FEU-NRMF Review Airway Management PDF

AIRWAY MANAGEMENT REOH B. DANOS, RTRP, MHA FEU–NRMF, SCHOOL OF RT  Endotracheal Intubation The placement of a tube into the trachea in order to maintain an open airway in patients who are unconscious or unable to breathe on their own  Indications  Respiratory Arrest/Fa...

AIRWAY MANAGEMENT REOH B. DANOS, RTRP, MHA FEU–NRMF, SCHOOL OF RT  Endotracheal Intubation The placement of a tube into the trachea in order to maintain an open airway in patients who are unconscious or unable to breathe on their own  Indications  Respiratory Arrest/Failure  Prevent Aspiration  Airway Obstruction  Prolonged Ventilatory Support  To Facilitate Suction  Contraindications  Inability to extend the head  Severe trauma to the cervical spine  Epiglottal infection  Mandibular fracture  Uncontrolled oropharyngeal hemorrhage  Awake patient  Complications  Trauma to the lips, tongue and teeth  Hypertension, tachycardia or arrythmia  Laryngospasm and Laryngeal edema  Increased intracranial pressure  Spinal cord trauma in cervical spine injury  Esophageal intubation   ETT Internal Diameter  For patient more than 1 year old the ETT diameter can be estimated using the following formula: ETT diameter (mm) = (Age (years) + 16) / 4 or Height in cm/20  6 to 12 months old = 4.0 mm  New Born based on weight < 1,000 g 2.5 mm 1,000 to 2,000 g 3.0 mm 2,000 to 3,000 g 3.5 mm >3,000 g 4.0 mm  ETT Internal Diameter Adult by Gender: Women 7.5 – 9.0 mm Male 8.0 – 9.5 mm  ETT Length  In pediatrics, infants and neonates, insert the tube based on the following guidelines:  Newborn ETT should be = 9.5 cm  6 month old infant = 11.5 cm  1 year old = 12 cm  Older pediatrics use the formula: ETT length = age(years) / 2 + 12  ETT Length  Adult Women – 21 cm  Adult Men – 23 cm  Approximately 23 to 25 cm mark at the teeth  Note: The end of ET tube should be 2 to 5 cm above the carina, The carina is seen on radiographs at the fourth rib or the fourth thoracic vertebra  Note: Never exceed 15 to 20 sec per intubation attempt (pre-oxygenate the patient) stimulation  Intubation Equipment Resuscitation bag  Proper size.  Functional  With 100 % O2 , Flow meter and O2 tubing. Proper size Oropharyngeal or Nasopharyngeal Airway Proper size Resuscitation Mask  Laryngoscope with proper size blades "Mac or Miller" (Double check that the bulb is tight and working)  Stylet (different sizes)  Proper size ETT (check the that the cuff is not ruptured if applicable) "keep sterile"  Water based Lubricant "Xylocaine maybe used"  Suctioning Equipments  Megyle Forceps "to be used for nasotracheal intubation  Stethoscope (to check the placement of the ETT post insertion)  Tapes and Ties (to secure the ETT post insertion) TRACHEOSTOMY Reoh B. Daños, RTRP, MHA FEU-NRMF School of RT  Tracheostomy  A surgical opening through the neck into the trachea through which a tube may be inserted to maintain an effective airway ventilation.  Indications  Prolonged mechanical ventilation  An oral or nasotracheal tube become difficult to manage  The upper airway needs to be bypassed as in an airway obstruction  Difficulty in weaning the patient from ventilatory support.  To reduce the risk of laryngeal injury caused by prolonged translaryngeal intubation and to improve oral hygiene.  To access and remove excessive secretions.  Contraindications  There are no absolute contraindications to tracheostomy except for Laryngeal carcinoma. Types of Tracheostomy Tube  Single cannula tracheostomy tube  Double Cannula Tracheostomy Tube  Fenestrated Tracheostomy Tube  Cuffed Tracheostomy Tube  Un-cuffed Tracheostomy Tube Single Cannula  Tube Used on all newborns and most pediatric patients.  Has one single passage used for both air flow and suctioning. Double Cannula  Features a removable inner cannula that fits inside an outer cannula.  Inner cannula must be in place to ventilate the patient  Outer cannula keeps the stoma open while the inner is removed for cleaning. Fenestrated  Teaches the patient to breathe through the upper airway.  Allows for speech.  Less airway resistance With Cuffed  Initial choice  Used during M.V.  Decreases the risk of aspiration.  Cuffs may be either foam or balloons.  Used for adults or older children. Un-Cuffed  Used when M.V. is not required  Less airway resistance compared to cuffed tube  Used for Pediatrics Changing of Trach – Tube  Trach – tube is typically changed every 1 – 4 weeks  Always change the trach – tube with 2 people present ( unless its an emergency)  Change the trach – tube before feeding or 2 hours after feeding Note: changing of tube must be done only by the EXPERT.  Changing of Trach –Tube  Needs to be done by 2 people.  Secure new ties before removing old ties to decrease chances of trach – tube dislodging.  Use a square-knot.  Ties are snug, but not too tight. (be able to slip 1 finger under the ties)  Change the position of the knot slightly with each change to avoid skin breakdown from the knot.  If skin irritation does occur, place a gauze pad under the ties.  Kinds of Trach – Ties When it becomes soiled, wet, loose or cause pressure to child’s skin. Daily routine on infants with short fat necks, overweight children, and children on high humidification. Not necessary for daily routine in home care.  Wound Care  Requires two persons to prevent loss of tracheostomy  Routine wound care  risk of infection  Daily examination of stoma  Clean dressing is inserted under the tracheostomy tube  Precut dressing should be used to reduce the risk of fibers entering the stoma  Procedure of Wound Care  Hand washing  Assembly of the materials Sterile H20/Hydrogen Peroxide/Cotton Applicator/Gauze pad/Gloves/Scissors Making T-Shape Guaze Tracheostomy Care Tracheal Humidification  Humidification is necessary because the tracheostomy bypasses the upper airway which normally moistens the air. The reduction of moisture and heat loss helps to maintain suitable viscosity of secretions  Types Delivering Tracheal humidification Tracheal Mask (attached to humidifier) HME (Heat Moisture Exchange)  Other Types Trach Ring Saline Solution  Complications Mucus plugs are the most common cause of respiratory distress for children with tracheostomy. Symptoms of a mucus plug include resistance when trying to suction or bag the patient.  Early Complications  Bleeding  Tracheostomy tube obstruction  Tracheostomy tube displacement  Infection  Late Complications  Tracheal Stenosis  Granulation tissue  Tracheocutaneus fistula  Tracheo - inominate fistula Tracheal Stenosis  Complications Tracheoesophageal Infection - Tracheitis Fistula Granuloma Pressure Necrosis Tracheoinnominate Fistula(rare)  Technique of Insertion Between 2-3 ring Right angles, cricoid hook Tracheostomy Emergencies Obstruction of the tube Displacement of the tube  Troubleshooting Dislodgement Causes  Ties too loose  Cough  cuff deflated  tube too short/wrong size for patient Clinical signs  Difficulty in ventilating patient  Increased airway pressure  Suction catheter obstructed  Non Ventilated Patient  Poor cough  Sudden voice change  Stridor, SOB What to do: Dislodgement  Extend neck  Remove inner cannula  Use obturator to redirect tracheotomy tube into lumen  If patient in distress and does not have fixed obstruction above, pull out trach tube  Ventilate with mask/intubate  Use flex bronchoscope or replace/OR S A L A M A T