Airway Management: Introduction
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Questions and Answers

Which of the following tasks is an RCP most likely to perform in the Emergency Department (ED)?

  • Inserting simple airway adjuncts such as oral and nasal pharyngeal airways (correct)
  • Elective intubation of patients with impending respiratory failure
  • Endotracheal tube (ETT) cuff pressure monitoring
  • Tracheotomy inner cannula replacement

    • In the Intensive Care Unit (ICU), RCPs are responsible for which of the following?

  • Airway clearance (suctioning)
  • Inserting simple airway adjuncts
  • Elective intubation of patients with impending respiratory failure (correct)
  • Supporting patients with BVM ventilation during respiratory arrest

    • RCPs are commonly involved in which of the following activities at the bedside?

  • Assisting physicians during bronchoscopy
  • Performing emergency endotracheal intubation
  • Extubation of patients ready for ventilator discontinuation
  • Rapid response to airway emergencies (correct)

    • What significant aspect differentiates the roles of EMS practitioners and anesthesiologists in airway management?

    <p>EMS practitioners usually manage airways under adverse conditions in the field</p> Signup and view all the answers

    Which of the following tasks is typically part of an RCP’s responsibility in the ICU, but not generally in the ED?

    <p>Endotracheal tube (ETT) cuff pressure monitoring</p> Signup and view all the answers

    Which role does not typically apply to an RCP in the ED?

    <p>Elective intubation</p> Signup and view all the answers

    Why does much of the literature about airway management not apply to RCP practice?

    <p>RCPs perform tasks that differ from those of EMS and anesthesiologists</p> Signup and view all the answers

    Which procedure is included in an RCP’s role in all clinical settings?

    <p>Airway clearance (suctioning)</p> Signup and view all the answers

    What is a specific responsibility of RCPs during a cardiac arrest in the ED?

    <p>Inserting oral pharyngeal airways</p> Signup and view all the answers

    In the ICU, which team member typically monitors the ETT cuff pressure?

    <p>RCP</p> Signup and view all the answers

    What is the primary reason endotracheal tube suctioning (ETS) is necessary for patients with endotracheal airways?

    <p>To remove secretions</p> Signup and view all the answers

    What is the length of most suction catheters used for bedside airway suctioning?

    <p>22 inches</p> Signup and view all the answers

    What type of precaution is specifically mentioned as necessary during open suctioning procedures?

    <p>Droplet precautions</p> Signup and view all the answers

    What procedure is necessary to clear secretions or foreign bodies located distal to the mainstem bronchi?

    <p>Bronchoscopy</p> Signup and view all the answers

    What is a critical component of every airway care procedure?

    <p>Strict adherence to aseptic technique</p> Signup and view all the answers

    According to the AARC Clinical Practice Guidelines, on what are most existing recommendations for ETS based?

    <p>Expert opinion and best practices</p> Signup and view all the answers

    What should be assessed as the first step in the ETS process?

    <p>Assessment of need</p> Signup and view all the answers

    What risk does ETS pose aside from those to the patient?

    <p>Infection risk to clinicians</p> Signup and view all the answers

    How should secretions be removed to minimize risks during ETS?

    <p>With the fewest number of catheter passes</p> Signup and view all the answers

    What elements are universally included in the endotracheal tube suctioning (ETS) process according to a recent Medscape Review?

    <p>Assessment of need and follow-up patient care</p> Signup and view all the answers

    Which of the following is NOT a potential hazard category of airway suctioning according to AARC CPG?

    <p>Gastrointestinal</p> Signup and view all the answers

    What is a common cause of cardiopulmonary complications during airway suctioning?

    <p>Sympathetic and parasympathetic stimulation</p> Signup and view all the answers

    What is the primary factor causing atelectasis during suctioning?

    <p>Removal of air volume in the lung</p> Signup and view all the answers

    Which maneuver is recommended to re-inflate atelectatic areas caused by suctioning?

    <p>Lung recruitment maneuvers (RM)</p> Signup and view all the answers

    What type of complication is biofilm dislodgement considered as?

    <p>Infectious</p> Signup and view all the answers

    What precaution is essential to take during open endotracheal suctioning (ETS)?

    <p>Droplet precautions</p> Signup and view all the answers

    What is the effect of suctioning on dynamic lung compliance?

    <p>Decrease in dynamic lung compliance</p> Signup and view all the answers

    Which of the following is a cardiovascular complication that can occur due to hypoxemia during suctioning?

    <p>Cardiac dysrhythmias</p> Signup and view all the answers

    What is a potential consequence of airway instrumentation by suction catheter?

    <p>Diffuse bronchospasm</p> Signup and view all the answers

    What infection control practice is critical during airway suctioning?

    <p>Strict adherence to aseptic technique</p> Signup and view all the answers

    What is a significant indicator that endotracheal suctioning (ETS) is necessary?

