Airway Management: Introduction

Airway Management: Introduction

• Airway management books and articles are primarily written for two main audiences: EMS practitioners and anesthesiologists.

RCPs' Role in Airway Management

• RCPs perform airway management in the Emergency Department (ED), Intensive Care Unit (ICU), and at the bedside.
• RCPs are responsible for airway clearance, airway establishment, and airway maintenance.

ED Responsibilities

• RCPs support patients with BVM ventilation during cardiac and respiratory arrest prior to endotracheal intubation and after extubation.
• RCPs insert simple airway adjuncts such as oral and nasal pharyngeal airways.
• RCPs perform emergency endotracheal intubation.
• RCPs assist the physician during endotracheal intubation, tracheotomy, and bronchoscopy.

ICU Responsibilities

• RCPs monitor endotracheal tube (ETT) cuff pressure.
• RCPs extubate patients ready for ventilator discontinuation.
• RCPs perform emergency re-intubation of accidentally or self-extubated patients.
• RCPs replace tracheotomy inner cannula.
• RCPs perform elective intubation of patients with impending respiratory failure.

Bedside Responsibilities

• RCPs perform airway clearance (suctioning).
• RCPs respond rapidly to airway emergencies.
• RCPs troubleshoot problems with artificial airways and ventilators.

Airway Clearance: Overview

• All airway care procedures require strict adherence to aseptic technique and standard precautions at all times.

Airway Suctioning

• Airway suctioning is performed by applying subambient pressure to the airway through a suction catheter.
• Endotracheal tube suctioning (ETS) is required for patients with endotracheal airways because the artificial airway impedes the normal cough mechanism.
• Most suction catheters available for bedside use are 22 inches long, only reaching the mainstem bronchi.

Importance of Suctioning

• Suctioning is necessary to maintain airway patency, but it is not a benign procedure.
• Clinicians must be aware of both the positive and negative effects of the procedure and the methods used to prevent or minimize complications.
• Open suctioning is an aerosol-producing procedure, requiring droplet precautions.

Clinical Practice Guidelines

• The AARC Clinical Practice Guidelines and other authoritative sources recognize the lack of strong clinical evidence for most ETS recommendations and clinical practices.
• Despite limited evidence, existing recommendations are based on expert opinion and represent available best practices.
• Until more evidence is accumulated, they remain the current standard of care.

Key Elements of ETS

• ETS includes the five common elements: assessment of need, patient preparation, procedure performance, patient monitoring, and follow-up patient care.
• ETS is an invasive procedure that exposes the patient to potential risks, requiring standard precautions and aseptic technique.
• In addition to patient risks, ETS also poses infection risks to clinicians and other patients.

Purpose of ETS

• The primary purpose of ETS is to remove secretions.
• Secretions vary in viscosity and volume, requiring appropriate catheter size and pressure selection.
• Every time the catheter is passed into the airway, the patient and clinician are exposed to all risk factors associated with the procedure.
• Secretions should be removed efficiently using the fewest number of catheter passes.

Airway Clearance: Suctioning Hazards

• Despite the hazards, failure to maintain a patent airway will result in the patient's death, so there are no absolute contraindications to Endotracheal Suctioning (ETS).

Respiratory Hazards

• Removal of air volume in the lung during suctioning can cause:
  • Decrease in dynamic lung compliance
  • Reduction in functional residual capacity
  • Atelectasis (also known as lung de-recruitment)
  • Hypoxemia and hypoxia

Cardiovascular Hazards

• Hypoxemia and sympathetic and parasympathetic stimulation can cause:
  • Cardiac dysthymias
  • Increased intracranial pressure

Neurologic Hazards

• Airway instrumentation can cause:
  • Diffuse bronchospasm

Infection Control Hazards

• Environmental contamination of the open suction catheter can cause:
  • Microbial colonization of the patient's lower airway
  • Biofilm dislodgement by the suction catheter
• Open ETS is an aerosol-producing procedure that requires droplet precautions.
• Strict adherence to infection control and aseptic technique throughout the procedure is essential.

