Emergency Management of Tracheostomy

Good morning, everyone. This morning we’re going to look at the emergency management of a tracheostomy. It’s really important, in the NAP, force of the National Auditing Projects in 2011, they looked to all airway management in the hospitals. About 20% of the adverse incidence happened in the ICU. And out of the patients that the incidence happened to there was at least 14 patients with tracheostomy emergencies. They acknowledge that we need to do more teaching and more management on how to deal with a tracheostomy that gets dislodged or removed in the ICU. So we’re going to have a quick look at the different types of tracheostomy. Since you’ve been in ICU, have you seen any tracheostomies being done? Yeah, I saw it.

He saw one yesterday. And what kind of tracheostomy was it? Not sure. You’re not sure. Did they do it in the unit? Or did they do it in surgery? Did it in the unit, yeah. In the unit. So that’s a percutaneous trache, OK? So that’s one that they dilate down. Then they put it in the ICU. The other type of trache is a surgical tracheostomy. Which is done in theatre by the ENT surgeon.

That has a little bit of a picture of it. And you can see there’s been a surgical tracheostomy and a percutaneous one. It’s quite important to know the difference between a surgical and a percutaneous, because of how long it takes for a trach to form. So has anybody got any ideas how long it would take for a formation of a trach? Three days. Three days, anyone else? A week maybe? For the percutaneous traches it can take 7 to 10 days. Surgical traches can be a wee bit quicker than that. So that’s why it’s really important when every patient that has a tracheostomy has an end-of-bed sign that says if it was a surgical or percutaneous trach.

That’s really just to give you the time frame of when that trache went in. And is there likely to be a formed trach? So if there is an emergency, you know that trache’s been in for two days or three weeks. That’s very important. Because if you’ve got a trach that’s been in three weeks, you’re you to have a nice formed stoma and a nice formed track. Whereas if you’ve got a trache that’s only been in a couple of days, that’s going to close up quite quickly. And it’s going to be more difficult to try and manage that. OK? So Traci’s trache’s only been in for a couple of days.

So we’ll keep that in mind when we go to our emergency management of what we’re going to do. One of the other things that happened was the CPOD in 2014– or NCEPOD, really, in 2014, they looked at “On the Right Trach” and about trache management. And that every patient, as well as the end of bedside, needed an emergency tracheostomy box. So if you’ve seen any of the tracheostomies in the ICU, and the patients, they will all have a box by their bedside. And this is all for the emergency management. So we’ll have a quick look at what’s in here. We have the algorithm about what to do in an emergency. And Traci, you have a look.

She’s got a size 7 trache in. So that means in our box we need to have a size 7 trache, and one size smaller. Any ideas why we’d need one size smaller?

In case that it’s– sorry. It could close up. Yeah. So if you have difficulty, if it comes out in emergency, and you can’t get the same size in, you’ve got another option. You can go for a smaller size. Especially if the trache’s only been in for a couple days, rather than anything else. Anybody know what these are? They open the– Yes, they’re the trache dilators. So you can use them if you so wish. The other things in the box is you need a stitch cutter. That’s purely for your surgical traches, because they tend to be stitched in either side. And the percutaneous don’t tend to be as much. Then very important, head torch.

Why do you think we need a head torch?

Because you’ll be doing things with your hands. Yeah. So it gives you freedom. Also, you’re looking at tracheostomy tube that is very small. And you’re trying to see what’s happening. And ICU’s not always the best-lit area. So sometimes it just gives you that wee bit extra light. We have– anybody know what this is? A non-rebreather mask. A non-rebreather mask. And this is obviously for the patient’s face.

So this is a– I can open it for you. This is a paediatric face mask. What might we use that for in trache emergencies? What size do you think it would fit over? The trache site? Yes. so that could seal your stoma site if you need it. And other important things that we’ve got is suction catheters. Very important in all trache emergencies. And the sterile syringe. So what do we think we’d need that for? Deflating the cuff. Yes, for deflating the cuff. So every trache, keeping it in place, has got a cuff. When we need to deflate that. The only other things we’ve got in is some lubrication. And that’s if you’re needing to be inserting a new trache.

