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A tube connecting the nasal cavity, mouth, larynx, and esophagus

Approximately 13 cm in length (in adults)

Extends from the base of the skull to the cricoid cartilage (at level of C)

Muscular wall is composed of skeletal muscle-This means that there is voluntary control which allows us to hold our breath


Indication for Intubation

  1. Failure of airway maintenane or protection
  2. Failure of ventilation or oxygenation
  3. Anticipated clinical course 



The patient who requires establishing of an airway also requires a way to protect their airway 

Breathing on you own does not necessarily mean they can protect their airway




Gag Reflex

The gag reflex is a way to show that the pt. can protect their airway

However the gag reflex is ubiquitous and clinically a GCS assessment (less than 8 intubate) and the ability to both manage and swallow secretions can be more valuble 


Causes of Respiratory Failure

  1. Hypercapneic Failure
  2. Hypoxemic Failure


Hypercapneic Failure

Second degree to impairment of ventilation

Type II Respiratory Failure

Generally due to: CNS dsyfunction, neuromuscular weakness, chest wall deformity, other pulmonary or metabolic conditions 


Hypoxemic Failure

Type I Respiratory Failure

Most often caused through a V/Q mismatch

Diffusion surface area reduced (pulmonary edema, pneumonia, atelectasis)

Dead space ventilation (pulmonary embolism)

R -> L Shunt (airway obstruction, alveoar hypoventilation, cardiac shunt, and non pulmonary)


Goals of Intubation

Isolate Airway

Keep airway patent

Reduce risk of aspiration

Faciliate trachea suctioning

Delivery high fiO2 if needed

Provide route for administering certain drugs (NAVEL)

Ensure deliervy of an adequate tidal volume (6-8 ml/kg) to maintain adequate lung inflation and ventilation


Endotracheal Tubes-General

Inserted into the airway and sit at the distal end below the larynx and 2-5 cm above the carina (in adults)

Open at both ends



Proximal End of Endotracheal Tube

Standard 15 mm connector that can attach to the manual resuscitators or ventilators


Distal End of Endotracheal Tube

Beveled and rounded to help prevent trauma

Has the cuff attached to this end. The cuff is attached to the one-way inflating valve. The cuff seals the airway and needs to be inserted before insertion. 


Endotracheal Tube-Parts

Murphy Eye-Where you can ventilate if the tube becomes blocked by secretions

E vap tube-Helps with suction

Radio-Opaque Line is used to see in x-ray to make sure that the placement is correct

Diameter is measure in mm and length is measured in cm



Used to visualize the larynx

There are many differnt kinds but they all have-handle (light source), blade (light source at distal 1/3)

There are two basic shapes-Straight (intended to pick up epiglottis) or curved (inserted to vallecula, depress hypoepiglottic ligament, and elevate epiglottis)

Average for adults is a size 3


Contradidications for Nasal Intubation



Advantages of Oral Intubations

Faster than nasal intubation

Less likely to kink, bending of kinking of the tube will increase ETT resistance (to airflow, suction, and passage of any tube)



Disadvantages of Oral Intubation

More liekly to stimulate gag reflex

Can interfere with oral hygiene

Production of oral secretions may be stimulated (swallowing secretions difficult)

Patients may bite down on oral tube obstructing it creating more resistance to the point that they may lose the airway 


Nasal Intubation Advantages

Route of choice when oral intubation is impossible

Easier insertion in pt. with impaired neck or jaw movement

pt. can not bite on nasal tube

Greater comfort-Awake intubations or long term intubations


What may make oral intubation unaccessible

Muscle Spasm, Seizures

Maxillofacial surgery or fractured mandible

Certain surgical procedures that require unobstructed oral access


Nasal Intubation Disadvantages

Soft tissue trauma and hemorrhage

Insertion may be limited by nares

Potential development for sinusitis or middle ear infection with lng term intubation

More difficult procedure for inexpienced practictioners



Oral Intubation Indications

Apnea (b/c it is quicker)

Nasal Fractures


Nasl obstruction

Deviated septum, polyps, coryza (nosebleeds), inflammed adenoids, foreign bodies, hematomas


Nasal Intubation Indications

Dyspenic patients who would worsen and can not tolerate the supine position

Oral cavity not accessible

inability to obtain sniffing position

When paralyzing agents are contradindicated (renal failure, burns)


