical ventilator circuit to insert a single-use catheter.
    • Disadvantages: Exposure to environmental pathogens, loss of Positive End-Expiratory Pressure ($\text{PEEP}$), loss of lung volume/recruitment, alveolar collapse.
  • Closed (In-Line) Suction Technique: A sterile catheter enclosed in a clear plastic sleeve directly attached to the ventilator circuit.
    • Advantages: Allows catheter advancement and suctioning without disconnecting the patient from the ventilator; maintains continuous $\text{PEEP}$, oxygenation, and lung volume.
    • Standard of care: Closed suctioning is the primary method used in modern mechanical ventilation.

• Suctioning Schedule Policy:

  • Suctioning must never be performed on a preset routine schedule (e.g., every $2\text{ hours}$).
  • Suctioning is invasive and traumatic; running a catheter into fragile tracheal tissue can cause mucosal erosion, bleeding, and airway damage.
  • Suctioning is performed on an as-needed ($\text{PRN}$) basis only upon patient assessment.

• Clinical Indicators for Endotracheal Suctioning:

  • Auscultation of hoarse crackles, gurgling, or coarse breath sounds over the trachea or lungs.
  • Ventilator Dynamics Changes:
    • Pressure Control Mode: Secretions narrow the airway diameter, increasing airway resistance ($R_{aw}$), which results in a sudden drop in delivered tidal volume ($V_T$).
    • Volume Control Mode: Secretions increase airway resistance ($R_{aw}$), causing peak inspiratory pressure ($\text{PIP}$) to rise.
  • Patient request (in alert, conscious patients who express a feeling of retained secretions).

• Suction Catheter Sizing Rules and Formulas:

  • Constraint: The external diameter of the suction catheter must occupy no more than $\frac{1}{2}$ ($50\text{\%}$) of the internal diameter ($\text{ID}$) of the artificial airway to allow air to enter around the catheter during suctioning, preventing complete airway occlusion and massive lung collapse.
  • Formula 1 (Three-Halves Rule):$\text{Catheter Size (Fr)} = \left(\text{ET ID (mm)} \times \frac{3}{2}\right) \rightarrow \text{use next larger French size}$
  • Formula 2 (Double and Down Rule - Preferred Quick Estimation):$\text{Catheter Size (Fr)} = (\text{ET ID (mm)} \times 2) \rightarrow \text{use next smaller French size}$
  • Calculation Examples:
    • Example 1: For a $7.0\text{ mm}$ ID endotracheal tube using Formula 2:             $7.0 \times 2 = 14 \rightarrow \text{next smaller size} = 12\text{ Fr}$
    • Example 2: For an $8.0\text{ mm}$ ID endotracheal tube using Formula 1:             $\left(8.0 \times \frac{3}{2}\right) = 12 \rightarrow \text{next larger size} = 14\text{ Fr}$

Endotracheal Suction Protocol & Saline Instillation Guidelines

• Step-by-Step Endotracheal Suction Protocol:

  1. Assess Patient: Identify clinical indications (breath sounds, ventilator graphics/pressures).
  2. Assemble Equipment: Select correct French size suction catheter based on ETT size.
  3. Hyperoxygenate:
     • Adults and Pediatrics: Administer $100\%\,O_2$ for $30-60\text{ seconds}$ prior to catheter insertion.
     • Neonates: Increase $FiO_2$ by $10\%$ over baseline setting to avoid oxygen toxicity, Retinopathy of Prematurity ($\text{ROP}$), and tissue injury.
  4. Insert Catheter & Apply Suction: Advance catheter into the airway to desired depth. Apply suction while withdrawing.
  5. Time Limitation: Limit total application of negative suction pressure to less than $15\text{ seconds}$ to prevent severe hypoxemia, cardiac arrhythmias, and atelectasis.
  6. Re-oxygenate: Post-suction, hyperoxygenate using the ventilator's $100\%\,O_2$ suction enrichment feature (typically provides $100\%\,O_2$ for $2\text{ minutes}$ timed).
  7. Re-assess Outcome: Check breath sounds, ventilator parameters, and pulse oximetry. Repeat steps only if clinical indications persist.

