Title: Managing the Artificial Airway
1Managing the Artificial Airway
2Tracheotomy/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
3RCPs Role During the Procedure
- Monitor the patient!
- Maintain adequate ventilation and oxygenation
- Assist physician as needed
4Try to leave the fresh trach undisturbed for 48
hours
- Suctioning obviously must be performed but as
gently as possible
5Complications Associated with ET and Trach Tubes
- Can be due to the insertion procedure or from
having the tube in the airway
6Intubation Complications
- Trauma to oral cavity, pharynx, and vocal cords
- Bleeding
- Laryngospasm
- Sub-Q Emphysema (from perforation of trachea)
- Improper tube placement
- Contamination/Infection
7Tracheotomy Complications
- Bleeding (can be life-threatening)
- Pneumothorax
- Sub-Q Emphysema
- Contamination/Infection
8Complications 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
9Complications 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
10Effects of Excessive Cuff Pressure
- Ischemia
- Inflammation
- Necrosis
- Fibrosis
- Stenosis
- Tracheal Malacia
- T-E Fistula
11Cuff Pressure Should NOT Exceed 25-30 cmH2O!
- The pressure in the cuff should be checked often,
eg each ventilator check
12Cuff Inflation Management Techniques
- MOV Minimal Occlusive Volume
- MLT- Minimal Leak Technique
13MOV- 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
14Minimal 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
15Again, 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
16Extubation
- Done when none of the four indications for an
artificial airway exist
17Extubation 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
18Possible Complications
- Inspiratory stridor due to glottic or sub-glottic
edema - Stridor that develops immediately after
extubation is an ominous sign - Laryngospasm/Bronchospasm
- Dyspnea
19Post-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
20Time to face the music!