Page 209 - Clinical Application of Mechanical Ventilation

Airway Management in Mechanical Ventilation 175

Adult endotracheal tubes with a small dorsal lumen above the cuff are available
to allow removal of subglottic secretions with a vacuum pressure of 20 mm Hg
or less. Since the vacuum pressure is relatively low, obstruction or blockage of the
dorsal lumen may occur. Patency of this lumen may be restored by injecting a small
amount of air through the lumen (Tyco Healthcare, 2004). In one study, inter-
mittent drainage of subglottic secretion has been shown to reduce the incidence
of ventilator-associated pneumonia in patients receiving mechanical ventilation
(Smulders et al., 2002).
The sequence outlined in Table 6-8 provides a general procedure for ET suction-
ing. It should be modified to suit individual situations and to comply with existing
protocols. For example, routine irrigation of the ET tube saline solution before suc-
tioning is not recommended (Demaray, 2002). Furthermore, use of saline during
endotracheal suctioning procedure may cause dislodging of bacteria into the lower
airway (Hagler et al., 1994).

Endotracheal Tube Changer

Occasionally, an ET tube may need to be changed (e.g., persistent cuff leak,
tube too small). The flexible fiberoptic bronchoscope has been used successfully
to change an ET tube without reintubation (Rosenbaum et al., 1981). Alter-
natively, an ET tube changer can be used to replace an existing endotracheal
tube without the need to perform traditional intubation. A tube changer is a
flexible guide that is ET tube size-specific and it should be sterilized before use.
Some tube changers allow ventilation and oxygenation and they are ideal for
extubation trial.
The main steps of using the endotracheal tube changer involve inserting the tube
changer into the existing ET tube, deflating the cuff, stabilizing the changer and ET
tube while removing the ET tube, replacing it with another ET tube, and inflating
the cuff.
The distal end of the tube changer placed in the existing ET tube should be
near the distal end of the ET tube. It should not protrude beyond the distal end
of the ET tube. The proper placement of the tube changer can be determined
by using the guide marks on the tube changer. Another approach is to insert
Use of tube changers can
lead to complications that the tube changer into a new identical ET tube until the distal end of the tube
include laceration of lateral changer rests at the distal end of the new ET tube. The marker on the tube
wall, bronchial perforation
with pneumothorax, loss changer at the proximal end of the ET tube can then be noted and used as a
of airway, hypoxemia, and visual guide.
potential need of a surgical
airway. Stabilization of the tube changer during the entire procedure is probably the most
crucial step. An unstable tube changer during the procedure may lead to main-stem
intubation, esophageal intubation, or lung laceration (DeLima et al., 1991). Use
For safety reasons, the of tube changers can lead to complications that include laceration of lateral wall,
person using the ET tube bronchial perforation with pneumothorax, loss of airway, hypoxemia, and potential
changer must be proficient in
intubation and experienced in need of a surgical airway (Nates et al., 2001). For safety reasons, the person using
airway management. the ET tube changer must be proficient in intubation and experienced in airway
management.

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