Respiratory Care Therapeutics Course (RT 264) Establishing an Artificial Airway (2024) PDF

Respiratory Care Therapeutics Course (RT 264) Establishing an Artificial Airway (Routes, Equipment, and Procedures) Part I,II 1445 (2024) Establishing an Artificial Airway Objectives Assess the need for and select an artificial airway. Identify the complica...

Respiratory Care Therapeutics Course (RT 264) Establishing an Artificial Airway (Routes, Equipment, and Procedures) Part I,II 1445 (2024) Establishing an Artificial Airway Objectives Assess the need for and select an artificial airway. Identify the complications and hazards associated with insertion of artificial airways Describe how to perform orotracheal and nasotracheal intubation of an adult. Assess and confirm proper endotracheal tube placement. Establishing an Artificial Airway  Why Establishing Airway and Maintaining Respiration is very essential?  Because of eventually all cells will die if deprived of oxygen. Establishing an Artificial Airway Anatomical Perspectives (Cont.)  The airway is divided into the The Glottis: Glottis is the area upper and lower airway. between the vocal cords.  Upper airway consists of: Nose, Mouth, Oral cavity, Pharynx and Larynx  Lower airways : trachea- and within the lungs, the bronchi, bronchioles, and alveoli Establishing an Artificial Airway Artificial Airway  Definition : Artificial Airway is a tube or tube-like device that is inserted through the nose, mouth, or into the trachea to provide an opening for ventilation. - Types of Artificial Airways  Pharyngeal airways (oropharyngeal & nasopharyngeal)  Tracheal (orotracheal, nasotracheal, tracheostomy tubes & cricothyroid tubes) ◦ Intubation: process of placing artificial airway into trachea ◦ Routes  Orotracheal intubation is when tube is passed through mouth on its way into trachea  Nasotracheal intubation is when endotracheal tube is passed through nose first Indications for Artificial Airways: 1-Relief of airway obstruction: -guarantees the patency of upper airway regardless of soft tissue obstruction. 2-Facilitation of tracheobronchial clearance:- mobilization of secretions from the trachea requires either an adequate cough or direct suctioning of the trachea 3-Facilitation of artificial ventilation:- ventilation with a mask should be used for short periods due to gastric insufflation 4-Protecting or maintaining an airway 5- absence or impairment of upper airways protective reflexes Establishing an Artificial Airway Indications for Artificial Airways(con..) - NB; Normally we have 4 main airway protective reflexes: 1. Pharyngeal reflexes - gag and swallowing reflexes; 9th & 10th cranial nerves 2. Laryngeal -vagovagal reflex -will cause laryngospasm 3. Tracheal -vagovagal reflex -cough when a foreign body or irritation in trachea 4. Carinal reflex -cough with irritation of carina So; absence or impairment of any of these protective reflexes may necessitate artificial airway insertion Establishing an Artificial Airway Pharyngeal Airways  Oral pharyngeal airway should be restricted to unconscious patient to avoid gagging & regurgitation ◦ Maintains patient airway by preventing tongue from obstructing oropharynx ◦ Can be used as bite block for patients with oral tubes ◦ It may be with single central channel (Guedel) or two parallel side channels (Berman)  Nasal pharyngeal airway is most often placed to facilitate frequent nasotracheal suctioning ◦ Minimizes damage to nasal mucosa caused by suction catheter Nasopharynge al Airway Oropharyngeal Airways 8 Establishing an Artificial Airway Oropharyngeal Airway Device designed for insertion along the tongue until the teeth &/or gingiva limit the insertion Lies between the posterior pharynx and the tongue and pushes the tongue forward (but does not isolate the trachea). Can be used in conjunction with BVM device Will activate the gag reflex, should use only in unconscious patient Correct sizing of airway is imperative (size is measured from the corner of the mouth to the angle of the jaw) Parts – flange, bite portion, air channel Establishing an Artificial Airway Oropharyngeal Airway (cont.,) Advantages - 1) Simple to use, cheap.  Uses – 1) To maintain open airway Disadvantages - 2) Prevent endotracheal tube occlusion 1) Injury due to incorrect size 3) Prevent tongue bite 2) Laryngospasm in awake patient 4) Facilitate suction 5) Obtain a better mask fit Hazards of Oropharyngeal  Contraindications – Airway 1) Intact gag reflex If too small, may not displace tongue or 2) Oropharyngeal growth may cause tongue to obstruct airway or may aspirated It too large, may cause epiglottis impaction Roof of mouth may be lacerated upon insertion Aspiration from intact gag reflex Establishing an Artificial Airway Oropharyngeal Airway Insertion 1 2 3 A- The jaw-lift technique 1. Select the proper size airway. 