Is everybody happy so far? Yeah?

In NHS Lothian, as well as the trache box, the head of bed site, we also have a checklist for the patients on the wards that have tracheostomies or laryngectomies, in situ. So we’ll have quick look at laryngectomies. Does anybody– or could anybody tell me the difference between a tracheostomy and a laryngectomy?

Shall I show you the signs and then you can maybe tell me what you think is the difference. So could you reverse a tracheostomy, but you can’t reverse a laryngectomy. Exactly. So laryngectomy, they’ve taken away the larynx. And they’ve separated the airway from this thing. And so it– [BACKGROUND NOISE] If any of you have a laryngectomy patient, they do not have a useful upper airway. So it’s really important. If the patient has had it, they’ve got a laryngectomy, they haven’t got an upper airway. Why would we do laryngectomies? Do you know? What would be the reason? If they’ve got, if they have a cancer. So normally it’s for emergency.

And obviously, with your tracheostomy patients, we should still have a patent upper airway most of the time. Why would be, what’s the indications for a tracheostomy? Why do we do them?

If the patient’s having difficulty being weened off the ventilator. So long-term ventilation, yes. We definitely do that. Because you can use less sedation. You can mobilise the patient easier. And it stops having pressure areas around the mouths. Anything else? Any other reasons that you can think of? Seems like an obstruction of the airway? So any kind of obstruction of the airway and swelling, anaphylaxis, something like that, it causes a huge amount of swelling. But you can use a tracheostomy. And there’s one other. Which is probably more long-term patients. So patients with neuromuscular conditions, that need a trache just to manage their secretions, because they’re not able to do it themselves.

Right. Shall we have a look at Traci and see if we can save her? Or shall we have a wee thing about the red flags first?

The red flags are put out there as things that would concern you if you were looking after a patient with a tracheostomy. So there’s airway red flags, breathing red flags, tracheostomy red flags, and general red flags. So if we start with the airway, what would be red flags or concerning issues with the airway?

Just think about what you’re trying to do and what you’re trying to achieve.

If it’s not patent, it’s blocked. Before that. So if you’re thinking about when you get a patient, have they got a stridor? [IMITATES WHEEZING] Can they speak? Is there bubbling, frothing at the mouth? Because all of those signs show you that maybe this trache’s not doing exactly what it should be doing. Because they’re able to vocalise. Which means there’s something wrong. Breathing red flags. What do you think?

Increased respiratory requirements? Yes, definitely. Increased respiratory. High oxygenation. So hypoxia. Apnea. Dyspnea. So they’re using their accessory muscles. And they increase the work of breathing. What about the tracheostomy itself? What would the red flags be for that? If they’re looking red. Or there’s a discharge from it. Discharge, yeah. Infection, you’re thinking of. What’s the other one that might cause a lot of problems, when a trache’s been in for a while? Bleeding. There’s quite a few arteries that are running close by. And trache’s have eroded into the dominant artery. And when that happens, that’s a catastrophe. So think about those. Then your general red flags are just all the things that you would look at in the bed space.

So your resp rate, your oxygenation, your heart rate. Their blood pressure. Their GCS, their mental state. Are they more confused? Are they getting agitated? All things to think about in the bed space. OK. So now that I’ve got my assistant, we’re going to look at what the algorithm tells us to do in an emergency. So you’ve just been called to the bed space. OK. This is Traci. Hi, Traci. Traci’s had flu, unfortunately, and has been in ITU for quite a while, and has just had her tracheostomy two days ago, as you can see on the side. And you’ve got called to the bed space because she’s suddenly desaturated. And when you get there she’s– sat’s only 82%.