Indications for Endotracheal Suctioning (ETS)

• ETS should only be performed when secretions are present
• Indications for ETS include:
• Audible or visible secretions in the ET tube
• Coarse gurgling sounds (rhonchi) on auscultation
• Coughing movements
• Increased work of breathing (WOB)
• Changes in ventilator graphics (saw tooth pattern on the expiratory half of the flow volume loop)

Suction Systems

• There are two categories of suction systems:
• Open suction systems (OSS)
• Closed suction systems (CSS)

Open Suction Systems (OSS)

• Use a sterile catheter
• Require strict adherence to aseptic technique
• Require the patient to be disconnected from the ventilator

Closed Suction Systems (CSS)

• Use a sterile catheter enclosed in a flexible plastic sleeve
• Only require standard precautions
• Do not require the patient to be disconnected from the ventilator

Preoxygenation

• Preoxygenation is intended to reduce the chance of hypoxia caused by suctioning
• The optimal level and duration of preoxygenation are not known
• The AARC CPG recommends:
• Administering 100% O2 for adult and pediatric patients
• Increasing the FiO2 by 10% for neonates for a period of 30 to 60 seconds before suctioning

Catheter Selection

• The catheter diameter selected must not occlude the ET tube
• The catheter must be able to efficiently aspirate secretions
• Catheter sizing rules of thumb and formulas only refer to airway occlusion size, not to the ability of the catheter to aspirate thick secretions

Vacuum Pressure Guidelines

• Vacuum pressure guidelines vary
• The AARC CPG recommends:
• -120 to -150 mmHg for adults
• -100 to -120 mmHg for children
• -80 to -100 mmHg for infants

Suctioning Techniques

• Measured suctioning (shallow suctioning) is the preferred technique to reduce mucosal trauma
• Most authors recommend that the duration of suctioning be limited to 10 to 15 seconds

Initial Set-up for In-Line Suction Catheter

• Select appropriate In-Line Suction Catheter Fr size for patient's ETT size
• Wash hands and apply clean gloves
• Attach suction catheter connector to vacuum source (wall suction) tubing
  • Set wall suction to appropriate level by pressing suction (thumb) control valve
• Attach Patient end connector to side port on elbow (modified T-piece)
  • Use T-piece for tracheostomy systems
  • Securely cap arm opposite circuit connection when using regular T-piece
• Connect ventilator tubing circuit to other arm of T-piece
• Attach T-piece to endotracheal tube
• Ensure irrigation port is closed

Equipment Components

• Patient end connector
• Suction catheter connector
• Modified T-piece
• Suction control valve
• Medicine injection port
• Flushing port
• ETT (endotracheal tube) filter
• Breath airway connector

Airway Clearance: Closed Catheter Technique

• A closed catheter is inserted into an airway through a ventilation port.

Steps of the Procedure

• Attach the suction catheter to the ventilation port with the non-dominant hand, holding it securely.
• Advance the catheter with the thumb and forefinger while sliding the plastic sheath back.
• Continue advancing the catheter until the length number or length color code is visible.
• Apply suction continuously while withdrawing the catheter.
• Ensure the catheter is completely withdrawn until the black line is visible within the sheath to prevent airway obstruction.
• Clean the catheter by instilling at least 5ml of 0.9% NaCl from a vial or syringe while applying continuous suction.

Importance of Cleaning the Catheter

• Failure to clean the catheter can lead to secretions drying and hardening, reducing line suction efficiency.

Airway Control and Adjuncts

• Airway control is the first and most important respiratory care function in emergencies
• RCPs must be proficient in the use of airway adjuncts, airway opening maneuvers, emergency ventilation, and definitive management of the airway (intubation)

Airway Adjuncts

• Airway adjuncts are simple, minimally invasive devices that prevent soft tissue airway obstruction (STAO)
• They include oropharyngeal and nasopharyngeal airways

Airway Opening Maneuvers

• Manual manipulations of the head and jaw to relieve soft tissue airway obstruction (STAO)
• Techniques include:
  • Head tilt chin lift
  • Chin lift without head tilt
  • Jaw thrust

Emergency Ventilation

• Giving positive pressure rescue breaths during CPR
• Techniques include:
  • Bag Valve Mask (BVM) ventilation (essential RCP skill)
  • Mouth to barrier device ventilation
  • Mouth to mouth ventilation (street CPR skill, not an RCP skill)
  • Use of automatic, pressure cycled demand valve devices