2. Open the patient’s mouth and hold the airway upside down and insert it in the patient’s mouth. 3. As the tip of the airway reach the hard palate rotate it 180° until the flange rests on the patient’s lips. B- Using tongue depressor: to displace the tongue away from the roof of the mouth, then the curved portion of the airway is slipped over the tongue, following the curvature of the oral cavity. Establishing an Artificial Airway Nasopharyngeal Airway Soft plastic or rubber tube that is designed to pass through one of the nares just inferior to the base of the tongue and it can provide a clear path for gas flow into the pharynx It can be used in patients with an intact gag reflex, so; can be tolerated by the conscious patient Useful for patient with a soft tissue obstruction who have jaw injury or spasm of jaw muscles Proper sizing and insertion (measured from tip of the nose to the patient,s earlobe) Parts – flange, airway channel, bevel Establishing an Artificial Airway Nasopharyngeal Airway(cont.,)  Advantages  Uses of nasopharyngeal airway 1) Nasal airway is better tolerated than an 1. To maintain airway in patients with intact gag oral airway if the patient has intact airway reflex reflexes. 2. To facilitate suctioning 2) Used in case of loose or poor dentition. 3. As a guide for a fiberscope or nasogastric tube 3) Used in case of Trauma or pathology of the oral cavity. 4. To apply continuous positive airway pressure (CPAP) 4) It can be used when the mouth cannot be 5. To dilate the nasal passages in preparation for opened. nasotracheal intubation  Contraindications 6. To maintain the airway and administer 1) Anticoagulation anesthesia during dental surgery. 2) Basilar skull fracture 3) Nasal pathology, sepsis, or deformity of the nose or nasopharynx 4) History of epistaxis requiring medical treatment. Establishing an Artificial Airway Nasopharyngeal airway Insertion 1 2 3 4 1- Select the proper size airway 2- The nasal airway is lubricated with a water soluble lubricant 3- The patient's head is slightly tilted backward and gently push the catheter into the nostril 4- The beveled tip is inserted directed towards the septum, with the airway directed perpendicular to the face If resistance 14 is met, rotating the airway may help, or the other nares may be used  https://youtu.be/vgqOrmBskaw  https://youtu.be/uALM3HqtTnI Establishing an Artificial Airway Tracheal Airways  Two basic types ◦ Endotracheal tubes are inserted through either mouth (orotracheal) or nose (nasotracheal), through larynx, & into trachea ◦ Tracheostomy tubes are inserted through surgically created opening in neck directly into trachea Orotracheal Airway Used in conditions of respiratory failure Usually the method of choice in emergencies that do not involve trauma to the mouth or mandible Oral route in usually easiest Accomplished by using a laryngoscope to directly visualize the trachea 16 Establishing an Artificial Airway Nasotracheal Airway More difficult route than oral Requires a longer and more flexible tracheal tube Insert through nose by touch and when in oropharynx use larynoscope and forceps (can perform “blind”) Usually Nasotracheal tube is better tolerated by patient than oral Tracheostomy Tube Tracheostomy is performed through the anterior tracheal wall either by the open method or percutaneous method Performed usually to prevent or treat long-term respiratory failure Decreases anatomic dead space by 50% Discussed later Establishing an Artificial Airway Tracheal Airways ET-Tube Trach-Tube Establishing an Artificial Airway Airway Intubation Establishing an Artificial Airway Endotracheal Intubation  Placement of a flexible plastic tube into the trachea to: ◦ maintain an open airway,  Is performed in critically injured, ill or anesthetized patients: ◦ to facilitate ventilation of the lungs, including mechanical ventilation, ◦ to prevent the possibility of aspiration and consequently asphyxiation or airway obstruction. Establishing an Artificial Airway Indications:  For supporting ventilation in patient with pathologic disease: ◦ Upper airway obstruction, ◦ Respiratory failure, ◦ Loss of consciousness  For supporting ventilation during general anaesthesia:  Patient has risk of pulmonary aspiration  Difficult mask ventilation Pre-Intubation Assessment 1-Patient Assessment (cont.,)  Recognizing abnormal breathing ◦ Fewer than 12 breaths/min OR more than 20 breaths/min ◦ Irregular rhythm ◦ Diminished, absent, or noisy auscultated breath sounds ◦ Reduced flow of expired air at nose and mouth ◦ Unequal or inadequate chest expansion OR Shallow depth ◦ Increased effort of breathing and use of accessory muscles of inspiration ◦ Skin that is pale, cyanotic, cool, or moist ◦ Also consider oxygenation.  Pulse oximetry is the rapid method to asses.  