Artificial Airways And Trach Tubes

Front 1

Pharyngeal airways

Back 1

Extend only to the pharynx to prevent airway obstruction.

Front 2

Endotracheal tubes

Back 2

Airways that are placed in the nose and mouth and extend into the trachea

Front 3

Two types of pharyngeal airways

Back 3

1. Oropharyngeal

2. Nasopharyngeal

Front 4

Berman Oropharyngeal Airway

Back 4

- Two channels: one on each side

- Rigid

Advantages:

- Rigidness makes it difficult for patients to occlude while biting

- Dual channels less likely to cause obstruction with mucous

Front 5

Geudel Oropharyngeal Airway

Back 5

- Single enclosed channel

- Semi-rigid

- Rigid only in the bite region

Front 6

Indications of Oropharyngeal Airway

Back 6

- Unconscious

- Assist bag-mask manual ventilation

- Bite block (with ET tube or seizure to prevent biting)

Front 7

Contraindications of Oropharyngeal Airway

Back 7

- Conscious patients

- Patients with oropharyngeal trauma

Front 8

Sizing

Back 8

- Place against pt's cheeck with flange parallel to front teeth

- Tip at the angle of the jaw

Front 9

If the airway is too large:

Back 9

The tip will press the epiglottis against the larynx

Front 10

If the airway is too small:

Back 10

The tongue will be pushed against the posterior pharynx and causes obstruction

Front 11

Insertion technique

Back 11

1. Insert with tip pointing towards the roof of the mouth

2. Once fully inserted, rotate airway 180 degrees into correct position

3. Airway should be left unsecured

Front 12

Oropharyngeal Airway Hazards

Back 12

1. Vomiting (Major risk)

- suction and give O2

2. Gagging and coughing

- remove airway

3. Airway obstruction

- too small (tongue obstruct airway)

4. Laryngospasm

- Too long (airway pushes on epiglottis)

5. Dental trauma

- broken teeth from biting airway

6. Pressure necrosis

Front 13

Nasopharyngeal Airway

Back 13

- Can be used on conscious patients

- Maintains pt airway by lying between the base of tongue and posterior wall of pharynx

- Facilitates naso-tracheal suctioning and protects nasal passage from trauma

Front 14

Indications

Back 14

Patients with jaw that cannot be seperated. Ex. Seizures

Front 15

Contraindications

Back 15

- Nasal trauma

- Basilar skull fracture

- Deviated septum

- Coagulation disorders

Front 16

Sizing

Back 16

Diameter:

- Outside diameter should be equal to inside diameter of nares

Length:

- Measured from tragus to center of nostrils plus about 1 inch

Front 17

If too short:

Back 17

Complete airway patency will not be achieved

Front 18

If too long:

Back 18

Laryngospasm may occur

Front 19

Insertion of naso-pharyngeal

Back 19

1. Lubricate airway with water-soluble gel

2. Insert into nostril with bevel up towards the septum

3. Turn and slide it down gently while inserting

- If resistant is met, redirect

- If excessive resistance is met, remove and try other nostril

Front 20

Complications of Naso-pharyngeal airway

Back 20

1. Trauma to mucosa

2. Epistaxis (nasal bleeding)

- low platelet count or anticoagulants

3. Sinus infections

4. Cranial vault intubation

- basilar skull fractures

5. Tissue necrosis

- change airway q 24 hrs

Front 21

Esophageal tracheal combitube

Back 21

- Pre hospital emergency airway

- Assures adequate ventilation regardless of tube placement

- Replaced by KING tube

Front 22

Sturcture of Combitube

Back 22

Double lumen in one tube:

- An esophageal tube (#1 BLUE)

- A tracheal tube (#2 CLEAR)

Two cuffs:

- Large cuff the seals oropharynx

- Small cuff that seals the trachea or esophagus

Front 23

Combitube insertion

Back 23

Blind insertion

- Insert until markers line up with the gims or teeth

- Inflate BLUE # 1 (pharyngeal cuff) with 80mls

- Inflate CLEAR #2 (tracheal/esophageal cuff) with 10mls

Front 24

Determining placement

Back 24

- 99% placement is in esophagus

- Inflate BLUE #1. If chest rises, tube is in esophagus

- If no chest rise, inflate CLEAR #2. You should then see chest rise. The tube is in trachea.