And she’s got an increased respiratory rate and looks a bit agitated. So what’s the first thing that you want to do? So having conducted an assessment of Tracy I would check that the tracheostomy is doing it’s job.

OK. Before we get there, what else would you want in the vicinity, or coming close? So once I’ve realised that I’d probably want additional support, to help. Yes. First thing you want to do is ask for help. You need somebody that can assist you, manage an airway, and hopefully do the advanced airway skills. First thing you do, take your time. You call for help. Then what you going to do? I’m going to follow the algorithm. Mhm. So the algorithm says, next thing we do is we look, listen, and feel. So where are you going to look, listen, and feel? So I’m looking Traci as a whole. So I’m looking mostly at her upper chest.

I would see if there is any chest movement at all to chest. chest. And have a listen with a stethoscope. And you want to listen at the mouth and at the tracheostomy site. Because you’re not sure where everything is at the moment. The other thing that came out of the NAP 4 trial was that capnography should be on every patient that has a tracheostomy. So every patient should have an end-tidal CO2 at their bed space. So that is your biggest indication whether the tracheostomy is in the right place. If you have a CO2 trace with every breath, you know it’s in the right place. The algorithm also suggests that you use a Mapleson C- circuit.

Which I’m always slightly dubious about. I think if you want to attach it, all you can do is see if the bag is moving. Because if I was to give Traci a big blast of air and the trache’s not in the right place, what’s likely to happen?

If that’s in the subcutaneous tissue and I give her a massive, big breath. Trauma. Trauma. You’re going to end up with a huge surgical emphysema in the neck. Because you’ve just given them a huge bag down to a trache that you don’t know is in the right place. So I’d be very careful with the C circuit. You can use it if you’ve not go capnography, just to purely see if the bag’s moving. But be very, very cautious about bagging a tracheostomy that you don’t is in the right place. On the algorithm– so we’ve looked, listened, and felt. The next thing we do is the patient breathing. And she is breathing. We want to apply oxygen.

Where are we going to apply the oxygen? Anybody have any ideas? It’s a tracheostomy patient. Which means she also has a patent upper airway. So where are we going to put the oxygen? Both places. Both, yes. So we want to put some high flow. You want to do that. And she’s already got a lovely T-piece so we’ll put 100% oxygen through that as well. So she’s got oxygen applied to the stomach. And we’re going to apply high-flow oxygen to her face as well.

So we know she’s still breathing. She’s got high-flow oxygen on both sources. Then we want to assess the patency of the tracking. How are we going to do that?

What’s the best way to assess if it’s patent?

You want to suction.

At this point, we’re going to remove the oxygen. We’re going to remove any caps or speaking valves or anything. Then we are going to remove the inner tube out of it. Why do you think I want to remove the inner tube? That could be in the obstructions. Yeah. Very much so. So this could be blocked. And that might be enough to give her some air in there. We’ve taken out the inner tube. And then you want to suction. So the next question on the algorithm is, can you pass the suction catheter? And no, you can’t pass said suction catheter. So what do we need to do now? We cannot pass the suction catheter. We don’t have capnography.

Where do we think the tube is? Is it in the airway? No. No. Probably not. The next thing we want to do is deflate the cuff of the trache.

Very well done. That way, when you’ve got your cuff up, you’re creating basically a area that you can’t get any air through. So when you take the cuff down, the tube is much smaller than the trachea. And you can get the air right in the tube. Then we want to reassess our patient. Has that made her feel any better? And because we know we can’t get a suction catheter down, she’s still deteriorating. And we’ve now deflated the cuff. But she’s still getting worse. What do you think we need to do now?

And this is the bit everybody finds very difficult. So we have a tracheostomy tube that we can’t guarantee is in the airway. So it could be blocked. Or it could be in a false passage. So is it doing any good? No. No. So what do we want to do? Take it out. Take it out.

