Airway Management: Overview and Practice Questions (2023)

Airway management is a critical component in various clinical settings, encompassing techniques and tools essential for ensuring an unobstructed passage of air to and from the lungs.

Whether during emergencies, surgical procedures, or life-saving interventions, maintaining a patent airway can be the determining factor between life and death.

Therefore, healthcare professionals must be well-versed in recognizing situations that require immediate airway intervention and skilled in the deployment of appropriate measures to secure and maintain a patent airway.

This article outlines the essential principles, techniques, and devices involved in airway management, emphasizing their clinical relevance and practical applications.

What is Airway Management?

Airway management refers to a set of medical procedures and techniques aimed at ensuring an open airway between the lungs and the outside environment. This is essential for effective breathing, oxygenation, and ventilation.

The objective is to prevent airway obstruction and thereby facilitate the adequate exchange of oxygen and carbon dioxide, both during normal breathing and under artificial ventilation.

Airway management is crucial in various settings, such as emergency medicine, anesthesiology, critical care, and pulmonology.

It is particularly vital during surgeries that involve general anesthesia, in the treatment of trauma patients, and in critical care settings where respiratory function is compromised.

Note: Effective airway management is vital for preventing life-threatening complications such as hypoxemia, hypercapnia, and aspiration of stomach contents into the lungs, among others. Failure in airway management can lead to severe consequences, including brain damage and death. Therefore, it is a critical skill for healthcare providers in multiple disciplines.

Types of Airway Management

Airway management encompasses a broad spectrum of techniques and devices, each with specific advantages, disadvantages, and indications for use.

Some examples of the most common types include:

• Endotracheal suctioning
• Sputum sampling
• Artificial airways
• Intubation
• Emergency surgical airways
• Securing the airway
• Confirming proper tube placement
• Secretion clearance
• Tracheostomy care
• Troubleshooting airway emergencies
• Extubation

Endotracheal Suctioning

Endotracheal suctioning is a procedure in which a suction catheter is inserted through an endotracheal tube to remove respiratory secretions.

This technique is primarily used in intubated patients, particularly those on mechanical ventilation, to maintain a clear airway and minimize the risk of infection.

Suctioning helps in preventing the accumulation of mucus and other secretions, which could otherwise lead to complications like pneumonia or atelectasis.

Sputum Sampling

Sputum sampling is the collection of mucus or phlegm from the respiratory tract, usually obtained through spontaneous expectoration or induced by procedures like bronchoscopy.

This type of sample is frequently collected to diagnose infections, identify causative agents, and guide antibiotic therapy.

Proper sampling techniques are essential for accurate diagnosis and effective treatment.

Artificial Airways

Artificial airways refer to devices that are inserted to maintain or create an open airway and may include nasopharyngeal airways, oropharyngeal airways, laryngeal mask airways, and endotracheal tubes, among others.

These devices can be used in various settings, such as emergencies, surgeries, or intensive care units.

The choice of device depends on the clinical situation, the expertise of the healthcare provider, and the specific needs of the patient.

Intubation

Intubation involves the insertion of an endotracheal tube through the mouth or nose into the trachea.

This procedure is commonly performed in settings requiring general anesthesia, in emergency situations involving respiratory distress, or in critical care settings to facilitate mechanical ventilation.

Intubation ensures a patent airway, allows for better control of oxygenation and ventilation, and protects the lungs from aspiration of gastric contents.

Emergency Surgical Airways

In situations where conventional methods of securing the airway fail or are not possible, emergency surgical airways, such as a cricothyroidotomy or tracheostomy, may be performed.

This involves making a surgical incision in the neck to access the airway directly.

These procedures are typically last-resort options, used in life-threatening situations where immediate airway access is required, such as severe facial trauma or an obstructed airway that can’t be cleared by other means.

Securing the Airway

Once an artificial airway device like an endotracheal tube is in place, it must be secured to prevent dislodgment.

This can be done through various methods such as adhesive tape, tube holders, or ties that wrap around the patient’s head.

