There are important considerations regarding tracheostomy management that differ from the standard approach to respiratory distress
APPROACH TO CAUSES IN ANY INTUBATED PATIENT
- 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.
- 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
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
- 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
- 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
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of LITFL.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of two amazing children.
On Twitter, he is @precordialthump.