Tracheal Airways, Laryngectomy & Tracheostomy Care

Objectives - Assess the need for and select an artificial airway, identify complications and hazards associated with artificial airway insertion, describe tracheal airway types, and review laryngectomy and tracheostomy care.

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Tracheal Airway Overview

Tracheal airway topics in this lesson include:

• Laryngeal mask airway
• King tube
• Esophageal tracheal Combitube
• Endotracheal tubes
• Double-lumen endotracheal tubes
• Subglottic suction endotracheal tubes, also called Hi-Lo or CASS tubes
• Laryngectomy tubes
• Tracheostomy tubes and care

Laryngeal Mask Airway

A laryngeal mask airway, or LMA, is a large-bore tube with an inflatable mask at the distal end. It forms a seal around the glottis while excluding the esophageal opening.

Indications:

• Airway protection and ventilation during short surgical procedures
• Difficult intubation
• Conduit for intubation, because a standard ETT can be inserted through the LMA into the trachea if necessary

Contraindication:

• Complete upper airway obstruction

King Tube

The King tube is a supraglottic airway inserted blindly into the esophagus. It is a curved tube with ventilation apertures between two inflatable cuffs. A single valve and pilot balloon inflate both cuffs.

• Distal cuff seals the esophagus
• Proximal cuff seals the oral pharynx
• A 15-mm adapter attaches to a standard breathing circuit or resuscitation bag

Indications:

• Unconscious patient without purposeful movement
• No gag reflex
• Unable to perform endotracheal intubation
• Apnea or respiratory rate below 6/min

Contraindications:

• Responsive patient with intact gag reflex
• Known esophageal disease
• Ingestion of caustic substances
• Patient less than 4 feet tall

Esophageal Tracheal Combitube

The esophageal tracheal Combitube, or ETC, is used in the prehospital or emergency setting only. It is not a long-term airway.

It is a dual-lumen airway blindly inserted through the oropharynx into the trachea or esophagus. The proximal end has two color-coded tubes. The distal end combines a tracheal lumen and esophageal lumen. Both cuffs are inflated after insertion.

Most commonly, the tube is placed in the esophagus:

• Esophagus is sealed by the distal cuff
• Ventilation is provided through the blue lumen
• Gas is delivered through perforations above the distal cuff

Less commonly, the tube is placed in the trachea:

• Trachea is sealed by the distal cuff
• Ventilation is provided through the clear lumen
• Gas is delivered through the distal opening

Endotracheal Tube Design

Endotracheal tubes are clear, semi-rigid PVC tubes with:

• Anatomical curvature
• Standard 15-mm connector or adapter
• Radiopaque line visible on x-ray
• Murphy eye
• Depth markers
• Left-facing beveled tip
• Pilot balloon
• Spring-loaded one-way valve for cuff inflation and deflation
• Air-filled tracheal cuff

The tracheal cuff seals the trachea so gas does not escape during positive pressure ventilation. It also protects the lower airway from secretions, blood, and vomit entering the trachea.

Endotracheal Tube Types

Subglottic suction ETTs are also called Hi-Lo or continuous aspiration of subglottic secretions, abbreviated CASS. Continuous suction is provided through a separate tube connected to vacuum pressure of 20 mm Hg.

A double-lumen ETT uses a larger cuff to seal the tracheal lumen and allow gas into one bronchus. A smaller cuff seals the opposite bronchial lumen.

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Laryngectomy and Tracheostomy

Laryngectomy

A laryngectomy is surgical removal of the patient's larynx, performed to treat upper airway carcinoma.

Key points:

• There is no longer any connection between the upper and lower respiratory tract
• The patient initially breathes through a laryngectomy tube
• The patient cannot be orally or nasally intubated
• The laryngectomy tube is removed after 3 to 6 weeks
• The patient then has a permanent stoma

Laryngectomy tubes maintain a patent airway after laryngectomy. They are made of soft pliable material, are usually shorter than standard tracheostomy tubes, and may have an inner cannula. Laryngectomy tubes do not have inflatable cuffs. If positive pressure ventilation is required, replace with a cuffed endotracheal tube.

