Airway Management Devices

• Artificial airways are specialized medical devices.
• They are designed to maintain a patent (open) airway.

Indications for Artificial Airways

• Artificial airways can relieve airway obstruction.
• They can facilitate the removal of secretions.
• Artificial airways can protect the lower airway from aspiration.
• They facilitate the application of positive pressure ventilation.
• Endotracheal tubes may be used as an alternate route for drug administration.

General Classification of Artificial Airways

• Oropharyngeal airways are also called "OPA" or "oral airway".
• Nasopharyngeal airways are also called "NPA" or "nasal trumpets / nasal airway".
• Laryngeal Mask Airways are also called an "LMA".
• Esophageal Tracheal Combitubes are also called combitubes or ETC.
• King Airways exist.
• Endotracheal Tubes are also called "ETT" or "ET tube".
• Tracheostomy Tubes are also called "Trache tube".
• Laryngectomy Tubes are also called "Larry Tubes".
• Double Lumen Endotracheal Tubes - also called "DLT or DLETT."
• Advantage and Disadvantages can be found in Table 37-7.

Oropharyngeal airways (Oral airway)

• Indications for Oropharyngeal airways include relieving upper airway obstruction.
• Useful for keeping the tongue off the posterior wall of the oropharynx.
• Oropharyngeal airways can prevent tongue lacerations in a seizure patient.
• May be used as a bite block with an oral ET tube.
• These are NOT in the trachea but sit in the oral cavity and pharynx.

More on oral airways

• Oropharyngeal airways are poorly tolerated in alert patients because of stimulation of the gag reflex, so they're used in unconscious, spontaneously breathing patients.
• Oropharyngeal airways come is different lengths
• Measure from the corner of the mouth to the angle of the jaw to determine proper size.
• Grab several when measuring to ensure correct sizing.

Insertion of oral airways

• Proper insertion involves pacing the airway so that the tip points toward the roof of the mouth (hard palate).
• Observe the airway pass the uvula and then rotate 180 degrees.
• Proper insertion involves displacing the tongue with a tongue depressor, then slipping curved part of the airway over the tongue.

Hazards of oral airways

• Gagging or fighting the airway means you should immediately remove the oral airway.
• Obstruction can occur if the base of the tongue is pushed into the back of the natural airway if the airway is too large.
• Aspiration or ineffective obstruction relief can occur if the airway is too small.

Types of oral airways

• There are two types of oropharyngeal airways.
• They are Berman and Guedel.
• When properly inserted, the tip of an oropharyngeal airway lies at the base of the tongue above the epiglottis with the flange portion extending outside the teeth.
• Only in this position can the device properly maintain airway patency

Berman vs. Guedel

• Berman airways are made of hard plastic and have a groove down either side to guide a suction catheter.
• Guedel airways are made of soft material and have an opening through the middle to allow passing of a suction catheter.

Nasopharyngeal Airway (nasal airway or nasal trumpet)

• Nasopharyngeal airways are indicated to maintain patency by lying between the base of the tongue and the posterior wall of the pharynx.
• It's used when an oral airway cannot be placed.
• It is used for frequent suctioning to minimize trauma.

Sizing nasal airways

• Nasal airways are sized by various external diameters and lengths.
• The largest diameter to pass without force or trauma is used.
• Measuring from tip of nose to tragus of ear approximates the length of the airway.

Insertion of nasal airway

• Proper insertion involves lubricating the airway with a water-soluble gel, then inserting it into the patient's nostril.
• Care should be taken to insert parallel to the floor of the nasal pharynx and slightly medial, without attempting to insert "up the nose.”
• The flanged end should rest against the nose with the distal tip resting behind the uvula.

Hazards of Nasal Airways

• Hazards include nasal bleeding.
• There is a risk of Aspiration if the airway is too small.
• Nasal irritation occurs if the airway is not alternated daily.
• Infection can occur, so change the airway every 24 hours.

Laryngeal Mask Airway (LMA)

• LMA is a "Mask on a tube".
• It's mostly often used in an OR setting.
• They're not meant to replace an ET tube, but are a useful emergency device.
• LMAs are easy to insert and learn.

Advantages & Disadvantages of LMA

• Advantages include providing a patent airway that is usually superior to that from an oral or nasopharyngeal device.
• LMA use does not require extreme head positioning.
• You can intubate without removing an LMA.
• LMA use avoids laryngeal and tracheal trauma.
• Disadvantages include that they are not meant to be used for extended mechanical ventilation.
• Aspiration is not prevented.
• LMAs cannot provide high ventilation pressures (typically <20 cmH2O).

