Chapter 35: Airway Management

Objectives

1. List indications for an artificial airway.

2. List complications of artificial airways.

3. Assess patients for extubation and decannulation.

4. Compare endotracheal intubation and tracheostomy.

5. Describe the use of a speaking valve.

Introduction

Although noninvasive ventilation (NIV) is used increasingly, many mechanically ventilated patients are managed with an endotracheal tube or tracheostomy. Thus, an understanding of airway management is important for those providing mechanical ventilation.

Indications for an Artificial Airway

Four traditional indications for an artificial airway are to: (1) provide ventilatory support, (2) aid in the removal of secretions, (3) bypass upper airway obstruction, and (4) prevent aspiration. Each of these is a relative indication. For example, ventilatory support and airway clearance can be provided noninvasively. Massive aspiration can be minimized by use of an artificial airway, although microaspiration commonly occurs in the presence of a cuffed artificial airway.

Orotracheal Versus Nasotracheal Intubation

Potential advantages of nasotracheal intubation include greater tolerance in the patient who is awake, easier oral hygiene, ease of intubation in the patient with cervical spine injury, and decreased likelihood of self-extubation. However, the disadvantages of nasal intubation outweigh these advantages. Because nasotracheal intubation requires a narrower and longer tube, it increases airway resistance, makes suctioning and bronchoscopy more difficult, and increases the likelihood of sinusitis and otitis media. Accordingly, oral intubation is usually recommended, and the oral route is used in most intubated patients.

Complications of Airways

Hypoxemia can occur at the time of intubation. NIV and high-flow nasal cannula (HFNC) are used increasingly during the intubation procedure. NIV can be provided prior to intubation and HFNC can be provided during the procedure. A practical limitation of this approach is the availability of equipment for NIV and HFNC at the time of emergent intubation.

A life-threatening complication of airway management is misplacement of the tube (Table 35-1). Although many patients who experience an unplanned extubation do not require reintubation, there is significant morbidity and mortality associated with the need for reintubation. Efforts to avoid unplanned extubation include securing the tube (around-the-head techniques are preferred), physical and pharmacologic restraint when necessary, and vigilance of airway position when the patient or ventilator tubing is moved. Increasingly, commercially available tube securing systems are used as an alternative to taping methods. The endotracheal tube can be misplaced into the esophagus or mainstem bronchus (usually the right). Although this usually occurs at the time of intubation, it can occur after intubation. The tip of the endotracheal tube can move several centimeters as the result of flexion and extension of the neck—flexion moves the endotracheal tube tip caudad and extension moves it cephalad.