Respiratory distress in Tracheostomy Patient

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?

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?

When was the tracheostomy performed?

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

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

LITFL

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]