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Artificial Airways
Outlines
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Basic techniques for opening the air way.
Laryngeal Mask Airway
Oropharyngeal Airway
Nasopharyngeal Airway
Skills and care for a patient with Artificial Airway
Endotracheal Tube ( ETT)
Skills and care for a patient with ETT
Tracheostomy
Skills and care for teacheostomy
Cricothyredictomy.
• Alternative Methods of Communication for
Patients with Artificial Airways
Artificial Airways
There are a number of different
artificial airways; each one has its
own criteria for use based on the
clinical circumstances
Basic techniques for
opening the air way.
• The are three manoeuvers to
improve an air way;
1. head tilt.
2. chin lift.
3. jaw thrust.
Laryngeal Mask Airway
• (LMA) is used for emergent intubation or in situations where
ETT intubation has failed.
• The LMA looks like an ETT with an inflatable, silicone rubber
collar at the bottom end.
• This collar surrounds and covers the supraglottic
providing a continuous upper airway.
area,
• Supine position.
• Head, neck aligned.
• Holding the tube like a
pen.
• Introduce into the
mouth.
• Connect the inflating
syringe.
(LMA)
• Sizes:
3 Small adult
4 normal adult
5 Large adult
LMA (Laryngeal Mask )
• Advantages
• Easy to insert and quickly.
• Allows ETT intubation through it, while
maintaining an open airway.
• Disadvantages
• Does not prevent aspiration.
• Can only be used short term until another
airway is established.
Oropharyngeal Airway
• The goal of an oropharyngeal airway is to keep the
tongue from obstructing the upper pharynx.
• Place the patient in the supine position if possible……
suction the mouth, and remove and dentures…….
estimate the appropriate size.
• The airway is inserted into the mouth upside down,
then rotated 180o as it is placed over the tongue.
Oropharyngeal Airway
Vertical distance between pt.’s incisors and the
angle of the jaw.
Sizes: 2, 3, 4 for adults respectively.
Oropharyngeal Airway
Advantages
– Prevents tongue from obstructing pharynx.
– May prevent the need for intubation in patients who are
temporarily unable to maintain their airway
(i.e., drug overdose).
Disadvantages
– Causes conscious patients to gag…… thus can only be used
in unconscious patients with a diminished gag reflex.
Nasopharyngeal Airway
• nasopharyngeal Airway airway is similar to
that of the oropharyngeal, But smaller in
millimeter in internal size.
• it’s lubricated and inserted through a
nostril into the posterior pharynx.
Nasopharyngeal Airway
• Advantages
Tolerated by conscious patients with an intact gag reflex.
Can be left in place for a few days. Provides route for
sterile suctioning of airway.
• Dis-advantages
Nures must be closely monitored for skin breakdown if
used for a few days.
Skills and care for a patient with Artificial Airway
• Hand washing before any procedure.
• The position of the airway in the patient’s and breath sounds should
be assessed frequently.
• Mouth care should be done every two to four hours and as needed,
can be done with a moistened swab.
• If the airway is coated with secretions, it can be removed and
cleaned if the patient’s respiratory status is stable.
• Immediately insert a clean airway before cleaning the soiled one with
hydrogen peroxide and water.
• This airway can be kept for future use with the same patient.
• If the patient has the oropharyngeal airway as a long-term measure,
the airway should be cleaned and replaced at least once every eight
hours.
Endotracheal Tube ( ETT)
• The endotracheal tube (ETT) is the
most common artificial airway used for
airway management or mechanical ventilation.
• Insertion of an ETT is indicated for airway
maintenance, secretion control, oxygenation and
ventilation, and administration of emergency
medications during cardiopulmonary arrest.
Endotracheal Tube
Advantages
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Provides route for sterile suctioning of airway.
Some emergency medications can be given via the
ETT (Narcan, atropine, epinephrine, lidocaine).
Can be inserted either nasally or orally.
Disadvantages
 Patients may need sedation and/or wrist
restraints to prevent accidental removal.
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Patients not able to speak.
• ETTs are available in a variety of
sizes…….For adults, this generally
includes tubes with an inner diameter of
6 mm to 8.5 mm.
• Obviously, a smaller tube may have to
be used for nasal intubation, …..and….
most patients can tolerate tube sizes
between 6 to 7.5 for this
Endo tracheal Intubation
The tube may be inserted either nasally or orally;
However, the oral route is preferred during emergency
placement because insertion is easier and a largerdiameter tube can be used.
Equipment
• Various sizes of ETT tubes (6 to 8.5).
• Larynge scope.
• Tape or device to secure ETT tube.
• Sterile gloves
• Lubricant.
• Suction catheter – port.
• Stethoscope.
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CO2 detector to confirm placement.
• Cardiac monitor.
• pulse oximeter.
Complication
– Mouth and teeth and upper airway
damage
– Vocal cords injury
– Risk for pneumonia
Skills and care for a patient with ETT
 it’s vital that you know the history and the events leading
up to the intubation.
 prepare the room ahead of time is also helpful:
This may include removing the head of the bed……. pulling
the bed away from the wall…… removing extra equipment
and asking visitors to step out of the room.