Arterial Blood Gases ( ABG) analysis Establishing an Artificial Airway 2-Airway Assessment  Failure to identify, in advance, characteristics associated with difficult intubation or ventilation is one of the leading causes of a failed airway in the operating room.  Difficult airway assessment requires determination of the potential for difficulty. (difficult laryngoscopy and intubation)  patients undergoing intubation in the ED found the- L:look externally, E:Evaluate, M: Mallampati score, O:Obstruction/Obesity, N:Neck mobility (LEMON) evaluation accurately stratified patients according to the risk of difficult intubation. Establishing an Artificial Airway Airway Assessment look externally Conditions that associated with difficult intubation:  Congenital anomalies  Pierre Robin syndrome , Down’s syndrome, cleft lips or palate  Infection in airway  Retropharyngeal abscess, Epiglottitis  Tumor in oral cavity or larynx  Enlarge thyroid gland trachea shift to lateral or compressed tracheal lumen  Maxillofacial ,cervical or laryngeal trauma  Temperomandibular joint dysfunction  Burn scar at face and neck  Morbidly obese or pregnancy Establishing an Artificial Airway (LEMON Assessment)  The size of the mandible, the distance between the mentum and the hyoid bone, and the extent of mouth opening are all important determinants of the success of direct laryngoscopy.  These relationships are represented by the 3-3-2 rule.  The rule describes three measurements found in normal patients (i.e, patients in whom difficult laryngoscopy is NOT expected).  This assessment indicates the ease of access to the airway.  A normal patient can open his/her mouth sufficiently to permit three of his/her own fingers to be placed between the incisors.  Adequate mouth opening facilitates both insertion of the laryngoscope and obtaining a direct view of the glottis.  The patient can open his/her mouth sufficiently to admit three of his/her own fingers. Establishing an Artificial Airway (LEMON Assessment) E: Evaluate (3-3-2 rule)/  This assessment provides an estimate of the volume of the submandibular space.  A normal patient is able to place three of his/her fingers along the floor of the mandible between the mentum and the neck/mandible junction (near the hyoid bone).  The distance between the mentum and the neck/mandible junction (near the hyoid bone) is the length of three of the patient’s fingers.  E: Evaluate (3-3-2 rule)/  This assessment identifies the location of the larynx relative to the base of the tongue.  A normal patient is able to place two fingers in the superior laryngeal notch (i.e, the space between the superior notch of the thyroid cartilage and the neck/mandible junction, near the hyoid bone).  If the larynx is too high in the neck, direct laryngoscopy is difficult or impossible because of the angles that have to be negotiated to permit visualization.  the space between the superior notch of the thyroid cartilage and the neck/mandible junction, near the hyoid bone, is the length of two of the patient’s fingers. Establishing an Artificial Airway (LEMON Assessment)  The Mallampati classification is a simple scoring system to help predict difficult intubation.  The Mallampati class, ranging from I to IV, relates the amount of mouth opening to the size of the tongue, and provides an estimate of space for oral intubation by direct laryngoscopy.  In general, Mallampati class I or II predicts easy laryngoscopy, class III predicts difficulty, and class IV predicts extreme difficulty. 3) Mallampati classification: Class 3,4 risk of difficult intubation Establishing an Artificial Airway (LEMON Assessment)  The presence of upper airway obstruction interferes with both laryngoscopy and intubation.  A supraglottic mass or infection, trauma with hematoma, injury with disruption of the upper airway, and vocal cord masses (eg, tumor),can obstruct the view of the glottis, or block access for tube insertion by narrowing the airway, or both.  The redundant tissues in the upper airway of the obese patient make visualization of the glottis by direct laryngoscopy more difficult, and an oversize laryngoscope blade may be required. Establishing an Artificial Airway (LEMON Assessment)  Ideally, the patient is placed in the sniffing position for intubation.  The sniffing position is achieved by flexing the neck forward on the body (thoracic spine) and elevating the head.  Thus, decreased cervical spine mobility compromises the direct laryngoscopic view.  Medical conditions, such as psoriatic or rheumatoid arthritis, or ankylosing spondylitis, or simply the degenerative joint disease that accompanies aging, can greatly reduce neck mobility.  In uncooperative, non-trauma patients, neck mobility can be assessed by passively extending the neck  Blunt trauma patients require in-line stabilization of the cervical spine during intubation, which also limits glottic view.  