Airway Management

By paul edmer corcuera

 Adequate ventilation is dependent on
free movement of air through the
upper and lower airways.
In many disorders the airway
becomes narrowed or blocked
Bronchoconstriction
Foreign body
secretions
 Emergency management of
upper airways obstruction
Causes
Food particles
Vomitus
Blood clots
Edema
Laryngeal carcinoma
Thick secretions
Goiter
Enlarged lymph nodes
Hematoma
Thoracic aneurysm
 Emergency management of
upper airways obstruction
Altered level of consciousness
Risk for upper airway obstruction

Inspection
Palpitations
auscultation
 Emergency management of
upper airways obstruction
Clearing on the upper
airway obstruction
Hyperextend the patients
neck
Assess the patient by
observing the chest and
listening and feeling of the
movement of air
Use a cross finger
technique to open the
mouth and observe for
obvious obstruction
If no passage of air is
detected, apply five quick
sharp abdominal thrust
just below the xiphoid
process
 Emergency management of
upper airways obstruction
After obstraction is
expelled,rolled the
patient as a unit onto
the side for recovery
When the patient
obstraction is relieve if
the patient can
breathe spontanuesly
but not cough, shallow
or gag insert an oral
or nasopharyngeal
airway.
 Emergency management of
upper airways obstruction
Bag and mask
resuscitation
Apply the mask to the
patients face and
create a seal by
pressing the thumb of
the nondominant hand
on the bridge of the
nose and the index
finger on the chin
Using the rest of the
fingers on that hand,
pull on the chin and the
angle of mandible to
maintain the head is
extension .
Use the dominant hand
to inflate the lungs by
squeezing the bag into
its full volume.
 Endotracheal intubation
Involves passing an
endotracheal tube
through the mouth or
nose into the trachea.
Provides patent
airway
Comatose, upper
airway obstruction
Mechanical ventilation
Suctioning secretions
 Endotracheal intubation
Cuff pressure should be maintained
between 15 and 20 mmHg
High cuff pressure can cause:
Tracheal bleeding
Ischemia
Pressure necrosis
Low cuff pressure can cause:
High risk of aspiration pneumonia
It may be used for no longer than 3
weeks.
 Endotracheal intubation
DISADVANTAGES
Discomfort
Cough reflux is depressed
Secretions may become thicker
Swallowing reflux are depressed
Inability of the patient to talk
 Endotracheal intubation
Unintentional removal of the tube is
life threatening complications of
endotracheal intubation.
Laryngeal swelling
Hypoxemia
Bradycardia
Hypotension
death
 Endotracheal intubation
Care of patient with Endotracheal tube.
Immediately after intubation
Chest symmetry or chest expansion
Auscultate breath sounds
Obtain order for chest x-ray
Check cuff pressure every 6 to 8 hours
Monitor the signs and symptoms of aspiration
Administer 02 concentration as prescribed
Secure the tube to the patients face
Use sterile suction technique and airway care
Continue to reposition the patient every 2 hours as
needed.
Provide oral hygiene and suction the oropharynx
when ever necessary.
 Endotracheal intubation
Extubation
Explain the procedure
Have self inflating bag and mask ready in
case ventilatory assistance is required
immediately after extubation
Suctioning and removal of tape
Give 100 % o2 for a few breaths, then insert
a new sterile suction catheter inside tube
Have the patient inhale. At peak inspiration
remove the tube, suctioning the airway
through the tube as it is pulled out
 Endotracheal intubation
Care of patient following extubation
Give 02 by mask and maintain the patient in
sitting or high fowlers position
Monitor RR
Monitor the patients o2 level using a pulse
oximeter
Keep NPO or give only ice chips for next few
hours
Provide mouth care
Teach patient how to perform coughing and
deep breathing exercises.
 Tracheostomy
A surgical
procedure in which
an opening is made
on the trachea.

