Airway Management

Neila Altobelli

Chapter Objectives

After reading this chapter you will be able to:

Describe how to perform endotracheal and nasotracheal suctioning safely.

Describe how to obtain sputum samples properly.

Assess the need for and select an artificial airway.

Identify the complications and hazards associated with insertion of artificial airways.

Describe how to perform orotracheal and nasotracheal intubation of an adult.

Assess and confirm proper endotracheal tube placement.

Describe the rationale and the methods for performing a tracheotomy.

Identify the types of damage that artificial airways can cause.

Describe how to maintain and troubleshoot artificial airways properly.

Describe techniques for measuring and adjusting tracheal tube cuff pressures.

Identify when and how to extubate or decannulate a patient.

Describe how to use alternative airway devices.

Describe how to assist a physician in setting up and performing bronchoscopy.

Key Terms

American Society for Testing and Materials (ASTM)

tracheoesophageal fistula

tracheoinnominate artery fistula

Respiratory therapists (RTs) are an important part of the health care team who aim to optimize patient ventilation and gas exchange. Because adequate ventilation and gas exchange are impossible without a patent airway, RTs often assume responsibility for airway management of patients in both the acute care and the post–acute care settings. RTs must develop skills in three broad areas of airway care. First, the RT must be proficient in airway clearance techniques, including methods designed to ensure the patency of the patient’s natural or artificial airway. Second, the RT must be able to insert and maintain artificial airways designed to support patients whose own natural airways are inadequate. Third, the RT must be able to assist physicians in performing special procedures related to airway management. This chapter explores each of these areas.

Suctioning

Airway obstruction can be caused by retained secretions, foreign bodies, and structural changes such as edema, tumors, or trauma. Retained secretions increase airway resistance and the work of breathing and can cause hypoxemia, hypercapnia, atelectasis, and infection. Difficulty in clearing secretions may be due to the thickness or amount of the secretions or to the patient’s inability to generate an effective cough.

RTs can remove retained secretions or other semiliquid fluids from the airways by suctioning. Suctioning is the application of negative pressure (vacuum) to the airways through a collecting tube (flexible catheter or suction tip). Removal of foreign bodies, secretions, or tissue masses beyond the main stem bronchi requires bronchoscopy, which is performed by a physician. RTs often assist physicians in performing bronchoscopy, which is discussed at the end of the chapter.

Suction can be performed in either the upper airway (oropharynx) or the lower airway (trachea and bronchi). Secretions or fluids can also be removed from the oropharynx by using a rigid tonsillar, or Yankauer, suction tip (Figure 33-1). Access to the lower airway is via introduction of a flexible suction catheter (Figure 33-2) through the nose (nasotracheal suctioning) or artificial airway (endotracheal suctioning). Tracheal suctioning through the mouth should be avoided because it causes gagging.

FIGURE 33-1 Rigid tonsillar, or Yankauer, suction tip. (Modified from Sills JR: The comprehensive respiratory therapist exam review, entry and advanced levels, ed 5, St. Louis, 2010, Mosby.)

Endotracheal Suctioning

Clinical Practice Guideline

To guide practitioners in safe and effective application of this procedure, the American Association for Respiratory Care (AARC) has developed a clinical practice guideline on endotracheal suctioning of mechanically ventilated patients with artificial airways. Excerpts from the AARC guideline, including indications, contraindications, hazards and complications, assessment of need, assessment of outcome, and monitoring, appear in Clinical Practice Guideline 33-1.¹

33-1

Endotracheal Suctioning of Mechanically Ventilated Patients With Artificial Airways

AARC Clinical Practice Guideline (Excerpts)*

Indications

• Need to maintain patency and integrity of the artificial airway

• Need to remove accumulated pulmonary secretions as evidenced by one of the following:

• Sawtooth pattern on the flow-volume loop on the monitor screen of the ventilator or the presence of coarse crackles over the trachea—both are strong indicators of retained pulmonary secretions

• Increased peak inspiratory pressure on volume-control ventilation or decreased tidal volume on pressure control ventilation

• Deterioration of O₂ saturation or blood gas values

• Visible secretions in the airway

• Inability of patient to generate an effective cough

• Acute respiratory distress

• Suspected aspiration of gastric or upper airway secretions

• Need to obtain a sputum specimen to rule out or identify pneumonia or other pulmonary infection or for sputum cytology

Contraindications

Endotracheal suctioning is a necessary procedure for patients with artificial airways. Most contraindications are relative to the patient’s risk of developing adverse reactions or worsening clinical condition as a result of the procedure. When indicated, there is no absolute contraindication to endotracheal suctioning because the decision to withhold suctioning to avoid possible adverse reaction may be lethal.