Most trauma patients, although identified as difficult airways because they require in-line cervical spine stabilization, can nonetheless be intubated successfully orally, unless other difficult airway markers are present. Neck mobility Flexion and extension of the neck) Establishing an Artificial Airway Preparing for intubation procedure Equipment that must be present to ensure a safe intubation:- - It is a must to Assemble all the following items before attempting intubation.  Suction Apparatus with tonsil tip and flexible suction catheters: This is extremely important. Often patients will have material in the pharynx, making visualization of the vocal cords difficult.  Airway. the oral airway is a device that lifts the tongue off the posterior pharynx, often making it easier to mask ventilate a patient. The inability to ventilate a patient is bad.  Also a source of Oxygen with a delivery mechanism (Ambu-bag and Mask) must be available.  Laryngoscope. This lighted tool is vital to placing an endotracheal tube.  Tube. Endotracheal tubes come in many sizes.  Introducer (stylets or Magill forceps).  Lubricant: Water-soluble sterile lubricant.  Tincture of benzoin, mucosal anesthetics (eg, 2% lidocaine), gloves & Syringe, 10-mL, to inflate the cuff.  Precut tape or ETT-holder.  Colorimetric carbon dioxide detector and Stethoscope  CDC barrier precautions (gloves, gowns, masks, goggles, or face shields) CDC( centr for disease control) Establishing an Artificial Airway Instruments used... LARYNGOSCOPIC BLADE Macintosh (curved) and Miller (straight) blade. Large for adults and Small for children : (Macintosh & Miller blades). A No.3 curved Macintosh or straight Miller laryngoscope blade is commonly used to intubate adults. Endotracheal tube Ambu Bag Magill Miller blade Macintosh blade Establishing an Artificial Airway  ETT-parts: -The key components of the ETT are : High volume Low volume  1-Standard adapter with a 15-mm external diameter. Low pressure cuff High pressure cuff  2- Length markings on the tube indicating the distance (in centi-meters) from the beveled tube tip. In addition to the beveled opening at the  3-Tip, there is a side port, or “Murphy eye,” that ensures gas flow if the main port become obstructed  4-The tube cuff is permanently bonded to the tube body.  Inflation of the cuff seals off the lower airway, either for protection from gross aspiration or to provide positive pressure ventilation.  5-The pilot balloon used to monitor cuff status and pressure when the tube is in place. Finally, a valve with a standard connector for a syringe allows inflation and deflation of the cuff.  NB; a woman is intubated with a No.7 or No.7.5 orotracheal tube and a man is intubated with a No. 8.0 or No. 8.5 orotracheal tube.  -Stylet is usually used for insertion to keep the curvature of the tube. Establishing an Artificial Airway Steps of Oro-tracheal Intubation:  Step 1: Assemble & check equipment  Step 2: Position patient  Step 3: Preoxygenate & ventilate patient  Step 4: Insert laryngoscope and Visualize glottis  Step 5: Displace epiglottis  Step 6: Insert tube  Step 7: Assess tube position and Stabilize tube/confirm placement ◦ Tip of tube should be about 3-6 cm above carina ◦ Listen for equal & bilateral breath sounds as patient is being ventilated ◦ Observe chest wall for adequate & equal chest expansion ◦ If ET tube in airway, CO2 levels begin to rise; seen on capnogram 37 Establishing an Artificial Airway Technique for oro-traheal intubation :  Step 1: Assemble & check equipment (mentioned before)  Step 2: Patient Positioning: Positioning to open the airway: Sniffing position: means Flexion at lower cervical spine and Extension at atlanto-occipital joint. Placement of one or more rolled towels under the patient’s shoulders helps. Next the RT flexes the patient’s neck and tilts the head backward with his or her hand, placing the patient into the sniff position. Establishing an Artificial Airway Technique for oro-traheal intubation (cont.,) :  Step3: Pre-oxygenate and ventilate the Patient: A patient in need of intubation is often apneic or in respiratory distress. Providing ventilation and oxygenation by manual resuscitator bag and mask with 100% O2 before intubation helps ensure the patient tolerates the intubation procedure. No more than 30 seconds should be devoted to any intubation attempt. If intubation fails, immediate ventilation and oxygenation of the patient for 3 to 5 minutes before the next attempt should occur.  