Cartilage of Larynx

There is 9 Cartilages of the Larynx

2 Arytenoid Cartilages

2 Cuneiform Cartilages

2 Corniculate Cartilages

1 Thyroid Cartilage

1 Cricoid Cartilage

1 Epiglottis Cartilage


Trachea Measurements

Extends from the larynx to the main stem bronchi 12-15 cm in length

~2 cm in diameter

16-20 C-shaped cartilage rings


Carina Topography

Carina sits behind “angle of Louis” anteriorly and level of T4 posteriorly


pH indication for intubation

pH of 7.25 or less means you will need to do on intubation



Ther period from the start of anaesthesia to the establishment of a depth of anaesthesia adequate for operation (unconsious)


Intubation (endotracheal)

Passage of a tube through the nose or the mouth into the trachea for maintenance of the airway auring anaesthesia, or in a patient with an imperilled (at risk) airway 



The administration, after preoxygenation of a potent induction agent followed immediately by a rapidly acting neuromuscular blocking agent to induce unconscious and motor paralysis for tracheal intubation 

To render the patient unconsious and paralyzed and thn to intubate the trachea without the use of BMV


7 Ps of RSI

  1. Preparation
  2. Preoxygenation
  3. Pretreatment
  4. Paralysis of Induction
  5. Positioning-HOB
  6. Placement with Proof-CO2, polymetric, ausculatation (listen to stomach first), mist on tube, chest rise
  7. Postintubation Management-CXR to see placement



T-minus 5-10 minutes

Assessed for difficultly of intubation (LEMON), monitoring equitment has been attached (SpO2, ECG, BP), drugs prepared, intubation equitment ready

Will occur at the same time as preoxygenation 



Used to assess how difficult the intubation will be 

L-Look Externally (if it looks difficult it probably will be)

E-Evaluate 3-3-2 Rule (3 finger in you mouth, 3 for chin length, and 4 hyoid cartilage to ligament).Mandible of Adequate Size ( to allow tongue displacement).

M-Mallampati Score 


N-Neck Mobility


LEMON-Look Externally

Examine the neck and mouth

DCAP BLS TIC-Deformity, Contusion, Abrasion, Puncture, Burn, Lacration, Swelling, Tenderness, Instability, Crepidious


Tracheal Deviation




Mallampati Score

Class One-Can view soft palate, uvula, facus, pillars

Class Two-Can view soft palate, uvula, and facus visible

Class Three-Soft Palate, base of uvula visible

Class Four-Hard palate only visible


LEMON-Neck Mobility

C-Spine mobility assessed by measureing the distance from lower border fo mandible to thyroid notch at full neck extension

Distance should be greater the 4 finger in adults


RSI-Equitment Preparation

Oxygen equitment and bagger-assembled and checked

Suction Equitment-Assembled, cheked, and turn on 

Laryngoscope-Assembled and checked

Endotracheal Tube-Opended, Distal End lubricated, Stylet inserted and shaped, cuff checked and deflated, syringe attached

Tube Securign Device-Opened/Made/PreCut

Tube Placement Confirmation Device


Endotracheal Tube Size-Infant

Infant >1000g Tube Size 2.5 and Diameter 9-11

Infant 1000-2000g Tube Size 3.0 and Diameter 9-11

Infant 2000-3000g Tube Size 3.5 and Diameter 10-12

Infant >3000g Tube Size 4.0 and Diameter 11-12


Endotracheal Tube Size-Children and Adults

Generally women should be intubated with a number 7 or 7.5 orotraheal tube 

A man is generally intubated with an 8-8.5 orotracheal tube


Another way to solve (Does not work for infants) is

(Age / 4) + 4= Tube Size


Laryngoscope Blade

The blade will depend upon the pat as straight blades are preferred in neonates

Also who is performing the laryngosope will have a preferrence




T Minus 3-5 min

Eastablish an oxygen reservior within the lungs, blood, and body tissue

Allow for several minutes of apnea time before desaturation to 90%-8 min for a healthy 70 kg adult (will be different if patient is obese or have other health conditions)

Once sat reach 90% after they will start to drop rapidly as desats from 90-0% will occur in 120 seconds


Preoxygenation of Patient

Usually done with manual resuscitator-3-5 minutes to obtain highest SpO2

100% O2 provides patient with reservere during intubation procedure



T Minus 3 min

Administration of drugs to mitigate adverse effects associated with intubation or underlying co-morbities

