11-Airway Trauma and maintainance updated1444.pdf

Airway Trauma and maintenance 1444(2023) Airway Trauma Mechanisms of airway trauma Artificial Airways may result in pressure on soft tissues that can lead to ischemia and ulceration Artificial Airway position can be changed during patient's head movement or manipulation of the t...

Airway Trauma and maintenance 1444(2023) Airway Trauma Mechanisms of airway trauma Artificial Airways may result in pressure on soft tissues that can lead to ischemia and ulceration Artificial Airway position can be changed during patient's head movement or manipulation of the tube that may result in friction-like injuries. Occasional reaction to the materials of the tube can cause problems 2 Airway Trauma Airway Trauma Associated With Tracheal Tubes Laryngeal lesions Occur only with oral or nasal endotracheal tubes (ie; in case of translaryngeal intubation). Most common injuries to larynx are: 1)- Glottic edema 2)- Vocal cord inflammation 3)- Laryngeal OR vocal cord ulcerations 4)- Vocal cord polyps or granulomas 5)- Less common but more serious injuries include vocal cords paralysis and laryngeal stenosis Glottic edema & Vocal cord inflammation Are transient changes Result from pressure or transient trauma during intubation May develop after extubation (this more dangerous, so follow up is needed for 24 h after extubation) Pt may complain of hoarsness of voice & stridor (most serious) 3 Airway Trauma Laryngeal lesions (cont.,) Treatment of glottic edema & Vocal cord inflammation Racemic epinephrine aerosol, steroid and severe cases may need reintubation or tracheostomy. Prevention; by giving IV steroid 24 h before extubation Vocal cord polyp & granuloma Occure in Pt with prolonged intubation Pt develop Symptoms; hoarsness of voice, stridor and difficult swallowing. Treatment; is conservative but in severe or persistent symptoms surgical removal is indicated. Vocal cord paralysis Usually resolve spontaneously within 24 h of extubation, but may persist, if obstruction is persistent tracheostomy is indicated Laryngeal stenosis The normal tissue of the larynx is replaced by scar tissue. Pt develop hoarseness & stridor. Does not resolve spontaneously. Usually need surgical correction Some Pt require permanent tracheostomy. 4 Airway Trauma Airway Trauma Associated With Tracheal Tubes (cont.) Tracheal lesions Can occur with any type of tracheal tubes & it may be: 1)- Granulomas 2)- Tracheomalacia 3)- Tracheal stenosis 4)- Less common but more serious Tracheoesophageal & tracheoinominate artery fistulas 5 Airway Trauma Tracheal lesions (cont.,) Tracheomalacia & tracheostenosis Tracheomalacia means softening of tracheal cartilages rings leading to collapse of the trachea during inspiration. Tracheostenosis means narrowing of the tracheal lumen due to fibrosis or scarring, and most often occur at the ETT- cuff site while in trach tube it may occur at cuff site, tube tip or most commonly at stoma site Many factors lead to stenosis at stoma site such as: too large stoma, infection, movement of tube, frequent tube changes and advanced age. 6 Airway Trauma Tracheal lesions (cont.,) Tracheomalacia & tracheostenosis Symptoms and signs: SOB(shortness of breath), Stridor and difficult expectoration. Investigation: tomography, PFT (flow-volume loop) Treatment: depend on the severity and length of damage: 1) -Laser therapy may be useful for small lesions 2)- Resection and end-to-end anastomosis (when damage involves less than 3 tracheal rings) 3) -Staged repair or stent in more extensive damage Tracheo-oesophageal fistula means direct communication between trachea and oesophagus. Leads to recurrent aspiration and abdominal distension Treatment ; by surgical closure of the defect. 7 Airway Trauma Tracheal lesions (cont.,) Tracheo-innominate fistula A very rare complication and occur more with tracheostomy tube. Massive hemorrhage and death occur in most cases Pulsation of the trach tube may be the only clue before actual hemorrhage. Treatment; surgical closure, however; even with proper corrective action, only 25 of patients survive. Prevention of airwayTrauma Associated With Tracheal Tubes Sedation can help to keep patient comfort and avoid self-extubation Nasotracheal tubes are easier to stabilize Swivel adapter can reduce tube traction Selection of correct airway size is important Pt should be discourage from unnecessary coughing or talk Maintain tube cuff pressures of 25-35 cm