Airway management involves ensuring that the patient has a patent airway through which effective ventilation can take place.
An obstructed airway means that the body is deprived of oxygen. If ventilation is not reestablished, brain death will occur within minutes. The primary purpose of airway management is to provide a continuously open airway along with a continuous source of oxygen. When a patient is critically ill and requires an artificial airway and mechanical ventilation, it is the responsibility of the healthcare professionals caring for the patient to ensure that the airway is secure.
Another goal of airway management is to provide an artificial airway that is as close to the patient's natural airway as possible. This may mean mechanically performing physiological functions such as humidifying inspired air and removing secretions.
Airway management is a necessity for any patient who has an artificial airway. If the patient is restless or agitated, it is recommended that activities such as suctioning or endotracheal tube care be postponed until either the patient is calm or a sedative has been given. This is to avoid inadvertent removal of the airway. However, if the patient's respiratory status is unstable, suctioning or repositioning the endotracheal tube should be done if it will stabilize the patient.
Airway management consists of much more than just keeping the breathing tube in the correct position. The tube must be managed so that it allows optimal ventilation with the fewest complications.
Humidification of inspired air normally takes place in the upper respiratory tract. When this area is bypassed by an artificial airway (such as an endotracheal or tracheostomy tube), humidification must be performed outside the body. If supplemental oxygen is used, it will require humidification to prevent drying and irritation of the respiratory tract and to facilitate removal of secretions. There are humidification devices available that can be attached to oxygen flow meters or ventilators.
Suctioning consists of inserting a sterile catheter into the endotracheal or tracheostomy tube in order to remove secretions. This is an extremely important part of caring for a patient with an artificial airway, since the reflex of coughing, which would normally remove these secretions, is not effective. The patient will experience respiratory distress if the tube is obstructed by sputum. Suctioning should be performed only when the patient needs it; however, the need should be assessed at least every two hours.
A number of studies have been done to find ways to minimize the complications of suctioning. Equipment should be sterilized to decrease the risk of infection. There are now closed suction systems available that are attached to the ventilator tubing on one end and to the artificial airway on the other. The catheter remains protected inside a sterile plastic sleeve that is changed every 24 hours. This system limits the amount of times the tubing must be disconnected from the airway, thus reducing exposure of the trachea to environmental contaminants.
Suctioning causes oxygen deprivation for the time that the suction is applied. Hypoxemia can be minimized by preoxygenating the patient with 100% oxygen prior to suctioning and between each pass of the suction catheter. (This can be done by either pushing the 100% oxygen button on the ventilator or by using a bagvalve-mask device.) The patient's pulse oximetry should be monitored while suctioning. The duration of each suction pass should be limited to 10 seconds and the number of passes should be limited to three or less if possible. This decreases hypoxemia and airway trauma. Studies have shown that using intermittent suction is no more beneficial than continuous suction.
Installation of a small amount of saline prior to suctioning was a common procedure in the past. It was thought that saline helped to loosen secretions and to facilitate their removal, but studies have shown this is not the case. On the contrary, saline installation has been shown to increase infection rates and to cause decreased oxygen levels for longer periods than suctioning without saline use. This procedure is no longer regarded as beneficial.
Preparation for airway management includes explaining all procedures that will be performed to the patient. Often, patients who are receiving mechanical ventilation are kept sedated or even paralyzed to facilitate optimal ventilation. The level of sedation should be assessed. If patients are not receiving continuous infusions of a sedating drug, they may have a physician's order for sedation as needed. If they are agitated, they should be given the prescribed dose of sedation prior to performing any airway-related procedures, to ensure that the airway is not inadvertently removed.
Patients receiving mechanical ventilation also often have bilateral soft wrist restraints applied to prevent accidental removal of the artificial airway. It is recommended that these be securely fastened before starting an airway-related procedure, or that another healthcare professional be at the bedside to help calm and hold the patient. Also, all needed supplies should be at the bedside prior to starting a procedure, so as to not cause excess discomfort or stress for the patient.
After the procedure is finished, the patient should be reassured if necessary and their respiratory status should be reassessed. The insertion point of the airway should be confirmed to be at the same place as prior to the procedure, unless the purpose was to change the depth of the tube. If the airway has been manipulated since suctioning, the patient may require suctioning again. Any waste should be disposed of in the garbage or in a biohazard container if there is a large amount of blood. Prior to the healthcare professional leaving the room, the patient should be made comfortable, further sedation or pain medication should be administered as needed and the patient should be confirmed to be stable.
The greatest risk of airway management is that the airway may be inadvertently removed, causing the patient to have respiratory distress. Procedures that require manipulating the airway may cause fear or agitation for patients if they feel that they do not have control over their breathing. If the patient becomes combative, it can be very difficult to finish the procedure without disturbing the airway.
The anticipated outcomes of airway management are a continuously open airway through which effective ventilation can take place, and prevention of infection.
Health care team roles
The nurse and respiratory therapist are equally responsible for monitoring and managing artificial airways. Both perform sterile suctioning and both document their assessment of the patient's respiratory status. The respiratory therapist is generally responsible for managing the ventilator, adding humidification, and changing ventilator tubing.
If the patient is accidentally extubated (the airway is removed), both the nurse and respiratory therapist must assist in reinsertion. This is usually done by an anesthesiologist, a certified registered nurse anesthetist (CRNA), a medical resident, or another physician. The respiratory therapist is generally responsible for ventilating the patient with a bag-valve-mask device until reintubation (reinsertion of the airway), while the nurse gathers equipment, administers medications, and monitors the patient's pulse oximetry, vital signs, and cardiac rhythm.
The nurse and respiratory therapist are also responsible for finding alternative means for the patient to communicate. Artificial airways are inserted through the vocal cords, making speaking impossible. The patient should be encouraged to try alternative methods such as mouthing words, writing, or pointing to letters, words, or pictures on a communication board. Communicating with these patients takes great patience and creativity, as well as dedication to helping them feel like their needs are being met.
Bag-valve-mask device— Device consisting of a manually compressible bag containing oxygen and a one-way valve and mask that fits over the mouth and nose of the patient.
Endotracheal tube— Tube inserted into the trachea via either the oral or nasal cavity for the purpose of providing a secure airway.
Hypoxemia— Abnormal deficiency of oxygen in the arterial blood.
Oxygen flow meter— Meter attached to a oxygen source that controls the amount of supplemental oxygen the patient receives.
Pulse oximeter— Noninvasive machine that measures the amount of hemoglobin that is saturated with oxygen.
Tracheostomy tube— Surgically created opening in the trachea for the purpose of providing a secure airway. This is used when the patient requires longterm ventilatory assistance.
Ventilator (mechanical ventilation)— Device used to provide assisted respiration and positive pressure breathing.
Norris, June, ed. Critical Care Skills: A Nurse's PhotoGuide. Springhouse: Springhouse Corporation, 1996.
Thelan, Lynne, et al. Critical Care Nursing: Diagnosis and Management. St. Louis, MO: Mosby, 1998.
Carroll, P. "Should Suctioning Be Left to the Nurse?" American Journal of Critical Care (March 2000):85-86.