Cardiopulmonary Evaluation and Airway Management

Cardiopulmonary Evaluation and Airway Management

Learning Objectives

• Endotracheal and nasotracheal suctioning safely.
• Sputum samples.
• Artificial airway.
• Identify the complications and hazards associated with insertion of artificial airways.
• Orotracheal and nasotracheal intubation of an adult.
• Assess and confirm proper endotracheal tube placement.
• Describe how to use alternative airway appliances.
• Describe the rationale and the methods for performing a tracheotomy.
• Identify the types of damage that artificial airways can cause.
• Describe how to maintain and troubleshoot artificial airways properly.
• Describe techniques for measuring and adjusting tracheal tube cuff pressures.
• Identify when and how to extubate or decannulate a patient.

Introduction

• Respiratory therapists (RTs) must develop skills in three broad areas of airway care:
  • Proficient in airway clearance techniques.
  • Able to insert and maintain artificial airways.
  • Able to assist physicians in performing special procedures related to airway management.

Suctioning

• Reasons for suctioning include:
  • Retained secretions (primary).
  • Foreign bodies.
  • Edema, tumors, or trauma related.
• Application of negative pressure to airways through collecting tube.
• Suctioning can be performed via either:
  • The upper airway (oropharynx).
  • The lower airway (trachea and bronchi).
• Tracheal suctioning through the mouth should be avoided because it causes gagging.

Endotracheal Suctioning

• Two techniques for endotracheal suctioning:
  • Open—sterile technique that requires disconnecting patient from ventilator.
  • Closed—technique uses sterile, closed, in-line suction catheter that is attached to ventilator circuit.
    • Suction catheter can be advanced into patient’s endotracheal airway without patient-ventilator disconnection.
    • Should be replaced based on manufacturers guidelines or when visibly soiled.

Equipment Needed for Suctioning

• Vacuum source (wall or portable).
• Calibrated, adjustable regulator.
• Collection bottle and connecting tubing.
• Disposable gloves: sterile (open suction) or clean (closed suction).
• Sterile suction catheter.
• Sterile water and cup (open suction), if needed to clear catheter.
• Goggles, mask, and other appropriate equipment for standard precautions.
• Oxygen (O_2) source with a calibrated flowmeter (open suction) or ventilator (closed suction).
• Pulse oximeter.
• Manual resuscitation bag equipped with O_2-enrichment device for emergency backup use.
• Stethoscope.

When to Suction

• Step 1: Assess patient for indications.
  • Patient should NEVER be suctioned according to preset schedule.
  • Abnormal breath sounds (e.g., coarse crackles) suggest that suctioning is needed.
• Step 2: Assemble and check equipment.
  • Selecting suction catheter size.
    • External diameter (ED) of suction catheter should be no more than one half of internal diameter (ID) of artificial airway.
    • Formula to estimate proper catheter size: ID \times 3/2
    • Example: Size 8.0mm ETT \times 3 = 24/2 = 12
• Step 3: Assess for hyperoxygenate patient
  • Use 100% oxygen for 30 to 60 seconds for pediatric and adult patients
  • Increased by 10% in neonates
• Step 4: Insert catheter
• Step 5: Apply suction/clear catheter
  • Total suction time should be <15 seconds
• Step 6: Reoxygenate patient
• Step 7: Monitor patient and assess outcomes

Endotracheal Suctioning Steps

• Steps 3 through 7 are repeated as needed.
• Minimizing complications and adverse responses:
  • Preoxygenation helps minimize incidence of hypoxemia.
  • Avoid atelectasis by limiting amount of negative pressure used, keeping duration of suctioning as short as possible, using appropriate size suction catheter, and avoiding disconnection from ventilator.

Complications and Adverse Responses

• Hypoxemia
• Cardiac Dysrhythmias
• Hypotension/Hypertension
• Atelectasis
• Mucosal Trauma
• Increased ICP
• Bacterial colonization of lower airway

Minimizing Complications and Adverse Responses

• Use sterile technique during suctioning and manually ventilating patient to minimize bacterial colonization.
• Do not routinely instill sterile normal saline into artificial airway prior to suctioning unless necessary to help mobilize thick secretions.

Nasotracheal Suctioning

• Indicated for patients who retain secretions but do not have artificial airway in place.
• Placing catheter in larynx and trachea is facilitated by having patient assume “sniffing position”.
• Procedure may cause patient to gag or regurgitate; avoid suctioning immediately after meals.
• Prepare to reposition patient and suction oropharynx if this occurs.

Sputum Sampling

• Collected to identify organisms affecting airway.
• Patients with strong enough cough can provide ample sputum specimen by expectorating in sterile cup.
• Sterile technique must be maintained when touching connection points on sterile Lukens trap.

