AIRWAY MANAGEMENT

• An adequate swallow must be present to decrease the risk for aspiration.
• Artificial airways are instruments/devices used for a variety of patients who require assistance in maintaining a patent airway.
• An artificial airway is required when the patient's natural airway can no longer perform its proper functions.
• Indications of artificial airway include airway compromise, respiratory failure, and need to protect the airway.
• Specific indications of artificial airway include airway emergency before endotracheal intubation, obstruction of the artificial airway, apnea, acute traumatic coma, penetrating neck trauma, cardiopulmonary arrest and unstable dysrhythmias, severe bronchospasm, severe allergic reactions with cardiopulmonary compromise, pulmonary edema, sedative/narcotic drug effect, foreign body obstruction, choanal atresia in neonates, aspiration, risk for aspiration, severe laryngospasm, self-extubation.
• Conditions in which endotracheal intubation may be impossible and in which alternative techniques may be used include but are not limited to the following: Restriction of endotracheal intubation by policy or statute.
• Difficult or failed Intubation in the presence of risk factors associated with difficult tracheal intubations such as: Short neck or bull neck, Protruding mandibular incisors, Receding mandible, Reduced mobility of atlantooccipital joint, Temporomandibular ankylosis, Congenital oropharyngeal wall stenosis, Anterior osteophytes of the cervical vertebrae, associated with diffuse idiopathic skeletal hyperostosis, Large substernal or cancerous goiters, Treacher Collins syndrome, Morquio-Brailsford syndrome, Endolaryngeal tumors, When endotracheal intubation is not immediately possible.
• Aggressive airway management (intubation or establishment of a surgical airway) may be contraindicated when the patient's desire not to be resuscitated has been clearly expressed and documented in the patient's medical record or other valid legal document.
• Difficult to stabilize because of the movement of the tube.
• Stimulates oral secretions.
• Gagging caused by tube irritation.
• More difficult to pass suction catheter as a result of the curvature of the tube and poor stabilization.
• Harder for the patient to communicate.
• Harder to attach equipment to a poorly stabilized ET tube.
• Patient may bite the tube, occluding air flow and setting off the ventilator high-pressure alarm, which ends inspiration prematurely.
• Erodes corners of patient's mouth.
• Orotracheal intubation is the preferred route for establishing an emergency tracheal airway because the oral passage is the quickest and easiest route in most cases.
• Orotracheal intubation can be safely performed by an appropriately trained physician, RT, nurse, or paramedic.
• The laryngoscope blade is a device designed to assist in the visualization of the trachea during intubation.
• The types of laryngoscope blade include the Straight blade, which is favored for children and are designed to posterior to the epiglottis, and the curved blade, which is designed so that the lip lies anterior to the epiglottis.
• Incorrect usage of the laryngoscope can cause trauma to the front incisers.
• Orotracheal intubation procedure involves assembling and checking equipment, positioning the patient, pre-oxygenating and ventilating the patient, inserting the laryngoscope, visualizing the glottis, displacing the epiglottis, inserting the tube, assessing tube position, stabilizing the tube and confirming placement.
• Nasotracheal intubation is the route of choice in certain clinical situations.
• Conditions requiring emergency tracheal intubation include persistent apnea, traumatic upper airway obstruction, accidental extubation of a patient unable to maintain adequate spontaneous ventilation, obstructive angioedema, massive uncontrolled upper airway bleeding, infection-related upper airway obstruction (partial or complete), epiglottitis in children or adults, acute uvular edema, tonsillopharyngitis or retropharyngeal abscess, suppurative parotitis.
• Coma with potential for increased intracranial pressure is a neonatal- or pediatric-specific condition.
• Neonatal- or pediatric-specific conditions include perinatal asphyxia, severe adenotonsillar hypertrophy, severe laryngomalacia, bacterial tracheitis, neonatal epignathus, obstruction from abnormal laryngeal closure owing to arytenoid masses, mediastinal tumors, congenital diaphragmatic hernia, presence of thick or particulate meconium in amniotic fluid, absence of airway protective reflexes, cardiopulmonary arrest, massive hemoptysis.
• A patient in whom airway control is not possible by other methods may require surgical placement of an airway (needle or surgical cricothyrotomy).
• The Passy-Muir valve is a commonly used tracheostomy speaking valve that is placed on the proximal end of the tracheostomy tube (with a 15-mm adapter).
• The cuff must be deflated when using the Passy-Muir valve.
• The patient's inspired air passes through the valve, but on exhalation the valve closes and directs the air up through the upper airway and vocal cords to allow the patient to talk.
• The patient should be suctioned with the cuff deflated before the valve is attached so that secretions that have pooled above the cuff will not be aspirated into the airway.
• The Passy-Muir valves may be used on spontaneously breathing patients or ventilator patients.
• If the valve is attached to a ventilator patient, the tidal volume must be increased to compensate for gas loss through the upper airway.
• Tracheal tube cuffs are used to seal the airway for mechanical ventilation or to prevent or minimize aspiration.
• Tracheal stenosis and tracheomalacia are associated with cuff use.
• The pathogenesis of these problems is related to the amount of cuff pressure transmitted to the tracheal wall, impeding the flow of blood and lymphatic fluid.
• If cuff pressure exceeds the mucosal perfusion pressure, ischemia, ulceration, necrosis, and exposure of the cartilage may result.
• Key aspects of airway care are cuff inflation and cuff pressure measurement and adjustment.
• The goal is to keep cuff pressures below the tracheal mucosal capillary perfusion pressure, estimated to range from 20 to 30 mm Hg.
• Higher pressure cuts off mucosal blood flow and causes tissue damage.