Very good. And this is always what people struggle with. Because everybody’s like, ooh, there’s a trache, I’ve got to leave it. But if you cannot guarantee it’s in the right place, then you take that trache out. Then what you want to do is seal over the stoma. Then go to the top end again. Then you do standard manoeuvres to manage our airway until you have help.

Then you could use, to back up mass, you could go back with an ET tube. Or use an LMA until you’ve got more help, depending on the skill set there. If that’s still becoming a problem and you feel like you’ve got a stoma that actually works, you could use a LMA over your stoma or your– somebody pass me a paediatric face mask. You could use your paediatric face mask. But that’s very much second line. And you would go top end, to start again.

Any questions? How would you feel about doing that?

Confident. [LAUGHTER] That’s what I like to hear. I suppose what you’ve got to remember is that you will have help coming. OK? As long as you’ve done that, the first thing on your algorithm, that you have called for help, you’ve got somebody coming to assist you with this airway, you are never going to get into trouble or have a problem because you’ve taken the trache out. If it’s not in the right place and you haven’t got capnography and you can’t suction down it, it’s not doing any good. The other thing to be aware is when you have if it has moved into a false track, and sometimes that can press on the airway even more.

And the other thing that can happen is once a false track is made, it’s really easy for things to go back into that false track. So going for your standard upper airway manoeuvres if your safest way. I’ve had quite a few trache emergencies in my time. And I think out of all the emergencies I’ve been to, we only ever once managed to put a tracheostomy back into the stoma. So just keep that in the back of your head. As long as you can manage your airway. Now, just to finish off with laryngectomy patients, obviously they don’t have an upper airway. However, if you’re not sure if it’s a laryngectomy or a trache, you can put oxygen at both points.

But if you know it’s a laryngectomy patient, you have to try and use the stoma. And you want to do the same. So you remove. You ask for help. You look, listen, and feel. You assess. You can use your end-tidal CO2, your capnography, or your bag to see if there’s any air movement. If you remove any caps, anything that’s in it. Quite often they have speaking valves and things, in their stomas. And you want to remove all of that. And laryngectomy patients don’t always have tubes, because they’re long term. So there might not be an inner tube to remove. Or any tube to remove. But you still need to check the patency of that airway you have to suction.

Then you go through. And that’s when your little paediatric face mask comes in handy, that you can seal that. And if you don’t have this, then you can use an LMA. Because that’ll give you a nice seal over as well. We’ve only got, really, two types of traches. We have the Portex ones. And we have adjustable flanges. The adjustable flange is longer. What do you think we might use that for? What is the epidemic going to be in the next 30 years? Obesity. Obesity, yes. So moving forward, we’re going to have a lot more patients with larger necks and shorter necks, just because of weight distribution. And sometimes you use an adjustable flange.

Adjustable flanges have an inner tube the same. They’re just longer. And you can clamp it where you need it. And this is the Portex trache. And they come with an inner tube and a spare inner tube. And you have a cuff that holds it in place and seals your trachea.

When traches are in, they should be taking into account the size of the patient and how big they are. So obviously, Traci’s very small. So she’s got a size seven, which is quite small. If you’ve got a larger male, you might want an eight or a nine. And obviously, your obese patients we would probably go for an adjustable flange valve, one of these.

You can have a little shot. Now, does anybody want a shot? We can go through the algorithm again and somebody else can have a shot. Now, don’t all jump at once. [LAUGHTER] I guess I’ll have a shot. Right. When I get the trache back.

One of you guys could read out the algorithm whilst the other one does it. Yeah? One of you want to have a look at the algorithm? [LAUGHTER] Tara, you play that card well. [LAUGHTER] OK. Because it’s clinical. Yes, of course.

