Ear, Nose & Throat
A 54 year old man is brought to the Emergency Department with an acute onset of respiratory distress. His family tell you he spent 3 months in Intensive Care (ICU) last year following a severe pneumonia. His ICU stay was complicated by a prolonged wean and he still has need for a tracheostomy. As part of your assessment you remove the inner tube but no improvement is seen, you therefore attempt to pass a suction catheter but this is unsuccessful. You proceed down the emergency tracheostomy problem algorithm. The next step is to deflate the cuff - there is no improvement. What is the next step in managing this patient's potential tracheostomy problem?
Answer:
The patient is not stable or improving after deflating the cuff. The tracheostomy may be completely blocked or displaced, and the patient cannot breathe round the tube adequately; remove the tracheostomy tube and look, listen and feel again.Emergency Tracheostomy Management
Ear, Nose & Throat / Procedural Skills (SLO6)
Last Updated: 13th February 2021
Tracheostomy Red Flags
- Airway flags
- If the patient has a cuffed tracheostomy correctly sited in the trachea, no gas should escape through the mouth
- If the patient is talking, or audible air leaks or bubbles of saliva are seen or heard at the mouth or nose, then gas is escaping past the cuff; this may imply that the cuff is damaged or the tube tip not correctly sited
- Grunting, snoring or stridor are also signs of an airway problem
- Breathing flags
- Apnoea, detected by capnography or clinically
- Difficulty in breathing or with ventilation
- Accessory muscle use
- Increased respiratory rate
- Higher airway pressures
- Lower tidal volumes
- Hypoxia
- Whistling noises or noisy breathing
- Specific tracheostomy flags
- Visibly displaced tracheostomy tube; if this is an adjustable flange tube, check where it was last positioned
- Blood or blood-stained secretions around the tube; a recently performed or changed tracheostomy bleeds a little, but if in doubt, it should be assessed
- Increased pain or discomfort
- Cuff requires lots of air to stay inflated
- cuff may be damaged or have an air leak (in which case, it needs to be replaced)
- tube may be displaced and the cuff needs 'hyperinflation' to keep it 'sealed'
- General flags
- Any physiological changes, specifically changes in
- Respiratory rate
- Heart rate
- Blood pressure
- Level of consciousness
- Anxiety, restlessness, agitation and confusion may also be due to an airway
problem
- Any physiological changes, specifically changes in
Emergency Algorithm for Tracheostomy
- Call for expert airway help
- Look, listen and feel at the mouth and tracheostomy
- Use waveform capnography where available; exhaled carbon dioxide indicates a patent or partially patent airway
- Is the patient breathing?
- If the patient isn't breathing, call the resuscitation team and start CPR if no pulse/signs of life
- If the patient is breathing, apply high flow oxygen to both the face and the tracheostomy
- Assess tracheostomy patency:
- Remove speaking valve or cap (if present)
- Remove inner tubes (if present)
- Can you pass a suction catheter?
- If yes, the tracheostomy tube is at least partially patent
- Perform tracheal suction
- Continue ABCDE assessment
- Ventilate (via tracheostomy) if patient isn't breathing
- If no, deflate the cuff (if present) and look, listen and feel again
- Is the patient stable or improving after deflating the cuff?
- If yes, airflow is moving past a partially obstructed or displaced tracheostomy tube; continue ABCDE assessment and await experienced assistance
- If no, the tracheostomy may be completely blocked or displaced, and the patient cannot breathe round the tube adequately; remove the tracheostomy tube and look, listen and feel again
- Is the patient breathing after removing the tube?
- If yes, continue ABCDE assessment and await experienced assistance
- If no, call resuscitation team and start CPR if no pulse/signs of life; emergency oxygenation
- Is the patient stable or improving after deflating the cuff?
- If yes, the tracheostomy tube is at least partially patent
Emergency Oxygenation for Tracheostomy
If the patient fails to improve after removing the tracheostomy tube, primary emergency oxygenation may be achieved by the oro-nasal route, the tracheostomy stoma or by both routes. In any airway emergency, oxygenation is the priority. It might be necessary to re-insert a new tracheostomy tube or other tube into the airway, but often, a patient can be (re)oxygenated by less invasive means. A stable, more oxygenated patient is in a much better position to tolerate airway procedures. Insertion of a new tracheostomy tube or endotracheal tube is likely to require expertise and equipment, and harm has resulted from inappropriate attempts to manipulate the stoma blindly when this is not immediately required.
Emergency oxygenation if patient is not breathing:
- Primary emergency oxygenation
- Standard oral airway manoeuvres
- Cover the stoma with swabs/hand
- Use bag-valve-mask, oral or nasal airway adjuncts or supraglottic airway device e.g. LMA
- Tracheostomy stoma ventilation
- Paediatric face mask applied to stoma (may need to occlude the nose and mouth)
- LMA applied to stoma
- Standard oral airway manoeuvres
- Secondary emergency oxygenation (if effective oxygenation or ventilation cannot be achieved)
- Attempt oral intubation
- Prepare for difficult intubation
- Uncut tube, advance beyond stoma
- Attempt intubation of stoma
- Small tracheostomy tube/6.0 cuffed ETT
- Consider Aintree catheter and fiberoptic scope/Bougie/Airway exchange catheter
- Attempt oral intubation
N.B. Patients with laryngectomies cannot breathe through their upper airways (their nose and mouth) as these are no longer connected to their lungs. If the patient has had a laryngectomy, then the stoma is the only route for delivering oxygen to the lungs.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
