Artificial Airways: Tubes and Trachs

Artificial airways are indicated to relieve obstruction, prevent aspiration, facilitate suctioning, and provide artificial ventilation. If a patient's normal protective airway reflexes are absent or compromised, an airway must substitute for their functions. Hazards of artificial airways include infection, loss of the protective cough, and damage to airway structures. Oral tracheal intubation is indicated for emergencies, while nasotracheal tubes are probably more suitable for longterm use. Any tube should be removed as soon as the indication for it has disappeared. Tracheostomy is better than upper airway intubation for longer terms than 72 hours, being easier to care for, suction through, and connect to ventilation, oxygen, and humidifying apparatus. If an endotracheal tube is used, it should be evaluated every day to decide whether tracheotomy may be preferable. Airway care includes suctioning, humidification, secretion cultures, and cuff care. Culture should be done at least every 3 days; infection requires antibiotics, but prophylactic antibiotics for contamination are contraindicated. The most common complication of endotracheal intubation is glottic edema, especially in children. Subglottic edema is most serious and usually requires reestablishment of an artificial airway to prevent threat to life. Steroids may be helpful also, but the airway is mandatory here. Tracheal stenosis after extubation can occur early or late; the best approach is preventive care by avoiding excessive tracheal wall cuff pressures. Modern high-residual volume cuffs, tubes with pressure-regulating valves, and foam cuff tubes are helping to meet this challenge. Minimal occluding volumes in cuffs and minimal leak techniques of cuff inflation during inspiration are useful approaches, while periodic cuff deflation no longer is regarded as useful. If a cuff has to be deflated, secretions resting above it should first be aspirated.