Proper securing is essential for ensuring the tube remains in the correct position, especially during patient transport or positioning.

Confirming Proper Tube Placement

After intubation or insertion of an artificial airway, it’s critical to confirm that the device is properly placed. Incorrect placement can lead to insufficient ventilation and other severe complications.

Methods for confirmation include visual inspection, auscultation of breath sounds, capnography, and chest X-rays.

Confirming proper placement ensures that the patient receives adequate oxygenation and ventilation.

Secretion Clearance

For patients with an artificial airway, regular clearance of respiratory secretions is necessary to maintain a patent airway and minimize the risk of complications like pneumonia.

Techniques may include endotracheal suctioning, chest physiotherapy, or the use of specialized devices like a mucus clearance device.

Keeping the airway free from secretions is essential for optimizing respiratory function and overall patient well-being.

Tracheostomy Care

A tracheostomy is a surgical procedure that creates an opening in the neck leading directly to the trachea, bypassing the upper airway.

Tracheostomy care involves maintaining the patency and cleanliness of this opening and the tracheostomy tube. Routine care includes cleaning the stoma, changing dressings, and monitoring for signs of infection or obstruction.

Proper tracheostomy care is vital for preventing complications such as infection, bleeding, and tube blockage.

Troubleshooting Airway Emergencies

Despite best practices, airway management can encounter complications like tube dislodgement, blockages, or leaks.

Troubleshooting involves the rapid identification and correction of these issues.

This can mean repositioning or replacing an airway device, removing foreign material, or transitioning to a more secure method of airway management.

Quick and effective troubleshooting is critical to prevent hypoxia and other life-threatening conditions.

Extubation

Extubation is the process of removing an endotracheal tube or other artificial airway device, usually once the patient has recovered sufficient respiratory function to breathe independently.

This procedure requires careful planning and timing, and it often involves weaning the patient off mechanical ventilation if applicable.

Proper technique and monitoring are essential during extubation to avoid complications like airway spasms, aspiration, or respiratory distress.

Note: Each of these procedures and techniques plays a crucial role in maintaining a secure and functional airway, which is vital for effective breathing and, ultimately, patient survival.

What is an Artificial Airway?

An artificial airway is a medical device used to maintain or create an open passageway for air to flow between the lungs and the atmosphere.

These devices are typically employed when natural airway structures are compromised due to medical conditions, injuries, or during surgical procedures requiring anesthesia.

Artificial airways are a critical component of airway management, and they are used to facilitate effective breathing, oxygenation, and ventilation.

The types of artificial airways commonly used include:

• Nasopharyngeal Airway: A flexible tube inserted through the nostril to keep the airway open, typically used for patients who are semi-conscious or who have a gag reflex.
• Oropharyngeal Airway: A rigid, curved device inserted through the mouth to maintain an open airway, usually used in unconscious patients without a gag reflex.
• Laryngeal Mask Airway (LMA): A supraglottic device that sits over the laryngeal inlet, allowing for easier ventilation without tracheal intubation. It is used in surgeries where endotracheal intubation is not necessary or in emergency situations as an alternative to endotracheal tubes.
• Endotracheal Tube: A flexible tube inserted through the mouth or nose and into the trachea, commonly used in surgical procedures requiring general anesthesia or in critical care settings for patients requiring mechanical ventilation.
• Tracheostomy Tube: A tube that is inserted into a surgically created opening (stoma) in the neck and trachea, often used for long-term ventilation or airway management.

The selection of an appropriate artificial airway depends on several factors, such as the clinical setting, patient condition, and the skills of the healthcare provider.

Proper use and management of artificial airways are crucial for ensuring effective oxygenation and ventilation and for minimizing complications such as infections, blockages, or trauma to the airway.