Esophageal Tracheal Combitube (ETC)

• An ETC is used for emergency airway management.
• The distal end combines a tracheal lumen and esophageal lumen into one tube.
• The proximal end separates these two lumens into separate color coded tubes.
• A large cuff attached to the proximal end and another large cuff is attached to the distal end.
• The ETC is placed blindly into either the esophagus or trachea.
• Careful assessment is essential to identify the presence of gastric sounds or bilateral breath sounds so that the appropriate lumen tract is used for ventilation.

Advantages & Disadvantages of ETC

• Advantages include requiring less skill than bag-valve-mask or intubation.
• No special equipment is necessary when using an ETC.
• ETCs provide protection against aspiration but does not stop it completely.
• ETC use facilities positive pressure ventilation.
• Disadvantages of use include that difficulty distinguishing the trachea versus esophageal insertion.
• They are used for only short-term use.
• Aspiration is possible during removal.
• It's not possible to suction in esophageal position.
• Only one size is available (adult).
• There is a potential for esophageal injury.

King Airway

• They're designed for emergency airway management.
• Insertion is blind and the distal tip resides in the esophagus.
• Placement confirmed with 5 point auscultation and capnography.
• Placement confirmed with 5-point auscultaion and capnography!
• Remember that the airway is meant ONLY for the esophagus, and must be removed and replaced if not correctly placed!
• Could also be called "Supra" glottic.

Components of ETT

• A Cuff, usually a high volume, low pressure cuff, seals off the trachea for positive pressure ventilation.
• A Murphy Eye is a side post/hole to allow for ventilation if main port is occluded.
• A One-way valve, pilot balloon, pilot cuff line is standard.
• The Radiopaque line confirms placement within the trachea by X-ray.
• Has a 15 mm adapter; inner diameter to match the ambu bag.
• The ID - internal diameter of the tube is measured in mm.
• This is how tubes are measured.
• The OD is the outside diameter.

Indications for an ETT

• Endotracheal tubes can provide relief of upper airway obstruction caused by laryngospasm, epiglottitis, or glottic edema.
• Endotracheal tubes help protect the airway.
  • Pharyngeal reflex (gagging, swallowing) -Laryngeal reflex (coughing when trachea irritated)
  • Tracheal reflex (coughing when trachea irritated)
  • Carinal reflex (coughing when carina is irritated
• To facilitate tracheal suctioning
• To assist manual or mechanical ventilation

Tracheostomy Tubes

• These sit in the trachea but does not go through the vocal cords.
• Inserted through an incision made between the 2nd and 3rd tracheal rings
• Components include:
  • Cuff
  • One-way valve, pilot balloon, and line
  • Flange
  • Obturator

Indications for trach tubes

• Trach tubes are usefull for long-term airway care as ET tubes should not be left in for more than 3-4 weeks.
• Trach tubes usually pertain to patients on mechanical ventilation.
• They bypass upper airway obstructions.
• They prevent problems posed by oral or nasal ET tubes.
• Allows the patient to swallow and receive nourishment.

Laryngectomy tubes

• Laryngectomy tubes are shorter in length than tracheostomy tubes.
• They are cuffless.
• Laryngectomy tubes are designed to be inserted into the stoma after laryngectomy to keep the stoma open until it heals.

Double-lumen endotracheal tube (DLT)

• DLTs include a tube with two independent lumina of different lengths.
• The longer lumen is inserted into either the left or right mainstem, and the shorter lumen is placed in the trachea above the carina.
• Each lumen can ventilate each lung separately, or they can be connected via a wye and share a single ventilation source.
• The bronchial cuff has a radiopaque line to confirm correct placement, which will be seen on the X-ray.

Indications for DLT

• DLTs are indicted in unilateral lung diseases for improving ventilation and oxygenation.
• They also treat bronchopleural fistulas, tracheobronchial tree disruption and surgical openings of a large airway to stop or promote healing and ventilate other areas of the lung
• Bronchopleural fistulas, tracheobronchial tree disruption and surgical openings of a large airway to stop or promote healing
• DLTs are used in surgery during a pneumonectomy, lobectomy, esophageal resection, and aortic aneurysm repair.
• Provides airway protection by preventing blood or infection from getting into the "good" lung.

Explore questions about airway management devices, their uses, and placement techniques. Learn about oropharyngeal airways, endotracheal tubes, and nasal trumpets. Assess your knowledge of proper sizing and minimizing trauma during insertion.