Respiratory Care Therapeutics: Establishing an Artificial Airway

Establishing an Artificial Airway

• The ultimate goal of establishing an artificial airway is to ensure oxygen delivery to the cells, as all cells will die if deprived of oxygen.

Anatomical Perspectives

• The airway is divided into the upper and lower airway.
• The upper airway consists of the nose, mouth, oral cavity, pharynx, and larynx.
• The lower airways include the trachea, bronchi, bronchioles, and alveoli within the lungs.
• The glottis is the area between the vocal cords.

Artificial Airway

• Definition: An artificial airway is a tube or tube-like device inserted through the nose, mouth, or into the trachea to provide an opening for ventilation.
• Types of artificial airways: pharyngeal airways (oropharyngeal and nasopharyngeal) and tracheal airways (orotracheal, nasotracheal, tracheostomy tubes, and cricothyroid tubes).
• Intubation: the process of placing an artificial airway into the trachea.
• Routes: orotracheal intubation (tube passed through the mouth) and nasotracheal intubation (tube passed through the nose).

Indications for Artificial Airways

• Relief of airway obstruction: guarantees the patency of the upper airway regardless of soft tissue obstruction.
• Can be used in conjunction with a BVM device.
• Correct sizing of the airway is imperative.

Oropharyngeal Airway

• Advantages: simple to use, inexpensive.
• Uses: to maintain an open airway, prevent endotracheal tube occlusion, prevent tongue bite, facilitate suction, and obtain a better mask fit.
• Contraindications: intact gag reflex, oropharyngeal growth.
• Hazards: injury due to incorrect size, laryngospasm in awake patients, and aspiration from intact gag reflex.

Oropharyngeal Airway Insertion

• Techniques: jaw-lift technique and using a tongue depressor.

Nasopharyngeal Airway

• Definition: a soft plastic or rubber tube designed to pass through one of the nares, inferior to the base of the tongue, and provide a clear path for gas flow into the pharynx.
• Uses: to maintain an airway in patients with an intact gag reflex, facilitate suctioning, as a guide for a fiberscope or nasogastric tube, and to apply continuous positive airway pressure (CPAP).
• Advantages: better tolerated than an oral airway in patients with intact gag reflex, useful in patients with jaw injury or spasm, and can be used when the mouth cannot be opened.
• Contraindications: anticoagulation, infection, or tumor in the airway.

Airway Assessment

• Look externally for conditions associated with difficult intubation, such as congenital anomalies, infection, tumor, or trauma.
• LEMON assessment: a method to evaluate the ease of access to the airway, considering the size of the mandible, the distance between the mentum and the hyoid bone, and the extent of mouth opening.

Opening the Airway

• Two methods: Head Tilt–Chin Lift Maneuver and Jaw-Thrust Maneuver.
• Head Tilt–Chin Lift Maneuver: for patients who have not sustained trauma, used to open the airway.
• Jaw-Thrust Maneuver: for patients with suspected cervical spine injury, used to open the airway.

Nasotracheal Intubation

• Route of choice in certain clinical situations, such as when the oral route is unavailable.
• Can be performed blindly or by direct visualization using a standard or fiberoptic laryngoscope with Magill forceps.
• A smaller ETT may be needed, and the tube should be pre-lubricated with water-soluble gel to aid passage.