Front 25

King Airways

Back 25

1. King LT-D tube

- single lumen

- no second lumen for gastric

2. King LTS-D airway

- one for ventilation

- one for gastic access

Front 26

King airway indications

Back 26

Pre-hospital emergency airway

- Difficult mask fit

- Unsuccessful intubation and difficulty ventilating with bag-mask

- No one available who can intubate with an ET tube

Front 27

King Airway sizes

Back 27

#3, 4-5 ft

#4, 5-6 ft

#5, > 6 ft

Front 28

Insertion

Back 28

- Insert device until the flange meets lip

- Inflate pilot balloon (range 45-90 ml)

- Begin ventilation and look for chest rise

Front 29

Laryngeal Mask Airway (LMA)

Back 29

- Used as an alternative to bag mask ventilation ( more ventilation is directed to the lungs)

- Does not stimulate the larynx (No Laryngospasm or vocal cord issues)

Front 30

LMA structure

Back 30

- Spoon shaped mask at end of the tube. Edges of mask are inflatable via q pilot balloon.

- Tube has 3 vertical slits which ventilation is provided

Front 31

LMA Indications

Back 31

- Difficult face mask fit (bag-mask)

- Unsuccessful endotracheal intubation

- Short term ventilation

Front 32

LMA Contraindications

Back 32

Risk of aspiration

- Cannot be used in a conscious or semiconscious pt

- The cuff DOES NOT prevent aspiration

Front 33

LMA insertion and placement

Back 33

- Place pt in sniffing position

- Lubricate mask

- Balloon should be deflated

- Advance along the hard palate using index finger

- Advance until resistance

- Inflate the cuff

Front 34

Tracheostomy Tube

Back 34

1. Lomg term intubation

2. Removal of secretions

3. To bypass upper airway obstruction

Front 35

Advantages of trach tubes

Back 35

1. Patient able to eat

- swallowing dysfunction or dysphagia --- 50% of patients

2. Patient is able to speak

3. Less airway resistance

4. Easier to tolerate than ET tube

Front 36

Trach tube Obturator

Back 36

Allow insertion without trauma

Front 37

Inner Canula

Back 37

Can be occluded if it becomes occluded

- Disposable --- replaced daily

- Non disposable (if trach is made of metal) --- removed and cleaned

Front 38

Fenestrated Trach Tubes

Back 38

- Outer canula has fenestrations or windows.

- Facilitate weaning from trach tube and used for pts who need intermittent mechanical ventilation (Ex: at night)

- During the day, inner canula is removed and cuff is deflated

Front 39

When using upper airway for breathing or speaking on Trach tube.

Back 39

1. Suction above cuff

2. Deflate cuff

3. Remove inner canula

4. Plug trach or attack speaking valve

Front 40

Metal Jackson Trach Tube

Back 40

- Stainless with inner and outer cannula

- NO cuff

- Requires 15 mm adaptor to attach resuscitator bag

Front 41

Metal Jackson Trach Indications

Back 41

1. Weaning patients from tracheostomy device

2. Need long term airway but not ventilator for PP ventilation, or a seal to protect against aspiration

Front 42

Foam Cuff Tracheostomy Tube

Back 42

- Foam filled cuff

- Pilot tube is open to atmosphere, the cuff self inflates

- Has NO pilot balloon

- Air must be evacuated prior to extubation

Front 43

Extra Long Trach Tubes

Back 43

Used for patients who require extra length proximally or distally because of anatomic issues.

Front 44

XL Proximal

Back 44

Used with those with thick neck or those with cervical collars

Front 45

XL Distal

Back 45

Placed past an abnormality in the trachea, such as tumor or tracheal stenosis.

