OVERVIEW

There are important considerations regarding tracheostomy management that differ from the standard approach to respiratory distress

APPROACH TO CAUSES IN ANY INTUBATED PATIENT

Think ‘DOPES’

• Displacement of the tube
• Obstruction of the tube
• Patient — especially pneumothorax; also: pulmonary embolism, pulmonary oedema, collapse, bronchospasm
• Equipment — ventilator problems
• ‘Stacked breaths’ — a reminder about bronchospasm and ventilator settings.

IMMEDIATE ASSESSMENT

Think ‘MASH’

• Movement of the chest during ventilation — is it absent or is movement only on one side? Is the chest hyper-expanded?
• Arterial saturation (SaO2) and PaO2 — obtain an ABG sample
• Skin colour of the patient (is he turning blue or pinking up?) — the SO2 monitor lags behind the true oxygen saturation of the patient
• Hemodynamic stability

IMPORTANT INFORMATION TO KNOW ABOUT A TRACHEOSTOMY PATIENT

Is the tracheostomy tube blocked or displaced?

• this requires removal or replacement
• check if able to pass a suction catheter
• can also use: ETCO2, CXR and bronchoscopy as adjuncts

Is the tube cuffed or cuffless?

• cuffed tubes are needed for airway protection and positive pressure ventilation
• the presence of a pilot balloon indicates a cuffed tube
• a cuff leak may be present (cut the inflation line and insert 20G cannula with 3 way stopcock as a temporary one-way valve to allow reinflation of the cuff if there is a defect in the distal inflation line or pilot balloon)

What is the outer diameter of the tracheostomy tube?

• if a tube is to be inserted it should be the same or smaller outer diameter
• outer diameter is different to the ‘size’

When was the tracheostomy performed?

• only safe to reinsert tracheostomy tube if >7 days

What was the indication for the tracheostomy?

• if laryngectomy or supraglottic pathology intubation from above will not be possible

APPROACH

Assess ABCs and call for help early

• look, listen and feel for breathing at the mouth and tracheostomy
• perform CPR if indicated

Administer high flow oxygen

• to the mouth/ nose and to the stoma site
• if laryngectomy then oxygen to the mouth/nose is not required (but sometimes this is uncertain initially)

Remove the inner cannula (and plug/ speaking valve if present) and check if tracheostomy tube is patent or displaced

• pass a suction catheter down and suction
• if unable to pass then the tube is either blocked or displaced
• If able to pass then the tube could still have a partial blockage or be partially displaced
• ETCO2, bronchoscopy and CXR can also be used depending on availability and urgency
• some inner cannulae need to be replaced to connect to breathing circuits

Attempt oxygenation via the tracheostomy if able to pass suction catheter or patency and location confirmed by other means

• look, listen and feel for breathing at the mouth and tracheostomy
• seek and treat other causes of respiratory distress
• ensure cuff inflated if positive-pressure ventilation required
• if cuffless may need to replace with a cuffed tracheostomy tube of the same or less outer diameter
• only replace a tracheostomy tube if at least 7 days old, otherwise call ENT

If tracheostomy tube is blocked or displaced

• remove tracheostomy tube
• attempt oxygenation and ventilation via the mouth
• if unsuccessful, attempt oxygenation and ventilation via the stoma (use a pediatric mask or an LMA held over the stoma site)
• if unsuccessful, attempt endotracheal intubation (expect a difficult airway) and ensure ETT advances beyond the stoma
• if unsuccessful, attempt intubation of the stoma
  • size 6-0 ETT or small tracheostomy tube
  • options include bougie, airway exchange catheter, fiberoptic bronchoscopy

References and Links

LITFL

• CCC — Tracheostomy
• CCC — Tracheostomy, advantages and disadvantages
• CCC — Tracheostomy Insertion Techniques
• CCC — Tracheostomy Literature Summaries
• CCC — Bleeding tracheostomy
• CCC — Respiratory distress in Tracheostomy Patient
• Pulmonary puzzle 012 — Man versus Machine

Journal articles

• Ball DR, Paton L, Jefferson P, Caldwell D. Tracheostomy ventilation using a laryngeal mask as a ‘bridge to extubation’. Anaesthesia. 2010;65:(12)1232-3. [pubmed]
• Bontempo LJ, Manning SL. Tracheostomy Emergencies. Emerg Med Clin North Am. 2019;37(1):109-119. [pubmed]
• Kannan S, Birch JP. Controlled ventilation through a tracheostomy stoma. Anaesthesia and intensive care. 29(5):557. 2001. [pubmed]
• Long B, Koyfman A. Resuscitating the tracheostomy patient in the ED. Am J Emerg Med. 2016;34(6):1148-55. [pubmed]
• McGrath BA et al. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012;67:1025-41. [pubmed]
• Morris LL, Whitmer A, McIntosh E. Tracheostomy care and complications in the intensive care unit. Crit Care Nurse. 2013;33:(5)18-30. [pubmed]
• Padley A. Yet another use for the laryngeal mask airway–ventilation of a patient with a tracheostomy stoma. Anaesthesia and intensive care. 29(1):78. 2001. [pubmed]
• Townsley RB, Baring DE, Clark LJ. Emergency department care of a patient after a total laryngectomy. Eur J Emerg Med. 2013 Feb 17. [pubmed]

FOAM and web resources

• ICN — Podcast 71: Prevent trache deaths (2013)
• INTENSIVE — More tracheostomy emergencies (2014)
• Resus.ME — LMA to stoma ventilation (2010)
• Resus Room — Airway Management in the Trached Patient: Not an Oxymoron! (2012)
• Taming the SRU — Trouble with Trachs – Recannulating the stenosed trach site (2014)
• UK National Tracheostomy Safety Project at www.tracheostomy.org.uk