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Airway Management in Mechanical Ventilation 153

provides closer access to the lower airways. It has a lower mechanical deadspace
volume than an ET tube. It also ventilates the patient more efficiently and en-
hances secretion removal. In spite of many advantages of a tracheostomy tube,
ET intubation is preferred as the initial means of establishing an artificial airway.
Oral and nasal intubations are commonly done by respiratory care practitioners.
When these two routes are not accessible or when the need for a long-term artificial
airway is expected, a tracheotomy is done by a physician who is proficient in this
surgical procedure.

Indications

The decision to perform ET intubation versus tracheotomy is based on the expected
duration of need. In general, if the patient requires an artificial airway for a brief
period (e.g., 10 days or less) and full recovery is expected, an ET tube is used. On
the other hand, if the patient’s condition is critical and recovery is not expected
any time soon (e.g., more than 21 days), a tracheostomy tube is preferred (Shapiro
et al., 1991).
Choosing when to intubate is also a difficult clinical decision because delayed
intubation may lead to hypoventilation, hypoxemia, and hypoxia. The timing of in-
tubation can be based on four indications: (1) relief of airway obstruction, (2) pro-
tection of the airway, (3) facilitation of suctioning, and (4) support of ventilation
(Shapiro et al., 1991). Some examples for each of these indications are listed in
Table 6-1.

TABLE 6-1 Indications for Using Artificial Airway

Indication Examples

Relief of airway obstruction Epiglottitis
Facial burns and smoke inhalation
Vocal cord edema

Protection of the airway Prevention of aspiration
Absence of coordinated swallow

Facilitation of suctioning Excessive secretions
Inadequate cough
Support of ventilation Ventilatory failure / respiratory arrest
Chest trauma
Postanesthesia recovery
Hyperventilation to intracranial pressure
➞
(Data from Shapiro et al., 1991; White, 2002; Whitten, 1997.)
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