Tracheostomy tube
Temporary
Permanent
 Tracheostomy
It is used to:
Bypass an upper airway
obstraction
Removal of secretions
Permit the long term use
of mechanical
ventilation
To prevent aspiration in
oral or gastric secretions
in comatose patient or
paralyzed patient.
Replace the
endotracheal tube
 Tracheostomy
Complications Long term
Bleeding complications
Pnuemothorax Airway obstraction
(secretions)
Air embolism
Infection
Aspiration
Dysphagia
Emphysema
Transeoesophageal
Recurrent laryngeal fistula
nerve damage Tracheal dilatation
Posterior tracheal wall Tracheal ischemia
penetration Necrosis
Tracheal stenosis
 Tracheostomy
Nursing management Analgesia and
Contintious monitoring sedative agents
Ensure the patency
Suctioning secretions OBJECTIVES
Position in fowlers Alleviate the patients
position apprehension
Promote ventilation Provide an effective
Drainage means of
Minimize edema communication
Prevent stain on the
suture lines
Chart 25-9
Suctioning for tracheal tube
For secretions In line suction device
It is performed with the mechanical
ventilator
when adventurous
Decrease patient
breath sounds are anxiety in suctioning
detected or secretions
whether secretions It protects staff from
are obviously seen. patients secretions
Equipments must
be sterile
Chart 25-10
 Promoting home and
community based care
Teaching patients Continuing care
best care Referral for home
Instruct the patient care is indicated for
and family about ongoing assessment
of the patient and
the daily care
family to provide
including
appropriate and safe
techniques to
care.
prevent infection.
Assess the ability of
the family and
patient to cope in the
situation.
 Mechanical Ventilation
It is a positive or
negative pressure
breathing device that
can maintain
ventilation and
oxygen delivery for a
prolonged period.
Mechanical ventilation
is the use of a
mechanical device
(machine) to inflate
and deflate the lungs.
 Mechanical Ventilation
Indications
O2 and in arterial COPD
CO2 level and Multiple trauma
persistent acidosis. Shock
Thoracic or Multi-system failure
abdominal surgery
coma
Drug overdose
Neuromuscular
disorders
Inhalation injury
 Mechanical Ventilation
Reasons Purpose
To control the Mechanical
patients respiration ventilation provides
during surgery or the force needed to
during treatment of deliver air to the
severe head injury , lungs in a patient
to oxygenate the
whose
blood when the
patients ventilatory ownventilatory
efforts are abilities are
inadequate, and to diminished or lost.
rest respiratory
muscle among others
 Classifications
Negative pressure Positive pressure
ventilators ventilators
Exert a negative The most common
pressure on the use ventilator
external chest .
Inflate the lungs by
Decreasing the
exerting positive
intrathoracic
pressure on the
pressure during
inspiration allows air
airway, pushing air
to flow into the lungs, in and forcing the
filling its volume. alveoli to expand
during inspiration.
 Mechanical Ventilation
Breathingrequires the movement of air into
and out of the lungs. This is normally
accomplished by the diaphragm and chest
muscles.
Mechanical ventilation systems come in a
variety of forms. Almost all systems use a
machine called aventilatorthat pushes air
through a tube for delivery to the patient's
airways. The air may be delivered through
anasalor face mask, or through an opening
in the trachea (windpipe), called
atracheostomy.
 Ventilatorscan either deliver a set
volume with each cycle, or can be
set to a specific pressure regimen.
Both are in common use. Volume
ventilator settings are adjustable for
total volume delivered, timing of
delivery, and whether the delivery is
mandatory or determined by the
patient's initial inspiratory effort.
 Continuous positive airway pressure (CPAP)
delivers a steady pressure of air, which assists
the patient's inspiration (breathingin) and
resists expiration (breathing out). The pressure
of CPAP is not sufficient to completely inflate the
lungs; instead its purpose is to maintain an open
airway.
Bilevel positive airway pressure (BiPAP) delivers
a higher pressure on inspiration, helping the
patient obtain a full breath, and a low pressure
on expiration, allowing the patient to exhale
easily. BiPAP is a common choice for
neuromuscular disease.
Positive end-expiratory pressure (PEEP) is the
alveolar pressure above atmospheric pressure
that exists at the end of expiration.
 ventilator malfunction - rare
Circuit problems
fluid pooling in circuit
fluid pooling in filter
kinking of circuit
Endotracheal tube obstruction
eg due to sputum, kinking, biting
Increased airway resistance
eg bronchospasm
Decreased respiratory system
compliance
Advantages
- reduced peak and mean airway pressures
- improved CVS stability due to above
- decreased risk of barotrauma
- allows adequate ventilation with a disrupted airway
(eg bronchopleural fistula)
- permits mechanical ventilation during bronchoscopy
- improves operating conditions eg in thoracic surgery
- allows ventilation through narrow catheters and thus
increases access during laryngeal and trachael
surgery
- avoidance of hypoxia during tracheobronchial toilet
Disadvantages
- specialized equipment required
- dangers of high pressure gas flows
- humidification of inspired gases difficult
- tidal volumes markedly affected by changes in
respiratory compliance
- monitoring of ventilation parameters difficult
- difficult to predict minute ventilation from ventilator
 Complications of short-
term Mechanical

Ventilation
Complications of short-term mechanical
ventilation are usually minor and may
include sore throat (from the endotracheal
tube) and INFECTION. Infection is a greater
risk with long-term mechanical ventilation,
with PNEUMONIA being the most common.
The longer a person receives mechanical
ventilation, the more difficult it becomes to
wean the person to breathe independently.
 Weaning
Respiratory weaning, the process of
withdrawing the patient from
dependence on the ventilator takes
place in three stages.
The patient is gradually removed from
the ventilator
Then from the tube
Finally from the o2
 Criteria for weaning
Stable showing signs of improvement
or reversal of the disease or
condition that caused the need for
mechanical ventilation, weaning
indices should be assessed.

Stable V/S and Arterial Blood Gases

 When the patient can breath
spontaneously, weaning trials using t
piece or tracheostomy mask are
normally conducted with the patient
from the ventilator and can perform
all work of breathing.
Monitor the sign of hypoxia
 Weaning from the tube
Weaning from the tube is considered
when the patient can breathe
spontaneously, maintain an adequate
airway by effectively coughing up
secretions, swallow and move the jaw.
O2
SUCTIONING is needed
Mouth breathing and nose breathing is
conducted
 Weaning from oxygen
Stable respiratory function
Stable O2 sat
Pa02- 70 to 100 mmHg
Less than 70 supplemental 02 is
recommended.
 Nutrition
Respiratory muscles become weak or
atrophied after just a few days .

Compensation for inadequate nutrition

must be undertaken with care:
Excessive intake can increase production of
carbon dioxide and the demand for O2.
Adequate intake of protein is important.
25% of total daily kilocalories
1.2 to 1.5 g/kg/day
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