KOFF

CHAPTER 36: THE AIRWAY MANAGEMENT

BATCH 2022 HANDOUT

SUCTIONING
Equipments for suctioning:
 Suctioning is the application of negative •Suction machine (wall attachment or portable unit)
pressure ( vacuum) to the airways through a •Suction catheter
collecting tube ( flexible catheter or suction tip). •Suction bottle
Removal of foreign bodies, secretions or tissue •Sterile water
masses beyond the main stem bronchi requires •Rubber Tubing
bronchoscopy, which is generally performed by •Sterile gloves
a physician.

REMINDERS BEFORE SUCTIONING:

1. Size
›Half the size of the tube's internal diameter.
2. Pressure
 Neonate: 60 -80 mmHg
 Pediatric: 80 - 100 mmHg
3. Bag-Valve Mask
Should always be ready at patient's bedside
4. Plain NSS
›Used to help loose secretions.
Airway obstruction can be caused by Neonate: 0.30-0.50 mL

 retained secretions Children: 1 - 3 mL

 foreign bodies, and structural changes 5. Time spent

 edema, tumors, or trauma ->10s maximum

Retained secretions increase airway resistance and the

work of breathing and can cause: SPECIAL CONSIDERATIONS:

 Hypoxemia  Closed-system suctioning:

> Advantage of remaining in the ventilator circuit &
 Hypercapnia
can be readily accessible for suctioning.
 Atelectasis
 Infection
 Oral & Nasal suctioning:
>Often used only to elicit cough.
›Care must be exercised.
 ›Lubricate suction catheter. endotracheal airway without disconnecting the patient to the
 Luken traps: ventilator.
> Used to obtain secretions for culture and sensitivity
There are also two methods of suctioning based on how
testing.
deep the suction catheter is inserted in the artificial
airway : deep and shallow

 Deep suctioning is when the catheter is inserted

until resistance is met and then withdrawn approximately
POSSIBLE HAZARDS AND COMPLICATIONS
1cm before applying suction.
HAZARDS:
 Shallow suctioning is when catheter is advanced and
 Hypoxemia
predetermined depth which is usually the length of the
 Cardiac problems (e. g. arrhythmias)
airway plus the adapter.
 Tissue Trauma

Indications for intubation are varied and may

COMPLICATIONS: (1) support for oxygenation or ventilation.

 Lung Collapse (e.g. Pneumonia) (2)protection of the airway

 Hypotension and cardiac arrest
(3) cardiopulmonary arrest.

Endotracheal suctioning

There are two techniques of endotracheal suctioning :

open and closed.
 Suction pressure should always be checked by
 Open technique requires disconnecting the patient
occluding the end of the suction tubing before attaching the
from the ventilator.
suction catheter. The suction pressure should be at the
 Closed technique uses a sterile, closed in-line
lowest effective level.
suction catheter that is attached to the ventilator circuit so
 Negative pressures of 80 to 100mmHg in neonates
that the suction catheter can be advanced into the patient’s
 manual resuscitator used during suctioning,
 should be delivering approximately 0, 10 greater Fin  For neonatal 0.33 mL saline may be instilled
 Novametrix device has been reported to reduce
bradycardia and oxygen saturation
 Nasal route is the easiest route for infants
 A curved-tip catheter, or catheter coudé, is available
to help direct access to the left main-stem bronchus.

 In infants and small children, the diameter of the

suction catheter should be less than 70% of the internal
diameter of the artificial airway.

An in-line suction catheter can be used for patients

receiving ventilatory support and is recommended
over open suction because ventilation is continued
during suctioning regardless of the level of
ventilatory support provided.
However, in-line suction catheters have no effect on
risk for ventilator-associated pneumonia (VAP).

Routine instillation of sterile normal saline to aid

secretion removal before suctioning is not
recommended because there is no evidence that this
practice is beneficial, and it may increase infection
risk and destabilize the patient.

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.

 25% greater pressures is normally used.