Airway Management Practice Questions

1. When is an artificial airway required?
When the patient’s natural airway can no longer facilitate ventilation

2. What are the contraindications of an artificial airway?
When the patient has a Do Not Resuscitate (DNR) order

3. What are the possible complications of an artificial airway?
Trauma to the nose, mouth, tongue, pharynx, larynx, vocal cords, trachea, or esophagus; aspiration; or infection

4. What does a pharyngeal airway do?
It prevents airway obstruction by keeping the tongue pulled forward and away from the posterior pharynx

5. Does the nasopharyngeal airway enter the trachea?
No, it extends only into the pharynx.

6. Which artificial airway is best to help with suctioning?
Nasopharyngeal airway

7. What artificial airway can be used as a bite block?
Oropharyngeal airway

8. Which artificial airway is mainly used in emergency life support?
Pharyngeal airways

9. What is an endotracheal tube?
An artificial airway that is placed in the trachea in order to support mechanical ventilation

10. What is intubation?
The process of placing an artificial airway into the trachea

11. Do pharyngeal airways extend only into the trachea?
No, they only extend into the pharynx.

12. What is orotracheal intubation?
When the tube passes through the mouth into the trachea, as opposed to being passed through the nose

13. What is nasotracheal intubation?
When the tube passes through the nose into the trachea, as opposed to being passed through the mouth

14. What are the two types of tracheal airways?
Endotracheal and tracheostomy tubes

15. Are tracheostomy tubes inserted surgically?
Yes

16. What is the purpose of the angle of the bevel on an endotracheal tube?
It minimizes mucosal trauma during insertion.

17. What is the purpose of inflating the cuff of an endotracheal tube?
It protects from aspiration and helps provide positive pressure ventilation.

18. What are the three areas of skill for respiratory therapists in airway management?
(1) Insert and maintain artificial airways, (2) Be proficient in airway clearance, and (3) Assist physicians in performing procedures related to airway management

19. What are the two categories of airways?
Pharyngeal and tracheal airways

20. What are the two types of pharyngeal airways?
Oropharyngeal airway (OPA) and nasopharyngeal airway (NPA)

21. What are oropharyngeal airways made of?
Metal, plastic, or rubber

22. What are the indications of an oropharyngeal airway?
(1) To prevent an airway obstruction by the tongue, (2) To be used as a bite block, and (3) To increase the effectiveness of bag/mask ventilation

23. What is a contraindication of an oropharyngeal airway?
A conscious patient with an intact gag reflex

24. What are some complications of oropharyngeal airways?
Laryngospasm/cough, vomiting/aspiration, airway obstruction, lip or tongue damage, and dental damage

25. How is an oropharyngeal airway sized?
From the angle of the jaw to the corner of the mouth

26. What are the most common oropharyngeal airway sizes for adults?
80 and 90

27. The nasopharyngeal airway (NPA) is also known as?
Nasal trumpet

28. Where is the nasopharyngeal airway inserted?
It is inserted into the nose and rests behind the tongue, just above the epiglottis.

29. What are the indications for a nasopharyngeal airway?
(1) To increase the effectiveness of bag/mask ventilation, (2) To aid with suctioning and bronchoscopy, (3) For the management of facial anomalies, and (4) To eliminate the risk of oral damage

30. What are the complications of using a nasopharyngeal airway?
Laryngospasm/cough, nosebleeds, sinus infections, and damage to the turbinates

31. The nasopharyngeal airway is tolerated best by what type of patient?
A conscious patient

32. What are the steps for placing a nasopharyngeal airway?
(1) Perform a head-tilt, (2) Use water-soluble lube, (3) Slowly advance the airway until it rests above the epiglottis, (4) Confirm correct placement using a tongue depressor

33. What are some indications for tracheal intubation?
(1) To bypass an upper airway obstruction, (2) To protect the airway from aspiration, (3) To apply positive pressure ventilation, (4) To aid clearance of secretions, and (5) To deliver high oxygen concentrations

34. Can you instill drugs directly down an endotracheal tube?
Yes, you can generally instill a dose that is twice the normal dose.

35. What drugs can be instilled down an endotracheal tube?
The drugs that can be used for direct instillation include narcan, atropine, valium/versed, epinephrine, and lidocaine. Remember NAVEL as an easy way to memorize these medications.