Step 4: Insert Laryngoscope and visualize glottis: The RT should use the left hand to hold the laryngoscope and the right hand to open the mouth. The laryngoscope is inserted into the right side of the mouth and moved toward the center, displacing the tongue to the left. The tip of the blade is advanced along the curve of the tongue until the epiglottis is visualized Establishing an Artificial Airway Technique for oro-traheal intubation (cont.,) :  Step 5: Insert Tube: When the epiglottis is displaced and the glottis is visualized, the tube is inserted from the right side of the mouth and advanced without obscuring the glottic opening. When the tube tip is seen passing through the glottis, it is advanced until the cuff has passed the vocal cords. When the tube is in place, the RT stabilizes it with the right hand and uses the left hand to remove the laryngoscope and stylet. The cuff is inflated to seal the airway, and ventilation and oxygenation are immediately provided.  Step6: Assess Tube Position and Stabilize tube/confirm placement: - Tip of tube should be about 3-6 cm above carina - Bedside Methods to Assess Endotracheal Tube Position  1-Auscultation of chest and abdomen  2-Observation of chest movement  3-Tube length (centimeters to teeth)  4-Colorimetry  5-Fiberoptic laryngoscopy or bronchoscopy  6-Videolaryngoscopy  Establishing an Artificial Airway Special considerations / Opening the Airway  Emergency medical care begins with ensuring an open airway.  Rapidly assess whether an unconscious patient has an open airway and is breathing adequately.Position the patient correctly. Supine position is most effective.  Unconscious patients should be moved as a unit. ◦ Most common cause of airway obstruction is the tongue. Other causes of airway obstruction: Dentures, Blood, Vomitus, Mucus, Food and Other foreign objects – There two methods for Opening the Airway:- either * Head Tilt–Chin Lift Maneuver * Jaw-Thrust Maneuver Establishing an Artificial Airway Special considerations / Opening the Airway I) Head Tilt–Chin Lift Maneuver  For patients who have not sustained or are not suspected of having sustained trauma  Follow these steps:With patient supine, position yourself beside patient’s head. ◦ Place heel of one hand on forehead, apply firm backward pressure with palm. ◦ Place fingertips of other hand under lower jaw. Lift chin upward, with entire lower jaw. II) Jaw-Thrust Maneuver  If you suspect a cervical spine injury, use this maneuver  Follow these steps: ◦ Kneel above the patient’s head. ◦ Place your fingers behind the angles of the lower jaw. ◦ Move the jaw upward. ◦ Use your thumbs to help position the jaw.  Use the look, listen, and feel technique to assess whether breathing has returned Establishing an Artificial Airway Nasotracheal Intubation  Although nasotracheal intubation is more difficult than orotracheal intubation, it is the route of choice in certain clinical situations. Examples include intubation of patients when the oral route is unavailable, such as patients with maxillofacial injuries or undergoing oral surgery.  Nasotracheal intubation is performed either blindly or by direct visualization. Direct visualization requires either standard or fiberoptic laryngoscope with the addition of Magill forceps  A mixture of 0.25% phenylephrine and 3% lidocaine may be applied to the nasal mucosa with a long cotton-tipped swab to provide local anesthesia and vasoconstriction of the nasal passage.  A smaller ETT also may be needed. The tube should be pre-lubricated with water-soluble gel to aid passage.  Steps for nasotracheal intubation are similar to those of orotracheal intubation 43 Establishing an Artificial Airway Contraindication for nasoendotracheal intubation - Fracture base of skull - Coagulopathy - Nasal cavity obstruction - Retropharyngeal abscess Establishing an Artificial Airway Complications of endotracheal intubation 1) During intubation 2) During remained intubation  Trauma to lip, tongue or teeth  Obstruction from kinking , secretion or over- inflation of cuff  Hypertension and tachycardia or arrhythmia  Accidental extubation or endobronchial (esp;  Pulmonary aspiration right mainstem bronchus) intubation  Laryngospasm  Disconnection from breathing circuit  Bronchospasm  Pulmonary aspiration  Laryngeal edema  Lip or nasal ulcer in case with prolong period of  Arytenoid dislocation  hoarseness intubation  Increased intracranial pressure  Sinusitis or otitis in case with prolong  Spinal cord trauma in cervical spine injury nasoendotracheal intubation  Esophageal intubation (the most dangerous) Establishing an Artificial Airway Complications of endotracheal intubation  https://youtu.be/1vd2T2KIad4 3) During Extubation  Oropharyngeal tube insertion Laryngospasm  https://youtu.be/6UF-VaUKmvg Pulmonary aspiration  https://youtu.be/uALM3HqtTnI  Nasopharyngeal airway insertion Edema of upper airway  https://youtu.be/pzMrEIVHce4 4) After Extubation  https://youtu.be/moofo-uafU8  https://youtu.be/8g2rCx0GI0s  Sore throat  https://youtu.be/qzIyTCx1Mfw  Hoarseness  Tracheal stenosis (Prolong intubation)  Laryngeal granuloma Establishing an Artificial Airway Thank You