 Artificial airways used for prolonged periods consisting of nasal and oral endotracheal tubes and tracheostomy tubes are used in patients to maintain airway patency and to provide ventilatory support and oxygenation. Although the establishment of an artificial airway may be a life-saving procedure, meticulous maintenance and care are needed to prevent infection and other complications which are associated with intubation. Critical components of airway maintenance consist of secretion clearance, securing the tube in maintaining proper tube position, and cuff maintenance. Secretion clearance is discussed in the airway sectioning training module. The other two airway maintenance techniques will be discussed in this module. As always, wash your hands and follow standard precautions. In general, always wear gloves while providing airway care. Prior to securing the endotracheal tube, note the depth to which the tube is placed. There are centimeter markings printed on the tube. To do so, check the markings on the side of the tube. Note the centimeter marking nearest to the closest anatomical landmark, such as the nares or nostrils for nasal tubes or the lips for oral tubes. The physician determines the depth of the airway for proper placement by listening for equal breath sounds bilaterally with a stethoscope, auscultation, observing the patient's bilateral chest expansion, and assuring that breath sounds are not heard over the stomach. The tube should remain at that depth at all times unless otherwise specified by a physician. In this case, the tube is at 21 and needs to be advanced to 23. The cheeks should be clean and dry and shaved if necessary. Tincture of benzoin may be applied with a 4x4 gauze to improve adhesiveness. There are many different acceptable methods of taping endotracheal tubes. In the method that will be demonstrated here, the tape is applied in alternating sequence, wrapping the tape around the tube, then above the top lip, and then across to the other side of the face. Be aware that this procedure should never be attempted alone, and that at least two people are required, one of which is a qualified healthcare professional such as a registered respiratory therapist. With one person holding the endotracheal tube at the predetermined depth, and another person securing the tube with tape, string, or other apparatus, be very cautious of the endotracheal tube shifting during the procedure due to patient movement. A third person may be necessary to maintain tube stability in combative patients. Then preparing the tape by cutting a length of one inch clothed tape by using your neck is demonstrated. The tape will need to be long enough to go behind the patient's neck and cross over in front of the patient's face. Approximately two feet of tape is required. Tear tape and lay two foot section of tape flat, sticky side up. Tear a smaller piece of tape, approximately four inches in length, and place sticky side down in the center of the longer piece of tape. This non-sticky center prevents the tape from adhering to the back of the patient's head. Select one end of the tape and tear in half down middle, approximately one inch in length. Fold ends down so tape doesn't stick together. Next, fold tape in half over a tongue blade to the center where the four inch piece of tape was placed, starting at torn end. Folding the tape as previously demonstrated prevents the tangling of the tape during the procedure. Slide tongue blade behind patient's neck and pull tape up, removing the tongue blade. Start the taping procedure on the side of the mouth, which the endotracheal tube is placed. Using the original one inch tear, create a longer tear on the tape. Select one strip of tape created by the tear and wrap it around the base of the endotracheal tube at the lips, again being very careful to avoid modifying the depth of the tube. After wrapping the tape around the endotracheal tube one to two times, adhere the remainder of the tape along the upper lip and cheek. Repeat the previous steps, alternating sides until three of the four strips of tape created by tearing the original piece of tape have been wrapped around the tube similarly and secured. It is vital that the tape be properly adhered along the upper lip. Use the last strip of tape to anchor the three pieces securely along the upper lip. Finally, it is important the tape is not wrapped too tightly around the patient's neck, thus impeding circulation. One finger must be able to slip under the non-sticky center section of the tape beneath the back of the patient's neck. Cuff management. The cuff of the endotracheal tube has three main components, the pilot balloon, the pilot line, and the cuff itself. The cuff of the endotracheal tube is inflated for two reasons. Prevent air leaking around the tube during ventilatory support and to prevent aspiration of oral secretions. When air is injected into the cuff via the pilot balloon, the cuff is inflated at the distal end of the endotracheal tube and the windpipe, thus sealing off upper airway. The main goal of cuff inflation is to fill the cuff with enough air to accomplish these two objectives, while simultaneously minimizing the risks associated with overinflation. These risks are noted as follows. Tissue pressure necrosis, tissue granulomas, trachea esophageal or arterial fissula, tracheomalacia, tracheal stenosis, vocal cord paralysis, vocal cord ulceration. The minimum occluding volume and minimal leak technique are two cuff inflation methods which are intended to minimize these risks. Minimum occluding volume. This procedure may be practiced on an intubated mannequin with another person providing manual ventilation and flight the cuff slowly using a clean dry 10cc syringe to inject air into the pilot balloon. Begin by injecting 1cc of air and listening for air leaks during peak inspiration. Continue injecting air in one half to 1cc increments while your partner continues to administer maximum inflation breaths with manual ventilation. Stop injecting air when a leak is no longer heard over the neck or through the mouth. Document the total amount of air you injected that was required to obtain a good seal during peak inspiration. Minimal leak technique. This procedure is very similar to minimum occluding volume method and may also be practiced on an intubated mannequin. With another person providing manual ventilation, inflate the cuff slowly using a clean dry 10cc syringe to inject air into the pilot balloon. Begin by injecting 1cc of air and listen for air leaks during the peak inspiration. Continue injecting air in one half to 1cc increments while your partner continues to administer maximum inflation breaths with manual ventilation. The difference between MLT and MOV is that once you have obtained a good seal with maximal inspiration, with MLT you now withdraw a small amount of air from the cuff until, using a stethoscope, a slight leak is heard above the cuff on the lateral neck. You will know that you have created too large a leak if air is leaking through the nose or mouth. Document the total amount of air that you've injected to inflate the cuff. Both cuff inflation methods may be applied in nasal and oral endotracheal tubes as well as tracheostomy tubes. There is no variation in either of the methods regardless of whether the patient is intubated with an oral, nasal, or tracheostomy tube. The determination of whether to use MOV or MLT is generally based on institutional or departmental policy. Either method is acceptable in the majority of cases.