36. What are the advantages of oral intubation?
(1) It’s faster, easier, less traumatic, and more comfortable for the patient, (2) Larger tubes can be tolerated, (3) It makes suctioning easier, (4) There is less airflow resistance, (5) It provides a decreased work of breathing, (6) There is a decreased risk of the tube kinking, and (7) It helps avoid nasal and paranasal complications

37. What are the disadvantages of oral intubation?
There is a greater risk of self-extubation, mainstem intubation, tube occlusion from biting, injury to the oral structures, and an increased risk of retching, vomiting, and aspiration.

38. What is the preferred method of intubation during CPR?
Oral

39. How is the endotracheal tube size measured?
It’s measured in millimeters on the inside diameter.

40. What do the centimeter markings on the endotracheal tube indicate?
They indicate the placement of the tube.

41. What is the purpose of using a stylet during intubation?
It gives the tube more rigidity.

42. What are the advantages of nasal intubation?
It provides greater comfort, less salivation, improved swallowing, more communication, no need for oral care, helps to avoid occlusion from biting, creates less damage to oral structures, provides better stabilization, reduces the risk of mainstem intubation, and does not require muscle relaxants or sedatives.

43. What are the disadvantages of nasal intubation?
There are nasal/paranasal complications, it is more difficult to perform, spontaneous breathing is required for the procedure, a smaller tube is necessary, suctioning is more difficult, there is an increased airflow resistance, there is an increased work of breathing, and it is more difficult to pass a bronchoscope.

44. What is the name of a curved laryngoscope blade?
Macintosh

45. Would you want to use the Macintosh blade for neonates?
No, a Miller blade is preferred in infants.

46. Where is the Macintosh blade designed to fit?
It is designed to fit into the vallecula so that it indirectly lifts the epiglottis.

47. What is the name of the straight laryngoscope blade?
Miller

48. Where is the Miller blade designed to fit?
It is designed to fit into the epiglottis.

49. Which laryngoscope blade is best for neonates?
Miller (straight blade)

50. What is the purpose of the Murphey’s eye?
It allows collateral ventilation.

51. What supplies are needed for oral intubation?
Oxygen flowmeter and tubing, manual resuscitator, suction setup, oropharyngeal airway, laryngoscope, endotracheal tube, stylet, stethoscope, tape, 10 cc syringe, towels for positioning, gloves, gowns, masks, eyewear, and a CO2 detector

52. Where should the tip of the endotracheal tube rest?
It should rest 2-4 cm above the carina.

53. What should the tube depth of the ET tube be for the adults?
21-23 cm at the lip

54. How long should you hyperinflate and hyperoxygenate a patient for oral intubation?
2-3 minutes

55. What is an extra piece of equipment you may need for nasal intubation?
Magill forceps

56. What position should the patient be in for nasal intubation?
Direct – supine blind (Fowler’s position)

57. How do you confirm the placement of an airway?
Auscultation, observation of chest movement, PetCO2, esophageal detection device, light wand, fiberoptic laryngoscopy, and CO2 detector.

58. What is the most accurate way to confirm tube placement after intubation?
Fiberoptic laryngoscopy

59. Should you use a chest x-ray to confirm tube placement after intubation?
No, it should only be used to determine the position of the tube.

60. When should you consider a tracheostomy?
When the ET tube will be inserted for more than seven days

61. What is the maximum recommended range for tracheal tube cuff pressure?
20-25 mmHg

62. Repeated connecting and disconnecting of a cuff pressure manometer to the pilot tube of a cuffed tracheal airway will do what?
It will decrease the cuff pressure.

63. What type of endotracheal tube should the respiratory therapist use when a unilateral lung disease occurs, and independent lung ventilation is needed?
A double-lumen endotracheal tube

64. When is an uncuffed tracheostomy tube used?
When there is no major concern about aspiration

65. What is the fenestrated tracheostomy tube?
A type of tracheostomy tube that can help facilitate speech

66. What complications occur after extubation?
Sore throat, stridor, odynophagia, pulmonary aspiration, and cough

67. What is the number one complication post-extubation?
Hoarseness

68. How do you prevent airway trauma?
Use sedation when necessary, use nasal tubes instead of oral tubes, use correctly sized tubes, avoid changing tubes, avoid unnecessary coughing, and limit the cuff pressure.

