Airway - Tracheostomy emergencies

Related Videos

We recommend a prepared box of equipment be available in each department, to be placed by the bed of tracheostomy patients in case of respiratory distress. This procedure guide is based on the flowcharts and approach produced and freely available at www.tracheostomy.org.uk.

Indications

Respiratory distress

Accidental decannulation

Contraindications (absolute in bold)

None

Sequential treatment

Easily reversible respiratory problems (sputum plugging, malposition) cause mortality in tracheostomy patients. We advocate a sequential approach prior to tube replacement.

High flow oxygen

Nebulised saline

Remove speaking valve or cap

Remove inner tube

Suction

Cuff deflation (allowing ventilation around tracheostomy)

Tube removal and ventilation (without replacement)

Tube replacement and ventilation (stomas >10 days old require a size smaller tracheostomy tube)

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

Potential complications (of tube replacement)

Failure

False passage (paratracheal, oesophageal)

Trauma (trachea, brachiocephalic trunk / innominate artery, vocal cords, nerves, thyroid)

Mucosal ulceration (cuff pressure)

Infection

Procedural hygiene

Standard precautions

PPE: non-sterile gloves, aprons, surgical mask, protective eyewear/shield

Area

Resuscitation bay prepared for a difficult airway

Including waveform capnography (gold standard for assessing stoma ventilation)

Staff

Team leader (working through the flowchart)

Two airway clinicians (stoma and upper airway)

Bedside equipment (ideally in a prepared box for use in tracheostomy emergencies)

Nurse call bell (patient may be unable to call for help verbally)

Adult airway adjuncts, LMA and bag valve mask

LMA size 2 (to be held over stoma to seal if required)

Two tracheostomy tubes to replace blocked tube (same size and one size smaller e.g. Shiley 5 + Portex 6, 7, 8)

Heat-moisture exchange device (to replace blocked heat-moisture exchange device)

Spare inner cannula (to replace blocked cannula)

Size 6 ETT (if tracheostomy tubes unavailable)

Bougie

Water-soluble lubricating jelly

Suction catheters (10-14F, larger may be required for mucus plugs)

Yankeur suction (oral suction)

Sterile water (cleaning the suction tube)

Tracheostomy mask, humidifier bulb and O2 connector

10 ml syringe for deflating and inflating tracheostomy cuff

Scissors and stitch cutter (cutting tracheostomy sutures)

Tracheal dilating forceps (may help open tract)

Dressing pack, tracheostomy dressings and tape

A fibreoptic scope if available (e.g. Ambu aScope)

Positioning

Position of comfort, usually sitting up to prevent aspiration

Medication

0.9% Saline for nebulisation

Sequence (respiratory distress with normal saturations)

High flow oxygen to stoma and face

Nebulise 0.9% sodium chloride via stoma

Remove phonation or humidification cap and inner cannula

Clean inner cannula

Suction stoma with suction catheter

Replace phonation or humidification cap and inner cannula

Sequence (respiratory failure (progress through steps until resolution))

High flow oxygen to stoma and face

Remove phonation or humidification cap and inner cannula

Insertion suction catheter to stoma and assess for patency (patent if passes easily deeply into trachea)

Ensure cuff deflated (allowing ventilation around a tracheostomy tube displaced against the tracheal wall)

Remove outer cannula (sutures may need to be cut)

Non-invasive ventilation (oral BVM or LMA and stoma oxygen by paediatric face mask or size 2 LMA held over stoma)

Invasive ventilation (insert new tracheostomy tube or size 6 ETT over bougie or fibreoptic scope)

Consider intubating via oral cavity with deep cuff placement beyond tracheostomy (not in laryngectomy)

Surgical airway below existing tracheostomy (see surgical airway procedure)

Sequence: accidental decannulation (progress through steps until resolution)

High flow oxygen to stoma and face

Non-invasive ventilation (stoma and mouth oxygen, LMA and paediatric LMA to stoma)

Invasive ventilation (insert new tracheostomy tube or size 6 ETT over bougie or fibreoptic scope)

Consider intubating via oral cavity with deep cuff placement beyond tracheostomy (not in laryngectomy)

Surgical airway below existing tracheostomy (see surgical airway procedure)

Post-procedure care

Monitor in resuscitation bay

Frequent saline nebulisers (reduce mucus viscosity)

Urgent ENT and anaesthetic assessment

If intubated tie tube (one finger space between tie and neck allowing for venous return)

Check cuff pressure through pilot cuff

Document procedures with size and type of tracheostomy placed

Tips

Expect a leak around an uncuffed tracheostomy tube (close mouth and pinch nares to minimise)

Percutaneous tracheostomies <10 days are impossible to replace (the dilated stoma tract tissues recoil)

Laryngectomy patients have no connection between the mouth and lungs, airway management from above is futile

Discussion

The principles of care for respiratory failure are the same as for other intubated patients

Apply the “DOPE” mnemonic in emergency situations (displacement, obstruction, patient, equipment)

If the patient loses cardiac output, these steps should be followed alongside standard ALS treatment

Speaking valves can be used incorrectly and small humidifying devices (e.g. Swedish noses) and inner tubes can become blocked with secretions. Any such device attached to a tracheostomy tube should be removed in an emergency, which may resolve the obstruction. Passing a soft suction catheter will then confirm patency. If patent, the patient can be ventilated via the tracheostomy (inflate cuff or close mouth and nares to reduce leak). If not patent, the tracheostomy tube will need to be removed, followed by oronasal ventilation with or without another tracheostomy tube being placed.

Laryngectomy patents do not have an upper airway in continuity with the lungs. The principles of the algorithm are the same, without the conventional upper airway management steps. Patients with laryngectomies usually do not have a tracheostomy tube in situ, but may have other devices inserted into their airways to allow speech via the oesophagus (tracheo-oesophageal puncture ‘TEP’ valves). These devices should be left in place during resuscitation.

We recommend a prepared box of equipment be available in each department to be placed by the bed of tracheostomy patients in case of respiratory distress.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

National Tracheostomy Safety Project. Manchester, UK

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

National Tracheostomy Safety Project. Manchester, UK: National Tracheostomy Safety Project; 2020. [cited June 2020] Available from: http://www.tracheostomy.org.uk

McGrath BA, Bates L, Atkinson D, Moore JA; National Tracheostomy Safety Project. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012;67(9):1025-1041. doi:10.1111/j.1365-2044.2012.07217.x

Long B, Koyfman A. Resuscitating the tracheostomy patient in the ED. Am J Emerg Med. 2016;34(6):1148-1155. doi:10.1016/j.ajem.2016.03.049

Bontempo LJ, Manning SL. Tracheostomy Emergencies. Emerg Med Clin North Am. 2019;37(1):109-119. doi:10.1016/j.emc.2018.09.010

NSW Agency for Clinical Innovation. Care of adult patients in acute care facilities with a tracheostomy. Sydney: ACI; 2013. 91pp. Available from: https://www.aci.health.nsw.gov.au/networks/icnsw/intensive-care-manual/statewide-guidelines/acute-tracheostomy

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges' clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O'Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Hess DR. Tracheostomy tubes and related appliances. Respir Care. 2005;50(4):497‐510.

Kannan S, Birch JP. Controlled ventilation through a tracheostomy stoma. Anaesth Intensive Care. 2001;29(5):557.

Ball DR, Paton L, Jefferson P, Caldwell D. Tracheostomy ventilation using a laryngeal mask as a 'bridge to extubation'. Anaesthesia. 2010;65(12):1232‐1233. doi:10.1111/j.1365-2044.2010.06552.

© Agency for Clinical Innovation 2021

Feedback