H2O (20 – 25 mmHg) to reduce tracheal wall injury Use of un-cuffed tube if the airway is placed solely for suctioning or to bypass obstruction 8 Airway Trauma Troubleshooting Airway Emergencies Tube obstruction 1)- Kinking or biting tube Obstruction is reversed by moving patient’s head & neck or repositioning tube 2)- Herniation of cuff over tip Deflate cuff If deflating cuff fails to overcome obstruction, try to pass suction catheter through tube 3) Obstruction of tube orifice against tracheal wall 4)- Mucus plugging Suction tube if instillation of sterile normal saline is not necessary 9 Airway Trauma Troubleshooting Airway Emergencies (cont.) Cuff leaks Primarily problem for patients receiving mechanical ventilation Will cause reduced delivery of tidal volume If pilot tube or valve is leaking, tube needs to be changed as soon as possible Ruptured cuff requires extubation & re-intubation or using endotracheal tube exchanger Endotracheal tube exchanger is semi-rigid guide, over which damaged tube can be removed & new tube inserted. Accidental extubation Partial displacement of airway out of trachea can be detected by: Decreased breath sounds Decreased airflow through tube Decreased ability to pass catheter past end of tube With positive pressure ventilation, airflow through mouth & nose or into stomach may be heard Completely remove tube & provide ventilatory support by manual resuscitator & mask as needed until patient can be reintubated or tracheostomy tube reinserted 10 Airway Maintenance Airway Maintenance Role of RTs Secure tube & maintain placement Provide for patient communication Ensure adequate humidification Minimize possibility of infection Aide in secretion clearance Provide appropriate cuff care Troubleshoot airway-related problems 11 Airway Maintenance I- Secure tube & maintain placement The most common way is to use tape. The tape is secured to one side of the face then wound around the tube and airway one or twice before the end is secured to the skin again. The other method is to use endotracheal tube holders or stabilizers; (the advantages are less skin damage, less tube movement and less self extubation) Proper placement of ETT or Trach tube 3 – 6 cm above the carina in adult or between 2nd & 4th tracheal rings… Why?; to minimize tube migration during neck flexion (up toward the larynx) or neck extension (down toward the carina) The normal mean range of movement of ETT is: 1.9 cm up during neck flexion and 3.8 cm down during neck extension. Skin preparation before using of tape, as shaving (may need consent), cleaning and drying. Secure tape over the upper lip whenever possible. Securing tube and maintain placement Endotracheal tube holder Trach tube holder By using ta Airway Maintenance II- Provide for patient communication Phonation requires movement of vocal cords and airflow and ETT prevent movement of vocal cords Standard Trach tube allow vocal cord movement but prevent airflow Without the patient's ability to speak, he cannot inform the health care provider by changes of symptoms or make basic requests, leading to agitation and stress. Methods of communications: 1)- Lip reading; difficult with ortracheal tube. 2)- Writing ; Pt writes message on a paper or any writing surface. 3)- Letter, phrases or pictures board (communication by simple pointing). 4)Talking Tracheostomy tube; in Pt with prolonged ventilation on tracheostomy tube (it provide a separate inlet for compressed gas to escape above the tube causing phonation. Airway Maintenance Methods of communications (cont.,): 5)- Speaking valve; a one way valve placed on the external opening of the tracheostomy tube, with deflation of tube cuff the Pt inhale around and through the tube and exhale only around the tube through the larynx. Speech is coordinated with exhalation through the larynx. The Pt must be stable, able to communicate and has low risk for aspiration. Speaking valve can be used in spontaneously breathing Pt and ventilator-dependent Pt. It is better to measure tracheal pressure before using speaking valve if more than 5 cm H2O it may indicate increased resistance during exhalation ( the tube may need to be changed into smaller size, to a cuffless tube or to a tube with tight- to – shaft cuff). Speech- language therapist may help in assessment of this Pt. https://youtu.be/QKqSQ-o4Fio Airway Maintenance III- Ensuring adequate humidification Decreased Humidity impair ciliary function and decrease mucociliary