Drugs include-Lidocaine (Prevent gagging) and Fentanyl (relax pt. and prevent ICP)

Gagging increases ICP



Paralysis With Induction

T-Zero We are not ready to intubate as pt. is sedated and paralyzed

Rapidly acting induction (sedation) agent given by IV push-Midazolam, propofol, etomidate, katamine

Neuromuscular blocking agent (paralytic) which are fast acting and a shirt duration-Succinylcholine, rocuronium




Make any final adjustment to patient position as the patient goes unconsious and flaccid 

Want them in sniffing position

Sellick Manoeuver (Optional)-Push back on cricoid cartilage 

No Bagging at this time

T Plus 20-30 seconds


RSI-Placement with Proof

ETT inserted

Stylet removed and cuff inflated

Tube placement confirmed

T Plus 45-60 seconds


Insertion of Laryngoscope

Insert blade into the right of the mouth and sweep tongue to the left


Displacement of the Epiglottis

Look for the arytenoids and epiglottis and if seen proceed to visulize the glottis

if they are not seen the blade is liklely to have gone in too far 

Curved (MacIntosh) Blade: Tip in the vallecula, resting on the hyoepiglottic ligemant. Lift and apply pressure flipping the epiglottis forward

Straight (Miller) Blade: Advance blade tip over posterior surface of epiglottis



For grade 3 or 4 Mallmpati Score we use this





May bring the glottis down into view, improve view by full 1 grade


Assess Position of the Tube


CO2 Detecteion

Esophageal Detection Device (EDD)


CO2 Detection

Most Reliable


Colormetry-Up to 6 breaths, Color change from purple to yellow is good and no color change is bad

Be careful to use during cardiac arrest


Esophageal Detection Device (EDD)

Deflate bulb attached directly to 15mm connector of ETT

If bulb inflate it is good

use immediatly after intubation before bagging resumes 


Tube Depth of Intubation

21-23 cm ATT is good

<18 ATT or >25 be very careful

tube depth alone give no indication of esophasgus or trachea


Fibreoptic Bronchoscopy

Visulization of the tracheal rings through a cameria in the brochscopy

Only true gold standard


Postintubation Management

ETT Secured

PPV initiated

Chest XRay obtained (Distal tip 2-5 cm above carina)

Hypotension is present is treated (may be caused due to the sedation agents used)

Long term sdation ordered and given

Cuff pressure ajusted


T plus one minute



ETT Cuff

Seals the airway during positive pressure vetilation

Prevent or minimize aspiration


Cuff Pressure

Early tracheal tube had low volume and high pressure cuffs which caused major airway damage

Now the norm is high volume and low pressure in order to reduce the incidence of airway damage. Over inflation of the cuff is equal to using the older low volume high pressure cuff

The new high volume low pressure cuff makes contact with a greater surface are and therefore less pressure is required to seal the airway


Acceptable Cuff Pressure

20-25 mmHg

25-35 cmH2O

If cuff pressure is too high tracheal mucosal perfusion pressure has been exceeded which may result in tracheomalacia, tracheal stenosis

If cuff pressure is too low is can result in secretions that will leak into the trachea and bronchi which may result in ventilator assisted pneumonia 


Maintenance of Cuff Pressure

Minimal Occulding Volume or Pressure Technique (MOV)-Injecting small amount of air until no leak is heard at PIP

Minimal Leak Test (MLT)-Inject small amount of air until leak is no longer heard then withdraw a small amount of air is heard at PIP (technique not recommended 

MOV and MLT are used when it is not possible to measure cuff pressure, as whenever possible a cuff pressure manometer should be used 

During a positive pressure breath, airways expand on inspiration. Therefore pressure in the trachea is less on inspiration than expiration. This means that the amount of ischemia that may result depends upon cuff pressure and the rate of PPV


Nasotracheal Intubation-Direct Visulization

Open Mouth

Insert Laryngoscopy

Visualize Glottis

Displace Epiglottis

Use Magill Forceps to manipulate the tube into the glottic inlet

Advance Tube


Nasotracheal Intubation-Blind Insertion 

Apply Sellick's Manouver-Aligns axis advancing tube with trachea and occuldes esophasgus 

Listen for breath sounds as tube approach the glottis

Advance tube though glottic (preferrably on inspiration)


Nasotracheal Intubation Depth

28 cm at nares for men

26 cm at nares for women 


Extubation Criteria

Is the patient getting better, is their inital condition resolved/imprved?