• Prevention of Complications:

  • Hypoxemia: Prevented via hyperoxygenation pre- and post-procedure.
  • Atelectasis: Avoided by limiting negative vacuum pressure, keeping suction duration under $15\text{ seconds}$, selecting appropriate catheter sizing, and using closed inline systems.
  • Infection: Avoided by using strict sterile technique and avoiding unnecessary ventilator circuit disconnections.

• Sterile Normal Saline Instillation Guidelines:

  • Routine instillation of sterile normal saline down an artificial airway prior to suctioning is strongly discouraged.
  • Risks: Dislodges bacterial biofilm inside the tube into lower airways, causes severe bronchospasm, and decreases arterial oxygen saturation.
  • Indications: Reserved strictly for refractory cases where secretions are extremely thick, tenacious, and desiccated, preventing clearance, or during emergent mucus plug obstruction.
  • Emergent Mucus Plug Procedure: Instill saline bullet down the ETT, manually ventilate with a bag-valve-mask (Ambu bag) to push saline distally and loosen the plug, then suction aggressively.
  • Alternative Pharmacological Mucolytics: Nebulized $3\%$ or $7\%$ hypertonic saline, dornase alfa (Pulmozyme for Cystic Fibrosis), or acetylcysteine.

• In-Line Catheter Maintenance & Anatomy:

  • Anatomy: Enclosed protective plastic sleeve, thumb control button with a rotational lock mechanism, irrigation port, and corrugated connection tubing.
  • Pediatric Markings: Pediatric inline catheters feature graduated depth numbers to prevent over-insertion into tiny, fragile airways.
  • Clearing the Catheter Line: After withdrawing the catheter fully into the sleeve post-suctioning, attach a saline bullet/syringe to the irrigation port, apply thumb suction, and flush the catheter shaft clean. Do not flush saline into the patient's lungs during this step.

Nasotracheal Suctioning (NTS) & Sputum Collection Techniques

• Nasotracheal Suctioning (NTS) Indications:

  • Indicated for patients retaining secretions in lower airways who do not have an artificial airway in place.
  • Common populations: Patients with traumatic brain injuries (TBI), sedated patients, obtunded individuals, or Do-Not-Resuscitate (DNR) patients in respiratory decline due to secretion retention who cannot be intubated.

• NTS Procedure Details:

  • Anatomical Alignment: Place patient in the sniffing position (head extended, neck slightly flexed) to align the pharynx with the trachea, guiding the catheter anteriorly into the larynx rather than posteriorly into the esophagus.
  • Catheter Passage: Advance the soft catheter through the naris along the floor of the nasal cavity. As the patient takes a deep breath in, the glottis opens wide; rapidly advance the catheter through the vocal cords into the trachea.
  • Complications: Gagging, regurgitation, vomiting, aspiration, nasal mucosal trauma, epistaxis, bronchospasm.
  • Timing: Avoid suctioning immediately following meals.

• Sputum Collection Methods:

  • Expectorated Samples: Patient coughs directly into a sterile specimen cup. Pre-cleaning the oral cavity (brushing teeth or rinsing mouth) is required to reduce oral flora contamination.
  • Suctioned Samples (Lukens Trap / Leukens Trap):
    • An inline collection bottle inserted between the suction catheter and vacuum tubing.
    • Critical Handling Rule: The Lukens trap must be held vertically/upright throughout suctioning. If tipped upside down, the collected sputum specimen will be drawn into the vacuum tubing line and lost.
    • Post-Collection Sealing: Remove the suction adapter lid and screw on a sterile solid cap (or loop the tubing directly back onto its port depending on hospital laboratory policy) before sending it to the lab on ice.
  • Induced Sputum Samples:
    • Indicated for patients unable to produce sputum spontaneously, or for mandatory state testing protocols (e.g., Tuberculosis screening).
    • Procedure: Administer nebulized hypertonic saline ($3\%$ or $7\%$) prior to specimen collection to draw fluid osmotic pressure into the airways and induce coughing.
    • Pre-treatment: Hypertonic saline causes airway irritation and bronchoconstriction. Always have a short-acting bronchodilator (e.g., albuterol) available; pre-treat patients with reactive airway disease (asthma/COPD) with albuterol prior to nebulizing hypertonic saline.

