Initiation and Modification of Therapeutic Procedures

1. Initiation and Modification of Therapeutic Procedures Maintain a Patent Airway Including the Care of Artificial Airways

2. Maintaining a patent airway and caring for artificial airways are critical components of good respiratory care. You must be • Familiar with many types of artificial airways and how to properly place, maintain, and remove these devices • Proficient in proper humidification of the airway

3. Patient Positioning Positioning is an essential component of • emergency airway management • Preventing ventilator-associated pneumonia • Managing conditions that cause hypoxemia or abnormally increase the production of respiratory tract secretions

4. Insert Oro- and Nasopharyngeal Airways • Oropharyngeal Airways • Used during resuscitation to prevent upper airway obstruction when providing bag-mask ventilation • Used as a bite-block in unconscious / heavily sedated intubated patients • May be indicated • In patients who are having a seizure • When a comatose patient develops upper airway occlusion • You must be able to • Select an appropriate sized oropharyngeal airway • Insert and secure the airway • Troubleshoot the airway

5. Insert Oro- and Nasopharyngeal Airways • Nasopharyngeal airways are used • In resuscitation, most often when an oropharyngeal airway is contraindicated • When a patient exhibits acute upper airway obstruction and is having severe seizures that prevent opening the mouth • To prevent trauma in patients requiring frequent nasotracheal suctioning • You must be able to • Select an appropriate sized nasopharyngeal airway • Insert and secure the airway • Troubleshoot the airway • Know the hazards and complications

6. Endotracheal Intubation In the NBRC Hospital, respiratory therapists must be skilled in endotracheal intubation. This section focuses on you performing the procedure independently. • Gather and confirm function of necessary equipment • Know the basic steps in orotracheal intubation • Nasotracheal intubation is discouraged because • The incidence of VAP and other infections is higher • Smaller/longer ET tubes are required, increasing airway resistance • Necrosis of the nasal septum and external meatus may occur

7. Tracheotomy The most common indications for tracheotomy are the need for long-term positive pressure ventilation or the need for a permanent artificial airway. A trach tube’s OD needs to be no more than two-thirds to three-quarters of the internal diameter of the trachea. The NBRC expects that you • Be skilled in basic tracheostomy care (equipment / supplies needed, and basic procedure) • Be skilled in changing these tubes in patients with established stomas

8. Specialized Tracheostomy Airways • Fenestrated tracheostomy tube • Facilitates weaning from a trach tube • Supports patients needing intermittent (e.g. nocturnal) ventilatory support • Always make sure that the cuff is fully deflated before plugging the tube • Attach a warning tag to the tube cap plug • Tracheostomy button • Small tube used to maintain an open stoma after the tracheostomy tube is removed • Maintain patency by regularly passing a suction catheter through the tube

9. Tracheal Airway Cuff Management Goal is to achieve an adequate seal at the lowest possible pressure (no higher than 20 – 25 mmHg) • Most manometers used for cuff pressure management are calibrated in cm H2O • 20 – 25 mmHg (ischemia pressure) equals 27 – 34 cm H2O • Most hospitals and the NBRC set 25 cm H2O as the “high-end” pressure • Always adjust pressure to the desired level, never just measure it • Cuff pressures exceeding 20 – 25 mm Hg may occur when • Using high peak pressures • The tracheal tube is too small for the patient’s airway

10. Tracheal Airway Cuff Management • Procedures most often used • Minimal leak technique (MLT) • Defined by most protocols as being less than 10% of delivered volume • Minimal occluding volume (MOV) • Alternative cuff designs • Lanz tube – external pressure-regulating valve and control reservoir designed to automatically maintain cuff pressure at approximately 30 cm H2O • Kamen-Wilkinson tube – foam cuff that seals the trachea at atmospheric pressure

11. Troubleshooting Tracheal Airways • Cuff leaks • Most common serious problem with tracheal airways • Differentiate between small-leaks vs large leaks (“blown cuff”) • Signs of partial extubation are essentially the same as those observed with a blown cuff, do not recommend reintubation until you confirm that a cuff leak is the real problem

12. Troubleshooting Tracheal Airways Accidental Extubation • Can be minimized by attention to the following: • The integrity of the securing tube tape or ties • The avoidance of traction on the tube connector • The adequacy of sedation • The appropriate use of restraints

13. Troubleshooting Tracheal Airways Dealing with an obstructed airway When a patient receiving ventilatory support exhibits severe signs of respiratory distress the first step is always to remove the patient form the ventilator, bag them manually with 100% O2, and reassess the situation