Is there any impeding conditions that may require ventilatory support?

Can patient manage secretions?

Can the patient protect their own airway through an adequate cough (requires minimal suctioning) 


Extubation-Clincally Stable

CNS Assessment-Adequate CNS function needed to stable ventilatory drive and cough. LOC, anxiety, depression, and dyspnea can impact weaning success

Airway Evaulation-Can pt. maintain airway, what is the risk of aspiration (they may be able to protect the airway but not ventilate). What is their LOC, secretions, cough, positive cuff leak test (means no swelling in airway and they are breathing past the cuff)

Oxygenation-P/F Ratio (PO2 to FiO2 Ratio) needs to be greater than 300

Respirtory Muscle Strength-MIP or NIF is -20 cmH2O

Stable VS, hemodynamics, nutiriotional status, functioning GI Tract


Cuff Leak Test

1) Can the patient breath spontaneously- Are they initiating each breath on their own

2) Suction mouth and upper airway

3) Deflate the cuff

4) Briefy occlude the EET

5) If the patient is unable to breathe around the occulasion, then the laryngeal edema should be expected 


Spontaneous Breathing Trial

After a 30-120 min spontaneous breathing trial pt. that can be extubated should have the following

  1. Resolution to their disease
  2. Hemodynamic Stability
  3. Adequate Oxygenation-Low FiO2 needs and PEEP 
  4. Adequate Ventilatiory Status-PaCO2, normal pH


Equitement for Extubation

Resuscitation Bag, O2 source, and O2 mask


Saline to help with secretions

Syringe (10 mL) for cuff deflation


After You Extubate

Watch for signs of O2 failure and Ventilation Failure

  • Decreased SpO2
  • Increased FiO2
  • Increased WOB
  • Decreased LOC

An exubation is considered successful is patient is able to remain extubated for 24 hours


Complications During and Immediately After Extubation List

Airway Obstruction-Due to laryngeal edema causing stridor (smoke, epiglottitis, angioedema) or compression of airway (tumor, abscess, trauma, post op). Only 1% will experience stridor and of that 1% require reintubation

Hoarseness-Will occur in up to 70% of extubated ICU patients, oral intubation and large tubes will increase risk. If does no resolve for 2 weeks it indicates that there is a serious complication (vocal cord paralysis)

Cough-About 25% of ICU pt. following prolonged intubation will develop cough

Sore Throat-15% of short term intubation and 40% of long term intubations have a sore throat

Aspiration-Sensory deficit and incompetent laryngeal reflexes post extubation will increase risk of aspiration, especially in pt. with an impaired cough

Odynophagia-Painful swallowing or talking. If severe may indicate glottic infection or ulceration (very rare)

Vocal Cord Paralysis-Permanent bilateral vocal cord paralysis is very rare but unilateral transient cord paralysis is common 



After Extubation-Stridor

Very rare but if occurs use cool aerosol with supplemental O2

Tx with nebulized 1:1000 epinephrine

Tx with Heliox mixtures by NRBM

Children are at a greater risk


Tracheotomy Access Incision

Procedure of establishing to the trachea via neck



Opening created by a tracheotomy

May be permenant or temporary

Usually associated with a tracheostomy tube

Unable to phonate as insufficent air passing through the vocal cords


Tracheostomy Tube

An Artifical airway inserted into the trachea via a tracheostomy



Surgical incision into the larynx

Usually a permanent stoma is linking the trachea to the surface of the neck

Trachea no longer in communication with pharynx

Unable to phonate as the vocal cords are no longer there



An opening between two cavivties or canals or between such and the of the body

Often used interchangeably with trachesostomy



Upper airway trauma or obstruction

Continuing need for artifical airway after a prolonged period of oral/naso intubation

To facilitate removal of secretions

Inability to wean from artifical airway

Long term care patients with neuromuscular diseases

Obstructive Sleep Apnea-At night everything is floppy making it harder to breath


Parts of Tracheostomy Tube


Rigid (Common)

Bent 90

15 mm Connecter (common)

