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Advanced airway clearance
1. ADVANCED AIRWAY CARE
Intensive Care Unit Perspective
Dr.Nidhi Ahya (Asst Prof)
Cardio-Vascular & Respiratory PT
DVVPF College of Physiotherapy,
Ahmednagar 414111
3. Oropharyngeal Airways
Oropharyngeal airways help restore airway
patency by separating the tongue from the
posterior pharyngeal wall and maintain adequate
ventilation
4. There are two basic designs:
Guedel
Bermen
Both types have a external flange, a
curved body that conforms to the
shape of the oral cavity and are
available in different sizes
Difference is between the number
of channels
Guedel has a single centre channel
Bermen has two parallel side
channels
5. To choose the correct size, the therapist has to
place the device on the side of the patient’s face
with the flange even with the patients mouth.
The correct size is measured from the corner of the
patients mouth to the angle of the jaw, following
the natural curve of the airway
6. Technique to place Oropharyngeal airways:
Slip Technique using a tongue depresser
Jaw lift technique with 180˚ rotation
7. Possible Complications:
Insertion of an oropharyngeal airway can provoke
a gag reflex, vomiting or laryngeal spasm
These devices are best suited for semi-conscious
or unconscious patients to maintain airway patency
as well as to assist in suctioning
8. Nasopharyngeal Airways
Nasopharyngeal airways are inserted through the
nose instead of the mouth
Provides passage from the external nares to the
base of the tongue
Restore airway patency
by separating the tongue from
the posterior pharyngeal
wall
9. Indications:
When oropharyngeal airway cannot be used as in
case of seizures, mandible fracture, space
occupying lesion in the oral cavity
Insertion:
Appropriate size can be estimated by measuring
the distance from the patients ear lobe to the tip of
the nose
10. Airway is lubricated with a water soluble jelly to
ease insertion and is positioned perpendicular to
the frontal plane of the patients face
It is slowly advanced in the same direction through
either of the nasal cavity
When properly placed, it gets stabilized by its own
flange
11. Bag valve Mask
Bag valve mask combines a self-inflating bag
with a non-rebreathing valve mechanism
These devices are capable of providing
ventilation with air or supplemental oxygen
12. Endotracheal Intubation
Endotracheal tube intubation is a preferred
method for securing the airway during emergency
It can-
Prevent aspiration of
gastric contents
Permit suctioning
Facilitate oxygenation and
ventilation
Route for drug administration
13. One way valve
Universal adaptor
Pilot balloon
Bevel lumen
Murphy’s eye
Cuff
Body
Filling
tube
Parts of Endotracheal Tube:
17. Possible Complications :
During Intubation
Bradycardia caused by vagal stimulation
Hypoxemia caused by delay in procedure
Cardiac Arrhythmias
Right-mainstem intubation
Oesophageal intubation
While tube is in situ
Tube Malposition
Pharyngeal edema
Loss of cuff integrity
Tube kinking or obstruction
Post Extubation- Glottic stenosis, Vocal Cord Paralysis
18. Tracheal Intubation
Tracheostomy tubes provide an airway access
directly at the level of the second or fourth tracheal
rings
Tracheostomy is indicated when-
Long-term secretion management is required
To reduce dead space ventilation and airway resistance
Protection of airway from aspiration
Prolonged mechanical Ventilation
20. Care of Tracheostomy Tube :
Cleaning around the stoma and external portion of
the tube
Changing the ties and dressing
Cannulated tracheostomy tubes require cleaning of
inner cannula
Suctioning the tube
Cuff care- Maintaining the cuff pressure
21. IMMEDIATE COMPLICATION ( FIRST 24 HOUR)
• Bleeding
• Pneumothorax
• Air embolism-due to tearing of pleural veins
• Subcutaneous emphysema
LATE COMPLICATIONS ( After 24 – 48 hours)
• Infection
• Hemorrhage
• Airway obstruction
• Dysfunction of the swallowing
• Tracheoesophageal fistula
23. WHAT IS SUCTIONING?
The patient with an artificial airway is not
capable of effective coughing, and hence the
mobilization of secretions from the trachea
must be facilitated by aspiration.
This application of negative pressure is
called as suctioning.
