Managing the Artificial Airway

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Managing the Artificial Airway

• RC 275

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Tracheotomy/Tracheostomy

• When intubation cant be done or the need for the
  airway is indefinitely long
• Traditional surgical incision or PDT
  (Percutaneous Dilatational Tracheotomy)
• PDT may not be as damaging to tracheal cartilage

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RCPs Role During the Procedure

• Monitor the patient!
• Maintain adequate ventilation and oxygenation
• Assist physician as needed

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Try to leave the fresh trach undisturbed for 48
hours

• Suctioning obviously must be performed but as
  gently as possible

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Complications Associated with ET and Trach Tubes

• Can be due to the insertion procedure or from
  having the tube in the airway

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Intubation Complications

• Trauma to oral cavity, pharynx, and vocal cords
• Bleeding
• Laryngospasm
• Sub-Q Emphysema (from perforation of trachea)
• Improper tube placement
• Contamination/Infection

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Tracheotomy Complications

• Bleeding (can be life-threatening)
• Pneumothorax
• Sub-Q Emphysema
• Contamination/Infection

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Complications due to irritation from the tube and
cuff

• Contamination/Infection
• Obstructed Tube
• Tracheitis (sore throat)
• Glottic and/or sub-glottic edema (may not
  manifest until tube is removed)
• Vocal cord damage (ET tubes only)
• Paralysis, polyps, granuloma formation

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Complications Due to High Cuff Pressures

• Normal Mean Hemodynamics in the Tracheal Mucosa
• Lymphatic 5mmhg
• Venous 18 mmhg
• Arterial 30 mmhg
• Impeding/occluding arterial flow causes ischemia!
• Impeding/occluding lymphatic or venous flow
  causes edema

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Effects of Excessive Cuff Pressure

• Ischemia
• Inflammation
• Necrosis
• Fibrosis
• Stenosis
• Tracheal Malacia
• T-E Fistula

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Cuff Pressure Should NOT Exceed 25-30 cmH2O!

• The pressure in the cuff should be checked often,
  eg each ventilator check

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Cuff Inflation Management Techniques

• MOV Minimal Occlusive Volume
• MLT- Minimal Leak Technique

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MOV- Minimal Occlusive Volume

• Air is slowly added to cuff until either pressure
  cycling occurs (if applicable) or exhaled volume
  equals inhaled tidal volume
• Cuff pressure is then checked to make sure it
  does not exceed 25-30 cmH20 and adjusted to still
  allow pressure cycling or returned exhaled volume

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Minimal Leak Technique

• Like MOV except after cycling or volume return is
  achieved, a slight amount of air is removed to
  cause either
• (1) a loss of no more than 50 ml of set Vt
• (2) An audible leak heard around trachea

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Again, these techniques should be utilized each
time the cuff is checked

• If high pressures are needed initially, the
  artificial airway is probably too small
• If cuff pressures gradually increase, damage to
  the trachea may be occurring

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Extubation

• Done when none of the four indications for an
  artificial airway exist

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Extubation Technique

• Have suction, BVM and O2, and intubation supplies
  ready(including tracheotomy tray)
• In Fowlers or semi-Fowlers, suction through
  tube and pharynx
• Loosen tape and deflate cuff

• Insert new suction catheter into tube and have
  patient take a deep breath
• Apply suction as tube is pulled out and have
  patient cough at the same time
• Monitor vitals and respiratory status

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Possible Complications

• Inspiratory stridor due to glottic or sub-glottic
  edema
• Stridor that develops immediately after
  extubation is an ominous sign
• Laryngospasm/Bronchospasm
• Dyspnea

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Post-Extubation Treatment

• O2 Therapy
• For stridor, nebulized racemic epinephrine and a
  steroid
• If distress is not helped by nebulized drugs,
  re-intubate
• If not possible, tracheotomy

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Time to face the music!