May be cuffed or uncuffed

may be fenestrated or unfenestrated 


Trach-Inner Cannula

Used for suctioning

Used for ventilation

Can be removed for cleaning

Inner diameter limits airflow 


Trach-Outer Cannula

Provides rigidity that can be used to protect the airway

May or may not be fensatrated

May or may not be cuffed

Outer diameter customizes fit


Trach Tubes-Obturator

Makes the passage through tissues less trauamtic during insertion

Prevents blood or muscus form entering tube while being inserted

Removed when the trach is in place

Kept at pt. bedside and may be needed if trach tube gets dislodgeed and has to be reinserted




Comes in various sizes at the distal end of the tube

Designed to seal and protect airway and to maintain position of tube

All cuffs inflated by syringe via attachment pilot balloon and accessible at all times

Can cause ischemia if over pressurized


Trach Care

It is a shared responsibility between the RN, RTs, and pt.

Done dily or as needed

the trach will need to be change every 3 months




Trach Care Steps

  1. Assemble and check equitment
  2. Assess the patient
  3. Explain the procedure
  4. Suction (if needed)
  5. Remove and clean inner canula
  6. Clean stoma site
  7. Change the ties (if needed)
  8. Re-insert inner cannula
  9. Reassess the pt.
  10. Chart procedure


New Trach Care

Trach care is only done if needed during first 24 hour post op

Inner Canula-Check q1h during first 24 hrs post op and clean q4h or prn during first 24 hours post op

Trach care is done aseptically for the 72 hours post op


Trach Humidifcation

the selction of humidifcation device should be based on pt. needs and assessment of the aireway and includes the volume an thickness of secretions as well as the history of mucus plugging or tube occulasion

Devices that can be used-Artifical nose, humidifer, large volume neb, instillation neb


Trach Communication

phonation requires airflow through vocal cords at a sufficient  force and a tracheostomy will negate that process

Device that can be use includes-passey muir valves (most common), talking trachs, artifical larynx, Blom-Singer valve (cheap so everyone can afford it)


Loss of Airway Patency

Causes of loss of airway patency can be divided into 2 general categories

Central Causes-Any condition that leads to a depression of the CNS (i.e. <8)

Peripheral Causes-Airway obstruction caused by something originating outside the body


Central Causes of Loss of Airway Patency

When the CNS is depressed and comes from within the body

The causes of CNS depression varies

Most common cause of upper airway obstruction is the tongue

Includes-Decrease in cardiac output, TBI, Anesthesia, drug overdose, hypoxemia/hypercarbia, hypothermia/hyperthermia, metbolic derrangements


Central Causes-Decrease in Cardiac Output

Acute myocardial infarction (MI)

Cardiac tamponade-But when cause through a infection it is considered to be a peripheral cause


V fib or V tach

Hypovolemic Shock

Septic Shock

Massive Pulmonary Embolism


Mechanisms of Upper Airway Obstruction

Decrease in tone of submandibular muscles leads to posterior displacement of tongue against the posterior pharyngeal wall While in a comatose state the position of the chin will worsen the obstruction • C-spine adopts a semi flexed position, narrowing the distance between the tongue and posterior pharyngeal wall • Epiglottis gravitates towards the larynx partially occluding the airway • Negative pressure cause by respiratory efforts in presence of obstruction draws tongue towards the airway


Peripheral Causes

Peripheral causes come from outside of the body Peripheral causes include Infection Infection • Viral and bacterial infection laryngotracheobronchitis (e.g. croup) • Parapharyngeal and retropharyngeal abscess • Lingual tonsillitis • Hematomas or abscess of the tongue or floor of the mouth • Epiglottitis (also known as supraglottitis) • Similar to croup but the patient will have low energy and is very serious and in this case we do not manipulate the airway Neoplastic • Laryngeal carcinomas • Hypopharyngeal and lingual (tongue) carcinomas Physical and Chemical Agents • Foreign bodies • Chocking something shoved up a nose • Thermal injuries-Can cause swelling • Caustic Injuries- Can cause swelling • Inhaled toxins Allergic/Idiopathic • Angiotensin converting enzymes inhibitors induced angioedema Traumatic • Blunt and penetrating neck and upper airway trauma


Signs of Loss of Airway Patency

• Tachypnea and dyspnea • Noisy snoring respirations • Paradoxical breathing • Tracheal tug or retractions • Nasal flaring o Usually seen in babies • Expiratory Grunting o Is a compensation for collapse o Usually seen in babies o Cardiac dysrhythmias • Pressure in chest and low oxygen levels will affect the heart • Stridor • Absence of breath sounds or visible chest movement • Cyanosis o Can be misleading due to polycythemia or hypothermia o Will be check at the inside of the lips