Pharyngeal Airways, Laryngeal Mask Airways, and Intubation Routes

• Pharyngeal Airways vs. Tracheal Airways:

  • Pharyngeal airways extend only into the pharynx (above the larynx).
  • Tracheal airways pass through the larynx directly into the trachea.

• Nasopharyngeal Airway (NPA / Nasal Trumpet):

  • Indication: Placed to facilitate frequent nasotracheal suctioning and protect the nasal mucosa from tissue trauma caused by repeated catheter insertion. Keeps upper airway open during manual bag-valve-mask ventilation.
  • Sizing: Measured from the tip of the nose to the tip of the earlobe.
  • Insertion: Thoroughly lubricated with water-soluble lubricant and advanced along the nasal floor. Must be rotated between nares periodically to prevent tissue ulceration.

• Oropharyngeal Airway (OPA):

  • Indication: Restricted strictly to unconscious patients without a gag reflex. Inserted to depress the tongue forward, preventing soft tissue upper airway obstruction during bag-valve-mask (BVM) manual ventilation.
  • Sizing: Measured from the corner of the mouth to the angle of the jaw/tip of the earlobe.
  • Contraindication: Never use in conscious or semi-conscious patients due to severe gagging, vomiting, and aspiration risks.
  • Bite Block Caution: OPAs should not be used as long-term bite blocks for intubated patients. Their rigid plastic construction causes pressure ulcers and lip/tongue necrosis. Commercial ETT holders with built-in soft bite blocks must be used.

• Laryngeal Mask Airway (LMA):

  • An airway appliance inserted blindly into the pharynx, seating over the laryngeal inlet.
  • Indications: Emergency management of difficult airways, unsuccessful intubations, or severe facial/mandibular trauma where achieving a outer face mask seal for BVM ventilation is impossible.
  • Limitation: Does not isolate the trachea; does not completely protect against gastric inflation or pulmonary aspiration.

Endotracheal Tube Anatomy & Specialized Tracheal Airways

• Standard Endotracheal Tube (ETT) Components:

  • ** Hub / Adapter:** Standard $15\text{ mm}$ outer diameter universal connector that connects to ventilator circuits and manual resuscitator bags.
  • Radiopaque Line: Imbedded line along the length of the tube visible on chest radiographs to assess insertion depth.
  • Centimeter Markings: Etched depth numbers along the tube body.
  • Bevel: Angled tip facilitating passage through vocal cords.
  • Murphy Eye: Side orifice near the distal tip providing an alternate airflow pathway if the primary bevel becomes occluded by the tracheal wall or secretions.
  • Inflatable Cuff: Inflatable balloon near the distal tip sealing the trachea to allow positive pressure ventilation and prevent gross aspiration.
  • Pilot Balloon & One-Way Valve: External assembly used to inflate the internal cuff and monitor cuff inflation status.

• Double-Lumen Endotracheal Tube (Carlens / Endobronchial Tube):

  • Anatomy: Features two distinct internal lumens, two separate cuffs (a tracheal cuff and a bronchial cuff), and two pilot balloons.
  • Placement: Intentionally advanced past the carina into either the right or left mainstem bronchus.
  • Indication: Used for Independent Lung Ventilation (ILV). Allows two separate mechanical ventilators to ventilate each lung independently when significant unilateral lung disease, lung trauma, or bronchial fistulas exist.