    <p>Increased Work of Breathing (WOB) with decreased airway pressure during pressure cycled ventilation</p> Signup and view all the answers

    What differentiates closed suction systems (CSS) from open suction systems (OSS)?

    <p>CSS uses a catheter with standard precautions only</p> Signup and view all the answers

    According to the AARC Clinical Practice Guidelines (CPG), what is the recommended duration for administering 100% $O_2$ to adult patients before suctioning?

    <p>30 to 60 seconds</p> Signup and view all the answers

    Why is routine saline instillation before ETS no longer recommended?

    <p>It has not been shown to be effective in liquefying secretions</p> Signup and view all the answers

    What is the recommended range of vacuum pressure for endotracheal suctioning in infants according to AARC CPG?

    <p>-80 to -100 mmHg</p> Signup and view all the answers

    What practice is recommended for reducing hypoxia during the endotracheal suctioning process?

    <p>Preoxygenation (hyperoxia)</p> Signup and view all the answers

    What type of suctioning is preferred to minimize mucosal trauma?

    <p>Measured suctioning</p> Signup and view all the answers

    Which feature in ventilator graphics can indicate the need for endotracheal suctioning?

    <p>Saw tooth pattern on the expiratory half of the flow-volume loop</p> Signup and view all the answers

    What is a guideline for post-suctioning oxygen administration as per the AARC CPG?

    <p>100% $O_2$ for one minute</p> Signup and view all the answers

    When selecting a suction catheter, what critical factor must be considered?

    <p>The catheter must efficiently aspirate secretions without occluding the ET tube</p> Signup and view all the answers

    Which component must be capped when using a regular T-piece in the setup?

    <p>The arm opposite the circuit connection</p> Signup and view all the answers

    What is the appropriate first step in setting up the In-Line (Closed) Suction Catheter?

    <p>Select the In-Line Suction Catheter Fr size appropriate for the patient's ETT size</p> Signup and view all the answers

    Where should the ventilator tubing circuit be connected in the T-piece setup?

    <p>To the other arm of the T-piece</p> Signup and view all the answers

    What must be ensured regarding the irrigation port during the setup?

    <p>It is closed</p> Signup and view all the answers

    During the setup, what should be done after washing hands and applying gloves?

    <p>Attach suction catheter connector to the vacuum source</p> Signup and view all the answers

    Which specific control valve should be pressed to set the wall suction to the appropriate level?

    <p>Suction (thumb) control valve</p> Signup and view all the answers

    What type of T-piece is mentioned as having a specific system in place for tracheostomy?

    <p>Modified T-piece</p> Signup and view all the answers

    When should the patient end connector be attached to the elbow's side port?

    <p>After attaching the suction catheter to the vacuum source</p> Signup and view all the answers

    What should be done to the catheter sheath while advancing the catheter?

    <p>Slide it back</p> Signup and view all the answers

    Which color indication signifies that the catheter length is correct and should stop advancing?

    <p>Black</p> Signup and view all the answers

    What is the first step in the airway clearance procedure using a closed catheter?

    <p>Attach the suction catheter to the ventilation port</p> Signup and view all the answers

    How should suction be applied during the catheter withdrawal?

    <p>Continuously</p> Signup and view all the answers

    What volume of 0.9% NaCl should be instilled to clean the catheter?

    <p>At least 5ml</p> Signup and view all the answers

    What consequence might arise if secretions are left in the catheter or suction line after suctioning?

    <p>They may dry and harden, reducing efficiency</p> Signup and view all the answers

    What is the purpose of seeing a length number or length color code during catheter advancement?

    <p>To verify correct insertion depth</p> Signup and view all the answers

    What should be visible within the sheath to confirm the catheter is fully withdrawn?

    <p>Black line</p> Signup and view all the answers

    When should 0.9% NaCl be instilled into the catheter?

    <p>While applying continuous suction for cleaning</p> Signup and view all the answers

    Which type of airway adjunct specifically prevents soft tissue airway obstruction (STAO)?

    <p>Oropharyngeal airways</p> Signup and view all the answers

    What is the primary purpose of the head tilt chin lift maneuver?

    <p>To relieve soft tissue airway obstruction</p> Signup and view all the answers

    Which of the following emergency ventilation methods is NOT typically an RCP skill?

    <p>Mouth to mouth ventilation</p> Signup and view all the answers

    Which tool is used to clear obstructions during laryngoscopy?

    <p>Magill forceps</p> Signup and view all the answers

    In the context of airway management, what does the 'A' in the CAB's of life support stand for?

    <p>Airway</p> Signup and view all the answers

    Which of these airway opening maneuvers does NOT involve tilting the head?

    <p>Chin lift without head tilt</p> Signup and view all the answers

    What skill is emphasized as essential for an RCP during CPR?

    <p>Bag Valve Mask (BVM) ventilation</p> Signup and view all the answers

    Study Notes

    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

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    Description

    An introductory quiz on airway management, focusing on the roles of RCPs in the Emergency Department, ICU, and at the bedside.

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