Hazards and Complications

• Decrease in dynamic lung compliance and functional residual capacity

• Atelectasis

• Hypoxia or hypoxemia

• Tissue trauma to the tracheal or bronchial mucosa

• Bronchoconstriction or bronchospasm

• Increased microbial colonization of lower airway

• Changes in cerebral blood flow and increased intracranial pressure

• Hypertension

• Hypotension

• Cardiac dysrhythmias

Routine use of normal saline instillation may be associated with the following adverse events:

• Excessive coughing

• Decreased O₂ saturation

• Bronchospasm

• Dislodgment of the bacterial biofilm that colonizes the endotracheal tube into the lower airway

• Pain, anxiety, dyspnea

• Tachycardia

• Increased intracranial pressure

Assessment of Need

Qualified personnel should assess the need for endotracheal suctioning as a routine part of a patient and ventilator system assessment as detailed under Indications.

Assessment of Outcome

• Improvement in appearance of ventilator graphics and breath sounds

• Decreased peak inspiratory pressure with narrowing of peak inspiratory pressure to plateau pressure difference; decreased airway resistance or increased dynamic compliance; increased tidal volume delivery during pressure-limited ventilation

• Improvement in arterial blood gas values or saturation as reflected by pulse oximetry (SpO₂)

• Removal of pulmonary secretions

Monitoring

The following should be monitored before, during, and after the procedure:

• Respiratory rate and pattern

• Hemodynamic parameters

• Pulse rate

• Blood pressure, if indicated and available

• Electrocardiogram, if indicated and available

• Sputum characteristics—color, volume, consistency, odor

• Cough characteristics

• Intracranial pressure, if indicated and available

• Ventilator parameters

• Peak inspiratory pressure and plateau pressure

• Tidal volume

• Pressure, flow, and volume graphics, if available

• FiO₂

*For complete guidelines, see American Association for Respiratory Care: Clinical practice guideline. Endotracheal suctioning of mechanically ventilated patients with artificial airways, Respir Care 55:758, 2010.

Equipment and Procedure

The procedure described here is for endotracheal suctioning of adults or children. Nasotracheal suctioning is described separately later in this chapter. There are two techniques for endotracheal suctioning: open and closed. The open, sterile technique requires disconnecting the patient from the ventilator. The closed technique uses a sterile, closed, in-line suction catheter later is attached to the ventilator circuit so that the suction catheter can be advanced into the patient’s endotracheal airway without disconnecting the patient from the ventilator.

There are also two methods of suctioning based on how deep the suction catheter is inserted in the artificial airway: deep suctioning and shallow suctioning. Deep suctioning is when the catheter is inserted until resistance is met and then withdrawn approximately 1 cm before applying suction. Shallow suctioning is when the catheter is advanced to a predetermined depth, which is usually the length of the airway plus the adapter.² Using shallow suctioning rather than deep suctioning is recommended in infants and children.³

Step 1: Assess Patient for Indications

Generally, a patient should never be suctioned according to a preset schedule. Although very thick secretions may not move with airflow and may not create any adventitious sounds, the patient should be assessed for clinical indicators, such as rhonchi heard on auscultation, which suggest the need for suctioning (see Clinical Practice Guideline 33-1).

Step 2: Assemble and Check Equipment

The equipment needed for endotracheal suctioning is listed in Box 33-1. The suction catheter, gloves, and cup are often prepackaged together in disposable sterile kits for use during the open suctioning technique. The AARC Clinical Practice Guideline suggests the closed suctioning technique to avoid disconnecting the patient from the ventilator, which interrupts ventilation and exposes the patient to infection risk. Suction pressure should always be checked by occluding the end of the suction tubing before attaching the suction catheter. The suction pressure should be set at the lowest effective level. Negative pressures of 80 to 100 mm Hg in neonates and less than 150 mm Hg in adults are generally recommended.⁴

Box 33-1 Equipment Needed for Suctioning

• Vacuum source

• Calibrated, adjustable regulator

• Collection bottle and connecting tubing

• Disposable gloves: sterile (open suction) or clean (closed suction)

• Sterile suction catheter

• Sterile water and cup (open suction)

• Goggles, mask, and other appropriate equipment for standard precautions

• O₂ source with a calibrated flowmeter (open suction) or ventilator (closed suction)

• Pulse oximeter

• Manual resuscitation bag equipped with O₂-enrichment device for emergency backup use

• Stethoscope

Optional Equipment

• Electrocardiograph

• Sterile sputum trap for culture specimen

Suction catheters are available in various designs, most with side ports to minimize mucosal damage. Most suction catheters for general purposes are 22 inches long (sufficient to reach the main stem bronchi) and sized in French units (external circumference). A curved-tip catheter, or catheter coudé, is available to help direct access to the left main stem bronchus. The size of the catheter may be more important than its design. A catheter that is too large can obstruct part or all of the airway by occupying too much of its opening. Too large a suction catheter combined with negative pressure quickly evacuates lung volume and can cause atelectasis and hypoxemia. To avoid this problem, the diameter of the catheter should be less than 50% of the internal diameter of the artificial airway in adults.5,6 In infants and small children, the diameter of the suction catheter should be less than 70% of the internal diameter of the artificial airway.⁷

Rule of Thumb

To estimate quickly the proper size of suction catheter to use with a given tracheal tube, first multiply the tube’s inner diameter by 2. Then use the next smallest size catheter.