69. What is the process of airway maintenance?
(1) Secure the tube and maintain proper placement, (2) Provide cuff care, (3) Aid in secretion clearance, (4) Ensure humidification, (5) Minimize the possibility of infection, (6) Provide patient communication, and (7) Troubleshoot emergencies

70. What do you need in order to secure an endotracheal tube?
Tape, velcro attachments, harness, and bite block

71. What do you need in order to secure a tracheostomy tube?
Velcro attachments or ties

72. What values should you record for the positioning of an endotracheal tube?
You should record the size of the tube and the positioning, which is recorded in centimeters.

73. Unplanned extubation occurs in what percentage of intubated patients?
Unplanned extubation occurs in 2-13% of patients. The primary contributing factor is a lack of secure placement.

74. What is an easy way to remember what equipment is needed during intubation?
You can remember SOAPME, which stands for suction equipment, oxygen, airway equipment, position the patient, monitors, and esophageal detectors.

75. What is the normal range for cuff pressure?
20-30 cmH2O

76. When maintaining cuff pressure, it is important to?
Keep the cuff pressure below the tracheal capillary perfusion pressure

77. How can you measure cuff pressure?
You can use a pressure manometer to measure cuff pressure.

78. What are some emergency airway situations?
Tube obstructions, cuff leaks, and accidental extubations

79. What are examples of a tube obstruction?
Kinking or biting, herniation of the cuff over the tube, jamming of the tube opening against the tracheal wall, and mucus plugging

80. What are the clinical signs of an airway emergency?
Respiratory distress, changes in breath sounds, and air movement through the mouth

81. How do you fix kinking of the endotracheal tube?
Reposition the head/neck

82. How do you fix biting of the endotracheal tube?
Use an oropharyngeal airway or bite block

83. What should you do in the case of a herniated cuff?
Deflate and re-inflate the cuff; then, you can try to pass a suction catheter to determine if the cuff is herniated

84. What should you do if the tip of the endotracheal tube is on the tracheal wall?
Reposition the airway and the patient’s head or neck

85. What should you do if there is a mucus plug?
Lavage, try to pass a suction catheter and then resort to extubation

86. What should you always do prior to extubation?
Suction the patient

87. What is extubation?
The procedure of removing an endotracheal tube

88. What are some indications for extubation?
The patient can maintain their upper airway patent, protect their lower airway from aspiration, clear secretions from the lower respiratory tract, and breathe without mechanical ventilation

89. What is the failure rate for extubation?
5-15% of cases are failures

90. A practitioner who performs extubation should also be able to do what?
Intubate

91. What can be used to maintain a stoma?
Tracheal button

92. How is the laryngeal mask airway (LMA) inserted?
It is blindly inserted.

93. How is the esophageal obturator (EOA) inserted?
It is inserted into the esophagus

94. How does an endotracheal tube exchanger work?
It is inserted through the ET tube, and then the ET tube is withdrawn and removed. A new ET tube can be slipped over the tube exchanger and threaded down into the proper location.

95. What are the supplies needed for tracheostomy care?
Suction supplies, oxygen therapy, hydrogen peroxide, sterile dressings and ties, sterile water, and a new inner cannula (or supplies to clean a reusable one).

