Managing the Artificial Airway

RC 275

Tracheotomy/TracheostomyWhen intubation can’t be done or the need for the airway is indefinitely longTraditional surgical incision or PDT (Percutaneous Dilatational Tracheotomy)

PDT may not be as damaging to tracheal cartilage

RCP’s Role During the Procedure

Monitor the patient!Maintain adequate ventilation and oxygenation

Assist physician as needed

Try to leave the fresh trach undisturbed for 48 hours

Suctioning obviously must be performed but as gently as possible

Complications Associated with ET and Trach Tubes

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

Intubation Complications

Trauma to oral cavity, pharynx, and vocal cordsBleedingLaryngospasmSub-Q Emphysema (from perforation of trachea)Improper tube placementContamination/Infection

Tracheotomy Complications

Bleeding (can be life-threatening)PneumothoraxSub-Q EmphysemaContamination/Infection

Complications due to irritation from the tube and cuff

Contamination/InfectionObstructed TubeTracheitis (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

Complications Due to High Cuff Pressures

Normal Mean Hemodynamics in the Tracheal Mucosa

Lymphatic: 5mmhgVenous: 18 mmhgArterial: 30 mmhg

Impeding/occluding arterial flow causes ischemia!Impeding/occluding lymphatic or venous flow causes edema

Effects of Excessive Cuff Pressure

IschemiaInflammationNecrosisFibrosisStenosisTracheal MalaciaT-E Fistula

Cuff Pressure Should NOT Exceed 25-30 cmH2O!

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

Cuff Inflation Management Techniques

MOV – Minimal Occlusive VolumeMLT- Minimal Leak Technique

MOV- Minimal Occlusive Volume

Air is slowly added to cuff until either pressure cycling occurs (if applicable) or exhaled volume equals inhaled tidal volumeCuff 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

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

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

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

Extubation

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

Extubation Technique

Have suction, BVM and O2, and intubation supplies ready(including tracheotomy tray)In Fowler’s or semi-Fowler’s, suction through tube and pharynxLoosen tape and deflate cuff

Insert new suction catheter into tube and have patient take a deep breathApply suction as tube is pulled out and have patient cough at the same timeMonitor vitals and respiratory status

Possible Complications

Inspiratory stridor due to glottic or sub-glottic edema

Stridor that develops immediately after extubation is an ominous sign

Laryngospasm/BronchospasmDyspnea

Post-Extubation Treatment

O2 TherapyFor stridor, nebulized racemic epinephrine and a steroidIf distress is not helped by nebulized drugs, re-intubateIf not possible, tracheotomy

Time to face the music!