Orotracheal and Nasotracheal Intubation Protocols

• Orotracheal Intubation Procedure Steps:

  1. Assemble and Check Equipment: Confirm function of suction, laryngoscope light, ETT cuff integrity, stylet insertion, suction setup, and colorimetric capnometer ($\text{EZ-Cap}$).
  2. Position Patient: Place patient in the sniffing position (head tilted back, neck slightly flexed, roll placed under shoulders) and adjust bed height.
  3. Pre-Oxygenate: Administer $100\%\,O_2$ for at least $3\text{ minutes}$ via non-rebreather or bag-valve-mask with $\text{PEEP}$ valve.
  4. Laryngoscopy & Visualization:
     • Macintosh Blade (Curved): Insert tip into the vallecula (space between base of tongue and epiglottis) and lift anteriorly to indirectly elevate the epiglottis.
     • Miller Blade (Straight): Insert tip directly over the epiglottis and lift anteriorly to expose vocal cords.
  5. Pass Tube: Advance ETT through vocal cords under direct visualization until cuff passes $1-2\text{ cm}$ past the cords.
  6. Verify Tube Placement:
     • Auscultate equal bilateral breath sounds over lung apices/axillary lines and confirm absence of stomach sounds over epigastrium.
     • Observe symmetrical chest wall rise.
     • Check for continuous $CO_2$ detection via capnography or colorimetric $CO_2$ detector ($\text{EZ-Cap}$ changing from purple to yellow).
     • Position tip $3-5\text{ cm}$ above the carina (aligned with 2nd–4th tracheal rings or aortic knob).
     • Confirm depth placement via Chest X-ray.

• Nasotracheal Intubation Protocol:

  • Passed through the naris into the trachea; performed blindly or guided via direct visualization using a flexible bronchoscope or Magill forceps.
  • Verification: Tube depth is documented and monitored at the naris (e.g., cm mark at nasal entrance).
  • Disadvantages: Higher risk of sinusitis, nasal tissue necrosis, difficult insertion, and impossibility of repositioning the tube laterally (unlike oral ETTs which are shifted side-to-side every $4\text{ hours}$ to prevent lip pressure ulcers).

Tracheotomy, Tracheostomy Tubes, and Laryngectomy Management

• Medical Terminology Distinctions:

  • Tracheotomy: The surgical procedure/incision made into the trachea.
  • Tracheostomy: The resulting open stoma/hole created in the anterior neck.

• Surgical vs. Percutaneous Dilational Tracheotomy (PDT):

  • Surgical Tracheotomy: Performed in the operating room with scalpels, dissecting tissue down to the trachea. Requires longer surgical recovery.
  • Percutaneous Dilational Tracheotomy (PDT): Performed at the bedside under direct bronchoscopic guidance. A needle punctures the anterior neck into the trachea, a guidewire is advanced, serial dilators stretch the stoma open, and the tracheostomy tube is seated over a dilator.
  • Closed-Loop Communication during PDT: The respiratory therapist manages the top airway, backing the ETT up on explicit command from the physician (e.g., Physician: "Withdraw ETT $2\text{ cm}$"; RT: "Withdrawing ETT $2\text{ cm}$"; RT confirms: "ETT withdrawn $2\text{ cm}$"). Unintentional premature withdrawal causes immediate extubation before stoma establishment.

• Emergency Cricothyroidotomy ("Crike"):

  • An emergency surgical airway performed in field/trauma situations where maxillofacial destruction prevents oral/nasal access.
  • Surgical incision is made directly through the cricothyroid membrane, dilated manually with a finger, and an ETT or tracheostomy tube is inserted into the opening.

• Tracheostomy Tube Anatomy:

  • Flange (Neck Plate): Rests against neck tissue; features side slots for trach ties.
  • Outer Cannula: Primary body holding the stoma open.
  • Inner Cannula: Fits inside outer cannula. Can be removed and disposed of or cleaned to clear sudden mucus blockages without decannulating the patient.
  • Obturator: Rigid, rounded tip device placed inside outer cannula during insertion to guide tube smoothly and prevent creating a false track (inserting tube into subcutaneous neck tissue outside trachea). Must be removed immediately post-insertion.
  • $\mathbf{15\text{ mm}}$ Outer Adapter: Standard fitting attached to outer/inner cannula allowing connection to BVMs or ventilator tubing.