24. Indications :
Therapeutic
Presence of artificial airway
Coarse Crackles
Visible secretions in the airway
Decreased SpO2 by pulse oximeter reading
Deterioration of arterial blood gas values
Clinically increased work of breathing
Patient’s inability to generate an effective cough
Increased PIP; decreased Vt during MV
Diagnostic
The need to obtain a sputum specimen / ETA (Endo
Tracheal Aspiration) for Bacteriological or
microbiological or investigations
During bronchoscopy
25. Contra-indications :
Most contraindications are relative to the
patient's risk of developing adverse reactions
Suctioning is contraindicated only when there
is fresh bleeding
There is no absolute contraindication
suctioning
26. Hazards and Complications :
Hypoxia / hypoxemia
Tracheal and / or bronchial mucosal trauma
Cardiac or respiratory arrest
Pulmonary hemorrage / bleeding
Cardiac dysrhythmias
Pulmonary atelectasis
Bronchoconstriction / bronchospasm
Hypotension / hypertension
Elevated ICP
Interruption of mechanical ventilation
27. Necessary Equipment:
Vaccum source with suction jar and adjustable
regulator
Sterile gloves
Sterile catheter of appropriate size
Clear protective goggles, apron & mask
Sterile normal saline
Ambu bag to preoxygenate the patient
31. Patient Preparation:
Explain the procedure to the patient (If patient
is concious)
The patient should receive hyper oxygenation
by the delivery of 100% oxygen for >30 seconds
prior to the suctioning (Either with Bain’s circuit
or by increasing the FiO2 by mechanical
ventilator)
Position the patient in supine position
Auscultate the breath sounds
32. Procedure:
Perform hand hygiene, wash
hands. It reduces transmission of
microorganisms.
Turn on suction apparatus and
set vacuum regulator to
appropriate negative pressure.
•For adult a pressure of 100-120
mmHg
•For pediatric 80-100mmhg
•For neonates 60-80mmhg
33. Wear Personal Protective
Equipment
Open the end of the suction
catheter package & connect it to
suction tubing (If you are alone)
Disconnect ventilator
Kink the suction tube & insert
the catheter in to the ETtube
until resistance is felt
Resistance is felt when the
catheter impacts the carina or
bronchial mucosa, the suction
catheter should be withdrawn
1cm out before applying suction
34. Apply continuous suction while
rotating the suction catheter
during removal
The duration of each suctioning
should be less the 15sec
Instill 3 to 5ml of sterile normal
saline in to the artificial airway, if
required
Resumes the ventilator
Give four to five manual breaths
with bag or ventilator
Wash the suction catheter with
saline
Discard the used equipments
35. Assessment of Outcome:
Improvement in breath sounds
Decreased peak inspiratory pressure
Increased tidal volume delivery during
ventilation
Improvement in arterial blood gas values or
saturation as reflected by pulse oximetry
Removal of pulmonary secretions
36. Limitations of Suctioning:
Suctioning is potentially an harmful procedure if
carried out improperly
Can cause barotrauma
Suctioning should be done when clinically
necessary (not routinely)
The need for suctioning should be assessed at
least every 2hrs or more frequently as need
arises.
37. Manual Hyperinflation
This technique is used in patients with an artificial
airway who are mechanically ventilated or on a
tracheostomy. It can also be used on non-intubated
patients using a naso-oral seal mask
This method of airway clearance promotes
mobilization of secretions and reinflates collapsed
areas of the lung.
Two caregivers are necessary to provide this
treatment
A manual ventilation bag attached to an oxygen
source is needed for lung inflation
Dr.Nidhi Ahya(MPT Cardio-
Vascular& Respiratory PT)
37
38. One caregiver squeezes the bag slowly to
inflate the lungs
A pause is maintained momentarily at the peak
of inflation to allow collateral ventilation
Release of the bag should be rapid and result in
high expiratory flow rate
After 6 cycles of inspiration/expiration, patients
airway is suctioned using sterile technique.
It a potential to cause significant barotrauma
with inflation and this technique is therefore
contraindicated in patients with unstable
hemodynamics, pulmonary edema, severe
bronchospasm
39. Squeeze- 1,2
Release- 1
5-6 times
Can be combined
with vibrations
Dr.Nidhi Ahya(MPT Cardio-
Vascular& Respiratory PT)
39