 While the physician is intubating the patient:
- be responsible for monitoring and documenting vital signs,
- administering medications.
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preparing equipment.
 Sterile suction should be set up and ready for use as
soon as the ETT is placed. Often, suctioning of mucus
or aspirate is all that’s needed to restore spontaneous
breathing after a respiratory arrest
• After intubation
you should have a stethoscope ready to listen for
bilateral breath sounds.
Many institutions also use CO2 detectors to confirm
that the ETT is in the lungs, and not the esophagus.
• chest x-ray is necessary to confirm the position of the ETT.
• You should have tape or an ETT holder ready to secure the tube, as
well as wrist restraints for the patient, in order to prevent accidental
removal of the tube.
• Monitor respiratory status and monitor signs of hemorrhage.
• Following placement , keep the area clean with frequent dressing
changes and frequent suction to prevent infection.
• Maintain appropriate endotracheal cuff to prevent aspiration and tube
displacement…..Monitor cuff pressure every 4-8hrs during expiration .
 Tilt the patient’s head back to open the airway, unless neck injury
is present. In this case, use a jaw thrust.
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The patient’s chest should rise with each squeeze of the bag.
 Ensure that 100% oxygen is hooked up to the resuscitation bag.
 Condensation in the mask indicates ventilation is taking place in the
lungs.
 Listen for lung sounds or tracheal sounds of air entering the lungs.
 If the patient has dentures, intubation may be easier to perform if
the dentures are left in.
 If the patient has any spontaneous breaths, manual breaths should
be coordinated with the patient’s own breaths.
Observational methods to confirm
correct tube placement
• Direct visualization of the tube passing through the
vocal cords.
• Clear and equal bilateral breath sounds on
auscultation of the chest
• Absent sounds on auscultation of the epigastrium
• Equal bilateral chest rise with ventilation
• An absence of stomach contents in the tube
Instruments to confirm correct tube placement
• Pulse oximetry (patients with a pulse) - delay in fall
of saturation, especially if pre-oxygenated
Tracheostomy
Tracheostomy
• A tracheostomy tube is the preferred artificial airway
for patients requiring long-term mechanical ventilation
(longer than three weeks).
• It’s also indicated for other conditions such as upper
airway obstruction or malformation, failed or repeated
intubations, complications from endotracheal intubations,
glottic incompetence, sleep apnea, or chronic inability to
clear secretions.
Tracheostomy
Advantages
• Can be used long-term; up to years.
• More comfortable for patient.Allows
speaking and eating if respiratory
status is stable.
• Patients can be taught how to care for
their tracheostomy at home.
• Complications and disadvantaged of insertion include:
 Hemorrhage.
 Pneumothorax.
 Laryngeal nerve injury
 Tracheoesophageal fistula (opening between trachea and
esophagus).
 Cardiopulmonary arrest.
 Wound infection.
 Subcutaneous emphysema (air in subcutaneous tissue).
 Tube obstruction.
 Tube displacement may also occur
Skills and care for teach.
 Monitor respiratory status and monitor signs of
hemorrhage
 Explain procedure and rational to the patient and assist
as needed with placement
 Following placement , keep the area clean with frequent
dressing changes and frequent suction to prevent
infection
 Maintain appropriate tracheal cuff to prevent aspiration
and tracheal pressure necrosis
 Perform routine cleansing of inner cannula and ostomy
site as needed
 Monitor cuff pressure every 4-8hrs during expiration
 Auscultate for presence of lung sounds bilaterally after
insertion and after changing trach.
 Assist with chest X rays exam as needed
Cricothyredictomy
• Cricothyredictomy is immediate and rapid technique.
• Patient supine, head is slightly extended.
• Identify the cricothyroid membrane …… between thyroid
cartilage and cricoid cartilage.
• The membrane is punctured vertically in the midline using
cannula
14 guage attached to a syringe.
• Aspiration of air to confirms the correct position.
• The cannula is angeled 45˚ and advanced gradulay.
• Attach to high oxygen using Y connector.
Complication.
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Co2 alimentation is less efficient .
Can cause surgical emphysema .
Hemorrhage .
Cannula displacement.
Osephegeal displacement.
Alternative Methods of
Communication for Patients with
Artificial Airways
• The ETT prevents speech because it passes through
the vocal cords; this may increase anxiety.
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Caregivers must enter the room (so the patient can
see them) frequently to reassure the patient that he
or she is being carefully monitored.
• Some patients may be able to mouth words well enough
for caregivers to read their lips.
• Having the patient write notes and draw
pictures is another option.
• The patient may have to use their nondominant
hand because of IVs and arterial lines.
• These are posters that usually have large-type
letters and numbers on one side, and pictures of
typical patient requests on the other side. The
pictures include items such as medication, pain,
nurse, doctor, family, call light, TV and water.