Artificial Airway Management

Artificial Airway Management

General

• Whenever the manipulation of an artificial airway involves the removal and/or loosening of the device that is securing the airway there should be at least two licensed individuals
• A RT must be present during artificial airway manipulation or insertion, or significant movement of a patient with an artificial airway
• All x-rays should be shot with the patient in a flat, midline, neutral position unless otherwise ordered
• All x-rays should be obtained at the peak inspiratory time. The RT should instruct the x-ray tech and if necessary, perform a breath hold to capture the film during inhalation.

ETT

• An ETT 3.5 or smaller requires use of neo-fit
• An ETT 5.0 and larger can be used with an AnchorFast
• DO NOT secure an orogastric (OG) or nasogastric (NG) tube to an artificial airway because it increases risk for inadvertent extubation and / or skin damage.

Steps for Securing the ETT

• Assess the patient for artificial airway management
• Prepare the stabilization tape and/or securing device to accommodate the patient
• Manually stabilize the ETT
• Position an oral bite-block, if indicated
• Note the cm position of the ETT at the gum or nares
• Apply Liquid skin barrierApply Liquid Adhesive to the skin surfaceApply the stabilization tape to the patients upper lip and cheeksSpiral-wrap the free ends of the stabilization tape securely around the ETTAssess that the ETT is adequately stabilized with minimal movement

Airway Circuit Stabilizers

Angel Frame

• Patient less than 4 kg in warmer/isolette
• Low activity levels (minimal head movement, turning, etc.)

Ventilator Arm

• Patient greater than 4 kg in warmer
• Patient in crib
• High activity levels (moving head, scooting in bed, etc.)

D.O.P.E.

• Word to remind us of the causes that need to be eliminated, when troubleshooting the patient.
• D – DislodgedDisplacement (right mainstem) or dislodgement of the endotracheal tube
• O – ObstructedThe endotracheal tube is no longer delivering flow due to a blockage, or there could be a blockage in the trachea.  (mucous plug, kink in ventilator tubing)
• P – PneumothoraxNot just any pneumothorax, but a tension pneumothorax. The pressure in the chest, due to an expanding airspace outside of the lung, pressing not just on both lungs, but on the heart and on the major blood vessels is causing a rather complex problem with a simple solution. This expanding air space in the chest is preventing the lungs and heart from working properly, even though the oxygen is being delivered. The problem is not with the pipes (ETT, Trachea).  Get an x-ray.
• E – EquipmentAny of the many problems that do not fall into the two categories of Dislodged and Obstructed tubes (unless what is dislodged or obstructed is within the ventilator). An interruption in the oxygen supply. Anything that causes the ventilator to stop delivering gas under pressure to the endotracheal tube/tracheostomy tube.

• If you think there is a problem with the ventilator take the patient off of the vent and switch to bagging.

OPA

• Works by lifting the posterior aspects of the tongue, elevating the epiglottis and adjacent soft tissue away from the pharyngeal wall.

Indications

• Maintain patent airway in comatose, unconscious patients, or patients who have decreased ability to spontaneously maintain airway
• Facilitate airway suctioning
• Prevent oral ETT occlusion from patient biting
• Protect oral fiberoptic bronchoscope from patient biting
• Maintain airway patency during bag/mask or mouth to mouth ventilation

Contraindications

• Conscious patients
• Recent oral, maxillary or facial surgery / trauma

Sizing

• The proper length airway should reach from mouth to meatus of the ear
• Too short can displace the tongue backward
• Too long can cause damage to soft tissue

Insertion

• While standing at the patient’s head insert 180 degrees from final postion advance past uvula then rotate into proper position, or
• Use a tongue depressor to move tongue forward so the airway can be placed without the rotation procedure

NPA

• Works to provide a patent airway by separating the tongue and posterior pharynx
• Position should be changed Q 24 hours

Indications

• A more tolerable alternative to the OPA in conscious or semiconscious patients
• Reduce trauma or discomfort in patients receiving frequent NTS
• Provide patent airway in patients with limited oral access

Contraindications

• Basilar skull fracture
• Nasal, facial fracture or instability

Sizing

• The proper length airway should reach from naris to meatus of the ear
• Diameter should be large enough to pass an appropriate size suction catheter and stabilize the airway and small enough not to cause trauma upon insertion

Insertion

• Assess the patient for artificial airway management
• Check airway size by measuring from naris to the meatus of ear
• Lubricate the nasopharyngeal airway
• Insert airway gently advance into nares
• Slow gentle pressure should advance device through nasal passage without trauma
• If resistance is met withdraw and attempt the other naris
• Secure to nose with adhesive tape

Cuff Pressures

• A minimal occluding volume shall be used unless otherwise ordered by physician.
• The maximum cuff pressure that shall be used is equal to the patients peak inspiratory pressure unless explicitly ordered
• If pressures greater than the peak inspiratory pressure are needed to seal the patients airway, the nurse and physician must be notified. An order should be written to either:
  • Increase the size of the airway
  • Put a specific volume or pressure in cuff
  • Maintain the current cuff pressure at the ordered peak inspiratory pressure
• Possible factors for pressures needed for a seal being greater than the PIP
  • Airway is too small for the trachea
  • Abnormal tracheal wall/cartilage