Establishing an Artificial Airway

• Routes:
  • Pharyngeal airways extend only into pharynx.
  • Artificial airways placed through mouth and nose into trachea are called endotracheal tubes.
• Intubation: process of placing artificial airway into trachea.
  • Orotracheal intubation is when tube is passed through mouth on its way into trachea.
  • Nasotracheal intubation is when endotracheal tube is passed through nose first.
• Procedures:
  • Orotracheal intubation.
  • Nasotracheal intubation.
  • Tracheotomy.

Pharyngeal Airways

• Nasal pharyngeal airway is most often placed to facilitate frequent nasotracheal suctioning (aka "trumpet").
  • Minimizes damage to nasal mucosa caused by suction catheter.
• Oral pharyngeal airway should be restricted to unconscious patient to avoid gagging and regurgitation.
  • Maintains patient airway by preventing tongue from obstructing oropharynx.
  • Can be used as bite block for patients with oral tubes.

Tracheal Airways

• Two basic types:
  • Endotracheal tubes are inserted through either mouth or nose, through larynx, and into trachea.
  • Tracheostomy tubes are inserted through surgically created opening in neck directly into trachea.
• Specialized endotracheal tubes:
  • Double-lumen ETT
  • Double-lumen airway (Combitube)
  • Special ETT adapter
  • LMA (Laryngeal Mask Airway)

Endotracheal Intubation

• Step 1: Assemble and check equipment.
• Step 2: Position patient.
• Step 3: Preoxygenate and ventilate patient.
• Step 4: Insert laryngoscope.
• Step 5: Visualize glottis.
• Step 6: Displace epiglottis.
• Step 7: Insert tube.
• Step 8: Assess tube position.
  • Tip of tube should be about 3-6 cm above carina.
• Step 9: Stabilize tube/confirm placement.
  • Listen for equal and bilateral breath sounds as patient is being ventilated.
  • Observe chest wall for adequate and equal chest expansion.
  • If ET tube in airway, chest CO_2 levels begin to rise; seen on capnogram.
  • Colorimetric ETCO_2 detector.
  • X-ray.

Nasotracheal Intubation

• More difficult than orotracheal intubation.
• Performed either blindly or with visualization.
  • Direct visualization requires either standard or fiberoptic laryngoscope.
  • Steps for nasotracheal intubation are similar to those for orotracheal intubation.

Tracheotomy

• Procedure of establishing access to trachea via neck incision.
• Either traditional surgical tracheotomy or percutaneous dilatational tracheotomy can be performed.
• Opening in neck is called “tracheostomy”.
• Procedure is best performed by physician or surgeon in surgical setting after patient’s airway is stabilized.
• Selection of tracheostomy tubes depend on patient’s age, height, weight, and airway anatomy.

Laryngectomy

• Removal of the larynx (voice box).
• Usually done to treat laryngeal cancer.
• Also done with trauma, radiation necrosis.
• Surgeon creates a stoma and attaches the trachea to the stoma.
• Laryngectomy tube may be inserted into the stoma to keep it open while it heal.
• The patient will breathe through this permanent stoma.

Airway Trauma Associated with Tracheal Tubes

• Laryngeal lesions:
  • Most common injuries to larynx are:
    • Glottic edema
    • Vocal cord inflammation
    • Laryngeal/vocal cord ulcerations
    • Vocal cord polyps or granulomas
  • Less common but more serious injuries include vocal cord paralysis and stenosis
• Tracheal lesions:
  • Granulomas
  • Tracheomalacia
  • Tracheal stenosis
  • Tracheoesophageal and tracheoinnominate artery fistula
• Treatment:
  • Depends on severity, especially length and circumference of damage.
  • Laser therapy may be useful for small lesions.
  • Resection and end-to-end anastomosis may be indicated when damage involves less than three tracheal rings.
  • Staged repair and stents may be required for more involved damages
• Prevention:
  • Tube movement is primary cause of injury.
  • Sedation can help avoid self-extubation.
  • Nasotracheal tubes are easier to stabilize.
  • Swivel adapter can reduce tube traction.
  • Selection of correct airway size is important.
  • Maintain pressures of 20-30 cm H_2O to reduce tracheal wall injury.
• Alternative cuff designs
  • Foam cuff designed to seal trachea with atmospheric pressure in cuff.
  • Not commonly used except in patients who have already developed tracheal injury.
  • Tight-to-shaft cuff is low-volume, high-pressure cuff design that maximizes airflow around tube when deflated.
  • Can be inflated with sterile water only; not air because it is made of porous silicone material.

