Respiratory care
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Management of the artificial airway includes securing the tube to prevent dislodgement or migration as well as removal of secretions. Preventive measures include adequate humidification and appropriate airway suctioning. ⋯ A number of new monitoring techniques have been introduced, and automated cuff pressure control is becoming more common. The respiratory therapist should be adept with all these devices and understand the appropriate application and management.
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Performing emergency endotracheal intubation necessarily means doing so under less than ideal conditions. Rates of first-time success will be lower than endotracheal intubation performed under controlled conditions in the operating room. Some factors associated with improved success are predictable and can be modified to improve outcome. Factors to be discussed include the initial decision to perform endotracheal intubation in out-of-hospital settings, qualifications and training of providers performing intubation, the technique selected for advanced airway management, and the use of sedatives and neuromuscular blocking agents.
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Tracheostomy tubes are used to administer positive-pressure ventilation, to provide a patent airway, and to provide access to the lower respiratory tract for airway clearance. They are available in a variety of sizes and styles from several manufacturers. The dimensions of tracheostomy tubes are given by their inner diameter, outer diameter, length, and curvature. ⋯ Specialized teams may be useful in managing patients with a tracheostomy. Speech can be facilitated with a speaking valve in patients with a tracheostomy tube who are breathing spontaneously. In mechanically ventilated patients with a tracheostomy, a talking tracheostomy tube, a deflated cuff technique with a speaking valve, or a deflated cuff technique without a speaking valve can be used to facilitate speech.
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Manual ventilation is a basic skill that involves airway assessment, maneuvers to open the airway, and application of simple and complex airway support devices and effective positive-pressure ventilation using a bag and mask. An important part of manual ventilation is recognizing its success and when it is difficult or impossible and a higher level of support is necessary to sustain life. Careful airway assessment will help clinicians identify what and when the next step needs to be taken. ⋯ Bag-mask ventilation (BMV) plays a vital role in effective manual ventilation, improving both oxygenation and ventilation as well as buying time while preparations are made for endotracheal intubation. There are, however, situations in which BMV may be difficult or impossible. Anticipation and early recognition of these situations allows clinicians to quickly make adjustments to the method of BMV or to employ a more advanced intervention to avoid delays in establishing adequate oxygenation and ventilation.
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Fiberoptic intubation (FOI) is an effective technique for establishing airway access in patients with both anticipated and unanticipated difficult airways. First described in the late 1960s, this approach can facilitate airway management in a variety of clinical scenarios given proper patient preparation and technique. ⋯ Evidence is presented comparing FOI to other techniques with regard to difficult airway management. In addition, we have reviewed the literature on training processes and skill development in FOI.