 Note : Set pressure 120 to 150
mmHg for adults, 100 to 120 mmHg for
children and 80 to 100 mmHg for
infants.
 Correct tube internal diameter for a child is:
 Age+16/4= ID
 Height in cm / 20 = ID

To minimize hypoxemia and lung decruitment when

suctioning a mechanically ventilated patient,
preoxygenate and suction the artificial airway with a  Nasotracheal Suctioning Technique
closed system in-line catheter to avoid disconnecting the
patient from ventilator. (A) Optimal position of the head to insert catheter
into the trachea. The neck is flexed, and the head is
extended. The tongue is protruded (and held by a 4 ×
4 gauze pad).

EQUIPMENT AND PROCEDURES (B) After catheter has advanced into the trachea, the
tongue is released, and the patient’s head is allowed
Endotracheal suctioning : sterile water soluble lubricant to assume a comfortable position.
jelly is needed to aid catheter passage through the nose
(C) View of vocal cords from above. The cords are
 nasopharyngeal airway should be considered to help most widely separated during inspiration.
reduce mucosal trauma in the nose of the patients who
required repeated long term nasotracheal suctioning.

 Nasotracheal suctioning: catheter insertion, after

lubricating the catheter the RT inserts it gently through Sputum Sampling
the nostrils, directing it toward the septum and floor of
the nasal cavity without applying negative pressure. This device consist of a plastic tube or cup with
flexible tubing on one end to attach to the suction
NASOTRACHEAL SUCTIONING is indicated for patients catheter. It is import to maintain sterile technique
who have retained secretions but do not have an when touching the connection points on the trap.
artificial airway

As the catheter enters the lower pharynx the

patients should assume a “ sniffing position “
ESTABLISHING AN ARTIFICIAL AIRWAY

ROUTES
 Bradycardia- most commonly problem during
nasotracheal suctioning Artificial airways are inserted for various reasons and
involve varying degrees of invasion into the upper
airway.
 Right mainstem intubation- frequently occurs on
neonates
 Pharyngeal airways extend only into the pharynx.
Artificial airways that are placed through the mouth or nose
 Tube must be largest size as possible
into the trachea are called endotracheal tubes (ETTs).
 Too larger risk of having decreased perfusion
 The process of placing an artificial airway into the
trachea is referred to as intubation.
 Cuffed used is not recommended under the age of 8
years
 When the ETT is passed through the nose first, the
procedure is referred to as nasotracheal intubation.
 Cricoid cartilage- the narrowest point of the airway
 endotracheal (translaryngeal) tubes and tracheostomy tubes
 When the tube is passed through the mouth on its (TTs).
way into the trachea, the procedure is called orotracheal
intubation.  ETTs are inserted through either the mouth or the
nose (orotracheal or nasotracheal), through the larynx, and
into the trachea.

PHARYNGEAL AIRWAYS
 Tracheostomy tubes are inserted through a
 Pharyngeal airways prevent airway obstruction by surgically created opening in the neck directly into the
keeping the tongue pulled forward and away from the trachea.
posterior pharynx.
 Pharyngeal airways are used mainly in emergency  ETT are semi-rigid tubes most often composed of
life support. polyvinyl chloride or related plastic polymes and use stylet for
insertion.
 15mm- proximal end of the tube
 Murphy eye- ensures gas flow if the main port
 Nasopharyngeal airway is most often placed in a should become obstructed .
patient who requires frequent nasotracheal suctioning,, it  Angle of the bevel- minimizes mucosal trauma
minimizes damage to the nasal mucosa that can be caused by  Cuff to pilot balloon- used to monitor cuff status and
the suction catheter. pressure when the tube is in place.

may be placed in a patient who was recently

extubated after facial surgery. The nasopharyngeal  Special mechanical ventilation may require unique
airway helps to maintain the patency of the upper types of ETT
airway despite
swelling.
THERE ARE IMPORTANT POINTS TO CONSIDER
WHEN USING DOUBLE LUMEN ETT’s
nasopharyngeal airway should be considered to help - Stiffer and Bulkier
reduce mucosal trauma in the nose of the patients
who required repeated long term nasotracheal
suctioning. Fiberoptic broncoscopy- should be performed to
ensure the proper placement

 Oropharyngeal airways are inserted into the A suction source is run continuously at negative
mouth over the tongue. pressure of 20 to 30 cmH2O.