Airway Maintenance

• Role of RTs:
  • Secure tube and maintain placement.
  • Provide for patient communication.
  • Ensure adequate humidification.
  • Minimize nosocomial infection.
  • Facilitate secretion clearance.
  • Provide appropriate cuff care.
  • Troubleshoot airway-related problems.
• Tracheostomy care:
  • Step 1: Assemble and check equipment.
  • Step 2: Explain procedure to patient.
  • Step 3: Suction patient.
  • Step 4: Remove and clean inner cannula.
  • Step 5: Clean and examine stoma site.
  • Step 6: Change ties/holder.
  • Step 7: Replace clean inner cannula (if present).
  • Step 8: Reassess patient.

Cuff Care

• Providing cuff care
  • The pathogenesis of these problems is related to the amount of cuff pressure transmitted to the tracheal wall, impeding the flow of blood and lymphatic fluid
  • If cuff pressure exceeds the mucosal perfusion pressure, ischemia, ulceration, necrosis, and exposure of the cartilage may result
• Importance of cuff pressure
• Measuring
  • A cuff pressure of 30 cm H_2O (22 mmHg) or less is recommended

Securing the Airway and Confirming Placement

• Most common is tape
• Commercial ETT stabilizers
• Cloth ties for tracheostomy
• Proper placement of an endotracheal or tracheostomy tube normally is confirmed by chest X-ray
• The tube tip should be approximately 3 to 6 cm above the carina in adults, or between the second and fourth tracheal rings

Providing for Patient Communication

• Phonation requires moving vocal cords
• ETTs prevent vocal cord movement and airflow through the cords
• Lip reading
• Writing
• Picture board
• Electronic devices
• Speaking valves
• Blom fenestrated tracheostomy tube

Ensuring Adequate Humidification

• Artificial tracheal airways bypass the normal humidification, filtration, and heating functions of the upper airway
• Selection of a humidification device ultimately should be based on:
  • Patient needs
  • Assessment of the airway
  • Volume and thickness of secretions and the history of mucous plugging or tube occlusions

Minimizing Nosocomial Infections

• Patients with tracheal airways are very susceptible to bacterial colonization and infection of the lower respiratory tract
• To guard against infection:
  • Adhere to sterile technique during suctioning
  • Ensure that only aseptically clean or sterile respiratory equipment is used for each patient
  • Consistent performing hand hygiene between patient contacts

Troubleshooting Airway Emergencies

• Tube obstruction
  • Kinking or biting tube
    • Obstruction is reversed by moving patient’s head and neck or repositioning tube
  • Herniation of cuff over tip
    • Deflate cuff
    • If deflating cuff fails to overcome obstruction, try to pass suction catheter through tube
  • Obstruction of tube orifice against tracheal wall
  • Mucus plugging
    • Suction tube
• Cuff leaks
  • Primarily problem for patients receiving mechanical ventilation
  • Will cause reduced delivery of tidal volume
  • If pilot tube or valve is leaking, tube needs to be changed as soon as possible
  • Pilot valve repair kit offers safe and effective alternative by permitting insertion of replacement valve into pilot tubing
  • Ruptured cuff requires extubation and reintubation or using endotracheal tube exchanger
    • Endotracheal tube exchanger is semirigid guide, over which damaged tube can be removed and new tube inserted
• Accidental extubation
  • Partial displacement of airway out of trachea can be detected by:
    • Decreased breath sounds
    • Decreased airflow through tube
    • Decreased ability to pass catheter past end of tube
    • With positive pressure ventilation, airflow through mouth and nose or into stomach may be heard
  • Completely remove tube and provide ventilatory support by manual resuscitator and mask as needed until patient can be reintubated or tracheostomy tube reinserted

Extubation/Decannulation

• Extubation: Process of removing oral or nasal endotracheal airway
• Decannulation: Process of removing tracheostomy tube
• Assess patient readiness for extubation or decannulation
  • Original problem is no longer present
  • Quantity and thickness of secretions
  • Upper airway patency
  • Presence of intact gag reflex
  • Ability to clear airway secretions

Steps of Extubation (Removal of ET Tube)

• Step 1: Assemble needed equipment
• Step 2: Suction endotracheal tube and pharynx above cuff
• Step 3: Oxygenate patient
• Step 4: Deflate cuff
• Step 5: Remove tube
• Step 6: Apply appropriate oxygen and humidity therapy
  • Oxygen with cool mist
• Step 7: Assess/reassess patient
  • Check for good air movement by auscultation

Decannulation

• Removal of tracheostomy tube
• Weaning process:
  • Fenestrated tubes
  • Double-cannulated tube that has opening in posterior wall of outer cannula above cuff
  • Progressively smaller tubes
  • Tracheostomy buttons