• Laryngectomy vs. Tracheotomy Procedures:

  • Laryngectomy: Complete surgical removal of the larynx (typically for laryngeal cancer). The trachea is permanently re-routed directly to a stoma in the neck. The upper airway (mouth/nose) is completely disconnected from the lungs.
  • Tracheotomy: Incision into the trachea; upper airway structures remain intact.
  • CRITICAL RESUSCITATION DIFFERENCE:
    • Tracheotomy Patient Emergency Ventilation: If a trach tube dislodges, you can occlude the neck stoma with gauze and manually bag-ventilate the patient through their mouth/nose.
    • Laryngectomy Patient Emergency Ventilation: You cannot ventilate a laryngectomy patient through the mouth or nose. Air will not reach the lungs. Gastric inflation or death occurs. You must place a small pediatric face mask attached to an manual resuscitator bag directly over the neck stoma to ventilate.

Airway Complications, Tissue Damage, and Vascular Fistulas

• Laryngeal Lesions (from ETTs): Glottic edema, vocal cord inflammation, vocal cord ulcerations, granulomas, vocal cord polyps, vocal cord paralysis, and laryngeal stenosis.

• Tracheal Lesions:

  • Tracheomalacia: Softening, destruction, and structural breakdown of tracheal cartilaginous rings, leading to tracheal collapse on exhalation.
  • Tracheal Stenosis: Scared narrowing of the tracheal lumen.

• Fistula Formation:

  • Tracheoesophageal Fistula (TEF): Severe pressure necrosis creates an erosion hole between the trachea and posterior esophagus, causing massive food/saliva aspiration into the lungs.
  • Tracheo-Innominate Artery Fistula (TIF): Severe tissue necrosis causes the distal tip or cuff of a low-seated tracheostomy tube to erode into the innominate artery, creating a massive, catastrophic arterial hemorrhage.
  • Emergency TIF Management Protocol:
    1. Immediately hyperinflate the cuff to tamponade the artery, or remove the tracheostomy tube completely.
    2. Insert a gloved finger directly into the tracheostomy stoma.
    3. Hook finger distal into trachea and pull anteriorly against the sternum to physically compress the innominate artery against the back of the sternum.
    4. Call an immediate emergency surgical code; maintain anterior pressure while patient is rushed to surgery.

• Preventing Tissue Damage:

  • Maintain ETT/Trach cuff pressures strictly between $20-30\text{ cmH}_2\text{O}$ (target $\le 25\text{ cmH}_2\text{O}$).
  • Support ventilator circuit tubing weight with circuit arms to eliminate drag and leverage traction on artificial airways.
  • Use swivel adapters on airway connections during patient repositioning and proning.

Alternative Cuff Designs and Advanced Tracheostomy Care

• Alternative Cuff Designs:

  • Kamen-Wilkinson Foam Cuff (Bivona): Filled with polyurethane foam that naturally expands against the tracheal wall at atmospheric pressure ($0\text{ cmH}_2\text{O}$ applied inflation pressure). To insert or remove, attach a syringe to the pilot valve to draw a vacuum, collapsing the foam flat. Once seated, open port to atmosphere to expand.
  • Tight-to-Shaft (TTS) Water-Filled Cuffs: Silicone cuffs designed to collapse flush against the tube shaft when deflated. Must be inflated with sterile water only (never air) because silicone is gas-permeable and air leaks out.

• Tracheostomy Care Protocol:

  • Perform routinely to prevent stoma breakdown, bacterial infection, and tube occlusion.
  • Replace disposable inner cannula (or clean reusable inner cannula with sterile water).
  • Clean around stoma site using sterile water and cotton applicators, wiping radially outward from the stoma to avoid pushing debris inward.
  • Avoid hydrogen peroxide unless stubborn, encrusted secretions exist; flush off completely with sterile water.
  • Inspect stoma for erythema or skin breakdown.
  • Replace soiled tracheostomy ties/holders (ensuring one finger width under ties) and replace split gauze dressing under flange.
  • Bedside Safety Requirement: Always maintain a spare inner cannula, complete tracheostomy kit of same size, one size smaller trach tube, and obturator at the bedside.

