What are the artificial airways used in respiratory therapy (RT)?

Artificial Airways in Respiratory Therapy

Primary Artificial Airway Devices

Artificial airways in respiratory therapy include endotracheal tubes, tracheostomy tubes, laryngectomy tubes, and supraglottic airway devices (such as laryngeal mask airways), each serving specific clinical purposes for maintaining airway patency and supporting ventilation. 1, 2

Endotracheal Tubes

• Endotracheal intubation is indicated for severe respiratory failure with criteria including severe tachypnea (respiratory rate >40 breaths/min), muscular respiratory failure with accessory muscle use, altered mental status, and/or severe hypoxemia despite supplemental oxygen 3
• The endotracheal tube provides definitive airway protection and enables mechanical ventilation, though it carries risks including ventilator-associated pneumonia (VAP), tracheal injury, and vocal cord paralysis 3, 2
• Early placement of an endotracheal tube is appropriate based on standard clinical criteria heralding respiratory failure to avoid complications associated with delayed intervention 3
• Proper positioning must be confirmed with waveform capnography, and the tube should be secured to prevent dislodgement or migration 4, 5

Tracheostomy Tubes

• Tracheostomies can be performed surgically or percutaneously, with over 5,700 surgical and 5,000-8,000 percutaneous procedures performed annually in England 3
• Clinical indications include management of upper airway obstruction, airway protection, facilitating weaning from mechanical ventilation, allowing long-term ventilation, and assisting with respiratory secretion removal 3
• Complications include immediate risks (hemorrhage, airway loss), short-term issues (blockage, tube displacement), and long-term problems (tracheomalacia, tracheal stenosis, stomal complications) 3, 2
• Management requires regular monitoring of airway patency, appropriate suctioning, adequate humidification, and cuff pressure control to prevent aspiration and mucosal damage 5

Laryngectomy Tubes

• Laryngectomy results in permanent alteration of the airway where the upper airway is not and cannot be connected to the trachea, creating a "neck breather" 3
• Approximately 570 laryngectomies were performed in England during 2009/10, primarily for laryngeal carcinoma 3
• Critical distinction: confusion between tracheostomy and laryngectomy anatomy can lead to serious complications if caregivers do not understand the anatomical differences 3

Supraglottic Airway Devices (SADs)

• The laryngeal mask airway (LMA) revolutionized airway management and became a MeSH keyword in 1993, with widespread adoption for procedures not requiring endotracheal intubation 3
• SADs are recommended over endotracheal intubation for brief superficial procedures (such as sentinel lymph node biopsy), as they reduce the incidence of laryngospasm and hypoxemia during device removal 6
• The Aintree Catheter facilitates tracheal intubation through a SAD when needed, and SADs have an important role in rescuing failed intubation 3
• SADs should not be used when significant aspiration risk exists, anticipated difficult mask ventilation, severe obesity with difficult LMA placement, or inability to tolerate brief apneic episodes 6

Mechanical Insufflation-Exsufflation (MI-E) as an Artificial Airway Interface

• MI-E devices deliver alternating positive and negative pressure using a facemask or artificial airway, effective for both upper and lower airway secretions in patients with neuromuscular disease 3
• This technique is indicated for reduced cough effectiveness not improved with alternative techniques and reduces morbidity and hospitalization 3

Critical Management Principles

Airway Clearance and Secretion Management

• Regular airway suctioning must accompany artificial airway management, with sterile technique starting immediately after intubation 7
• Adequate humidification is essential to prevent secretion inspissation and airway obstruction 5
• Glycopyrrolate (0.1-0.2 mg IV every 4 hours as needed) is the preferred anticholinergic for reducing excessive oral and airway secretions in intubated patients due to its superior safety profile 7

Cuff Pressure Management

• Cuff pressure management is critical for preventing aspiration and mucosal damage while assuring adequate ventilation 5
• Automated cuff pressure control is becoming more common and should be utilized when available 5

Oxygenation Goals

• Maintain oxygen saturation approximately 88-90% (approximating PaO2 of 60 mmHg) with nontoxic oxygen concentrations ideally FiO2 <0.60 using supplemental oxygen and PEEP as needed 3

Common Pitfalls to Avoid

• Do not delay endotracheal intubation in patients meeting respiratory failure criteria, as delayed intervention increases complications 3
• Avoid noninvasive positive-pressure ventilation (NIPPV) in sepsis-related ALI/ARDS patients, as they are more likely to fail this therapy and delay in mechanical ventilation may result in complications 3
• Do not use endotracheal intubation routinely for brief superficial procedures when SADs are appropriate, as intubation increases risk of cough, laryngospasm, and hemodynamic instability without additional benefit 6
• Ensure caregivers understand the anatomical differences between tracheostomy and laryngectomy to prevent life-threatening management errors 3
• Monitor for tube displacement, blockage, and complications continuously, as these can rapidly lead to patient harm depending on the clinical setting 3, 2