04.03 Artificial Airways

In this lesson we’re going to cover artificial airways. This is something that isn’t covered very well in most nursing programs and students sometimes find it hard to identify which airway to choose in which situation. So we’re gonna break it down really simple for you so it’s super easy to understand.

There is only one general reason why a patient would require airway management and that is airway obstruction. Now I’m not talking about those who aren’t breathing at all - we KNOW they need to be on a ventilator. I’m talking about people who can’t manage their own airway. Maybe they have a physical obstruction of some sort, like if they’re choking. But the most common are excessive secretions that they can’t clear on their own or obstruction by the tongue. As you can see here, in a patient who is unconscious, their tongue tends to fall back in their throat and block their airway. You may see them gasping or even snoring, IF they are breathing at all. There are a couple of maneuvers we can implement without the use of an artificial airway first. One is the head-tilt chin lift, which you see here. This lifts the chin forward and pulls the tongue away from the back of the airway. If you have a patient in cervical spine precautions, maybe they were in a car wreck, then you’ll use the jaw thrust method. You put your fingers behind their jaw and thrust it up this way. That will also help pull the tongue out of the back of the airway.

So when this doesn’t work, we begin moving on to our artificial airways, so let’s cover them one at a time.

The least invasive is called the nasopharyngeal airway, or the nasal trumpet. The main indication for this is for someone who can breathe, but can’t clear their own secretions. We will insert this into the nose and then we can actually suction through it to clear secretions from the back of their throat. You will measure from the patient’s nose to the angle of their jaw to find the right size. Then insert it with the bevel towards the inside. The bevel is the slanted opening at the end. That will put it right in here and allow us to suction out any secretions. A key thing here is that this patient is usually conscious. It’s not contraindicated in an unconscious person, but if they are unconscious we need another intervention to pull their tongue away from the back of their throat.

That’s when the oropharyngeal or oral airway comes in. This is used ONLY on unconscious patients. Typically this patient is the one who’s gasping or snoring because they’re unconscious and their tongue is blocking their airway. You insert the oral airway and, because it is a hollow tube, it provides a pathway for the air to get into the patient’s lungs. Measure these from the corner of the mouth to the angle of the mandible to find the right size. The goal when you insert is to pull their tongue forward with it. This should lift their tongue and protect their airway. Now, again, this is UNCONSCIOUS patients ONLY and they’re typically breathing or trying to breathe. So, what do we do if we have a patient who isn’t breathing?

That’s when we move on to the endotracheal or ET tube. Anytime we talk about a patient being ‘intubated’, this is what we’re referring to. We intubate patients who are either not breathing at all or at least not breathing effectively or who simply cannot protect their own airway no matter what we try. We will also use this for anyone requiring mechanical ventilation. As you can see the endotracheal tube is inserted through the mouth and passes through the vocal cords. Then this balloon you see at the end is inflated. This provides one main benefit. It somewhat anchors it in place, but it is NOT secure just because the balloon is inflated and that is not the purpose. We inflate the balloon because we are going to be connecting this to a ventilator. That means we will be pushing positive pressure air through this tube into the patient’s lungs. If this balloon wasn’t inflated, all of that air would just come right back out. This blue thing you see here is the port we use to inflate the cuff. You HAVE to protect this. If it accidentally gets cut, the balloon deflates and we have to fully replace the whole tube. Key point here - this is an advanced airway and inserted only by providers. It is outside of your scope of practice as a nurse, BUT you are the one who can recognize the need and call for help if you need it.

The last advanced airway is the tracheostomy. There are a variety of reasons why we might use this. You may see an emergency tracheostomy performed because someone has some sort of physical tracheal obstruction that can’t be cleared. We also use a tracheostomy for patients who are struggling to wean off the ventilator. The shorter tube means less work for the patient so they can work on getting stronger to get off the vent and breathe on their own. And then many patients will require this as a long-term solution. Examples would be quadriplegics, people with neuromuscular disorders like ALS, or people who have had some sort of tracheal damage like cancer. As you can see, the tracheostomy tube is inserted through the neck below the vocal cords. There are various types of tracheostomies depending on the need. Some have cuffs like you see here to allow positive pressure ventilation. Some have a hole in them called fenestration to allow air to flow over and through the trach. We use this for patients who are weaning off the trach and breathing on their own. When we do trach care we pull out this inner cannula to clean and we change these ties you see here. Big safety tip - this is called the obturator. If this trach gets dislodged, you MUST have this obturator to be able to replace it - most of the time we keep it in a little baggie taped above the bed. So make sure you look for it if your patient has a trach.

This is also an advanced airway that is placed by a provider, usually a surgeon. So let’s look at what this decision-making process looks like for you as a nurse.

First things first - assess their airway. Is it open? Are they protecting it? Or do you hear that gasping and snoring sound? If you determine they aren’t protecting their airway, you know they need some sort of artificial airway. The second question is are they breathing? Are they putting forth respiratory effort but just struggling with their airway? Then we assess their LOC - are they conscious or not? If they ARE breathing, we know it’s either nasal or oral airway. If they are CONSCIOUS, your only option is a nasopharyngeal airway. If they are UNCONSCIOUS, the best option is an oropharyngeal airway. Now, if they AREN’T breathing, we need to get an advanced airway so we need to call for help immediately. Get your respiratory therapist in the room and call the provider. Many times we’ll still use an oropharyngeal airway to pull their tongue forward, and then we’ll use a bag-valve mask to help breathe for them until we can secure their airway with an ET tube.

Make sure you check out the cheatsheet attached to this lesson to get an awesome decision tree to help you choose the right artificial airway for your patient. Now, go out and be your best selves today, and, as always, happy nursing!