Peripheral Causes-Infection

Viral and bacterial infection laryngotracheobronchitis (e.g. croup)

Parapharyngeal and retropharyngeal abscess

Lingual tonsillitis

Hematomas or abscess of the tongue or floor of the mouth

Epiglottitis (also known as supraglottitis)

Similar to croup but the patient will have low energy and is very serious and in this case we do not manipulate the airway


Peripheral Causes-Neoplastic

Laryngeal carcinomas Hypopharyngeal and lingual (tongue) carcinomas


Peripheral Causes-Physical and Chemical Agents

Foreign bodies Chocking something shoved up a nose Thermal injuries-Can cause swelling Caustic Injuries- Can cause swelling Inhaled toxins


Peripheral Causes- Allergic/Idiopathic

Angiotensin converting enzymes inhibitors induced angioedema


Peripheral Causes- Traumatic

Blunt and penetrating neck and upper airway trauma


Central Causes-Hypoxemia/Hypercarbia

COPD, Asthma, ARDS, Pneumonia, moderate PEs 


Central Causes-Metabolic Derangements



hypokalemia (lead to heart malfunction)

metabolic acidosis

hepatic encephalopathy


Signs of Loss of Airway Patency

Tachypnea and dyspnea

Noisy snoring respirations

Paradoxical breathing

Tracheal tug or retractions

Nasal flaring-Usually seen in babies

Expiratory Grunting-Is a compensation for collapse and usually seen in babies

Cardiac dysrhythmias-Pressure in chest and low oxygen levels will affect the heart


Absence of breath sounds or visible chest movement

Cyanosis-Can be misleading due to polycythemia or hypothermia, will be check at the inside of the lips


Presentation of Obstructed Airway 


Hot Potato Voice- Horse Voice

Difficultly in Swallowing Secretions

Drooling is a very serious sign


STRIDOR-Means a complete obstruction is imminent




High pitched inspiratory sound

Indicated that airway has already lost at least 50% of its usual caliber

Complete obstruction may be imminent

The volume and pitch are related to the velocity of air flow-Air flow is dependent on patient’s level of consciousness and inspiratory muscle strength

Often audible but may be detected early via auscultation over the trachea-Can normally be heard without a stethoscope

If it is epiglottitis don’t place the stethoscope near the throat just keep them calm


Establishing and Maintaining Patient Airways Manuevers

Head-tilt/ Chin-Lift

Jaw Thrust Maneuver

Occasionally opening the airway is all that is require to re-establish the airway


Oropharyngeal Airways (OPAs)

Rigid, curved devices with an air passage, placed through the mouth with the end resting distal to the tongue above the glottis opening


Oropharyngeal Airways (OPAs) Indication for Use

  • Used in patients with decreased submandibular tone
    • Obtunded 2 degrees to any of the central cause of airway obstruction
    • Anesthesia
    • Deep sedation
  • Used when manually ventilating a patient
  • Used as aid for deep suctioning
  • Used as a bite block
  • Some model used to facilitate intubation


OPA Contraindications for Use

Patients with obvious oral trauma

Awake or semi-conscious patients

May cause vomiting or gagging

IMPORTANT-If a patent is awake enough to spit or tongue the device out then they are too awake for the device to be used



OPA Sizing

Proper sizing

Place the airway next to the face with the flange at the mouth and the tip of the airway should reach the angle of the jaw (tragus of the ear)



Complications of OPA

May cause trauma to the lips, mouth, or teeth-Rare

May cause pressure necrosis

Difficult to perform mouth care

May cause gagging and vomiting-May push the tongue back


Nasopharyngeal Airways (NPAs)


AKA nasal trumpet

Soft or semi-rigid hollow tube placed through the nares, the tip lying distal to the tongue above the glottic opening

May be sized in mm I.D. or French sizes


NPA Indications for Use



  • Semi-awake patients who require some airway maintenance and do not tolerate the OPA
  • Ay be used when insertion of OPA is difficult or contraindicated
  • Maybe used to facilitate deep suctioning
  • Pierre-Robin Syndrome (in neonates)
    • Micrognathia-Tiny Chin
    • Mandibular hypoplasia