96. What can you give to reduce inflammation post-extubation?
Decadron

97. What should the patient’s FiO2 be in order to proceed with extubation?
40% or less

98. Tracheal airways increase the incidence of pulmonary infections for all of the following reasons except:
Lower levels of humidification

99. What types of obstructions can occur in a natural airway?
(1) Soft/tissue (tongue) obstruction, (2) Foreign body, (3) Supraglottic or subglottic edema, and (4) Thick secretions

100. What are the signs of a complete obstruction in a natural airway?
(1) Paradoxical chest movement, (2) Inability to vocalize, (3) Marked use of accessory muscles, (4) Nasal flaring, and (5) Severe anxiety or agitation

101. What maneuvers can help establish patency in a natural airway?
(1) Modified jaw thrust and (2) Head-tilt/chin-lift

102. What is a modified jaw thrust?
It is a modified technique of moving the jaw that aims to avoid head extension and is good for suspected neck trauma patients. It is done by pushing the mandibular process to extend the jaw and open the airway.

103. How do you perform the head-tilt/chin-lift maneuver?
It is done by lifting the front edge of the patient’s jaw with one hand while pushing the forehead upward. You should not use this when there is a suspected neck or spinal cord injury.

104. What is the procedure for extubation?
(1) Clear the airway by suctioning below and above the airway, (2) Explain the procedure to the patient, (3) Remove the air from the cuff, (4) Have the patient inhale and hold their breath at maximum inspiration while removing the tube, (5) Instruct the patient to cough and expectorate, (6) Perform suctioning if needed

105. What is the purpose of suctioning while an artificial airway is in place?
To remove secretions, promote expectoration of secretions (cough), or collect a sputum sample

106. What is the procedure for suctioning while an artificial airway is in place?
Pre-oxygenate the patient with 100% oxygen before and after suctioning for 1-3 minutes. The procedure should be sterile, and you should suction for no longer than 15 seconds. Stop suctioning if the patient shows signs of distress.

107. What are the hazards of suctioning while an artificial airway is in place?
Cardiac changes can occur due to vagal stimulation (e.g., bradycardia or hypotension). Hypoxemia can also occur as oxygen is suctioned away from the patient.

108. To ensure adequate humidification for a patient with an artificial airway, inspired gas at the proximal airway should be 100% saturated with water vapor, and at what temperature?
32 to 35 degrees C

109. How do we determine the size of a nasopharyngeal airway?
The outside diameter of the airway should be equal to the inside diameter of the patient’s external nares. The length of the airway is measured from the tip of the earlobe to the center of the nostrils.

110. How do you insert an oropharyngeal airway?
It should be inserted opposite of its anatomic shape. Therefore, you can insert it upside down to the back of the throat and then rotate it into its correct position.

111. How do you insert a nasopharyngeal airway?
It should be inserted in the direction of its anatomical shape using a water-soluble lubricant.

112. What is the minimal leak technique (MLT)?
It is a technique that involves slowly injecting air into the cuff during positive pressure inspiration until the leak stops.

113. How do you troubleshoot a laryngoscope?
If the light doesn’t work, you can tighten the bulb, check the handle attachment, change the blade, or change the batteries.

114. What are the normal blade sizes?
Adult: size 3; Pediatric: size 2; Term infant: size 1; Pre-term infant: size 0

115. What is a stylet?
It is used to aid in oral intubations only and helps shape the tube for easier insertion.

116. What are Magill forceps?
They are used to aid in nasal intubation and are inserted into the mouth to lift the tube into the trachea.

117. What are the normal endotracheal tube markings?
For oral intubation, the tube is inserted 21-25 cm at the lip. For nasal Intubation, the tube is inserted 26-29 cm at the nares.

118. What is a double-lumen tube?
It’s an artificial airway with two independent lumens of different lengths. The longer tube is inserted in either the left or right mainstem bronchus. The shorter tube is placed in the trachea above the carina. Each Lumen can ventilate one lung separately, or they can be connected via wye and share the same ventilation source.

119. Where is a laryngeal mask airway (LMA) positioned?
It is positioned directly over the opening of the trachea (hypopharynx).

