Airway Management Techniques Quiz

Introduction to Respiratory Care

• Respiratory care is a vital profession focusing on optimizing cardiopulmonary function and health.
• Breathing is essential for life, making respiratory care a crucial medical specialty.

Airway Management

• Airway management involves devices to maintain open, patent airways.
• These devices aim to either displace the tongue or directly insert into the trachea, bypassing obstructions.
• Common airway management devices used in the discussion are:
  • Oropharyngeal airway (OPA)
  • Nasopharyngeal airway (NPA)
  • Laryngeal mask airway (LMA)
  • Endotracheal tube (ETT)
  • Tracheostomy

Oropharyngeal Airway (OPA)

• A rigid tube inserted through the mouth to the pharynx.
• Used in unconscious patients to prevent airway obstruction by the tongue, and for potential seizure situations.
• Different sizes exist for varying patient needs (4.0mm ID - 120mm).
• Indications include unresponsive patients without a gag reflex, unconscious patients with difficult bag/mask seal, and patients experiencing a seizure.

Oropharyngeal Airway (OPA): Contraindications

• Conscious patients
• Patients with a gag reflex

Oropharyngeal Airway (OPA): Complications

• Gagging/vomiting, aspiration, laryngospasm (especially in alert or semi-conscious patients with a gag reflex)
• Damage to teeth and oral mucosa, bleeding
• Airway obstruction (if too long) or failure of airflow
• Tongue displacement (if too short)

Nasopharyngeal Airway (NPA)

• A soft rubber or silicone tube inserted through the nose into the pharynx.
• Used to prevent airway obstruction caused by the tongue or soft palate falling against the posterior wall of the pharynx.
• It can also be used as a dilator for the nose.

Nasopharyngeal Airway (NPA): Indications

• Patients who will not tolerate an oropharyngeal airway.
• Patients without a history of a fractured nasal bone.
• Facilitating spontaneous breathing and bag-valve-mask ventilation for patients needing head-tilt/chin-lift or jaw-thrust maneuvers.

Nasopharyngeal Airway (NPA): Contraindications

• Nasal bleeding or bleeding disturbance
• Suspected or existing basilar skull fractures (CSF discharge from nose)
• Nasal trauma (facial trauma)
• Resistance to insertion

Nasopharyngeal Airway (NPA): Complications

• Epistaxis
• Deterioration requiring intubation (in semi-conscious patients)
• Potential deterioration and intubation in semi-conscious patients

Laryngeal Mask Airway (LMA)

• A device with a tube and a triangular distal end that fits over the laryngeal inlet.
• Oxygen can be delivered directly into the trachea.

Laryngeal Mask Airway (LMA): Advantages

• Easy and fast insertion
• Avoids laryngeal and tracheal trauma
• Intubation possible without removing the LMA

Laryngeal Mask Airway (LMA): Disadvantages

• Short-term use only
• Unable to provide high ventilation pressures
• Potential for esophageal injury
• Aspiration still possible, though risk is decreased

Laryngeal Mask Airway (LMA): Placement

• Lubricate the posterior surface of the mask
• Fully deflate the cuff
• Use the index finger to guide insertion along the palate and into the oropharynx
• Inflate the cuff to a maximum of 60 cmH₂O

Endotracheal Tubes (ETT)

• Hollow, flexible airways typically made of PVC.
• Inserted through the mouth or nose, larynx, and into the trachea.
• Proper position is 2 cm above the carina, verified by chest radiograph.
• Used to bypass soft tissue obstructions.

Endotracheal Tube (ETT): Indications for Intubation

• Maintain airway patency
• Prevent aspiration
• Cardiopulmonary arrest
• Establish or maintain mechanical ventilation
• Bronchial hygiene

Endotracheal Tube (ETT): Contraindications for Intubation

• Patients with an intact gag reflex.
• Patients likely to react with laryngospasm during intubation attempts (e.g., children with epiglottitis).
• Basilar skull fracture—avoid nose-tracheal intubation.

Endotracheal Tube (ETT): Advantages of Intubation

• Protects the airway from aspiration
• Provides access to the tracheobronchial tree for suctioning secretions.
• Prevents gastric distention and regurgitation.
• Maintains a patent airway, avoiding further obstruction.
• Enables aerosolized medication delivery

Endotracheal Tube (ETT): Complications Associated with Intubation

• Damage to turbinates, causing epistaxis, and potential nasopharyngeal mucosa perforation
• Hypertension and tachycardia from intubation stimulation (especially in CAD patients)
• Transient cardiac arrhythmias due to vagal and sympathetic nerve traffic
• Cuff damage, resulting in a cuff leak and poor seal

Endotracheal Tube (ETT): Additional Intubation Complications

• Esophageal intubation, resulting in gastric distention and regurgitation during ventilation attempts.
• Barotrauma due to over-ventilation without a pressure release valve (pneumothorax).
• Complete airway obstruction due to laryngospasm from larynx overstimulation
• Unilateral intubation (right bronchus) from inserting the tube too deeply.
• Airway obstruction due to foreign material, dried respiratory secretions, and/or blood

Endotracheal Tube (ETT): Tube Marking/Identification

• I.T.: Implant tested
• I.D.: Inner diameter
• O.D.: Outer diameter
• Z-79: Meets standards for non-toxicity
• Radiopaque line: Determines position after placement
• Centimeter markings: Indicate depth of placement

Endotracheal Tube (ETT): Sizes

• Adult male: 7.5-8 mm
• Adult female: 7-7.5 mm
• Pediatric: (16+ Age)/4

Tracheostomy

• An incision made below the cricoid cartilage through the 2nd-4th tracheal rings.
• Creates an opening (stoma) to insert a tracheostomy tube.

Tracheostomy: Indications

• Maintain patent airway (temporarily or permanently impaired)
• Bypass an obstructed airway
• Facilitate removal of secretions
• Permit long-term ventilation / prevent aspiration with prolonged comas.
• Decrease work of breathing in severe COPD

Tracheostomy: Procedures

• Various methods exist (transtracheal jet ventilation, cricothyrotomy/laryngotomy).

Tracheostomy: Equipment

• Flange
• Outer cannula
• Inner cannula
• Obturator
• Cuff

Tracheostomy: Types

• Cuffed or un-cuffed
• Fenestrated or non-fenestrated
• Disposable or non-disposable inner cannulas ('Shiley' tubes)
• Mini tracheostomy
• Talking tracheostomy tube (to facilitate speaking)

Tracheostomy: Complications

• Hemorrhage
• Pneumothorax
• Subcutaneous emphysema
• Dislodged tube
• Airway obstructions
• Infection (Aspiration, Tracheal damage)
• Obstruction (Clinical Presentation: Skin color, respirations, BP, O2 sat.)

Tracheostomy: Prevention & Documentation

• Skilled and timely nursing assessment and care are key to prevention.
• Thorough respiratory assessments are needed, especially in patients with tracheostomies (at least Q4 hrs regardless of the shift).

Intubation

• Procedures to insert an endotracheal tube (ETT) into the trachea.
• Procedures to verify proper placement include observing breath sounds, end-tidal CO2 checks, and physical assessments.

Intubation: Equipment

• Laryngoscopes (Macintosh, Miller)
• Suction equipment
• Forceps
• Stylets
• End-tidal CO2 detectors
• Equipment for cuff inflation (syringes, etc)

Intubation: Nasal Intubation

• Inserting an endotracheal tube through the nasal passages.

Intubation: Technique

• Detailed steps are detailed in slide 62.

Specialized Endotracheal Tubes

• Covers various tubes suited to different patients, abnormalities, and procedures. (These are listed and described in the slides)