Contraindications of NPA



Obvious nasal trauma

Deformities of the nose

Basal fractures of the nose (Racoon eyes and battle sign)-This may indicate skull fractur but use history to help determine

Coagulation disorder-NPA can cause nosebleeds


Complication from Use of NPA


If too long can enter into the esophagus causing gastric distension and hypoventilation

May cause vomiting and laryngospasm (big issue with infection) in semi-conscious patient

Injury of nasal mucous with bleeding


Bypassing natural defenses

Otitis Media (ear infection)

Intubation of meninges (basal skull fracture)

Occlusion of airway by secretions

Tissue necrosis



Used when pt. is not breathing on their own

Manual Resuscitator

Bag-Valve-Mask (BVM)

Bag-Mask Ventilator (BMV)


“Portable handheld devices that provide a means of delivering positive pressure to a patient’s airway”

“Deliver room air (R/A), oxygen air-oxygen mixtures via a mask or through an adapter that attaché directly to a patients ET”

You will know you are giving enough air if there is chest rise 


Manual Resuscitator

Hand squeezing a bag provides the mechanical force necessary to generate a positive pressure

Requires an oxygen source to deliver FiO2 greater than 0.21

In the baby and child versions they will have pop off valves


Commonalities in Bag

  • Universal connector (15/22 mm)
    • This allows them all to be connected to trachs
  • Requires an O2 sources for FiO2 >0.21
    • Oxygen flow meter
    • 50 psi source
      • Wall outlet
      • Cylinder
  • Originally designed for use during CPR


Self Inflating Manual Resuscitator 

Does not require a compressed gas source for operation

Re-usable or disposable


Self Infalting Resuscitator Parts

  • Self –inflating bag
    • (volume depends on patient population)
  • Air inlet/Oxygen Reservoir attachment site
  • Oxygen Inlet
  • Patient Outlet
  • Valve assembly
    • One way, non-rebreathing
  • Oxygen reservoir  (required for high FiO2)
  • Pressure release (pop-off) valve (optional)
  • Pressure Gauge / Guage attachment site (optional)


Classess of Non-Rebreathing Valves

  • Spring-Loaded
  • Diaphragm
    • Duckbill (most common)
    • Leaf-type
    • Fishmouth


Pneumatic Resuscitators

  • Used when unable to bag
  • Commonalities
  • Universal connector (15/22 mm)
    • This allows them all to be connected to trachs
  • Requires an O2 sources for FiO2 >0.21
    • Oxygen flow meter
    • 50 psi source
      • Wall outlet
      • Cylinder


Safety Mechanisms of Resuscitators

  • Non-Rebreathing Valve (Self-Inflating)
    • Prevents rebreathing of exhaled gases
  • High Pressure Pop-Off Valves (self-Inflating)
    • Prevents delivery of overly high pressure to patient (infant and children only)
  • Maximum circuit pressure control (T-Piece Resuscitator)
    • Will take away the variability of the pressure delivered in a breath
  • Standard 15/22 mm connectors
    • Allows for easy connection and disconnection


Quality Control Mechanisms

  • Operation manual should specify
    • BVM device underwent safety and standard testing
    • Criteria was met


Standard Construction for Resuscitators

  • Resuscitators capable of delivering FiO2 > or = 0.95
  • Must be able to operate at-Extreme temperatures and Relative humidity 40-96%
  • Deliver Vt > or equal to 600 ml into test lung for adult baggers
    • With compliance of 0.2L/cmH2O
    • With resistance of 20 cmH2O/L/sec
  • Non-rebreathing valve withstand oxygen flow rate up to 30lpm
  • If valve malfunctions due to foreign obstruction (e.g. vomitus), must be restored within 20 seconds
  • Must have standard 15/22 mm connectors
  • Adult resuscitators not have pressure limiting system
  • Resuscitators for infants and children have pressure relief valve that limits PIP to:
    • 40  +/- 10 cmH2O for children
    • 30  +/-  5 cmH2O for infants
  • When incorporating pressure limiting system, override capability must exist and must be apparent to operator
  • Resuscitator able to operate after being dropped from height of 1 meter on to concrete floor
  • Easily disassembled for sterilization and disinfection purposes
  • Should not be possible to accidentally interchange parts
    • making unit malfunction
    • not function at all 


Mask Seal

Hand Positioning-Single Hand

Lift chin up to the mask


Proper Ventilation

Connect bag to mask and O2

Should not use entire volume of bag

Assess for mask seal

Should feel some resistance in the bag.