120. What three methods can be used to determine the correct position of an ET tube?
(1) Look for bilateral chest expansion during inspiration, (2) Auscultation of the patient’s chest should reveal bilateral breath sounds, and (3) The chest x-ray should show the radiopaque line on the endotracheal tube

121. How can a respiratory therapist maintain airway patency?
Suctioning

122. When checking for proper placement of an endotracheal tube in an adult patient on a chest radiograph, it is noted that the distal tip of the tube is 2 cm above the carina. Which of the following actions would you recommend?
Withdraw the tube 2 to 3 cm

123. When checking for proper placement of an endotracheal or tracheostomy tube on a chest radiograph, how far above the carina should the distal tip of the tube be positioned?
3 to 6 cm

124. What size laryngoscope blade is used for adult patients?
Size 3

125. What size laryngoscope blade is used for term infants?
Size 1

126. What is the approximate endotracheal tube size for a pre-term infant?
2.5-3.0 mm

127. What is the approximate endotracheal tube size for a full-term infant?
3.0-3.5 mm

128. What is the appropriate endotracheal tube size for adults?
Males: 8.0-9.0mm; Females: 7.0-8.0 mm

129. A patient receiving mechanical ventilation is being transported to radiology for a CT scan. The respiratory therapist is arranging equipment when the low-volume alarm begins to sound. She also notes that the oral endotracheal tube is taped at the 28 cm mark. Where should the tube actually be located?
Between 21-25 cm

130. Why should the endotracheal tube be removed at peak inspiration?
To prevent vocal cord damage

131. What should you do if the patient self-extubates?
Alert the physician and re-intubate the patient

132. What is a complication of extubation?
Post-extubation stridor and a sore throat, which can be managed with humidity, oxygen, and/or racemic epinephrine

133. When is a tracheostomy preferred over endotracheal intubation?
It is the preferred method of providing an airway for patients who require long-term ventilation.

134. What are two possible immediate complications of a tracheostomy procedure?
Bleeding and a possible pneumothorax

135. What are two possible late complications of a tracheostomy procedure?
Infection and hemorrhage

136. When should a tracheostomy tube cuff be inflated?
It should be inflated if the patient is eating or if they are receiving positive pressure ventilation.

137. When is a fenestrated tracheostomy tube recommended?
It is used for weaning and temporary mechanical ventilation with an inner cannula.

138. What are the characteristics of a standard tracheostomy tube?
They are often white, made of plastic, and may have an inner cannula for easy cleaning.

139. What should you do to the cuff of a tracheostomy tube when using a tracheal speaking valve?
The cuff must be deflated.

140. What is the most commonly used airway for ventilating a patient with a manual resuscitator?
Oropharyngeal airway

141. Which of the following techniques or procedures should be used to help minimize infection of a tracheostomy stoma?
Regular aseptic stoma cleaning, adherence to sterile techniques, and regular changing of the tracheostomy dressings

142. What does LMA stand for?
Laryngeal Mask Airway

142. Oropharyngeal airways are indicated for what types of patients?
Unconscious patients

143. Can the incorrect placement of an oropharyngeal airway (OPA) push the tongue further back into the pharynx and make an obstruction worse?
Yes

144. What should you do if you encounter resistance upon insertion of a nasopharyngeal airway in the right nare?
Try the left nare

145. What is the most common airway maneuver that can be used to ventilate an apneic patient during CPR?
Head-tilt/chin-lift

146. What is the proper way to estimate the appropriate length of a nasal airway?
Measure from the patient’s earlobe to the tip of the nose

147. When is the jaw thrust technique indicated to help maintain an open airway?
During most CPR efforts

148. When should a laryngeal mask airway be used?
It should be used for short-term ventilation of an unconscious patient.

149. A physician is concerned about the potential for tracheal damage due to tube movement in a patient who recently underwent tracheostomy and is now receiving 40% oxygen through a T- tube. What would be the best way to limit the tube movement in this patient?
Switch from the T-tube to a tracheostomy collar

150. What is a hazard of the insertion of an oropharyngeal airway?
Vomiting

151. What is the position of a correctly sized and properly inserted oropharyngeal airway?
The distal tip should be at the base of the tongue, and the flange should be outside the teeth.