15. Alternative Emergency Airways • Laryngeal Mask Airway (LMA) • Used primarily by anesthesiologists as an alternative to endotracheal intubation during surgery • Use for emergency airway management of unconscious patients in whom tracheal intubation cannot be performed or fails • Avoid using to establish an airway in patients who are conscious, who have intact gag reflexes, or who resist insertion • Avoid using in patients who will need tracheobronchial suctioning • Should not be inserted in patients with trauma to or obstructive lesions of the mouth or pharynx

16. Alternative Emergency Airways • Esophageal-tracheal Combitube • Used as an alternative to endotracheal intubation for emergency ventilatory support and airway control • Designed to be inserted blindly • Should not be inserted in conscious patients or those with intact gag reflexes • Contraindicated for infants, small children, patients with esophageal trauma or disease • The majority of blind intubations with the ECT end up in the esophagus • The initial attempt at ventilation should always be via the longer (blue) #1 pharyngeal tube

17. Maintaining Adequate Humidification Humidity therapy is indicated • Either to humidify dry medical gases or to overcome the humidity deficit when bypassing the upper airway • Facilitate mobilization of secretions • Heated humidification can be used to treat hypothermia and bronchospasm associated with inhaling cold air The use of unheated active humidifiers is contraindicated in patients with bypassed upper airways.

18. Maintaining Adequate Humidification Selecting a Humidification Strategy • Whether or not the patient has an artificial tracheal airway • The thickness of the secretions • The gas flow • The need for and duration of mechanical ventilation • The presence of contraindications against using an HME

20. Maintaining Adequate Humidification Patients Requiring Ventilatory Support You can begin with an HME unless it is contraindicated • The HME must meet or exceed the 30 mg/L standard for humidification of gases delivered to the trachea • Contraindications include • Thick and bloody secretions • Hypothermia (<32oC) • Large tidal volumes (> 1000 ml) • Large system leaks • If the HME needs frequent changing you should switch to a heated humidifier

21. Maintaining Adequate Humidification • HME’s • Increase deadspace by 30 – 70 ml • Increase flow resistance through the breathing circuit by about 1 – 3 cm H2O/L/sec • Heated passover humidifiers • Can be used in conjunction with heated-wire circuits • Will always cause condensation in the circuit in the absence of heated wires

23. Peform Extubation Should be considered only in patients who • Can maintain adequate oxygenation and ventilation without ventilatory support (spontaneous breathing trial) • Are at minimal risk for upper airway obstruction (check by performing a cuff-leak test) • Have adequate airway protection and are at minimal risk for aspiration (positive gag and the ability of the patient to raise their head off the bed) • Can adequately clear pulmonary secretions on their own (patient alert and coughs deeply on suctioning; can generate MEP greater than 60 cm H2O)

24. Common Errors to Avoid on the Exam • Never place or keep an oropharyngeal airway in a conscious patient • Never use McGill forceps during intubation without direct visualization • Never tie tracheostomy ties with a bow; instead use a square knot • Never force the inner cannula of a tracheostomy tube during insertion, nor pull on or rock it when attaching equipment

25. More Common Errors to Avoid on the Exam • Never just measure cuff pressure; always adjust the pressure if it is not correct • Never use more than 60 cm H2O to inflate an LMA cuff • Never cover a heated-wire breathing circuit with towels, drapes, or linens • Never extubate a patient without being prepared to reintubate

26. Exam Sure Bets • Always be sure a nasopharyngeal airway is well lubricated before insertion • Always keep an obturator and unopened tubes in the same size and one size smaller at the bedside of patients with tracheostomies • Always use the lowest cuff inflation pressures need to protect the airway and provide for adequate ventilation • Always suction the patient’s oropharynx before you measure cuff pressure or extubate

27. More Exam Sure Bets • Always provide 100% O2 to patients prior to suctioning and before/after extubation • Always pass a suction catheter through artificial tracheal airways regularly to ensure patency • Always make sure that the cuff of a fenestrated trach tube is fully deflated before plugging it • Always provide all patients receiving ventilatory support via an artificial tracheal airway at least 30 mg/L water vapor (equivalent to 100% relative humidity at 32-35oC)

28. Reference: Certified Respiratory Therapist Exam Review Guide, Craig Scanlon, Albert Heuer, and Louis Sinopoli Jones and Bartlett Publishers