• Passy-Muir Speaking Valves (PMV):

  • A one-way valve attached to a tracheostomy tube ($15\text{ mm}$ hub). Inhalation opens valve, allowing air entry into lungs; exhalation closes valve, forcing air upward past vocal cords and out mouth/nose to enable speech.
  • CRITICAL MANDATE: THE TRACHEOSTOMY CUFF MUST BE FULLY DEFLATED BEFORE APPLYING A SPEAKING VALVE.
  • Fatal Hazard: If a speaking valve is placed while the cuff remains inflated, the patient can inhale through the valve but cannot exhale past the inflated cuff or valve. Air trapping occurs rapidly, causing lung hyperinflation, tension pneumothorax, and fatal asphyxiation.
  • Contraindications: High $\text{PEEP}$ requirements, high minute ventilation demands, severe aspiration risk requiring inflated cuff.

Troubleshooting Airway Emergencies & Accidental Extubation

• Evaluating Tube Obstruction:

  • Attempt to pass a suction catheter down the tube. If catheter stops abruptly, determine occlusion site:
    • Obstruction before mouth: Tube kinking (unkink tubing).
    • Obstruction at teeth level: Patient biting down (insert OPA/bite block).
    • Obstruction distal to teeth: Mucus plug (suction/saline instillation) or cuff herniation over tube bevel.
    • Obstruction at distal tip: Beveled tip impaled against tracheal wall (slightly rotate or re-position tube depth).

• Cuff Leaks and Repair Options:

  • Pilot Valve Leak: Use a commercial pilot valve repair kit. Cut severed pilot line, insert temporary needle valve, and reinflate cuff as a temporary fix.
  • Ruptured Internal Cuff: Requires complete endotracheal tube exchange using an Endotracheal Tube Exchanger (Bougie / Cook Catheter).

• Accidental Extubation / Partial Displacement:

  • Signs: Sudden drop in delivered tidal volumes, high peak pressure alarms, audible gurgling/speech, air escaping mouth/nose during mechanical breath, inability to pass suction catheter.
  • Verification: Open mouth/lips and physically inspect pharynx. If inflatable cuff is visible inside oral cavity, the tube is completely displaced above vocal cords.
  • Action: Fully deflate cuff, immediately remove displaced tube, manually bag-ventilate patient with $100\%\,O_2$, and prepare for reintubation.

Extubation and Decannulation Procedures

• Extubation Readiness Assessment Criteria:

  • Resolution of initial disease process requiring intubation.
  • Adequate secretion clearance ability and manageable secretion viscosity.
  • Intact protective reflexes (cough and gag reflexes).
  • Cuff Leak Test (Upper Airway Patency Assessment):
    • Suction oral pharynx thoroughly.
    • Deflate ETT cuff and occlude distal end of tube (or listen over trachea with stethoscope during positive pressure breath).
    • Positive Cuff Leak Test: Audible air passage around deflated cuff confirms absence of severe glottic swelling, indicating safe extubation.

• Required Extubation Equipment:

  • Intubation tray (laryngoscope, ETTs—including one size smaller, stylet).
  • Suction apparatus and Yankauer.
  • Bag-valve-mask connected to oxygen.
  • Nebulizer and racemic epinephrine (for post-extubation stridor).
  • Supplemental oxygen delivery system (cool mist face mask, high-flow nasal cannula, or BiPAP).

• Step-by-Step Extubation Procedure:

  1. Suction ETT and oral pharynx thoroughly.
  2. Loosen tape or commercial tube holder.
  3. Attach syringe and fully deflate cuff.
  4. Instruct patient to take a maximum deep inspiration (glottis opens maximally during inspiration).
  5. Smoothly pull ETT out at