clearance of airway secretions and hence their retention and predispose to infection. Thick secretions can obstruct a tracheal tube and cause asphyxiation. In non-ventilated Pt with tracheostomy; use either heated humidifier or large–volume jet nebulizer to deliver heated humidity. HME used in mechanically ventilated Pt in absence of thick secretions or using aerosol therapy. Also Passover humidifier can be used. Goal; AH 30mg/L and temp between 32 – 35 C. Airway Maintenance IV- Minimizing nosocomial infections The presence of infection is suggested changed in the Pt,s sputum (color, amount and consistency), breath sounds ( bronchial BS, wheezes & crackles) or chest radiograph ( consolidation or infiltration and atelectasis). Also fever tachycardia and leukocytosis. How to minimize nosocomial infections? 1)- Adhering to sterile technique during suction. 2)- Ensuring that only aseptically clean or sterile respiratory equipment is used for each Pt. 3)- Consistently performing hand hygiene between patient contacts. 4) prevention of secretion retention and frequent suctioning and use of closed suction technique and adequate humidification. 5)- Routinely change the inner cannula of tracheostomy tube. 6)- Chest physiotherapy Airway Maintenance IV- Minimizing nosocomial infections (cont.,) 7)-Techniques to decrease the consequences of aspiration; a- use of medication for stress ulcer prophylaxis b)- positioning of the Pt with head of the bed elevated 30 degrees or more to decrease reflux. c)- Continuous aspiration of subglottic secretions. d)- Using ETT with an high-volume, low-pressure (HVLP) cuff– This ETT was developed to reduce the incidence of ventilator-associated pneumonia (VAP). Why tracheal airways increase the incidence of pulmonary infections? ----- Because of:- 1)- Bypass upper airway filtration. 2)- Increased aspiration of oropharyngeal secretions. 3)- Contaminated equipment or solutions. 4)- Impaired mucociliary clearance in trachea. 5)- Increased mucosal damage owing to tube or suction. 6)- Ineffective clearance via cough. Airway Maintenance V- Providing Cuff Care What is the importance of cuff? 1)- Seal the airway (prevent leaks) for mechanical ventilation 2)- To prevent or minimize aspiration What is the main drawback of cuff? 1) tracheal stenosis 2) tracheomalacia What is the pathogenesis of these problems? - is related to the amount of cuff pressure transmitted to the tracheal wall, impeding the blood flow and lymphatic fluid. If cuff pressure exceeding the mucosal perfusion pressure, it will lead to ischemia, ulceration, necrosis and lastly exposure of the cartilage Airway Maintenance V- Providing Cuff Care (cont.,) Initial Cuff Designs Modern Cuff Design Low pressure and high High Pressure and low residual volume residual volume Not as damaging to Much tracheal mucosa tracheal mucosa if damage managed and monitored properly Airway Maintenance V- Providing Cuff Care (cont.,) What is the importance of cuff pressure? - High-residual volume low pressure (HVLP) cuffs is the norm, when probably used , these cuffs transmit low pressure to the tracheal wall than the older high- pressure cuffs. The key aspect of airway care are cuff inflation and cuff pressure measurement and adjustment. Cuff pressure must be monitored at least every 4 hours or according hospital policy and each Pt should have his Own manometer. What is the goal of cuff pressure adjustment? - is to keep cuff pressure below the tracheal mucosal capillary perfusion pressure, estimated to range from 25 – 35 cm H2O (20- 25 mmHg) which should prevent tracheal mucosal injury and silent aspiration. Low pressure leads to aspiration and high pressure cause tracheal necrosis It is measured by specific manometer at the end of inspiration by connecting the manometer to the one way valve of pilot balloon. Airway Maintenance V- Providing Cuff Care (cont.,) What are the alternative cuff designs?  Alternative cuff designs  Lanz tube incorporates external pressure regulating valve & control reservoir Designed to limit cuff pressure between 16 & 18 mm Hg.  Foam cuff designed to seal trachea with atmospheric pressure in cuff Not commonly used except in patients who have already developed tracheal injury  Tight-to-shaft cuff is low-volume, high pressure cuff design that maximizes airflow around tube when deflated Can only be inflated with sterile water; not air since it is made of porous silicone material Airway Maintenance Thank You