Does the chest rise?

Can you hear a leak?





Steps to improve mask seal

Remove mask and reseat to face

Is airway patent

Head tilt chin lift?


Suction oropharynx

Two hand mask seal

Reinserting patient's false teeth


Assessment of effective ventilation.

Goal is for visible chest rise

Chest rise and fall with ventilation

Breath sounds with ventilation

Improving SpO2

Capnograph waveform-end tidal CO2 (confirmation of intubation and can tell us about effectiveness of CPR by seeing if you are pumping enough blood through the body)


Ventilating the Patient

  • 12 breaths per minute
    • Every 5 seconds
  • Target 500-600 mls for an adult
  • Ti 1.0s
    • Decrease insufflation of stomach with gentle ventilation
    • Esophageal sphincter opening pressures ~25cmH2O


BMV Golden Rules

Manual ventilation skill with proper equipment is a fundamental premise of advanced airway management

Anybody (almost) can be oxygenated and ventilated with a bag and a mask

The art of bagging should be mastered before the art of intubation


What Will Make Resuscitation Difficult



  • M- Mask Seal
    • Bushy beards, trauma
  • O- Obesity/Obstruction
    • ↑ weight of chest, ↓ diaphragmatic excursion
    • ↑ Resistance 2° to swelling, adipose tissue
  • A- Age
    • Older than age 55 (not a hard,fast rule)
  • N- No Teeth
    • Face tends to cave in
  • S- Stiff, Snoring Hx
    • Lungs resistant to ventilation (asthma, COPD)


Describe three major hazards associated with manual resuscitation. Which is the most common?

  • Delivery of excessive high airway pressure (most common)
    • Common in intubated patients
  • Defective nonrebreathing valve
    • Can cause an inspiratory leak and tidal volume escaping through the exhalation port and not delivered to the patient
  • Faulty pressure-relief valves
    • Can cause gas delivery at excessively high pressures and increases the risk of barotrauma


1. What is the difference between tracheotomy and tracheostomy?


A tracheostomy is a surgically created hole at the front of the neck into the trachea. The procedure of creating this hole and placing a tube within it (through which the patient breathes) is called a tracheotomy.



List factors considered when determining whether the patient should have a tracheotomy/tracheostomy.

Indications of a tracheotomy include:

-Upper airway obstruction or trauma

-Continuing need for artificial airway after a prolonged period of oro/nasotracheal intubation

-To facilitate removal of secretions from tracheobronchial tree when patient is unable to raise secretions

-Inability to wean from artificial airway even after being weaned off of mechanical ventilation

-Long term care patients with neuromuscular disease

-Obstructive sleep apnea



Briefly describe the two main methods of tracheotomy.

Cricothyroidotomy is a surgical incision to the trachea which passes through the cricothyroid membrane and results in the insertion of an endotracheal tube or a tracheostomy tube. Under this method, a single horizontal incision is done through the skin to the trachea.

Percutaneous dilatory tracheostomy (PDT) is the more common method of tracheotomy due to its effectiveness, simplicity, and low incidence of complications. This method is performed mostly in the ICU if the patient is in the unit and intubated for more than 7 days. PDT is performed mostly with the Ciaglia method: a guide wire is placed between the first and second or second and third tracheal rings and plastic dialators is pushed through the soft tissue until the appropriate size is met. This method is usually aided with the use of a bronchoscopy.



Describe the four mechanisms of airway emergencies in patients with artificial airways and how to troubleshoot these situations. Which mechanism is the most common?


Displacement: Reposition (if possible) or remove tube and bag until reintubation is possible.

Obstruction: (Most Common!) Many different causes, but move patient’s head/neck to reposition, deflate cuff, suction catheter through tube, or flush tube with saline or mucus shaving device

Pressure: The pressure of the cuff on the ETT can cause issues if under-inflated or over-inflated. If under-inflated, air and secretions can leak around the cuff and cause ventilation issues. Over-inflation can cause the trachea to become inflamed and cause further ventilatory issues.  

Equipment: Anything that causes a stoppage in the flow of oxygen to the patient. Check the tubing or vent to see if any kinks have developed, and have back-ups. You can also remove tube and bag patient until they can be reintubated.