Use of oropharyngeal airways should be restricted to

unconscious patients to avoid gagging and
regurgitation. These airways maintain a patent
airway when the tongue would otherwise obstruct
the oropharynx. The airway also can be used as a
TRACHEOSTOMY CARE
bite block for patients with oral tubes. Pharyngeal Tracheostomy is specifically indicated
airways are used mainly in emergency life support.
when:
 Prolonged mechanical ventilation
TRACHEAL AIRWAYS  Oral and nasal intubation become difficult
 Tracheal airways extend beyond the pharynx into
 Upper airways need to be bypassed
the trachea. The two basic types of tracheal airways are
  Double cannula- are specially ensure the patient tolerates the intubation
recommended for patients who are going home procedure.
with tracheostomy tube.

No more than 30 secs should be devoted to any

 Orotracheal intubation- is the usual intubation attempt.
method of choice for emergency because the
oral passage is the quickest and easiest route in
the most cases. If intubation fails, immediate ventilation and
oxygenation of the patient for 3 to 5 minutes
before the next attempt.
Ideally, the tip of an ETT should be positioned in
However in prolonged intubation, nasotracheal the trachea about 3 to 6 cm above the carina.
intubation may be appropriate

BEDSIDE METHODS TO ASSESS ENDOTRACHEAL

TUBE POSITION
- Auscultation of chest and abdomen
- Observation of the chest movement
- Tube length ( centers to teeth)
- Esophageal detection device
- Lights wand
- Capnometry
- Colorimetry
- Fiberoptic bronchoscopy
- Videolaryngoscopy

Air movement or gurgling sounds over the

epigastrium indicate possible esophageal
intubation.

 The combination of the decreased breath sounds

and chest wall movement on the left side may indicate right
 Nasotracheal tubes are used somewhat less often in mainstem intubation
the neonatal population than in other age groups.
Right mainstem intubation is corrected by
withdrawing the tube while listening for the left-side
To ease insertion , the outer surface of the tube breath sounds.
should be lubricated with water- soluble gel.
 Decreased breath sounds in the left lung:
- Atelectasis
For the position, RT flexes the patient’s neck - Pleural effusion
and tilts the head backward with his or her hand
, placing the patient into sniff position.
 Esophageal detection device- may used to
determine wether the tube is in the
A patient in need of intubation is often apneic or esophagus or trachea. It is not
in respiratory distress. Providing ventilation and recommended for detecting esophageal
oxygenation by manual resuscitating bag and intubation in children younger than 1 year.
mask with 100% before intubation helps to
 If the tube is in the trachea, aspirating air in the
syringe is easy.  Macintosh blade- a curve blade that does not allow
straight displacement of the epiglottis
Esophageal intubation- can be assessed using
exhaled carbon dioxide, analysis capnometry.

 Inspired air – contains approximately 0.04% CO2

 End tidal gas- contains 5% CO2

ETT in the respiratory tract causes CO2 levels to

increase abruptly during expiration.

If the tube is in the esophagus, CO2 levels remain

zero.

 Colorimetric devices – are portable and disposable

and are commonly used in hospitals.

Proper tube placement in the trachea can be

confirmed without a chest radiograph by using
fiberoptic or bronchoscope

The most common complication of emergency

airway management is tissue trauma.

While the serious complications are acute

hypoxemia, hypercapnia, bradycardia, and cardiac
 Tracheostomies- can be difficult to maintain with
arrest.
the infant patient
These problems can be minimized by using proper
ventilation and oxygenation ( before, during and
after)

 Anaesthesia and sedation- can reduce compilations

and facilitate intubation in a semi comatose and combative
patient.

Difficult intubations occur because of inability to

open the patient’s mouth, inability to position the
patient unusual airway anatomy.

An endotracheal tube has a tapered tip (Cole)

is not the best choice because the tip may cause
cord damage or hinder suctioning efforts.

 Miller blade- it should be long enough to reach the

epiglottis easily