Tracheotomy and Tracheostomy

A tracheotomy is the surgical procedure that creates an opening through the neck into the trachea.

A tracheostomy is the opening or stoma created by the tracheotomy. A tracheostomy tube is placed through the opening to provide an airway and remove secretions.

Tracheostomy Tube Indications and Advantages

Indications:

• Failed intubation
• Long-term ventilation
• Upper airway obstruction
• Need for an airway that is easier to stabilize, suction, and tolerate

Advantages:

• No upper airway complications
• More comfortable and secure
• Aids feeding, oral care, and speech
• Preserves intact glottic function
• Less work of breathing
• Reduced anatomical dead space
• Improves ventilator weaning

Tracheostomy Complications

Immediate complications within the first 24 hours:

• Bleeding, which is the major hazard
• Pneumothorax
• Air embolism
• Subcutaneous emphysema

Late complications:

• Infection
• Hemorrhage
• Obstruction
• Tracheoesophageal fistula

Tracheostomy Tube Types

When plugging a fenestrated tube, deflate the cuff, remove the inner cannula, and then plug the tracheostomy tube.

Do not inflate a foam cuff with a syringe.

Tracheal Speaking Devices

A tracheal speaking device is a one-way valve that attaches to the tracheostomy tube.

• During inspiration, the valve opens and air enters through the tube
• During exhalation, the valve closes and air passes around the cuff and through the vocal cords
• The cuff must be deflated

Before placing a speaking valve:

• Suction the airway if needed
• Suction the mouth and nose as needed
• Deflate the airway cuff
• Attach the valve with a twisting motion to the right, about one-quarter turn

Remove the valve by twisting it off to the left.

Hazards and cautions:

• Remove during aerosol treatments
• Do not use while sleeping
• Remove immediately if the patient has difficulty breathing
• Do not use with the cuff inflated

Clean daily with mild soapy water, rinse with cool to warm water, let air dry completely, and replace when sticky, noisy, or vibrating. Do not use a brush, vinegar, peroxide, bleach, or alcohol on the valve.

Cuff Rules

The cuff should be kept inflated whenever the patient is eating or receiving positive pressure ventilation, including mechanical ventilation.

Tracheostomy Care

Indications for tracheostomy care:

• Maintain airway patency
• Prevent infection
• Keep the incision site clean and dry for comfort and healing

Contraindication:

• Follow hospital policy, especially for a fresh trach placed within the last 48 hours

Tracheostomy Care Procedure

Assemble and check:

• PPE
• Sterile gloves
• Suction equipment
• Oxygen and manual ventilation device
• Tracheostomy care kit
• New inner cannula
• New tracheostomy tube

A tracheostomy care kit may include sterile gloves, basin, brush, cotton-tipped applicators, hydrogen peroxide, sterile water, 4x4 gauze, precut gauze, and trach tie.

Before the procedure:

• Explain the procedure
• Place the patient in semi-Fowler's position unless contraindicated

During care:

• Suction the patient
• Remove the inner cannula
• Replace a disposable inner cannula with a new one
• Clean a non-disposable inner cannula with a brush
• Inspect that the lumen is clean and clear of mucus
• Soak in peroxide solution as directed
• Remove gauze dressing from behind the flange
• Clean around the stoma with cotton-tipped applicators and 4x4s dampened with peroxide and sterile water
• Dry the site with sterile 4x4s
• Examine the stoma for redness, swelling, pus, or foul smell
• Notify the physician if those infection signs are present
• Replace split gauze dressing
• Do not cut 4x4s to use as dressing
• Change the tie or holder
• Rinse and replace the inner cannula
• Make sure the inner cannula is locked in place
• Assess the patient

High-Yield Review