[LAUGHTER] Years of pulling this…

OK, so this is day one in the MAU. You’re it. You’re the FY1 on. OK. [LAUGHTER] You’re it. Making me stress. [LAUGHS] Don’t be stressed. Just think about it and we’ll work through it. And Oliver’s going to call out what you need to do next. OK? OK. A few times will help. Let’s see if I was listening. [LAUGHTER] Right. just say when. Wait till he got his gloves on. OK. I can be the nurse at bed space. So Oliver’s over there. I’ve got a problem with my patient. Mhm? She’s suddenly desaturated. And she’s getting really agitated. She’s moving all around her bed. I don’t know what’s wrong with her. OK. That’s fine.

Just looking at her just now, has she been making any breathing sounds or anything? Oh she is, actually. Yeah. I think you’re right. She was trying to talk to me earlier. OK. And what did that sound like, the sound? Well, she just sounded like she had a voice. OK, that’s fine. So hopefully that’s– What’s the first thing you want to do in your algorithm? Call for airway expert help. OK. So first we should call for someone senior. Shall I go and do that? Yeah. Lovely. Thank you. And if you’d look, listen, and feel at the mouth and the tracheostomy. OK. I think that– should I take this off? Yeah.

Just have a look at the tracheostomy. And a listen. Look. Well, she is speaking. And she is speaking. Oh, OK. [LAUGHTER] But she’s got a respiratory rate of about 49. And her sats are at about a 76. OK. What should we do now? Yeah, I think it’d be good to have some oxygen. OK. Where would you like that oxygen? Have some oxygen over her mouth, as well as over the tracheostomy. So I’m just going to put an oxygen mask on your face there. And– Put some high flow in that. I’ll put some.

OK. Good. Assess the tracheostomy patency. OK. So what do you need to do now?

We need to suction. So before you do that– you will suction. But you need to tape off any caps, inner tubes, anything that’s on top. Like a Passy-Muir valve, a speaking valve. So you don’t want to take the cuff down just yet. So what we’ll do is just take out her inner tube. So just pull. So that’s remove speaking valve or cap. And remove inner tube. Lovely. So you’ve removed this inner tube. Oh it looks OK. Not too much of a problem. But she’s not getting any better. Keep the oxygen on hand. Can you pass the suction catheter? So can you pass the suction catheter? Well, let’s find out. This. OK.

Oh no, that suction cath is not going anywhere. It’s not going anywhere. OK. Oh, and it looks like it’s got a big clog. Big clog. What colour is the clog? It’s kind of creamy-coloured.

Can’t go down past the suction catheter. I think it might be time to take out the trache. What you going to do before you take it out? That you wanted to do earlier? Hmm, this– Deflate the cuff. [CHUCKLE]

So a deflated cuff. Then we’re going to go back and assess. OK. Look, listen, and feel at the mouth and the tracheostomy. OK.

She’s still quite agitated and she’s all over the place. And her sats are only 79. So they’re still dropping. Mhm. And your help’s coming. But it’s not here yet. So what we’re going to do? Take the trach out. I don’t know, what’s next? Remove the tracheostomy tube. OK. I’m just going to remove the tube. You need to take the tapes off.

Sorry, but– And that is very much real life, is sometimes they can be really sticky. And they can be really caught. So you get a friend to cover. Then what we do now? Pop out a paediatric. We can do. Or we can try– what would we do? Also before we get out paediatric face mask. What’s our first manoeuvres? Head tilt, chin lift.

Yeah. So you can bag valve mask LMAs. You can do that first before. OK. OK? And if that’s not working, then you could think about your stoma. But then you would use that. But like I say, in many years in ITU I have very rarely seen us able to put a tube back in the stoma. How does it feel doing it? Yeah, I didn’t really know what I’m doing. [LAUGHTER] And you know the one thing that we’ve missed all the way through that is we did not look at the capnography. And that is a vitally important part of your assessment. I’d say it just wasn’t available. It says wasn’t available, so it wasn’t available. Wasn’t available.

But yes, that is your– that should be your first go-to. Because that is the only thing that’s going to tell you, if it’s in the airway.