Front 46

Binova TTS (Tight To Shaft) Cuffs

Back 46

The cuff is inflated with STERILE water instead of AIR because of the silicone construction.

Front 47

Binova TTS Indication

Back 47

Patients with sensitive tracheal mucosa or stoma sites because of its high flexibility and ability to conform to patient's anatomy

Front 48

Binova TTS Disadvantage

Back 48

- Cuff pressure can not be measured

- Use MOV technique and record the ml of water used to seal the cuff

Front 49

Insertion of Trach tubes

Back 49

- Surgical incision between 2nd and 3rd tracheal rings

- ET tube is removed as the trach tube is being inserted once tip is visible inside the trachea at the surgical site.

Front 50

Complications of Trach Tubes

IMMEDIATE (FIRST 24 HOURS)

Back 50

1. Bleeding

2. Pneumothorax

3. Subcutaneous Emphysema

4. Air embolism (Rare)

Front 51

Complications of Trach Tubes

LATE (> 24 HOURS)

Back 51

1. Infection

2. Hemorrhage

3. Obstruction

4. T-E fistula

Front 52

Management of Trach Tubes

Back 52

1. Cuff chould be kept deflated unless patient is on positive pressure vent or if swallow mechanism is impaired

2. Daily trach care

3. Daily cleaning of stoma

Front 53

Trach Care

Back 53

Inner cannula cleaning

- Remove inner cannula

- Place inner cannula in hydrogen peroxide and sterile water (equal parts) and scrub clean

- Rinse inner cannula with sterile water

- Reinsert cannula and reconnect to vent or oxygen

* Most trach tubes now come with disposable inner cannula

Front 54

Stoma Care

Back 54

1. Suction the patient

2. Remove trach dressing

3. Use swab or Qtip dipped in equal parts of hydrogen and sterile water --- wipe away from stoma

4. Repeat on other side

5. Clean dressing around tube and under flange

6. Assess for need of clean trach tie

7. Look for skin breakdown on neck

Front 55

Troubleshooting Trach Tubes

Back 55

1. Evidence of obstruction --- Pull tube and ventilate

2. High cuff pressure required to seal --- tube is too small --- change to a larger tube

3. Unable to seal after inserting air into cuff --- punctured cuff --- replace the tube

Front 56

Criteria for Decannulation

Back 56

1. Protect their airway

- intact gag reflex

- tolerate cuff deflation and manage secretions

- have minimal secretions

2. Pass swallow study

- patient is given ice, water, or pudding

- observed if able to swallow and then suctioned to determine aspiration occured.

Front 57

Decannulation procedure

Back 57

1. Have patient cough to clear secretions or suction

2. Remove trach tube

3. Do not suture stoma close

4. Apply sterile dressing and/or antibiotic to site

5. Clean periodically with hydrogen peroxide

Front 58

Tracheal Button

Back 58

- Short Hollow tube

- To maintain a patent stoma in case a problem arises and trach need to be re-inserted

- Allows tracheal suction and phonation with the LEAST amount of resistance

- Patient has complete use of upper airway

Front 59

Passy-Muir valves

Back 59

One-way valve that attaches to trach tube.

- During inspuration, valve opens and air enter lungs through tube

- Valve closes and air passes around cuff and through the vocal cords

- Trach tube cuff must be deflated

Front 60

Placing Passy-Muir valve on Trach

Back 60

1. Suction trach and mouth

2. Deflate cuff

3. Attach valve

Front 61

Indications of Laryngectomy Tubes

Back 61

1. Surgical removal of patientls larynx

2. Treat upper airway CA

3. No longer any connection between pt's upper airway and lower airway.

4. Pt can not be orally or nasally intubated

Front 62

Laryngectomy Tubes

Back 62

1. Designed to maintaib patent airway after a laryngectomy

- made of soft pliable material

- NO cuff

2. They are removed after 3-6 weeks and pt has a permanent stoma

3. Replace with ET tube if PPV is needed