It’s 2am and the crash bleep goes off. You arrive at the bedside of 5 year old Jerry who has suddenly dropped his sats to 80%. He looks like he has a tracheostomy tube in his neck. Can you keep your cool and handle it like a pro?
Thanks to the team at tracheostomy.org.uk for their support in writing this post. Much of the content is a summary from all the wonderful learning resources on their website and also from their library of videos.
Tracheotomy – an incision in the trachea
Tracheostomy – a stoma in the trachea (i.e. an opening which has been created)
Laryngectomy – surgical remove of the larynx – tracheal remants are stitched to the anterior tracheal wall and there is no connection from the mouse and nose to the rest of the airway
Tracheotomy or tracheostomy patients potentially have two airways but a larygnectomy patient only has one.
It’s very hard to tell by looking at the patient which they have, and most hospital inpatients will have a sheet above their bed making it clear which type they have.
The key things you need to know are:
- is there a connection between their mouth/nose and their lungs? (i.e. 1 or 2 airways)
- are they known to have a difficult airway?
- how old is the tracheostomy and what was the procedure to make it?
A surgical tracheostomy is made by making an incision in the neck and stitching it open – this type of approach will create an established tract. A percutaneous tracheostomy just stretches the skin back to make the stoma and so it more likely to close in 7-10 days if not kept patent.
- to secure an airway when there is upper airway obstruction
- in patients with facial injuries
- to protect the airway in kids with risk of aspiration (e.g. cerebral palsy or neuromuscular conditions)
- to allow for suction of secretions in kids with a poor cough
- to enable long-term ventilation
Trachoestomy.org.uk has fabulous elearning resources that goes through the anatomy in more detail. But for now, we can recognise our major landmarks…
The trachea is entered by making a cut in the anterior tracheal wall at the level of the 2nd or 3rd tracheal cartilage.
There are several different surgical incisions that can achieve this:
- a horizontal slit – this can be accompanied by stay sutures which sutures the tracheal wall to the skin – this makes it easier for tube replacement and holds to the stoma open – they are usually removed after 5-7 days
- a window – a small part of the anterior tracheal ring is removed, creating a window opening
- a vertical slit – this can be made in an ‘h’ shape and the flaps are sutured back to create the opening and all the sutures to be pulled to widen the opening
- Bjork flap – done in some centres
In a percutaneous tracheostomy the stoma is dilated to create the opening using the Seldinger technique – needle, then guide wire, then dilators.
Complications of tracheostomies are split into peri-operative, early post-operative, and late post-operative
Peri-operative: haemorrhage; misplaced tube; pneumothorax; tube occlusion; surgical emphysema
Early post-operative (<7 days): tube blockage; tube displacement; site infection; lung infection; tracheal ulceration; fistula; haemorrhage
Late post-operative (>7 days): granuloma; tracheal collapse; blocked tube; haemorrhage; tracheal stenosis
The key differences between the types of tubes (as well as size and length) are:
- cuff or no cuff
- inner cannula or no inner cannual
- fenestrations (holes) or none
If a patient has an uncuffed tube, that patient has no airway protection from aspiration, and positive pressure ventilation will be ineffective, but air can flow through the mouth and nose and down past the tube.
If a patient has a cuffed tube, that patient’s airway is protected from aspiration, positive pressure ventilation can be delivered, but the tracheostomy is the only route for air flow (which is a problem if the tube becomes blocked). If you deflate the cuff, air can flow from the mouth and nose down the trachea.
Fenestrated tubes have holes that allow air to flow through the tracheostomy but also through the mouth and nose. This allows the patient to speak, but allows the risk of aspiration. An inner cannula can be used to block the holes.
Now we have a good understanding of the anatomy and types of tracheostomies, how are we going to help Jerry?
Follow a step-by-step approach to managing tracheostomy emergencies.
- Call for help (anaesthetics or ENT). Establish how many airways we have to work with. Has Jerry had a laryngectomy (one airway) or a tracheostomy (two airways)? Look for a sign around his bed.
2. Look, listen, and feel at the mouth and the stoma. Is the patient breathing?
Jerry is breathing, but if he wasn’t we would check a pulse and follow the APLS algorithm. He has a tracheostomy with a cuffed tube.
3, Apply oxygen – to the mouth and nose (if the patient has two airways, which we now know Jerry does) and to the tracheostomy
Then think about some common tracheostomy problems:
- Remove any attachments e.g. speaking valve or caps
- Remove the inner cannula if there is one
- Assess patency by putting a suction catheter down (this is better than just bagging first because if the tube is dislodged you will cause surgical emphysema by bagging). If you can pass the catheter then you should suction and ventilate if they are not breathing.
You try to pass a suction catheter down Jerry’s tube, but you cannot pass it.
If you can’t pass the catheter then the problem is that the tracheostomy is blocked and it’s time to problem solve.
You should deflate the cuff as this will allow some air to pass through from the mouth and nose. If this helps Jerry then he has a partially obstructed tube, and as he’s now improving we can wait for expert help to arrive and use a fibre-optic scope to take a closer look.
If deflating the cuff doesn’t help Jerry then we need to remove the tube. You need to cut and remove any tapes or sutures. Then check again by look, listening, and feeling at the tracheostomy and mouth/nose (and reapply oxygen).
You have removed the tracheostomy tube but Jerry is still not breathing (he has a pulse). You need to oxygenate him.
Try oral airway maneouvres by covering the stoma with gauze or your hand and: bag-valve mask; oral or nasal airway adjuncts; or an LMA.
Or try ventilating via the stoma with a face mask over the stoma, or an LMA over the stoma.
If you aren’t able to ventilate Jerry with these basic maneouvres. It’s time for something more invasive.
Attempt oral intubation, but prepare for a difficult intubation and make sure your ETT passes the stoma.
Attempt intubation of the stoma (using an ETT, a trachy tube, a bougie). There is a risk of blindly intubating a stoma as you may create a false tract. If you have someone (or are someone) with more experience, you can put your finger into the trachea and guide the bougie, or use a fibre-optic technique.
Thankfully using a face mask over the stoma works and Jerry picks up just as the Anaesthetic Consultant arrives.
If you want a nice summary with Sheila rather than Jerry – then watch this fabulous video of the emergency tracheostomy algorithm.
The Association of Anaesthetists of Great Britain & Ireland grants readers the right to reproduce the algorithms included in this article (Figs 1 and 2) for non-commercial purposes (including in scholarly journals, books and non-commercial websites), without the need to request permission. Each reproduction of any algorithm must be accompanied by the following text: Reproduced from McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012 Jun 26. doi: 10.1111/j.1365-2044.2012.07217, with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell Publishing Ltd.
Check out tracheostomy.org.uk for more resources on this topic