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Tracheostomy

Emergency management

The assessment and treatment of a patient with a tracheostomy in respiratory distress is a key skill for the emergency physician. We provide a guide in our procedures section. This procedure guide is based on the flowcharts and approach produced and freely available at www.tracheostomy.org.uk.

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.

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Overview

Tracheostomy refers to an artificial opening into the trachea, which may be temporary or permanent. Bypassing the upper airway causes significant alterations to normal physiology that include:

  • Bypassing normal gas humidification processes
  • Normal mucociliary clearance
  • Disruption of normal communication and eating
  • Pooling of oropharyngeal secretions above the cuff leading to micro aspiration and increased risk of nosocomial pneumonia.

Key knowledge for the emergency physican

  • Most tracheostomies have an inner and an outer tube, which means any blockage to the inner tube can be resolved by removing that tube.
  • The tracheostomy may be fenestrated which allows passage of air through the vocal cords to allow phonation.
  • Patients who have a high risk of aspiration or who require ventilation may have a cuffed tracheostomy (high volume low pressure). Most tracheostomy patients outside hospital have uncuffed tubes.
  • Passive humidification is provided by a heat moisture exchange cap on the external aspect of the tracheostomy, which can block

Clinicians should be aware of the difference between a stoma following laryngectomy and a tracheostomy. After a laryngectomy there is no link between the mouth and the lungs, all ventilation must be via the stoma. With tracheostomy there may be the potential to ventilate the patient via the nose and mouth in an emergency.

Emergency management

The assessment and treatment of a patient with a tracheostomy in respiratory distress is a key skill for the emergency physician. We provide a guide in our procedures section. This procedure guide is based on the flowcharts and approach produced and freely available at www.tracheostomy.org.uk.

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.

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