Airway management in the critical care setting depends on 4 steps which, when followed adequately, ensure patient’s safety:
- timely clinical identification of airway compromise in patient
- use of the most appropriate airway maneuver for the patient
- appropriately choosing and introducing airway adjuncts
- becoming aware if and when the need for ventilation arises, and delivering it effectively
Oropharyngeal and Nasopharyngeal airways are tubes made of plastic or rubber used to help maintain airway patency by keeping the tongue out of the way from obstructing the upper airway. Whilst in use, patient breathing should be assessed and confirmed so that proper positioning is ensured.
Complications
- gagging
- vomiting (may lead to aspiration)
- bleeding following trauma to the oral or nasal cavity
- airway obstruction caused by the oropharyngeal airway pushing the tongue to the back
- laryngospasm – vocal chord spasm which causes temporary difficulties with breathing and speaking
NOTE: The oropharyngeal airway should only be used in unconscious patients with an absent gag reflex.
NOTE: Do not use the nasopharyngeal airway on patients with a fractured skull base.
Oropharyngeal & Nasopharyngeal Airway Insertion
Oral & Nasal Endotracheal Tubes
Oral endotracheal tubes are commonly used in emergency situations. Whilst oral ETTs can be inserted easily, they also facilitate insertion of a larger tube that facilitates breathing and secretion suctioning.
Nasal endotracheal tubes provide less discomfort to the patient since they enable swallowing and oral hygiene, as well as facilitate communication. They can be easily secured and stabilised, minimising the risk of unintentional extubation. Additionally, a nasal ETT is preferred for paediatric use, post-extensive dental or neck surgery, and for patients with a fractured jaw.
Endotracheal tubes are available in many sizes. At the distal end of an endotracheal tube is a cuff which can be inflated by an external pilot balloon using between 15 to 25ml of water. This helps the ETT to stay in place, helps keep ventilated air in the ETT without escaping back up, and may also help prevent aspiration (although micro-aspiration can still pass through). At the proximal end a 15mm adaptor can be attached. This adaptor enables the ETT to be connected to ventilator tubings or to manual resuscitation bags.
NOTE: in paediatrics, the ETT used is usually without a cuff, which means it can be easily coughed out.
Intubation Equipment
- ETTs (different sizes)
- Stylet and Boogie (used in difficult intubations)
- Checked Suction
- Suction Catheters
- Manual Resuscitation Bag (connected to oxygen)
- Ventilation Masks
- Laryngoscope Handle + Blades (pre-checked)
- IV Access
- Haemodynamic and Respiratory Monitoring Equipment
Use of McCoy Laryngoscope & bougie
The McCoy laryngoscope’s blade has an adjustable hinged tip for improved visualisation of the vocal cords during difficult intubations.
Intubation Drugs
- analgesics
- sedatives (short-acting) eg. Etomidate or Propofol
- muscle relaxants (short-acting) eg. Suxamethonium (Scoline) or Atracurium (Tracrium)
- resuscitation drugs eg. adrenaline or atropine
NOTE: when ventilating a patient, it is very important to administer sedation first. When sedation effects kick in, a muscle relaxant can then be administered. Baseline parameters are then taken and patient is continuously monitored.
Intubation Procedure
- prepare equipment and ensure that all is checked and in working order
- position patient in a way which ensures airway patency
- suction the patient’s oral cavity and the pharynx
- provide patient with 100% oxygen through manual ventilation for a few minutes
- attempt intubation – limit attempt/s to 30 seconds
- use the BURP technique to increase visibility (apply pressure on thyroid cartilage whilst moving backward, upward, and rightward)
- insert tube and inflate cuff
- ensure correct tube positioning through auscultation of bilateral breath sounds, visible chest rise, x-ray imaging, and ETCO2 monitor
- document size and depth of ETT used
ATTENTION: if the ETT is misplaced into the stomach and not in the trachea, upon ventilating with 100% oxygen, the stomach would inflate instead of the lungs – chest.
Intubation Complications
- vomiting and aspiration
- laryngospasm
- trauma to the mouth, nose, pharynx, trachea and/or oesophagus
- gastric intubation
- right main bronchus intubation
- hypoxaemia and/or hypercapnia leading to hyper/hypotension and tachy/bradycardia
Prolonged Intubation Complications
- patient discomfort
- communication difficulty
- patient anxiety
- hypersalivation
- tube displacement
- tube obstruction
- aspiration
- nasal injury
- mucosal lesions
- cricoid abscess – causes airway compromise reversible with treatment
- sinusitis – causes nasal discharge and undetermined fever
- laryngeal stenosis – scarring within the larynx at or above the vocal cords which limits the larynx from opening as it normally does
- tracheal stenosis – unusual narrowing of the trachea which restricts normal breathing
- tracheo-oesophageal fistula – unusual connection between the trachea and oesophagus which causes swallowed liquids and foods to be aspirated into the lungs
NOTE: An ETT should not be used for more than 12 days. If further ventilation is required, a tracheostomy should be considered instead.
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