152. A patient has been receiving positive pressure ventilation through a tracheostomy tube, and there was evidence of both recurrent aspiration and abdominal distention. There was also minimal air leakage around the tube cuff. What is the most likely cause of this problem?
Tracheoesophageal fistula

153. What is a stoma?
A hole in the trachea without a tube in place

154. What are the complications of a tracheostomy?
Bleeding, pneumothorax, air embolism, subcutaneous emphysema, infection, hemorrhage, and tracheal stenosis.

155. What is a Passy-Muir speaking valve?
It’s a one-way valve that attaches to the 15 mm adaptor and allows for speech and secretion management. It allows air to enter only during inspiration. The blue-colored ones are used with ventilators. The white ones are for spontaneously breathing patients.

156. What is a tracheostomy button used for?
It’s used to aid in weaning from a tracheostomy tube, and it helps keep the stoma open.

157. What does a tracheostomy button look like?
It’s a short, soft, and hollow tube that fits in the stoma in place of a tracheostomy tube.

158. A patient is being evaluated for tracheal damage sustained while having undergone prolonged tracheostomy intubation approximately three months earlier. The flow-volume loop demonstrates a fixed obstructive pattern. What is the most likely cause of the problem?
Tracheal stenosis

159. What are the methods for weaning from a tracheostomy tube?
Tracheostomy buttons, fenestrated tubes, and progressively smaller tracheostomy tubes.

160. Tracheal stenosis occurs in as many as 1 in 10 patients after prolonged tracheostomy. Where does this stenosis usually occur?
The cuff site, the tip of the tube, and the stoma site

161. What is the biggest problem with an LMA?
Regurgitation during insertion

162. What is one of the most common causes of airway obstruction?
Tube obstruction

163. How do you know when there is an obstruction in the tube?
When the peak airway pressure on the ventilator increases

164. When will you need to remove the entire airway and replace it?
If all the other methods are not working.

165. Which airway is preferred during an emergency?
Oral

168. What should you do when weaning a tracheostomy patient?
Remove the inner cannula, deflate the cuff, and cap the tracheostomy

169. What types of artificial airways are inserted through the larynx?
Nasotracheal and orotracheal tubes

170. Compared with the oral route, the advantages of nasal intubation include all of the following except:
Reduced risk of kinking

171. Compared with trans-laryngeal intubation, the advantages of a tracheostomy include all of the following except:
Decreased frequency of aspirations

172. What is the purpose of the additional side port on most modern endotracheal tubes?
To ensure gas flow if the main port is blocked

173. What is the purpose of the cuff on an artificial tracheal airway?
To seal off and protect the lower airway

174. What is the purpose of the pilot balloon on an endotracheal or tracheostomy tube?
To monitor cuff status and pressure

 175. The removable inner cannula that is commonly incorporated into modern tracheostomy tubes serves what purpose?
It aids in routine cleaning and provides a patent airway should an obstruction occur.

176. Before beginning an intubation procedure, the practitioner should check and confirm the operation of what?
Laryngoscope light source, endotracheal tube cuff, and suction equipment

177. Which of the following statements are false about methods used to displace the epiglottis during oral intubation?
Levering the laryngoscope against the teeth can aid in displacement

178. What is the most common sign associated with the transient glottic edema or vocal cord inflammation that follows extubation?
Hoarseness

179. After the removal of an oral endotracheal tube, a patient exhibits hoarseness and strider that do not resolve with racemic epinephrine treatments. What is most likely the problem?
Vocal cord paralysis

180. Which of the following injuries are NOT seen with tracheostomy tubes?
Glottic edema and vocal cord granulomas

Final Thoughts

Airway management is an indispensable skill set for healthcare professionals that directly impacts patient survival and outcomes.

Techniques such as endotracheal intubation, use of supraglottic airway devices, and application of rapid sequence induction have evolved as medicine has advanced, but the core principle remains the same: ensuring a secure and open airway to facilitate essential oxygenation and ventilation.

Continued education, training, and research in this field are vital for advancing best practices and reducing patient morbidity and mortality related to airway complications.

In a healthcare landscape where seconds can mean the difference between life and death, the importance of competent airway management cannot be overstated.