Example: 6-mm endotracheal tube: 2 × 6 = 12; next smallest catheter is 10F

Example: 8-mm endotracheal tube: 2 × 8 = 16; next smallest catheter is 14F

An in-line suction catheter can be used for patients receiving ventilatory support (Figure 33-3). These systems are incorporated directly into the ventilator circuit and used repeatedly. Because this system allows suctioning without disconnecting the patient from the ventilator, it is recommended for suctioning patients who require high fractional inspired oxygen (FiO₂) and positive end-expiratory pressure (PEEP), who are at risk for lung derecruitment, and for neonates.^8–10 In addition, cross contamination is less likely with such systems. The use of in-line suction catheters has been shown to be cost-effective because they need to be changed only if soiled or malfunctioning and not on a daily basis.¹¹ However, in-line suction catheters have not been shown either to increase or to decrease the risk of ventilator-associated pneumonia.¹² The extra weight an in-line catheter adds to a ventilator circuit may increase tension on the endotracheal tube, so care should be taken to support the ventilator tubing appropriately.

FIGURE 33-3 In-line, closed-system multiuse suction catheter. (Modified from Sills JR: The comprehensive respiratory therapist exam review, entry and advanced levels, ed 5, St. Louis, 2010, Mosby.)

Basic indications for the use of closed suction catheters are listed in Box 33-2.¹³ Routine instillation of sterile normal saline to aid secretion removal before suctioning is not recommended because there is insufficient evidence that this practice is beneficial, and it may increase infection risk (see Hazards and Complications in Clinical Practice Guideline 33-1). If the secretions are extremely tenacious, instillation of acetylcysteine or sodium bicarbonate (2%) may be more effective than normal saline; this generally requires a physician’s order. The use of these medications is discussed in more detail in Chapter 32.

Box 33-2 Indications for Use of Closed Suctioning Technique

Mechanically ventilated patients, especially neonates and patients with:

• PEEP ≥ 10 cm H₂O

• Mean airway pressure ≥20 cm H₂O

• Inspiratory time ≥1.5 seconds

• FiO₂ ≥ 0.60

• Frequent suctioning (≥6 times/day)

• Hemodynamic instability associated with ventilator disconnection

• Respiratory infections requiring airborne or droplet precautions (see Chapter 4)

• Inhaled agents that cannot be interrupted by ventilator disconnection (e.g., nitric oxide, helium/O₂ mixture)

After connecting the catheter to the suction source, the level of suction pressure should be checked by closing the catheter thumb port and aspirating some sterile water or saline from the basin. If no vacuum is generated, it is necessary to check for leaks in the tubing, at the collection container, or at the suction regulator. In addition, if the collecting bottle is full, the float-valve closes and prevents vacuum transmission.

Rule of Thumb

Set suction pressure to −120 to −150 mm Hg for adults, 100 to 120 mm Hg for children, and 80 to 100 mm Hg for infants.

Step 3: Hyperoxygenate Patient

Before suctioning, delivery of 100% oxygen (O₂) for 30 to 60 seconds to pediatric and adult patients is suggested, especially to patients who are at risk for hypoxemia. Also, the O₂ concentration should be increased by 10% in neonates before suctioning ¹⁴; this may be done by increasing the set FiO₂ or activating the temporary 100% setting on microprocessor ventilators. Manual ventilation is not recommended because it is sometimes difficult to deliver 100% O₂ this way.¹⁵ However, if there is no other alternative to hyperoxygenate the patient, PEEP should be maintained during the manual ventilation with 100% O₂.

Step 4: Insert Catheter

To prevent tracheal mucosal trauma, especially in infants, the shallow suction method should be used advancing the catheter just to the end of the artificial airway as recommended in the AARC guidelines.

Step 5: Apply Suction and Clear Catheter

Suction is applied while withdrawing the catheter. Total suction time should be kept to less than 15 seconds.16,17 After removing the catheter, it should be cleared using the sterile cup filled with sterile water or saline. The closed suction catheter has an adapter for saline vials to be placed in line with the device. The catheter is cleared by squeezing the saline vial and applying suction at the same time. Caution must be used to ensure saline is being drawn into the catheter and not down the airway. If any untoward response occurs during suctioning, the catheter should be immediately removed, and the patient should be oxygenated.